User login
Healthy youth sports participation excludes early specialization
CHICAGO – When a boy receives five college football scholarship offers and a girl commits to playing soccer for a university before either of them starts ninth grade, it’s time to take several steps back in youth sports.
, including the risk of potentially discouraging a lifetime of healthy athletic participation, according to Joel S. Brenner, MD, MPH, a sports medicine expert at the Children’s Hospital of The King’s Daughters and Eastern Virginia Medical School, both in Norfolk.
“This paradigm should be discouraged by society,” Dr. Brenner told attendees at the American Academy of Pediatrics annual meeting. “Sports specialization refers to focusing on one sport to the exclusion of all others, often playing that single sport year-round. Dr. Brenner authored the AAP’s 2016 clinical report on sports specialization and intensive training in young athletes.
Dr. Brenner emphasized the benefits of delaying sports specialization until after puberty, the risks of specializing sooner, and the importance of rest to prevent burnout and injuries.
This is not a new problem, he noted, showing the attendees two Time Magazine covers, from 1999 and 2017, that featured the concern of “Sports Crazed Kids.” But it is so far-reaching that it will requires more than just physicians to change.
“This is not just an athlete problem, a parent problem, a coach problem, or even a physician problem,” Dr. Brenner said. “It’s a societal problem, a youth sports culture problem, and one that all of us as stakeholders need to attack and try to change the culture.”
Youth sports offer a broad range of benefits, such as developing physical activity, and leadership skills, and promoting self-esteem, socialization, and teamwork, Dr. Brenner said.
“But one benefit that often gets forgotten by people, including the coaches, the parents, and the athletes, is that sports is supposed to be about having fun,” he said.
The old model of kids’ sports was loosely organized fun, with kids playing multiple sports throughout the year and less direct involvement from adults, such as street hockey games and pick-up basketball. But those bygone days, Dr. Brenner noted wistfully, have been replaced with a different paradigm today: Children specialize in a single sport very early, and parents and coaches are the driving forces behind their involvement.
Today’s culture of very early sports specialization and college recruitment increases pressure on parents and young athletes to play year-round on multiple teams to stay on the radar of scouts and colleges. And this specialization has expanded to younger and younger ages, with 7-year-olds participating in travel leagues and national rankings of children in their sport as early as sixth grade.
“We should not be ranking kids in middle school or even in early high school,” Dr. Brenner said to wide applause. “We should allow kids to develop in a low-pressure, healthy system before we do that.”
The effects of high pressure have potentially lifelong ramifications. By the time children are 13 years old, 70% have dropped out of organized sports, Dr. Brenner said, and injuries from overuse account for more than half of all sports-related injuries in youth.
Yet the alternative – early diversification and late specialization – can really benefit kids, he said. The early specialization paradigm of playing just one sport focuses on deliberate practice and performance from the start. By contrast, early diversification with multiple sports focuses on deliberate play, during which children develop foundational athletic skills. Children who play a variety of sports are more likely to participate for more years – and it meets youth’s more realistic, long-term needs for lifelong physical activity through “fun, variety, and play,” he said.
Dr. Brenner said that just 1% of high school athletes receive any athletic scholarships, and only 3%-11% of high school athletes compete at the college level. The numbers for high school athletes that go on to play at the professional level is, of course, even smaller: 0.03% to 0.5%, depending on the sport.
And the irony is that the goal of early specialization – producing such elite level athletes – is actually better accomplished through playing multiple sports, Dr. Brenner said. Most Division 1 National Collegiate Athletic Association (NCAA) athletes and 90% of National Football League (NFL) first-round picks played multiple sports in high school. So the benefits of waiting until late adolescence to specialize are twofold: a greater likelihood of athletic success, even at elite levels, and minimizing the risks of injury.
Overuse injuries pose serious risks
More than half of sports injuries are from overuse, and a number of factors contribute to those injuries, such as muscle imbalance, playing surfaces, and training errors, Dr. Brenner said. But the biggest contributors are early specialization, playing year-round sports, and playing on multiple teams.
“This is a problem we see daily,” Dr. Brenner said. “We can see the young dancer, who’s dancing 6-7 days a week, who develops back pain and continues to dance, and develops a stress fracture in her lumbar spine known spondylosis.
“Or we see the young soccer player who plays on multiple teams and develops heel pain, who starts limping with activities of daily living, continues to play soccer despite limping, and develops calcaneal apophysitis, known as Sever’s disease. Or the young baseball pitcher, who pitches for two teams, who develops arm pain and weakness, who has a stress fracture through the proximal humeral epiphysis, known as Little League shoulder.” 
Two broad pieces of guidance can help reduce the risk of injuries, particularly from overuse. First, young athletes should take off at least 1 month from a specific sport at least three times a year to give them adequate time for physical and psychological recovery. Second, ensuring young athletes take at least 1 or 2 days off of practice each week further reduces the likelihood of injury.
In addition to the physical problems these young athletes may develop, they also risk anxiety, depression, burnout, early retirement, and social isolation from peers who don’t play their sport, Dr. Brenner said. Family members also may experience greater stress, he added. And then there’s the risk of missing out on learning other sports they may excel in that offer a lifetime of enjoyment, such as tennis or swimming.
It is not clear where the threshold of involvement is for reducing overuse injury, burnout, and attrition, but Dr. Brenner provided some guidelines as a starting place. High school athletes should not train more 16 hours a week, and organized sports should not exceed free play time by a greater ratio than 2:1. Another guideline is not to exceed more hours per week in organized sports than a child’s age in years.
The primary focus of sports should be learning lifelong physical activity skills and having fun, Dr. Brenner said. Pediatricians should encourage patients to play in a wide variety of sports at least until puberty, thereby decreasing the chance of injuries, stress, and burnout, he said. That can include sports that are not necessarily an official part of school or club competition. Waiting until later to specialize may lead to a higher likelihood of athletic success.
Dr. Brenner said he had no relevant financial disclosures.
CHICAGO – When a boy receives five college football scholarship offers and a girl commits to playing soccer for a university before either of them starts ninth grade, it’s time to take several steps back in youth sports.
, including the risk of potentially discouraging a lifetime of healthy athletic participation, according to Joel S. Brenner, MD, MPH, a sports medicine expert at the Children’s Hospital of The King’s Daughters and Eastern Virginia Medical School, both in Norfolk.
“This paradigm should be discouraged by society,” Dr. Brenner told attendees at the American Academy of Pediatrics annual meeting. “Sports specialization refers to focusing on one sport to the exclusion of all others, often playing that single sport year-round. Dr. Brenner authored the AAP’s 2016 clinical report on sports specialization and intensive training in young athletes.
Dr. Brenner emphasized the benefits of delaying sports specialization until after puberty, the risks of specializing sooner, and the importance of rest to prevent burnout and injuries.
This is not a new problem, he noted, showing the attendees two Time Magazine covers, from 1999 and 2017, that featured the concern of “Sports Crazed Kids.” But it is so far-reaching that it will requires more than just physicians to change.
“This is not just an athlete problem, a parent problem, a coach problem, or even a physician problem,” Dr. Brenner said. “It’s a societal problem, a youth sports culture problem, and one that all of us as stakeholders need to attack and try to change the culture.”
Youth sports offer a broad range of benefits, such as developing physical activity, and leadership skills, and promoting self-esteem, socialization, and teamwork, Dr. Brenner said.
“But one benefit that often gets forgotten by people, including the coaches, the parents, and the athletes, is that sports is supposed to be about having fun,” he said.
The old model of kids’ sports was loosely organized fun, with kids playing multiple sports throughout the year and less direct involvement from adults, such as street hockey games and pick-up basketball. But those bygone days, Dr. Brenner noted wistfully, have been replaced with a different paradigm today: Children specialize in a single sport very early, and parents and coaches are the driving forces behind their involvement.
Today’s culture of very early sports specialization and college recruitment increases pressure on parents and young athletes to play year-round on multiple teams to stay on the radar of scouts and colleges. And this specialization has expanded to younger and younger ages, with 7-year-olds participating in travel leagues and national rankings of children in their sport as early as sixth grade.
“We should not be ranking kids in middle school or even in early high school,” Dr. Brenner said to wide applause. “We should allow kids to develop in a low-pressure, healthy system before we do that.”
The effects of high pressure have potentially lifelong ramifications. By the time children are 13 years old, 70% have dropped out of organized sports, Dr. Brenner said, and injuries from overuse account for more than half of all sports-related injuries in youth.
Yet the alternative – early diversification and late specialization – can really benefit kids, he said. The early specialization paradigm of playing just one sport focuses on deliberate practice and performance from the start. By contrast, early diversification with multiple sports focuses on deliberate play, during which children develop foundational athletic skills. Children who play a variety of sports are more likely to participate for more years – and it meets youth’s more realistic, long-term needs for lifelong physical activity through “fun, variety, and play,” he said.
Dr. Brenner said that just 1% of high school athletes receive any athletic scholarships, and only 3%-11% of high school athletes compete at the college level. The numbers for high school athletes that go on to play at the professional level is, of course, even smaller: 0.03% to 0.5%, depending on the sport.
And the irony is that the goal of early specialization – producing such elite level athletes – is actually better accomplished through playing multiple sports, Dr. Brenner said. Most Division 1 National Collegiate Athletic Association (NCAA) athletes and 90% of National Football League (NFL) first-round picks played multiple sports in high school. So the benefits of waiting until late adolescence to specialize are twofold: a greater likelihood of athletic success, even at elite levels, and minimizing the risks of injury.
Overuse injuries pose serious risks
More than half of sports injuries are from overuse, and a number of factors contribute to those injuries, such as muscle imbalance, playing surfaces, and training errors, Dr. Brenner said. But the biggest contributors are early specialization, playing year-round sports, and playing on multiple teams.
“This is a problem we see daily,” Dr. Brenner said. “We can see the young dancer, who’s dancing 6-7 days a week, who develops back pain and continues to dance, and develops a stress fracture in her lumbar spine known spondylosis.
“Or we see the young soccer player who plays on multiple teams and develops heel pain, who starts limping with activities of daily living, continues to play soccer despite limping, and develops calcaneal apophysitis, known as Sever’s disease. Or the young baseball pitcher, who pitches for two teams, who develops arm pain and weakness, who has a stress fracture through the proximal humeral epiphysis, known as Little League shoulder.”
Two broad pieces of guidance can help reduce the risk of injuries, particularly from overuse. First, young athletes should take off at least 1 month from a specific sport at least three times a year to give them adequate time for physical and psychological recovery. Second, ensuring young athletes take at least 1 or 2 days off of practice each week further reduces the likelihood of injury.
In addition to the physical problems these young athletes may develop, they also risk anxiety, depression, burnout, early retirement, and social isolation from peers who don’t play their sport, Dr. Brenner said. Family members also may experience greater stress, he added. And then there’s the risk of missing out on learning other sports they may excel in that offer a lifetime of enjoyment, such as tennis or swimming.
It is not clear where the threshold of involvement is for reducing overuse injury, burnout, and attrition, but Dr. Brenner provided some guidelines as a starting place. High school athletes should not train more 16 hours a week, and organized sports should not exceed free play time by a greater ratio than 2:1. Another guideline is not to exceed more hours per week in organized sports than a child’s age in years.
The primary focus of sports should be learning lifelong physical activity skills and having fun, Dr. Brenner said. Pediatricians should encourage patients to play in a wide variety of sports at least until puberty, thereby decreasing the chance of injuries, stress, and burnout, he said. That can include sports that are not necessarily an official part of school or club competition. Waiting until later to specialize may lead to a higher likelihood of athletic success.
Dr. Brenner said he had no relevant financial disclosures.
CHICAGO – When a boy receives five college football scholarship offers and a girl commits to playing soccer for a university before either of them starts ninth grade, it’s time to take several steps back in youth sports.
, including the risk of potentially discouraging a lifetime of healthy athletic participation, according to Joel S. Brenner, MD, MPH, a sports medicine expert at the Children’s Hospital of The King’s Daughters and Eastern Virginia Medical School, both in Norfolk.
“This paradigm should be discouraged by society,” Dr. Brenner told attendees at the American Academy of Pediatrics annual meeting. “Sports specialization refers to focusing on one sport to the exclusion of all others, often playing that single sport year-round. Dr. Brenner authored the AAP’s 2016 clinical report on sports specialization and intensive training in young athletes.
Dr. Brenner emphasized the benefits of delaying sports specialization until after puberty, the risks of specializing sooner, and the importance of rest to prevent burnout and injuries.
This is not a new problem, he noted, showing the attendees two Time Magazine covers, from 1999 and 2017, that featured the concern of “Sports Crazed Kids.” But it is so far-reaching that it will requires more than just physicians to change.
“This is not just an athlete problem, a parent problem, a coach problem, or even a physician problem,” Dr. Brenner said. “It’s a societal problem, a youth sports culture problem, and one that all of us as stakeholders need to attack and try to change the culture.”
Youth sports offer a broad range of benefits, such as developing physical activity, and leadership skills, and promoting self-esteem, socialization, and teamwork, Dr. Brenner said.
“But one benefit that often gets forgotten by people, including the coaches, the parents, and the athletes, is that sports is supposed to be about having fun,” he said.
The old model of kids’ sports was loosely organized fun, with kids playing multiple sports throughout the year and less direct involvement from adults, such as street hockey games and pick-up basketball. But those bygone days, Dr. Brenner noted wistfully, have been replaced with a different paradigm today: Children specialize in a single sport very early, and parents and coaches are the driving forces behind their involvement.
Today’s culture of very early sports specialization and college recruitment increases pressure on parents and young athletes to play year-round on multiple teams to stay on the radar of scouts and colleges. And this specialization has expanded to younger and younger ages, with 7-year-olds participating in travel leagues and national rankings of children in their sport as early as sixth grade.
“We should not be ranking kids in middle school or even in early high school,” Dr. Brenner said to wide applause. “We should allow kids to develop in a low-pressure, healthy system before we do that.”
The effects of high pressure have potentially lifelong ramifications. By the time children are 13 years old, 70% have dropped out of organized sports, Dr. Brenner said, and injuries from overuse account for more than half of all sports-related injuries in youth.
Yet the alternative – early diversification and late specialization – can really benefit kids, he said. The early specialization paradigm of playing just one sport focuses on deliberate practice and performance from the start. By contrast, early diversification with multiple sports focuses on deliberate play, during which children develop foundational athletic skills. Children who play a variety of sports are more likely to participate for more years – and it meets youth’s more realistic, long-term needs for lifelong physical activity through “fun, variety, and play,” he said.
Dr. Brenner said that just 1% of high school athletes receive any athletic scholarships, and only 3%-11% of high school athletes compete at the college level. The numbers for high school athletes that go on to play at the professional level is, of course, even smaller: 0.03% to 0.5%, depending on the sport.
And the irony is that the goal of early specialization – producing such elite level athletes – is actually better accomplished through playing multiple sports, Dr. Brenner said. Most Division 1 National Collegiate Athletic Association (NCAA) athletes and 90% of National Football League (NFL) first-round picks played multiple sports in high school. So the benefits of waiting until late adolescence to specialize are twofold: a greater likelihood of athletic success, even at elite levels, and minimizing the risks of injury.
Overuse injuries pose serious risks
More than half of sports injuries are from overuse, and a number of factors contribute to those injuries, such as muscle imbalance, playing surfaces, and training errors, Dr. Brenner said. But the biggest contributors are early specialization, playing year-round sports, and playing on multiple teams.
“This is a problem we see daily,” Dr. Brenner said. “We can see the young dancer, who’s dancing 6-7 days a week, who develops back pain and continues to dance, and develops a stress fracture in her lumbar spine known spondylosis.
“Or we see the young soccer player who plays on multiple teams and develops heel pain, who starts limping with activities of daily living, continues to play soccer despite limping, and develops calcaneal apophysitis, known as Sever’s disease. Or the young baseball pitcher, who pitches for two teams, who develops arm pain and weakness, who has a stress fracture through the proximal humeral epiphysis, known as Little League shoulder.”
Two broad pieces of guidance can help reduce the risk of injuries, particularly from overuse. First, young athletes should take off at least 1 month from a specific sport at least three times a year to give them adequate time for physical and psychological recovery. Second, ensuring young athletes take at least 1 or 2 days off of practice each week further reduces the likelihood of injury.
In addition to the physical problems these young athletes may develop, they also risk anxiety, depression, burnout, early retirement, and social isolation from peers who don’t play their sport, Dr. Brenner said. Family members also may experience greater stress, he added. And then there’s the risk of missing out on learning other sports they may excel in that offer a lifetime of enjoyment, such as tennis or swimming.
It is not clear where the threshold of involvement is for reducing overuse injury, burnout, and attrition, but Dr. Brenner provided some guidelines as a starting place. High school athletes should not train more 16 hours a week, and organized sports should not exceed free play time by a greater ratio than 2:1. Another guideline is not to exceed more hours per week in organized sports than a child’s age in years.
The primary focus of sports should be learning lifelong physical activity skills and having fun, Dr. Brenner said. Pediatricians should encourage patients to play in a wide variety of sports at least until puberty, thereby decreasing the chance of injuries, stress, and burnout, he said. That can include sports that are not necessarily an official part of school or club competition. Waiting until later to specialize may lead to a higher likelihood of athletic success.
Dr. Brenner said he had no relevant financial disclosures.
EXPERT ANALYSIS FROM AAP 2017
Make teen suicide screenings a part of everyday practice
CHICAGO – at the annual meeting of the American Academy of Pediatrics.
An estimated 2 million teenagers, aged 15-19 years, have attempted suicide within the past year, based on data from the Centers for Disease Control and Prevention. According to the CDC’s 1991-2015 High School Youth Risk Behavior Survey data, nearly a third of students (30%) have felt so sad or helpless nearly daily for at least 2 weeks that they stopped doing their normal activities, and 18% had seriously considered suicide within the past year. One in seven (15%) had made a plan for attempting suicide, 9% had attempted suicide at least once, and 3% attempted suicide that required medical treatment. About twice as many females as males had considered, planned, and/or attempted suicide.
“The offspring of suicide attempters have a sixfold higher risk of suicide than their peers whose parents have not attempted suicide,” Dr. Cody said. Other major risk factors include a history of being bullied, a history of abuse, and a history of substance abuse, particularly alcohol and opioids.
Once you identify a patient at risk for suicide, Dr. Cody advised that you should follow a suicide assessment management protocol, such as the one developed by Angela Stanley, PsyD, of the Medical College of Wisconsin and the Children’s Hospital of Wisconsin, both in Milwaukee. Doctors should identify the teen’s intensity of suicidal ideation, ask how far they are in their plans, ascertain their access to means, create a safety plan, refer the patient for mental health care, and follow up frequently.
Dr. Cody emphasized that “suicide contracts” and “safety plans” are different things. Suicide pacts are agreements not to hurt oneself, whereas safety plans include concrete, collaborative, proactive steps a person will take if experiencing suicidal thoughts.
“There is no evidence that contracts prevent suicide, but a lot of research shows that safety or crisis plans are much more effective at preventing a person from committing suicide,” Dr. Cody stated.
The first step of screening is asking a patient directly whether they have ever wished they were dead or had thoughts about killing themselves.
“Some pediatricians are afraid to ask the questions because they’re afraid they’re going to put the idea of suicide in the child’s head, but there is no evidence that screening puts kids at risk,” Dr. Cody said. The other reason you may feel uneasy asking about self-harm is not knowing what to do if a teen says that she is feeling suicidal. That’s where an assessment protocol helps.
If a patient has considered suicide more than a month prior, it shouldn’t be ignored, although the situation may require less urgency but further follow-up. For those with more recent suicidal ideation but without a plan or intent, Dr. Cody recommends following up within 2 weeks because the adolescent’s situation may change.
For those with suicidal ideation and a plan, you should ask three questions:
- What ways of killing yourself have you thought about?
- How likely is it you will follow through on your plan?
- When you think about killing yourself, what stops you?
These questions can help you determine risk acuity: The more specific, realistic, available, and lethal a plan is, the more acute the risk. You then should ask questions to try to determine how likely the teen is to follow through, such as asking about his future plans, his connectedness with others, and his religious beliefs.
Asking about a plan helps determine how much access the patient has to a lethal, realistic means. Firearms are responsible for 52% of teen suicides, followed by hanging/suffocation (25%) and poisoning (16%).
“This is why it’s a really important part of social history to screen for guns in the house,” Dr. Cody told attendees. “I know it’s been really controversial, but it’s something that’s really important, especially if you have an adolescent in the house that’s having suicidal ideation.”
Teens with suicidal ideation and a plan but no intent require a safety plan along with follow-up within 1 week. Those with a plan and intent, or those with no intent but an unwillingness agree to a safety plan, should be immediately hospitalized, Dr. Cody said.
These suicide screenings should occur at annual well-child visits, Dr. Cody said, but they also should be done at acute visits; basically, any time you see your preteen and adolescent patients. Ideally, these should take place during alone time, without any parents present.
You also should share resources with your patients, including the National Suicide Prevention Lifeline at 1-800-273-8255 and the Crisis TextLine at 741741.
Dr. Cody reported having no disclosures, and no external funding was used for the presentation.
CHICAGO – at the annual meeting of the American Academy of Pediatrics.
An estimated 2 million teenagers, aged 15-19 years, have attempted suicide within the past year, based on data from the Centers for Disease Control and Prevention. According to the CDC’s 1991-2015 High School Youth Risk Behavior Survey data, nearly a third of students (30%) have felt so sad or helpless nearly daily for at least 2 weeks that they stopped doing their normal activities, and 18% had seriously considered suicide within the past year. One in seven (15%) had made a plan for attempting suicide, 9% had attempted suicide at least once, and 3% attempted suicide that required medical treatment. About twice as many females as males had considered, planned, and/or attempted suicide.
“The offspring of suicide attempters have a sixfold higher risk of suicide than their peers whose parents have not attempted suicide,” Dr. Cody said. Other major risk factors include a history of being bullied, a history of abuse, and a history of substance abuse, particularly alcohol and opioids.
Once you identify a patient at risk for suicide, Dr. Cody advised that you should follow a suicide assessment management protocol, such as the one developed by Angela Stanley, PsyD, of the Medical College of Wisconsin and the Children’s Hospital of Wisconsin, both in Milwaukee. Doctors should identify the teen’s intensity of suicidal ideation, ask how far they are in their plans, ascertain their access to means, create a safety plan, refer the patient for mental health care, and follow up frequently.
Dr. Cody emphasized that “suicide contracts” and “safety plans” are different things. Suicide pacts are agreements not to hurt oneself, whereas safety plans include concrete, collaborative, proactive steps a person will take if experiencing suicidal thoughts.
“There is no evidence that contracts prevent suicide, but a lot of research shows that safety or crisis plans are much more effective at preventing a person from committing suicide,” Dr. Cody stated.
The first step of screening is asking a patient directly whether they have ever wished they were dead or had thoughts about killing themselves.
“Some pediatricians are afraid to ask the questions because they’re afraid they’re going to put the idea of suicide in the child’s head, but there is no evidence that screening puts kids at risk,” Dr. Cody said. The other reason you may feel uneasy asking about self-harm is not knowing what to do if a teen says that she is feeling suicidal. That’s where an assessment protocol helps.
If a patient has considered suicide more than a month prior, it shouldn’t be ignored, although the situation may require less urgency but further follow-up. For those with more recent suicidal ideation but without a plan or intent, Dr. Cody recommends following up within 2 weeks because the adolescent’s situation may change.
For those with suicidal ideation and a plan, you should ask three questions:
- What ways of killing yourself have you thought about?
- How likely is it you will follow through on your plan?
- When you think about killing yourself, what stops you?
These questions can help you determine risk acuity: The more specific, realistic, available, and lethal a plan is, the more acute the risk. You then should ask questions to try to determine how likely the teen is to follow through, such as asking about his future plans, his connectedness with others, and his religious beliefs.
Asking about a plan helps determine how much access the patient has to a lethal, realistic means. Firearms are responsible for 52% of teen suicides, followed by hanging/suffocation (25%) and poisoning (16%).
“This is why it’s a really important part of social history to screen for guns in the house,” Dr. Cody told attendees. “I know it’s been really controversial, but it’s something that’s really important, especially if you have an adolescent in the house that’s having suicidal ideation.”
Teens with suicidal ideation and a plan but no intent require a safety plan along with follow-up within 1 week. Those with a plan and intent, or those with no intent but an unwillingness agree to a safety plan, should be immediately hospitalized, Dr. Cody said.
These suicide screenings should occur at annual well-child visits, Dr. Cody said, but they also should be done at acute visits; basically, any time you see your preteen and adolescent patients. Ideally, these should take place during alone time, without any parents present.
You also should share resources with your patients, including the National Suicide Prevention Lifeline at 1-800-273-8255 and the Crisis TextLine at 741741.
Dr. Cody reported having no disclosures, and no external funding was used for the presentation.
CHICAGO – at the annual meeting of the American Academy of Pediatrics.
An estimated 2 million teenagers, aged 15-19 years, have attempted suicide within the past year, based on data from the Centers for Disease Control and Prevention. According to the CDC’s 1991-2015 High School Youth Risk Behavior Survey data, nearly a third of students (30%) have felt so sad or helpless nearly daily for at least 2 weeks that they stopped doing their normal activities, and 18% had seriously considered suicide within the past year. One in seven (15%) had made a plan for attempting suicide, 9% had attempted suicide at least once, and 3% attempted suicide that required medical treatment. About twice as many females as males had considered, planned, and/or attempted suicide.
“The offspring of suicide attempters have a sixfold higher risk of suicide than their peers whose parents have not attempted suicide,” Dr. Cody said. Other major risk factors include a history of being bullied, a history of abuse, and a history of substance abuse, particularly alcohol and opioids.
Once you identify a patient at risk for suicide, Dr. Cody advised that you should follow a suicide assessment management protocol, such as the one developed by Angela Stanley, PsyD, of the Medical College of Wisconsin and the Children’s Hospital of Wisconsin, both in Milwaukee. Doctors should identify the teen’s intensity of suicidal ideation, ask how far they are in their plans, ascertain their access to means, create a safety plan, refer the patient for mental health care, and follow up frequently.
Dr. Cody emphasized that “suicide contracts” and “safety plans” are different things. Suicide pacts are agreements not to hurt oneself, whereas safety plans include concrete, collaborative, proactive steps a person will take if experiencing suicidal thoughts.
“There is no evidence that contracts prevent suicide, but a lot of research shows that safety or crisis plans are much more effective at preventing a person from committing suicide,” Dr. Cody stated.
The first step of screening is asking a patient directly whether they have ever wished they were dead or had thoughts about killing themselves.
“Some pediatricians are afraid to ask the questions because they’re afraid they’re going to put the idea of suicide in the child’s head, but there is no evidence that screening puts kids at risk,” Dr. Cody said. The other reason you may feel uneasy asking about self-harm is not knowing what to do if a teen says that she is feeling suicidal. That’s where an assessment protocol helps.
If a patient has considered suicide more than a month prior, it shouldn’t be ignored, although the situation may require less urgency but further follow-up. For those with more recent suicidal ideation but without a plan or intent, Dr. Cody recommends following up within 2 weeks because the adolescent’s situation may change.
For those with suicidal ideation and a plan, you should ask three questions:
- What ways of killing yourself have you thought about?
- How likely is it you will follow through on your plan?
- When you think about killing yourself, what stops you?
These questions can help you determine risk acuity: The more specific, realistic, available, and lethal a plan is, the more acute the risk. You then should ask questions to try to determine how likely the teen is to follow through, such as asking about his future plans, his connectedness with others, and his religious beliefs.
Asking about a plan helps determine how much access the patient has to a lethal, realistic means. Firearms are responsible for 52% of teen suicides, followed by hanging/suffocation (25%) and poisoning (16%).
“This is why it’s a really important part of social history to screen for guns in the house,” Dr. Cody told attendees. “I know it’s been really controversial, but it’s something that’s really important, especially if you have an adolescent in the house that’s having suicidal ideation.”
Teens with suicidal ideation and a plan but no intent require a safety plan along with follow-up within 1 week. Those with a plan and intent, or those with no intent but an unwillingness agree to a safety plan, should be immediately hospitalized, Dr. Cody said.
These suicide screenings should occur at annual well-child visits, Dr. Cody said, but they also should be done at acute visits; basically, any time you see your preteen and adolescent patients. Ideally, these should take place during alone time, without any parents present.
You also should share resources with your patients, including the National Suicide Prevention Lifeline at 1-800-273-8255 and the Crisis TextLine at 741741.
Dr. Cody reported having no disclosures, and no external funding was used for the presentation.
EXPERT ANALYSIS FROM AAP 2017
Teens smoking more pot than cigarettes
CHICAGO – The challenge of addressing marijuana use by children and teens is increasing with its wider availability; 29 states have now legalized cannabis for medical use, and 8 of them plus the District of Columbia have legalized recreational marijuana use.
“Past-month marijuana use is now higher than past-month use of cigarettes” based on teens’ responses to surveys from the National Institute on Drug Abuse (NIDA), Karen M. Wilson, MD, said at the annual meeting of the American Academy of Pediatrics.
Dr. Wilson emphasized the importance of discussing drug use and attitudes about drug use with young teens, as well as educating them about risks.
Recent research suggests the brain does not fully mature until the mid-20s, and marijuana has been shown to impair working memory, cognitive flexibility, learning, attention, and verbal functions. Marijuana may alter the developing brain in ways that cannot be repaired in those who halt use at an older age, said Dr. Wilson, division chief of general pediatrics and vice-chair for clinical and translational research at the Icahn School of Medicine at Mount Sinai, New York. Marijuana use becomes an addictive behavior in 9% of users, and this addictive behavior is more likely to persist in those who begin to use marijuana at a young age.
“Whether it’s alcohol or marijuana or tobacco, even if they’re only using it on the weekends,” the behavior can progress to addictive behavior, she said. Discussions should determine how much cannabis is used, how often, and why it is used.
“Kids may be self-medicating if they have depression, anxiety, or chronic pain,” Dr. Wilson said. “That could be something you could provide a more appropriate pharmacological intervention for.”
Motivational interviewing – a collaborative, person-centered form of guiding to elicit and strengthen motivation for change – can be the impetus for discussion about whether young patients can try quitting for a short time to show they can do it.
One challenge of discouraging and reducing teens’ marijuana use is the increasing diversity of products and consumption methods. From candy and baked goods to electronic “vaping” products and dissolvable strips similar to breath mints, it’s difficult to keep up. Dr. Wilson showed an image of a new product that looks exactly like a medical inhaler.
Couse of marijuana with tobacco also presents challenges since researchers have little data on how dual use may affect the ability to quit using either drug. “Joints,” rolled in paper, contain only marijuana, but a “blunt” is marijuana rolled in a tobacco leaf, and “spliffs” contain both marijuana and tobacco. Both blunts and spliffs, therefore, include nicotine which is addictive.
Other inhaled substances that can potentially damage the lungs include “lung juice,” a herbal product marketed to “clean out” the lungs. “We should encourage teens to get clean lungs by not inhaling things that aren’t good for you.”
Dr. Wilson reported having no disclosures, and no external funding was used for the presentation.
CHICAGO – The challenge of addressing marijuana use by children and teens is increasing with its wider availability; 29 states have now legalized cannabis for medical use, and 8 of them plus the District of Columbia have legalized recreational marijuana use.
“Past-month marijuana use is now higher than past-month use of cigarettes” based on teens’ responses to surveys from the National Institute on Drug Abuse (NIDA), Karen M. Wilson, MD, said at the annual meeting of the American Academy of Pediatrics.
Dr. Wilson emphasized the importance of discussing drug use and attitudes about drug use with young teens, as well as educating them about risks.
Recent research suggests the brain does not fully mature until the mid-20s, and marijuana has been shown to impair working memory, cognitive flexibility, learning, attention, and verbal functions. Marijuana may alter the developing brain in ways that cannot be repaired in those who halt use at an older age, said Dr. Wilson, division chief of general pediatrics and vice-chair for clinical and translational research at the Icahn School of Medicine at Mount Sinai, New York. Marijuana use becomes an addictive behavior in 9% of users, and this addictive behavior is more likely to persist in those who begin to use marijuana at a young age.
“Whether it’s alcohol or marijuana or tobacco, even if they’re only using it on the weekends,” the behavior can progress to addictive behavior, she said. Discussions should determine how much cannabis is used, how often, and why it is used.
“Kids may be self-medicating if they have depression, anxiety, or chronic pain,” Dr. Wilson said. “That could be something you could provide a more appropriate pharmacological intervention for.”
Motivational interviewing – a collaborative, person-centered form of guiding to elicit and strengthen motivation for change – can be the impetus for discussion about whether young patients can try quitting for a short time to show they can do it.
One challenge of discouraging and reducing teens’ marijuana use is the increasing diversity of products and consumption methods. From candy and baked goods to electronic “vaping” products and dissolvable strips similar to breath mints, it’s difficult to keep up. Dr. Wilson showed an image of a new product that looks exactly like a medical inhaler.
Couse of marijuana with tobacco also presents challenges since researchers have little data on how dual use may affect the ability to quit using either drug. “Joints,” rolled in paper, contain only marijuana, but a “blunt” is marijuana rolled in a tobacco leaf, and “spliffs” contain both marijuana and tobacco. Both blunts and spliffs, therefore, include nicotine which is addictive.
Other inhaled substances that can potentially damage the lungs include “lung juice,” a herbal product marketed to “clean out” the lungs. “We should encourage teens to get clean lungs by not inhaling things that aren’t good for you.”
Dr. Wilson reported having no disclosures, and no external funding was used for the presentation.
CHICAGO – The challenge of addressing marijuana use by children and teens is increasing with its wider availability; 29 states have now legalized cannabis for medical use, and 8 of them plus the District of Columbia have legalized recreational marijuana use.
“Past-month marijuana use is now higher than past-month use of cigarettes” based on teens’ responses to surveys from the National Institute on Drug Abuse (NIDA), Karen M. Wilson, MD, said at the annual meeting of the American Academy of Pediatrics.
Dr. Wilson emphasized the importance of discussing drug use and attitudes about drug use with young teens, as well as educating them about risks.
Recent research suggests the brain does not fully mature until the mid-20s, and marijuana has been shown to impair working memory, cognitive flexibility, learning, attention, and verbal functions. Marijuana may alter the developing brain in ways that cannot be repaired in those who halt use at an older age, said Dr. Wilson, division chief of general pediatrics and vice-chair for clinical and translational research at the Icahn School of Medicine at Mount Sinai, New York. Marijuana use becomes an addictive behavior in 9% of users, and this addictive behavior is more likely to persist in those who begin to use marijuana at a young age.
“Whether it’s alcohol or marijuana or tobacco, even if they’re only using it on the weekends,” the behavior can progress to addictive behavior, she said. Discussions should determine how much cannabis is used, how often, and why it is used.
“Kids may be self-medicating if they have depression, anxiety, or chronic pain,” Dr. Wilson said. “That could be something you could provide a more appropriate pharmacological intervention for.”
Motivational interviewing – a collaborative, person-centered form of guiding to elicit and strengthen motivation for change – can be the impetus for discussion about whether young patients can try quitting for a short time to show they can do it.
One challenge of discouraging and reducing teens’ marijuana use is the increasing diversity of products and consumption methods. From candy and baked goods to electronic “vaping” products and dissolvable strips similar to breath mints, it’s difficult to keep up. Dr. Wilson showed an image of a new product that looks exactly like a medical inhaler.
Couse of marijuana with tobacco also presents challenges since researchers have little data on how dual use may affect the ability to quit using either drug. “Joints,” rolled in paper, contain only marijuana, but a “blunt” is marijuana rolled in a tobacco leaf, and “spliffs” contain both marijuana and tobacco. Both blunts and spliffs, therefore, include nicotine which is addictive.
Other inhaled substances that can potentially damage the lungs include “lung juice,” a herbal product marketed to “clean out” the lungs. “We should encourage teens to get clean lungs by not inhaling things that aren’t good for you.”
Dr. Wilson reported having no disclosures, and no external funding was used for the presentation.
EXPERT ANALYSIS FROM AAP 2017
AAP recommends hepatitis B vaccine within 24 hours of birth for all infants
All newborns with a birth weight of at least 2,000 grams (4.4 pounds) should receive the hepatitis B vaccine within 24 hours of birth, according to a new policy statement by the American Academy of Pediatrics that brings its recommendations in line with those of the Advisory Committee on Immunization Practices at the Centers for Disease Control and Prevention.
“The birth dose can prevent infection of infants born to infected mothers in situations in which the mother’s results are never obtained, are misinterpreted, are falsely negative, are transcribed or reported to the infant care team inaccurately, or simply not communicated to the nursery,” announced the new statement from the AAP Committee on Infectious Diseases and the Committee on Fetus and Newborn (Pediatrics. 2017 Aug 28. doi: 10.1542/peds.2017-1870).
A dose of the hepatitis B vaccine within 24 hours of birth is 75%-95% effective at preventing perinatal hepatitis B transmission. “When postexposure prophylaxis with both hepatitis B vaccine and hepatitis B immune globulin (HBIG) is given, is timed appropriately, and is followed by completion of the infant hepatitis B immunization series, perinatal infection rates range from 0.7% to 1.1%,” according to the statement.
Approximately 1,000 newborns still contract perinatal hepatitis B infections every year. Of these, 90% will develop chronic hepatitis B infections, and a quarter of those who don’t receive treatment will die from liver cirrhosis or cancer. There has been an increase in the incidence of new hepatitis B infections in some states because of opioid epidemic in the United States, according to MMWR reports.
The cost effectiveness of preventing hepatitis B with the vaccine and, when necessary, HBIG, is estimated at $2,600 per quality-adjusted year of life. The most common side effects reported after hepatitis B administration are pain (3%-29%), erythema (3%), swelling (3%), fever (1%-6%) and headache (3%).
There has been extensive analysis of the safety of hepatitis B vaccines, the policy statement indicated. Analysis of Vaccine Safety Datalink data has found no causal link between administration of the hepatitis B vaccine and the following: neonatal sepsis or death, rheumatoid arthritis, Bell’s palsy, autoimmune thyroid disease, hemolytic anemia in children, anaphylaxis, optic neuritis, Guillain-Barré syndrome, sudden-onset sensorineural hearing loss, or other chronic illnesses.
Specific recommendations
• Infants born to mothers who test positive for hepatitis B surface antigen (HBsAg): Administer the hepatitis B vaccine and HBIG within 12 hours of birth.
• Infants weighing at least 2,000 g and born to mothers who are HBsAg negative: Administer the hepatitis B vaccine within 24 hours of birth.
• Infants weighing less than 2,000 g and born to mothers who are HBsAg negative: Administer the hepatitis B vaccine at hospital discharge or at age 1 month (whichever is first).
• Infants weighing at least 2,000 g and born to mothers with an unknown HBsAg status: Administer the hepatitis B vaccine within 12 hours of birth and HBIG by hospital discharge or age 7 days (whichever is first) if HBsAg status remains unknown or is confirmed positive.
• Infants weighing less than 2,000 g and born to mothers with an unknown HBsAg status: Administer the hepatitis B vaccine within 12 hours of birth and then HBIG within 12 hours unless the mother tests negative for HBsAg by then.
All newborns with a birth weight of at least 2,000 grams (4.4 pounds) should receive the hepatitis B vaccine within 24 hours of birth, according to a new policy statement by the American Academy of Pediatrics that brings its recommendations in line with those of the Advisory Committee on Immunization Practices at the Centers for Disease Control and Prevention.
“The birth dose can prevent infection of infants born to infected mothers in situations in which the mother’s results are never obtained, are misinterpreted, are falsely negative, are transcribed or reported to the infant care team inaccurately, or simply not communicated to the nursery,” announced the new statement from the AAP Committee on Infectious Diseases and the Committee on Fetus and Newborn (Pediatrics. 2017 Aug 28. doi: 10.1542/peds.2017-1870).
A dose of the hepatitis B vaccine within 24 hours of birth is 75%-95% effective at preventing perinatal hepatitis B transmission. “When postexposure prophylaxis with both hepatitis B vaccine and hepatitis B immune globulin (HBIG) is given, is timed appropriately, and is followed by completion of the infant hepatitis B immunization series, perinatal infection rates range from 0.7% to 1.1%,” according to the statement.
Approximately 1,000 newborns still contract perinatal hepatitis B infections every year. Of these, 90% will develop chronic hepatitis B infections, and a quarter of those who don’t receive treatment will die from liver cirrhosis or cancer. There has been an increase in the incidence of new hepatitis B infections in some states because of opioid epidemic in the United States, according to MMWR reports.
The cost effectiveness of preventing hepatitis B with the vaccine and, when necessary, HBIG, is estimated at $2,600 per quality-adjusted year of life. The most common side effects reported after hepatitis B administration are pain (3%-29%), erythema (3%), swelling (3%), fever (1%-6%) and headache (3%).
There has been extensive analysis of the safety of hepatitis B vaccines, the policy statement indicated. Analysis of Vaccine Safety Datalink data has found no causal link between administration of the hepatitis B vaccine and the following: neonatal sepsis or death, rheumatoid arthritis, Bell’s palsy, autoimmune thyroid disease, hemolytic anemia in children, anaphylaxis, optic neuritis, Guillain-Barré syndrome, sudden-onset sensorineural hearing loss, or other chronic illnesses.
Specific recommendations
• Infants born to mothers who test positive for hepatitis B surface antigen (HBsAg): Administer the hepatitis B vaccine and HBIG within 12 hours of birth.
• Infants weighing at least 2,000 g and born to mothers who are HBsAg negative: Administer the hepatitis B vaccine within 24 hours of birth.
• Infants weighing less than 2,000 g and born to mothers who are HBsAg negative: Administer the hepatitis B vaccine at hospital discharge or at age 1 month (whichever is first).
• Infants weighing at least 2,000 g and born to mothers with an unknown HBsAg status: Administer the hepatitis B vaccine within 12 hours of birth and HBIG by hospital discharge or age 7 days (whichever is first) if HBsAg status remains unknown or is confirmed positive.
• Infants weighing less than 2,000 g and born to mothers with an unknown HBsAg status: Administer the hepatitis B vaccine within 12 hours of birth and then HBIG within 12 hours unless the mother tests negative for HBsAg by then.
All newborns with a birth weight of at least 2,000 grams (4.4 pounds) should receive the hepatitis B vaccine within 24 hours of birth, according to a new policy statement by the American Academy of Pediatrics that brings its recommendations in line with those of the Advisory Committee on Immunization Practices at the Centers for Disease Control and Prevention.
“The birth dose can prevent infection of infants born to infected mothers in situations in which the mother’s results are never obtained, are misinterpreted, are falsely negative, are transcribed or reported to the infant care team inaccurately, or simply not communicated to the nursery,” announced the new statement from the AAP Committee on Infectious Diseases and the Committee on Fetus and Newborn (Pediatrics. 2017 Aug 28. doi: 10.1542/peds.2017-1870).
A dose of the hepatitis B vaccine within 24 hours of birth is 75%-95% effective at preventing perinatal hepatitis B transmission. “When postexposure prophylaxis with both hepatitis B vaccine and hepatitis B immune globulin (HBIG) is given, is timed appropriately, and is followed by completion of the infant hepatitis B immunization series, perinatal infection rates range from 0.7% to 1.1%,” according to the statement.
Approximately 1,000 newborns still contract perinatal hepatitis B infections every year. Of these, 90% will develop chronic hepatitis B infections, and a quarter of those who don’t receive treatment will die from liver cirrhosis or cancer. There has been an increase in the incidence of new hepatitis B infections in some states because of opioid epidemic in the United States, according to MMWR reports.
The cost effectiveness of preventing hepatitis B with the vaccine and, when necessary, HBIG, is estimated at $2,600 per quality-adjusted year of life. The most common side effects reported after hepatitis B administration are pain (3%-29%), erythema (3%), swelling (3%), fever (1%-6%) and headache (3%).
There has been extensive analysis of the safety of hepatitis B vaccines, the policy statement indicated. Analysis of Vaccine Safety Datalink data has found no causal link between administration of the hepatitis B vaccine and the following: neonatal sepsis or death, rheumatoid arthritis, Bell’s palsy, autoimmune thyroid disease, hemolytic anemia in children, anaphylaxis, optic neuritis, Guillain-Barré syndrome, sudden-onset sensorineural hearing loss, or other chronic illnesses.
Specific recommendations
• Infants born to mothers who test positive for hepatitis B surface antigen (HBsAg): Administer the hepatitis B vaccine and HBIG within 12 hours of birth.
• Infants weighing at least 2,000 g and born to mothers who are HBsAg negative: Administer the hepatitis B vaccine within 24 hours of birth.
• Infants weighing less than 2,000 g and born to mothers who are HBsAg negative: Administer the hepatitis B vaccine at hospital discharge or at age 1 month (whichever is first).
• Infants weighing at least 2,000 g and born to mothers with an unknown HBsAg status: Administer the hepatitis B vaccine within 12 hours of birth and HBIG by hospital discharge or age 7 days (whichever is first) if HBsAg status remains unknown or is confirmed positive.
• Infants weighing less than 2,000 g and born to mothers with an unknown HBsAg status: Administer the hepatitis B vaccine within 12 hours of birth and then HBIG within 12 hours unless the mother tests negative for HBsAg by then.
FROM PEDIATRICS
Key clinical point: All infants should receive hepatitis B vaccine within 24 hours of birth.
Major finding: Hepatitis B vaccine prevents 75%-95% of perinatal hepatitis B infections.
Data source: A literature review of data on hepatitis B epidemiology in the United States.
Disclosures: The statement did not receive external funding, and the authors stated that they have no conflicts of interest.
Latest U.S. alcohol use data critiqued
The findings of a recent study in JAMA Psychiatry suggest dramatic increases – approaching 50% – in the prevalence of alcohol use disorders in the United States. But the study’s methodology has come under scrutiny: The data sets that the researchers used might be too different for reliable comparison.
The JAMA Psychiatry research, led by Bridget F. Grant, PhD, of the National Institute on Alcohol Abuse and Alcoholism, analyzed data from two waves of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a cross-sectional, federal survey administered during 2001-2002, known as Wave 1, and during 2012-2013, known as Wave 3 (JAMA Psychiatry. 2017 Aug 9. doi: 10.1001/jamapsychiatry.2017.2161). The findings were stark: In addition to a sharp increase in the rate of 12-month alcohol use and high-risk drinking, Dr. Grant and her associates found that the rate of DSM-IV alcohol use disorder climbed from 8.5% of the population during the first wave to 12.7% of the population during the third.
“I would urge caution in drawing conclusions based on only two time points,” Dr. Grucza said. Comparing those two waves of data is inherently problematic, he explained.
“The NESARC made important changes between 2001-2002 and 2012-2013 – and several of these changes could be expected to lead to higher rates of disclosure,” said Dr. Grucza, a professor of psychiatry at Washington University in St. Louis. “This would lead to apparent increases in a variety of things – for example, they saw a 100% increase in prevalence of marijuana use among adults. So, the problem isn’t with the 2012-2013 NESARC, per se, but in the comparison between the 2012-2013 NESARC and the 2001-2002 NESARC.”
The changes include differences in the way each wave of the data was collected. The 2001-2002 survey was conducted using U.S. Census Bureau employees and didn’t offer participants incentives for survey completion. The 2012-2013 NESARC, however, was conducted through a private contractor; in addition, participants provided biological samples and received modest cash incentives for completing the survey.
“We can only speculate, but [the collection of DNA through samples of saliva] might make the participants think that their drug use would be known – and that they might therefore disclose it, anyway,” Dr. Grucza said. “I would guess that they would have been assured that this wasn’t the case during the informed consent process, but that process tends to be long, and people don’t pay attention to the whole informed consent document.”
The NESARC findings differed substantially from those found by the National Survey on Drug Use and Health (NSDUH), a federal survey of people aged 12 or older released annually by the Substance Abuse and Mental Health Services Administration. The NSDUH gathers data first in a screening phase and then in an interview phase; data are gathered in the interview phase through computer-assisted, self-administered interviews. Dr. Grucza said countless studies “suggest people respond more faithfully when disclosing to a computer as opposed to a live interviewer.”
According to the NSDUH, the rate of past-month use of alcohol fell slightly in 2015 from the previous year’s rate and was comparable to the estimates in 2005-2013.
However, Dr. Grant pointed out that substantial changes made to the questions on the 2015 NSDUH also make comparisons to previous years problematic. As a result, she said, the “NSDUH is not able to estimate the trends during the time period analyzed in the NESARC,” Dr. Grant said. “We stand by the reliability and validity of our survey data.”
For his part, Robert L. DuPont, MD, said it’s important to look at the data broadly. “The bigger picture is that alcohol is the most commonly used addictive substance by Americans, and there is evidence of increased problems resulting from drinking. For example, alcohol liver disease and cirrhosis of the liver are rising in adults and have been described as one of a group of ‘diseases of despair,’ along with suicide and drug overdose deaths,” said Dr. DuPont, the first director of the National Institute on Drug Abuse and the president of the Institute for Behavior and Health in Rockville, Md. “The fundamental message is that alcohol (and drug use) patterns show complexity that has significant public health importance. Alcohol use and related problems are more complex than a bumper sticker stating that they are either ‘up’ or ‘down.’ ”
Dr. Grucza, Dr. Grant, and Dr. DuPont had no conflicts to disclose.
The findings of a recent study in JAMA Psychiatry suggest dramatic increases – approaching 50% – in the prevalence of alcohol use disorders in the United States. But the study’s methodology has come under scrutiny: The data sets that the researchers used might be too different for reliable comparison.
The JAMA Psychiatry research, led by Bridget F. Grant, PhD, of the National Institute on Alcohol Abuse and Alcoholism, analyzed data from two waves of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a cross-sectional, federal survey administered during 2001-2002, known as Wave 1, and during 2012-2013, known as Wave 3 (JAMA Psychiatry. 2017 Aug 9. doi: 10.1001/jamapsychiatry.2017.2161). The findings were stark: In addition to a sharp increase in the rate of 12-month alcohol use and high-risk drinking, Dr. Grant and her associates found that the rate of DSM-IV alcohol use disorder climbed from 8.5% of the population during the first wave to 12.7% of the population during the third.
“I would urge caution in drawing conclusions based on only two time points,” Dr. Grucza said. Comparing those two waves of data is inherently problematic, he explained.
“The NESARC made important changes between 2001-2002 and 2012-2013 – and several of these changes could be expected to lead to higher rates of disclosure,” said Dr. Grucza, a professor of psychiatry at Washington University in St. Louis. “This would lead to apparent increases in a variety of things – for example, they saw a 100% increase in prevalence of marijuana use among adults. So, the problem isn’t with the 2012-2013 NESARC, per se, but in the comparison between the 2012-2013 NESARC and the 2001-2002 NESARC.”
The changes include differences in the way each wave of the data was collected. The 2001-2002 survey was conducted using U.S. Census Bureau employees and didn’t offer participants incentives for survey completion. The 2012-2013 NESARC, however, was conducted through a private contractor; in addition, participants provided biological samples and received modest cash incentives for completing the survey.
“We can only speculate, but [the collection of DNA through samples of saliva] might make the participants think that their drug use would be known – and that they might therefore disclose it, anyway,” Dr. Grucza said. “I would guess that they would have been assured that this wasn’t the case during the informed consent process, but that process tends to be long, and people don’t pay attention to the whole informed consent document.”
The NESARC findings differed substantially from those found by the National Survey on Drug Use and Health (NSDUH), a federal survey of people aged 12 or older released annually by the Substance Abuse and Mental Health Services Administration. The NSDUH gathers data first in a screening phase and then in an interview phase; data are gathered in the interview phase through computer-assisted, self-administered interviews. Dr. Grucza said countless studies “suggest people respond more faithfully when disclosing to a computer as opposed to a live interviewer.”
According to the NSDUH, the rate of past-month use of alcohol fell slightly in 2015 from the previous year’s rate and was comparable to the estimates in 2005-2013.
However, Dr. Grant pointed out that substantial changes made to the questions on the 2015 NSDUH also make comparisons to previous years problematic. As a result, she said, the “NSDUH is not able to estimate the trends during the time period analyzed in the NESARC,” Dr. Grant said. “We stand by the reliability and validity of our survey data.”
For his part, Robert L. DuPont, MD, said it’s important to look at the data broadly. “The bigger picture is that alcohol is the most commonly used addictive substance by Americans, and there is evidence of increased problems resulting from drinking. For example, alcohol liver disease and cirrhosis of the liver are rising in adults and have been described as one of a group of ‘diseases of despair,’ along with suicide and drug overdose deaths,” said Dr. DuPont, the first director of the National Institute on Drug Abuse and the president of the Institute for Behavior and Health in Rockville, Md. “The fundamental message is that alcohol (and drug use) patterns show complexity that has significant public health importance. Alcohol use and related problems are more complex than a bumper sticker stating that they are either ‘up’ or ‘down.’ ”
Dr. Grucza, Dr. Grant, and Dr. DuPont had no conflicts to disclose.
The findings of a recent study in JAMA Psychiatry suggest dramatic increases – approaching 50% – in the prevalence of alcohol use disorders in the United States. But the study’s methodology has come under scrutiny: The data sets that the researchers used might be too different for reliable comparison.
The JAMA Psychiatry research, led by Bridget F. Grant, PhD, of the National Institute on Alcohol Abuse and Alcoholism, analyzed data from two waves of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a cross-sectional, federal survey administered during 2001-2002, known as Wave 1, and during 2012-2013, known as Wave 3 (JAMA Psychiatry. 2017 Aug 9. doi: 10.1001/jamapsychiatry.2017.2161). The findings were stark: In addition to a sharp increase in the rate of 12-month alcohol use and high-risk drinking, Dr. Grant and her associates found that the rate of DSM-IV alcohol use disorder climbed from 8.5% of the population during the first wave to 12.7% of the population during the third.
“I would urge caution in drawing conclusions based on only two time points,” Dr. Grucza said. Comparing those two waves of data is inherently problematic, he explained.
“The NESARC made important changes between 2001-2002 and 2012-2013 – and several of these changes could be expected to lead to higher rates of disclosure,” said Dr. Grucza, a professor of psychiatry at Washington University in St. Louis. “This would lead to apparent increases in a variety of things – for example, they saw a 100% increase in prevalence of marijuana use among adults. So, the problem isn’t with the 2012-2013 NESARC, per se, but in the comparison between the 2012-2013 NESARC and the 2001-2002 NESARC.”
The changes include differences in the way each wave of the data was collected. The 2001-2002 survey was conducted using U.S. Census Bureau employees and didn’t offer participants incentives for survey completion. The 2012-2013 NESARC, however, was conducted through a private contractor; in addition, participants provided biological samples and received modest cash incentives for completing the survey.
“We can only speculate, but [the collection of DNA through samples of saliva] might make the participants think that their drug use would be known – and that they might therefore disclose it, anyway,” Dr. Grucza said. “I would guess that they would have been assured that this wasn’t the case during the informed consent process, but that process tends to be long, and people don’t pay attention to the whole informed consent document.”
The NESARC findings differed substantially from those found by the National Survey on Drug Use and Health (NSDUH), a federal survey of people aged 12 or older released annually by the Substance Abuse and Mental Health Services Administration. The NSDUH gathers data first in a screening phase and then in an interview phase; data are gathered in the interview phase through computer-assisted, self-administered interviews. Dr. Grucza said countless studies “suggest people respond more faithfully when disclosing to a computer as opposed to a live interviewer.”
According to the NSDUH, the rate of past-month use of alcohol fell slightly in 2015 from the previous year’s rate and was comparable to the estimates in 2005-2013.
However, Dr. Grant pointed out that substantial changes made to the questions on the 2015 NSDUH also make comparisons to previous years problematic. As a result, she said, the “NSDUH is not able to estimate the trends during the time period analyzed in the NESARC,” Dr. Grant said. “We stand by the reliability and validity of our survey data.”
For his part, Robert L. DuPont, MD, said it’s important to look at the data broadly. “The bigger picture is that alcohol is the most commonly used addictive substance by Americans, and there is evidence of increased problems resulting from drinking. For example, alcohol liver disease and cirrhosis of the liver are rising in adults and have been described as one of a group of ‘diseases of despair,’ along with suicide and drug overdose deaths,” said Dr. DuPont, the first director of the National Institute on Drug Abuse and the president of the Institute for Behavior and Health in Rockville, Md. “The fundamental message is that alcohol (and drug use) patterns show complexity that has significant public health importance. Alcohol use and related problems are more complex than a bumper sticker stating that they are either ‘up’ or ‘down.’ ”
Dr. Grucza, Dr. Grant, and Dr. DuPont had no conflicts to disclose.
Prenatal ART regimen with lowest risk is TDF-FTC-EFV
The antiretroviral therapy (ART) regimen associated with the least risk of adverse birth outcomes among pregnant women with HIV, relative to other regimens, is tenofovir disoproxil fumarate (TDF), emtricitabine (FTC), and efavirenz (EFV), according to a new study.
“Our results provide reassurance for the more than 90% of HIV-infected women who live in countries that follow WHO recommendations to use TDF-FTC-EFV,” wrote Rebecca Zash, MD, of Beth Israel Deaconess Medical Center in Boston and her associates in JAMA Pediatrics.
Using data collected from August 2014 through August 2016, the researchers compared outcomes among 47,027 births by women from Botswana, average age 26 years, who reached at least 24 weeks’ gestation. The study’s data came from eight government hospitals throughout Botswana, where approximately 45% of births had occurred nationwide.
The 11,932 infants exposed to HIV, representing about a quarter of all infants in the study, had a higher risk of adverse birth outcomes: 39.6% of HIV-exposed infants had adverse outcomes, compared with 28.9% of unexposed infants.
Nearly half (48.4%) of the HIV-exposed infants had also been exposed to ART from conception. Among these 5,780 infants, those exposed to the ART regimen comprising tenofovir disoproxil fumarate (TDF), emtricitabine (FTC), and efavirenz (EFV) had the lowest rate of adverse birth outcomes. The following percentages of infants exposed to different ART regimens had adverse outcomes:
- 36.4% of infants exposed to TDF-FTC-EFV.
- 41.7% of infants exposed to TDF-FTC and nevirapine (NVP).
- 44.9% of infants exposed to zidovudine (ZDV), lamivudine (3TC), and lopinavir-ritonavir (LPV-R).
- 47.4% of infants exposed to ZDV-3TC-NVP.
- 48.5% of infants exposed to TDF-FTC-LPV-R.
The risk of adverse birth outcomes, compared with exposure to TDF-FTC-EFV, was 15% higher for TDF-FTC-NVP, 21% higher for ZDV-3TC-LPV-R, 30% higher for ZDV-3TC-NVP, and 31% higher for TDF-FTC-LPV-R after researchers adjusted for age and potential sociodemographic confounders.
The risk of severe adverse outcomes for ART exposure from conception was as follows:
- 12.3% for exposure to TDF-FTC-EFV.
- 17.9% for exposure to TDF-FTC-NVP.
- 19.5% for TDF-FTC–LPV-R.
- 20.7% for ZDV-3TC-NVP.
- 23.4% for ZDV-3TC–LPV-R.
The risk for giving birth to an infant small for gestational age was lowest for TDF-FTC-EFV, compared with the other regimens.
“Differences between TDF-FTC-EFV and other ART regimens were greater for small for gestational age than for preterm birth,” suggesting a “drug-specific mechanism at the placental level because the health of the placenta is directly related to fetal growth,” the researchers wrote. “An ART effect at the level of the placenta may also explain why women receiving ART before conception have more adverse outcomes than [do] those who start ART after conception because endothelial dysfunction during placentation would be expected to have a more detrimental effect on the pregnancy,” they added.
The ZDV-3TC-NVP regimen was linked to greater risk for stillbirth, very preterm birth, and neonatal death; the ZDV-3TC-LPV-R regimen was linked to a greater risk of preterm and very preterm birth, as well as neonatal death.
“Our study findings may be difficult to integrate into settings with ART regimen choices beyond those available in Botswana,” the authors wrote. “Whether the magnitude of the differences we found in Botswana will be similar in higher-resource settings is unclear.”
The research was funded by the National Institutes of Health. The authors reported no conflicts of interest.
The antiretroviral therapy (ART) regimen associated with the least risk of adverse birth outcomes among pregnant women with HIV, relative to other regimens, is tenofovir disoproxil fumarate (TDF), emtricitabine (FTC), and efavirenz (EFV), according to a new study.
“Our results provide reassurance for the more than 90% of HIV-infected women who live in countries that follow WHO recommendations to use TDF-FTC-EFV,” wrote Rebecca Zash, MD, of Beth Israel Deaconess Medical Center in Boston and her associates in JAMA Pediatrics.
Using data collected from August 2014 through August 2016, the researchers compared outcomes among 47,027 births by women from Botswana, average age 26 years, who reached at least 24 weeks’ gestation. The study’s data came from eight government hospitals throughout Botswana, where approximately 45% of births had occurred nationwide.
The 11,932 infants exposed to HIV, representing about a quarter of all infants in the study, had a higher risk of adverse birth outcomes: 39.6% of HIV-exposed infants had adverse outcomes, compared with 28.9% of unexposed infants.
Nearly half (48.4%) of the HIV-exposed infants had also been exposed to ART from conception. Among these 5,780 infants, those exposed to the ART regimen comprising tenofovir disoproxil fumarate (TDF), emtricitabine (FTC), and efavirenz (EFV) had the lowest rate of adverse birth outcomes. The following percentages of infants exposed to different ART regimens had adverse outcomes:
- 36.4% of infants exposed to TDF-FTC-EFV.
- 41.7% of infants exposed to TDF-FTC and nevirapine (NVP).
- 44.9% of infants exposed to zidovudine (ZDV), lamivudine (3TC), and lopinavir-ritonavir (LPV-R).
- 47.4% of infants exposed to ZDV-3TC-NVP.
- 48.5% of infants exposed to TDF-FTC-LPV-R.
The risk of adverse birth outcomes, compared with exposure to TDF-FTC-EFV, was 15% higher for TDF-FTC-NVP, 21% higher for ZDV-3TC-LPV-R, 30% higher for ZDV-3TC-NVP, and 31% higher for TDF-FTC-LPV-R after researchers adjusted for age and potential sociodemographic confounders.
The risk of severe adverse outcomes for ART exposure from conception was as follows:
- 12.3% for exposure to TDF-FTC-EFV.
- 17.9% for exposure to TDF-FTC-NVP.
- 19.5% for TDF-FTC–LPV-R.
- 20.7% for ZDV-3TC-NVP.
- 23.4% for ZDV-3TC–LPV-R.
The risk for giving birth to an infant small for gestational age was lowest for TDF-FTC-EFV, compared with the other regimens.
“Differences between TDF-FTC-EFV and other ART regimens were greater for small for gestational age than for preterm birth,” suggesting a “drug-specific mechanism at the placental level because the health of the placenta is directly related to fetal growth,” the researchers wrote. “An ART effect at the level of the placenta may also explain why women receiving ART before conception have more adverse outcomes than [do] those who start ART after conception because endothelial dysfunction during placentation would be expected to have a more detrimental effect on the pregnancy,” they added.
The ZDV-3TC-NVP regimen was linked to greater risk for stillbirth, very preterm birth, and neonatal death; the ZDV-3TC-LPV-R regimen was linked to a greater risk of preterm and very preterm birth, as well as neonatal death.
“Our study findings may be difficult to integrate into settings with ART regimen choices beyond those available in Botswana,” the authors wrote. “Whether the magnitude of the differences we found in Botswana will be similar in higher-resource settings is unclear.”
The research was funded by the National Institutes of Health. The authors reported no conflicts of interest.
The antiretroviral therapy (ART) regimen associated with the least risk of adverse birth outcomes among pregnant women with HIV, relative to other regimens, is tenofovir disoproxil fumarate (TDF), emtricitabine (FTC), and efavirenz (EFV), according to a new study.
“Our results provide reassurance for the more than 90% of HIV-infected women who live in countries that follow WHO recommendations to use TDF-FTC-EFV,” wrote Rebecca Zash, MD, of Beth Israel Deaconess Medical Center in Boston and her associates in JAMA Pediatrics.
Using data collected from August 2014 through August 2016, the researchers compared outcomes among 47,027 births by women from Botswana, average age 26 years, who reached at least 24 weeks’ gestation. The study’s data came from eight government hospitals throughout Botswana, where approximately 45% of births had occurred nationwide.
The 11,932 infants exposed to HIV, representing about a quarter of all infants in the study, had a higher risk of adverse birth outcomes: 39.6% of HIV-exposed infants had adverse outcomes, compared with 28.9% of unexposed infants.
Nearly half (48.4%) of the HIV-exposed infants had also been exposed to ART from conception. Among these 5,780 infants, those exposed to the ART regimen comprising tenofovir disoproxil fumarate (TDF), emtricitabine (FTC), and efavirenz (EFV) had the lowest rate of adverse birth outcomes. The following percentages of infants exposed to different ART regimens had adverse outcomes:
- 36.4% of infants exposed to TDF-FTC-EFV.
- 41.7% of infants exposed to TDF-FTC and nevirapine (NVP).
- 44.9% of infants exposed to zidovudine (ZDV), lamivudine (3TC), and lopinavir-ritonavir (LPV-R).
- 47.4% of infants exposed to ZDV-3TC-NVP.
- 48.5% of infants exposed to TDF-FTC-LPV-R.
The risk of adverse birth outcomes, compared with exposure to TDF-FTC-EFV, was 15% higher for TDF-FTC-NVP, 21% higher for ZDV-3TC-LPV-R, 30% higher for ZDV-3TC-NVP, and 31% higher for TDF-FTC-LPV-R after researchers adjusted for age and potential sociodemographic confounders.
The risk of severe adverse outcomes for ART exposure from conception was as follows:
- 12.3% for exposure to TDF-FTC-EFV.
- 17.9% for exposure to TDF-FTC-NVP.
- 19.5% for TDF-FTC–LPV-R.
- 20.7% for ZDV-3TC-NVP.
- 23.4% for ZDV-3TC–LPV-R.
The risk for giving birth to an infant small for gestational age was lowest for TDF-FTC-EFV, compared with the other regimens.
“Differences between TDF-FTC-EFV and other ART regimens were greater for small for gestational age than for preterm birth,” suggesting a “drug-specific mechanism at the placental level because the health of the placenta is directly related to fetal growth,” the researchers wrote. “An ART effect at the level of the placenta may also explain why women receiving ART before conception have more adverse outcomes than [do] those who start ART after conception because endothelial dysfunction during placentation would be expected to have a more detrimental effect on the pregnancy,” they added.
The ZDV-3TC-NVP regimen was linked to greater risk for stillbirth, very preterm birth, and neonatal death; the ZDV-3TC-LPV-R regimen was linked to a greater risk of preterm and very preterm birth, as well as neonatal death.
“Our study findings may be difficult to integrate into settings with ART regimen choices beyond those available in Botswana,” the authors wrote. “Whether the magnitude of the differences we found in Botswana will be similar in higher-resource settings is unclear.”
The research was funded by the National Institutes of Health. The authors reported no conflicts of interest.
FROM JAMA PEDIATRICS
Key clinical point: Different antiretroviral regimens pose different adverse birth outcome risks for pregnant women with HIV.
Major finding: The ART regimen with the lowest level of risk was tenofovir, emtricitabine, and efavirenz, with a 36.5% risk for adverse outcomes and 12.3% risk for serious adverse outcomes.
Data source: The findings are based on an observational study of 47,027 births to women at eight government hospitals in Botswana from 2014 to 2016.
Disclosures: The research was funded by the National Institutes of Health. The authors reported no conflicts of interest.
Improving children’s sleep may reduce internalizing problems long term
SAN FRANCISCO – , new research showed.
“Interventions addressing externalizing difficulties may lead to improvements in sleep, but addressing internalizing difficulties are unlikely to lead to benefits for children’s sleep,” concluded Jon Quach, PhD, of the University of Melbourne and Murdoch Children’s Research Institute, Victoria, Australia, and his colleagues.
Although they also conclude that “addressing sleep problems at earlier time points may reduce both internalizing and externalizing difficulties,” the researchers said the data are inconsistent, only weakly suggesting that sleep influences later externalizing problems at only two different age points, Dr. Quach said when presenting the findings at the Pediatric Academic Societies meeting.
Data collection every 2 years included parent-reported sleep problems and child behavior. Behavior assessment came from the parent-reported Strengths and Difficulties Questionnaire for externalizing and internalizing difficulties. Parents reported severity of sleep difficulties and presence of specific problems at least 4 nights a week: difficulty falling asleep, night waking, sleep restlessness, and not wanting to sleep alone.
The researchers investigated the direction of influence – potential but unproven causation – between sleep problems and internalizing and externalizing problems. The analysis also assessed the extent of the associations. The first pair of analyses examined the relationship between sleeping and either externalizing or internalizing problems, independently assessed.
The findings revealed that sleeping problems were primarily associated with later internalizing difficulties, strongly suggesting that sleeping issues may cause or contribute to internalizing issues 2 years later.
With externalizing problems, however, the effect of poor sleep was inconsistent: Only at one point did it appear that sleeping difficulties contributed to externalizing difficulties. Instead, externalizing problems appeared to contribute to sleeping difficulties at three out of four time points. (The exception was that externalizing problems at ages 8-9 years did not appear to affect sleep at ages 10-11 years.) Though inconsistent, the results suggest that externalizing problems likely affect difficulty sleeping much more so than the other way around.
Then the researchers assessed the interacting associations between all three factors together. At all ages, poor sleep appeared to lead to internalizing difficulties 2 years later. Only once – at ages 6-7 years – did internalizing problems appear to influence sleep 2 years later.
The relationship between sleeping problems and externalizing problems was more complex and less consistent. Externalizing problems often, but not always, were positively associated with sleeping problems 2 years later. And only at ages 4-5 years did difficulty sleeping appear to lead to externalizing problems at ages 6-7 years.
In addition, independent of any interaction with sleeping problems, externalizing difficulties appeared to lead to internalizing problems at all time points.
Although this type of analysis can strongly suggest a direction of causality, Dr. Quach noted, the associations remain subject to the limitations of any observational data, where clearly determining causation or its direction is not possible.
The Australian Research Council and the National Health Medical Research Council in Australia funded the research. The authors did not report any conflicts of interest.
SAN FRANCISCO – , new research showed.
“Interventions addressing externalizing difficulties may lead to improvements in sleep, but addressing internalizing difficulties are unlikely to lead to benefits for children’s sleep,” concluded Jon Quach, PhD, of the University of Melbourne and Murdoch Children’s Research Institute, Victoria, Australia, and his colleagues.
Although they also conclude that “addressing sleep problems at earlier time points may reduce both internalizing and externalizing difficulties,” the researchers said the data are inconsistent, only weakly suggesting that sleep influences later externalizing problems at only two different age points, Dr. Quach said when presenting the findings at the Pediatric Academic Societies meeting.
Data collection every 2 years included parent-reported sleep problems and child behavior. Behavior assessment came from the parent-reported Strengths and Difficulties Questionnaire for externalizing and internalizing difficulties. Parents reported severity of sleep difficulties and presence of specific problems at least 4 nights a week: difficulty falling asleep, night waking, sleep restlessness, and not wanting to sleep alone.
The researchers investigated the direction of influence – potential but unproven causation – between sleep problems and internalizing and externalizing problems. The analysis also assessed the extent of the associations. The first pair of analyses examined the relationship between sleeping and either externalizing or internalizing problems, independently assessed.
The findings revealed that sleeping problems were primarily associated with later internalizing difficulties, strongly suggesting that sleeping issues may cause or contribute to internalizing issues 2 years later.
With externalizing problems, however, the effect of poor sleep was inconsistent: Only at one point did it appear that sleeping difficulties contributed to externalizing difficulties. Instead, externalizing problems appeared to contribute to sleeping difficulties at three out of four time points. (The exception was that externalizing problems at ages 8-9 years did not appear to affect sleep at ages 10-11 years.) Though inconsistent, the results suggest that externalizing problems likely affect difficulty sleeping much more so than the other way around.
Then the researchers assessed the interacting associations between all three factors together. At all ages, poor sleep appeared to lead to internalizing difficulties 2 years later. Only once – at ages 6-7 years – did internalizing problems appear to influence sleep 2 years later.
The relationship between sleeping problems and externalizing problems was more complex and less consistent. Externalizing problems often, but not always, were positively associated with sleeping problems 2 years later. And only at ages 4-5 years did difficulty sleeping appear to lead to externalizing problems at ages 6-7 years.
In addition, independent of any interaction with sleeping problems, externalizing difficulties appeared to lead to internalizing problems at all time points.
Although this type of analysis can strongly suggest a direction of causality, Dr. Quach noted, the associations remain subject to the limitations of any observational data, where clearly determining causation or its direction is not possible.
The Australian Research Council and the National Health Medical Research Council in Australia funded the research. The authors did not report any conflicts of interest.
SAN FRANCISCO – , new research showed.
“Interventions addressing externalizing difficulties may lead to improvements in sleep, but addressing internalizing difficulties are unlikely to lead to benefits for children’s sleep,” concluded Jon Quach, PhD, of the University of Melbourne and Murdoch Children’s Research Institute, Victoria, Australia, and his colleagues.
Although they also conclude that “addressing sleep problems at earlier time points may reduce both internalizing and externalizing difficulties,” the researchers said the data are inconsistent, only weakly suggesting that sleep influences later externalizing problems at only two different age points, Dr. Quach said when presenting the findings at the Pediatric Academic Societies meeting.
Data collection every 2 years included parent-reported sleep problems and child behavior. Behavior assessment came from the parent-reported Strengths and Difficulties Questionnaire for externalizing and internalizing difficulties. Parents reported severity of sleep difficulties and presence of specific problems at least 4 nights a week: difficulty falling asleep, night waking, sleep restlessness, and not wanting to sleep alone.
The researchers investigated the direction of influence – potential but unproven causation – between sleep problems and internalizing and externalizing problems. The analysis also assessed the extent of the associations. The first pair of analyses examined the relationship between sleeping and either externalizing or internalizing problems, independently assessed.
The findings revealed that sleeping problems were primarily associated with later internalizing difficulties, strongly suggesting that sleeping issues may cause or contribute to internalizing issues 2 years later.
With externalizing problems, however, the effect of poor sleep was inconsistent: Only at one point did it appear that sleeping difficulties contributed to externalizing difficulties. Instead, externalizing problems appeared to contribute to sleeping difficulties at three out of four time points. (The exception was that externalizing problems at ages 8-9 years did not appear to affect sleep at ages 10-11 years.) Though inconsistent, the results suggest that externalizing problems likely affect difficulty sleeping much more so than the other way around.
Then the researchers assessed the interacting associations between all three factors together. At all ages, poor sleep appeared to lead to internalizing difficulties 2 years later. Only once – at ages 6-7 years – did internalizing problems appear to influence sleep 2 years later.
The relationship between sleeping problems and externalizing problems was more complex and less consistent. Externalizing problems often, but not always, were positively associated with sleeping problems 2 years later. And only at ages 4-5 years did difficulty sleeping appear to lead to externalizing problems at ages 6-7 years.
In addition, independent of any interaction with sleeping problems, externalizing difficulties appeared to lead to internalizing problems at all time points.
Although this type of analysis can strongly suggest a direction of causality, Dr. Quach noted, the associations remain subject to the limitations of any observational data, where clearly determining causation or its direction is not possible.
The Australian Research Council and the National Health Medical Research Council in Australia funded the research. The authors did not report any conflicts of interest.
AT PAS 17
Key clinical point: Improving children’s sleep may reduce internalizing problems 2 years later.
Major finding: Externalizing problems were associated with sleep problems later on, and sleeping difficulties were linked to later internalizing problems.
Data source: The findings are based on analysis of four longitudinal, biennial questionnaires from parents of 4,983 Australian children aged 4-5 years, starting in 2004.
Disclosures: The Australian Research Council and the National Health Medical Research Council in Australia funded the research. The authors did not report any conflicts of interest.
Alcohol use, high-risk drinking increases in U.S. to ‘crisis’ levels
Nearly one in eight adults in the United States had been diagnosed with alcohol use disorder in 2012-2013, a nearly 50% increase from a decade earlier, according to a study published Aug. 9. Other substantial increases occurring across virtually all demographic groups included overall 12-month alcohol consumption and high-risk drinking, particularly among adults aged 65 and older, racial/ethnic minorities, women, and those with lower education and incomes.
“The marked increases in high-risk drinking and DSM-IV [alcohol use disorder] between 2001-2002 and 2012-2013 also mirror recent sharp increases in morbidity and mortality from diseases and injuries in which alcohol use has a substantial role or deceleration of previously seen declines,” wrote Bridget F. Grant, PhD, of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) in Rockville, Md., and her associates. High-risk drinking was defined as five drinks (14 g of ethanol each) per occasion for men and four drinks per occasion for women at least weekly.
“Mortality among alcohol-affected drivers who were simultaneously distracted also increased between 2005 and 2009 by 63%,” they wrote (JAMA Psychiatry. 2017 Aug 9. doi: 10.1001/jamapsychiatry.2017.2161).
The researchers analyzed data from 43,093 respondents to the National Epidemiologic Survey on Alcohol and Related Conditions (April 2001-June 2002) and from 36,309 respondents to the National Epidemiologic Survey on Alcohol and Related Conditions III (April 2012-June 2013). Both surveys involved face-to-face interviews with a nationally representative sample of U.S. adults.
The findings showed that 12-month alcohol use had increased 11.2% between 2001-2002 and 2012-2013, from 65.4% to 72.7%. A substantial increase also occurred in high-risk drinking and alcohol use disorder as defined in the DSM-IV. High-risk drinking increased 29.9% during that time, from 9.7% to 12.6%, representing an increase of approximately 9.4 million Americans engaging in high-risk drinking.
Alcohol use disorder (AUD) increased 49.4%, from 8.5% to 12.7% – a percentage that accounts for an additional 12.3 million Americans with the diagnosis. That increase dwarfs the 14.8% increase in alcohol use disorder that was seen between 1991-1992 and 2001-2002, the authors pointed out. The prevalence of 12-month AUD rose significantly among adults aged 65 and older (106.7%), African American individuals (92.8%), and women (83.7%). Interestingly, all subgroups reported significant increases in AUD except for Native Americans and people living in rural areas. By comparison, the 12-month prevalence of AUD among men increased by a third (34.7%), and their high-risk drinking increased 15.5%.
“Drinking norms and values have become more permissive among women, along with increases in educational and occupational opportunities and rising numbers of women in the workforce, all of which may have contributed to increased high-risk drinking and AUD in women during the past decade,” the authors wrote. “Stress associated with pursuing a career and raising a family may lead to increases in high-risk drinking and AUD among women.”
These increases indicate potential future increases among women in alcohol-related conditions, such as breast cancer and liver cirrhosis. Increases may also occur in fetal alcohol spectrum disorder and exposure to violence, the authors wrote.
The increases in alcohol use, high-risk drinking, and AUD found among minorities may be related to increased stress and demoralization as wealth inequality widened between minorities and whites in the wake of the 2008 recession. Other inequalities, such as income and educational disparities, unemployment, residential segregation, discrimination, and less health care access may also play a role in those increases, the authors wrote.
One limitation of the study is that certain populations were not surveyed, such as homeless individuals and people who are incarcerated. This means that the prevalence of alcohol use, high-risk drinking, and AUD could be underestimated, Dr. Grant and her colleagues said. However, they said, the large sample sizes of the surveys might balance out that limitation and others.
Nevertheless, the increases found in alcohol use, high-risk drinking, and AUD “constitute a public health crisis that may be overshadowed by increases in much less prevalent substance use (marijuana, opiates, and heroin) during the same period,” Dr. Grant and her colleagues wrote. “The findings herein highlight the urgency of educating the public, policymakers, and health care professionals about high-risk drinking and AUD.” In addition, they called for broader effors to address the “individual, biological, environmental, and societal factors” influencing high-risk drinking and AUD.
The research was sponsored by the NIAAA, and funded by the National Institutes of Health. The authors reported having no disclosures.
“This timely article by Grant et al. ... makes a compelling case that the United States is facing a crisis with alcohol use, one that is currently costly and about to get worse,” Marc A. Schuckit, MD, wrote in an accompanying editorial (JAMA Psychiatry. 2017 Aug 9. doi: 10.1001/jamapsychiatry.2017.1981). However, he said, several studies show that lowering the risk for future alcohol-related problems in 18 year olds is possible.
He said his group delivered an intervention to 500 college freshmen using Internet-based videos aimed at helping them “recognize their vulnerability toward heavy drinking.” Six and 12 months after watching four 50-minute videos, the effects on how much the students drank remained significant, he wrote. In addition, other studies have identified programs that help lower drinking during pregnancy. “These are only a few examples of ongoing hopeful developments,” Dr. Schuckit wrote.
The number in the study that is especially concerning for him, Dr. Schuckit said, is the 106% increase in AUDs among older individuals because of the many preexisting medical disorders “that can be exacerbated by heavier drinking. These drinkers are also likely to be taking multiple medications that can interact adversely with alcohol, with resulting significant and costly health consequences,” according to Dr. Schuckit.
“There is also some disturbing news,” he wrote. “The proposed cuts to the National Institutes of Health budget being considered in Washington in 2017 are potentially disastrous for future efforts to decrease alcohol problems and are likely to result in higher costs for us all. Efforts to identify risk factors for substance-related problems and to test prevention approaches take time and money and are less likely to be funded in the current financial atmosphere. … If we ignore these problems, they will come back to us at much higher costs through emergency department visits, impaired children … and higher costs for jails and prisons that are the last resort for help for many.”
Dr. Schuckit is affiliated with the department of psychiatry at the University of California, San Diego. He reported having no disclosures.
“This timely article by Grant et al. ... makes a compelling case that the United States is facing a crisis with alcohol use, one that is currently costly and about to get worse,” Marc A. Schuckit, MD, wrote in an accompanying editorial (JAMA Psychiatry. 2017 Aug 9. doi: 10.1001/jamapsychiatry.2017.1981). However, he said, several studies show that lowering the risk for future alcohol-related problems in 18 year olds is possible.
He said his group delivered an intervention to 500 college freshmen using Internet-based videos aimed at helping them “recognize their vulnerability toward heavy drinking.” Six and 12 months after watching four 50-minute videos, the effects on how much the students drank remained significant, he wrote. In addition, other studies have identified programs that help lower drinking during pregnancy. “These are only a few examples of ongoing hopeful developments,” Dr. Schuckit wrote.
The number in the study that is especially concerning for him, Dr. Schuckit said, is the 106% increase in AUDs among older individuals because of the many preexisting medical disorders “that can be exacerbated by heavier drinking. These drinkers are also likely to be taking multiple medications that can interact adversely with alcohol, with resulting significant and costly health consequences,” according to Dr. Schuckit.
“There is also some disturbing news,” he wrote. “The proposed cuts to the National Institutes of Health budget being considered in Washington in 2017 are potentially disastrous for future efforts to decrease alcohol problems and are likely to result in higher costs for us all. Efforts to identify risk factors for substance-related problems and to test prevention approaches take time and money and are less likely to be funded in the current financial atmosphere. … If we ignore these problems, they will come back to us at much higher costs through emergency department visits, impaired children … and higher costs for jails and prisons that are the last resort for help for many.”
Dr. Schuckit is affiliated with the department of psychiatry at the University of California, San Diego. He reported having no disclosures.
“This timely article by Grant et al. ... makes a compelling case that the United States is facing a crisis with alcohol use, one that is currently costly and about to get worse,” Marc A. Schuckit, MD, wrote in an accompanying editorial (JAMA Psychiatry. 2017 Aug 9. doi: 10.1001/jamapsychiatry.2017.1981). However, he said, several studies show that lowering the risk for future alcohol-related problems in 18 year olds is possible.
He said his group delivered an intervention to 500 college freshmen using Internet-based videos aimed at helping them “recognize their vulnerability toward heavy drinking.” Six and 12 months after watching four 50-minute videos, the effects on how much the students drank remained significant, he wrote. In addition, other studies have identified programs that help lower drinking during pregnancy. “These are only a few examples of ongoing hopeful developments,” Dr. Schuckit wrote.
The number in the study that is especially concerning for him, Dr. Schuckit said, is the 106% increase in AUDs among older individuals because of the many preexisting medical disorders “that can be exacerbated by heavier drinking. These drinkers are also likely to be taking multiple medications that can interact adversely with alcohol, with resulting significant and costly health consequences,” according to Dr. Schuckit.
“There is also some disturbing news,” he wrote. “The proposed cuts to the National Institutes of Health budget being considered in Washington in 2017 are potentially disastrous for future efforts to decrease alcohol problems and are likely to result in higher costs for us all. Efforts to identify risk factors for substance-related problems and to test prevention approaches take time and money and are less likely to be funded in the current financial atmosphere. … If we ignore these problems, they will come back to us at much higher costs through emergency department visits, impaired children … and higher costs for jails and prisons that are the last resort for help for many.”
Dr. Schuckit is affiliated with the department of psychiatry at the University of California, San Diego. He reported having no disclosures.
Nearly one in eight adults in the United States had been diagnosed with alcohol use disorder in 2012-2013, a nearly 50% increase from a decade earlier, according to a study published Aug. 9. Other substantial increases occurring across virtually all demographic groups included overall 12-month alcohol consumption and high-risk drinking, particularly among adults aged 65 and older, racial/ethnic minorities, women, and those with lower education and incomes.
“The marked increases in high-risk drinking and DSM-IV [alcohol use disorder] between 2001-2002 and 2012-2013 also mirror recent sharp increases in morbidity and mortality from diseases and injuries in which alcohol use has a substantial role or deceleration of previously seen declines,” wrote Bridget F. Grant, PhD, of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) in Rockville, Md., and her associates. High-risk drinking was defined as five drinks (14 g of ethanol each) per occasion for men and four drinks per occasion for women at least weekly.
“Mortality among alcohol-affected drivers who were simultaneously distracted also increased between 2005 and 2009 by 63%,” they wrote (JAMA Psychiatry. 2017 Aug 9. doi: 10.1001/jamapsychiatry.2017.2161).
The researchers analyzed data from 43,093 respondents to the National Epidemiologic Survey on Alcohol and Related Conditions (April 2001-June 2002) and from 36,309 respondents to the National Epidemiologic Survey on Alcohol and Related Conditions III (April 2012-June 2013). Both surveys involved face-to-face interviews with a nationally representative sample of U.S. adults.
The findings showed that 12-month alcohol use had increased 11.2% between 2001-2002 and 2012-2013, from 65.4% to 72.7%. A substantial increase also occurred in high-risk drinking and alcohol use disorder as defined in the DSM-IV. High-risk drinking increased 29.9% during that time, from 9.7% to 12.6%, representing an increase of approximately 9.4 million Americans engaging in high-risk drinking.
Alcohol use disorder (AUD) increased 49.4%, from 8.5% to 12.7% – a percentage that accounts for an additional 12.3 million Americans with the diagnosis. That increase dwarfs the 14.8% increase in alcohol use disorder that was seen between 1991-1992 and 2001-2002, the authors pointed out. The prevalence of 12-month AUD rose significantly among adults aged 65 and older (106.7%), African American individuals (92.8%), and women (83.7%). Interestingly, all subgroups reported significant increases in AUD except for Native Americans and people living in rural areas. By comparison, the 12-month prevalence of AUD among men increased by a third (34.7%), and their high-risk drinking increased 15.5%.
“Drinking norms and values have become more permissive among women, along with increases in educational and occupational opportunities and rising numbers of women in the workforce, all of which may have contributed to increased high-risk drinking and AUD in women during the past decade,” the authors wrote. “Stress associated with pursuing a career and raising a family may lead to increases in high-risk drinking and AUD among women.”
These increases indicate potential future increases among women in alcohol-related conditions, such as breast cancer and liver cirrhosis. Increases may also occur in fetal alcohol spectrum disorder and exposure to violence, the authors wrote.
The increases in alcohol use, high-risk drinking, and AUD found among minorities may be related to increased stress and demoralization as wealth inequality widened between minorities and whites in the wake of the 2008 recession. Other inequalities, such as income and educational disparities, unemployment, residential segregation, discrimination, and less health care access may also play a role in those increases, the authors wrote.
One limitation of the study is that certain populations were not surveyed, such as homeless individuals and people who are incarcerated. This means that the prevalence of alcohol use, high-risk drinking, and AUD could be underestimated, Dr. Grant and her colleagues said. However, they said, the large sample sizes of the surveys might balance out that limitation and others.
Nevertheless, the increases found in alcohol use, high-risk drinking, and AUD “constitute a public health crisis that may be overshadowed by increases in much less prevalent substance use (marijuana, opiates, and heroin) during the same period,” Dr. Grant and her colleagues wrote. “The findings herein highlight the urgency of educating the public, policymakers, and health care professionals about high-risk drinking and AUD.” In addition, they called for broader effors to address the “individual, biological, environmental, and societal factors” influencing high-risk drinking and AUD.
The research was sponsored by the NIAAA, and funded by the National Institutes of Health. The authors reported having no disclosures.
Nearly one in eight adults in the United States had been diagnosed with alcohol use disorder in 2012-2013, a nearly 50% increase from a decade earlier, according to a study published Aug. 9. Other substantial increases occurring across virtually all demographic groups included overall 12-month alcohol consumption and high-risk drinking, particularly among adults aged 65 and older, racial/ethnic minorities, women, and those with lower education and incomes.
“The marked increases in high-risk drinking and DSM-IV [alcohol use disorder] between 2001-2002 and 2012-2013 also mirror recent sharp increases in morbidity and mortality from diseases and injuries in which alcohol use has a substantial role or deceleration of previously seen declines,” wrote Bridget F. Grant, PhD, of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) in Rockville, Md., and her associates. High-risk drinking was defined as five drinks (14 g of ethanol each) per occasion for men and four drinks per occasion for women at least weekly.
“Mortality among alcohol-affected drivers who were simultaneously distracted also increased between 2005 and 2009 by 63%,” they wrote (JAMA Psychiatry. 2017 Aug 9. doi: 10.1001/jamapsychiatry.2017.2161).
The researchers analyzed data from 43,093 respondents to the National Epidemiologic Survey on Alcohol and Related Conditions (April 2001-June 2002) and from 36,309 respondents to the National Epidemiologic Survey on Alcohol and Related Conditions III (April 2012-June 2013). Both surveys involved face-to-face interviews with a nationally representative sample of U.S. adults.
The findings showed that 12-month alcohol use had increased 11.2% between 2001-2002 and 2012-2013, from 65.4% to 72.7%. A substantial increase also occurred in high-risk drinking and alcohol use disorder as defined in the DSM-IV. High-risk drinking increased 29.9% during that time, from 9.7% to 12.6%, representing an increase of approximately 9.4 million Americans engaging in high-risk drinking.
Alcohol use disorder (AUD) increased 49.4%, from 8.5% to 12.7% – a percentage that accounts for an additional 12.3 million Americans with the diagnosis. That increase dwarfs the 14.8% increase in alcohol use disorder that was seen between 1991-1992 and 2001-2002, the authors pointed out. The prevalence of 12-month AUD rose significantly among adults aged 65 and older (106.7%), African American individuals (92.8%), and women (83.7%). Interestingly, all subgroups reported significant increases in AUD except for Native Americans and people living in rural areas. By comparison, the 12-month prevalence of AUD among men increased by a third (34.7%), and their high-risk drinking increased 15.5%.
“Drinking norms and values have become more permissive among women, along with increases in educational and occupational opportunities and rising numbers of women in the workforce, all of which may have contributed to increased high-risk drinking and AUD in women during the past decade,” the authors wrote. “Stress associated with pursuing a career and raising a family may lead to increases in high-risk drinking and AUD among women.”
These increases indicate potential future increases among women in alcohol-related conditions, such as breast cancer and liver cirrhosis. Increases may also occur in fetal alcohol spectrum disorder and exposure to violence, the authors wrote.
The increases in alcohol use, high-risk drinking, and AUD found among minorities may be related to increased stress and demoralization as wealth inequality widened between minorities and whites in the wake of the 2008 recession. Other inequalities, such as income and educational disparities, unemployment, residential segregation, discrimination, and less health care access may also play a role in those increases, the authors wrote.
One limitation of the study is that certain populations were not surveyed, such as homeless individuals and people who are incarcerated. This means that the prevalence of alcohol use, high-risk drinking, and AUD could be underestimated, Dr. Grant and her colleagues said. However, they said, the large sample sizes of the surveys might balance out that limitation and others.
Nevertheless, the increases found in alcohol use, high-risk drinking, and AUD “constitute a public health crisis that may be overshadowed by increases in much less prevalent substance use (marijuana, opiates, and heroin) during the same period,” Dr. Grant and her colleagues wrote. “The findings herein highlight the urgency of educating the public, policymakers, and health care professionals about high-risk drinking and AUD.” In addition, they called for broader effors to address the “individual, biological, environmental, and societal factors” influencing high-risk drinking and AUD.
The research was sponsored by the NIAAA, and funded by the National Institutes of Health. The authors reported having no disclosures.
FROM JAMA PSYCHIATRY
Key clinical point: Drinking and alcohol use disorder have substantially increased across virtually all demographic groups, particularly racial/ethnic minorities, adults aged 65 and older, and women.
Major finding: High-risk drinking increased 9.7%, and alcohol use disorder increased 49.4% among U.S. adults between 2001-2002 and 2012-2013.
Data source: The findings are based on data from 43,093 U.S. adults in 2001-2002 and 36,309 U.S. adults in 2012-2013.
Disclosures: The research was sponsored by the National Institute on Alcohol Abuse and Alcoholism, and funded by the National Institutes of Health. The authors reported having no disclosures.
Online intervention aims to prevent teen depression
AT PAS 17
SAN FRANCISCO – One in eight teenagers experienced at least one major depressive episode in 2015, according to the National Institute for Mental Health. Yet the recent uptick in teen suicide rates suggests that U.S. mental health care services are not meeting their needs.
A team at the University of Illinois in Chicago, led by Benjamin Van Voorhees, MD, MPH, hopes so, and they have spent the past several years developing and testing such a program with a National Institute of Mental Health (NIMH) grant.
“Adolescents are in a really plastic moment in their psychobehavioral repertoire and brain development as they program themselves to adapt to adult life,” Dr. Van Voorhees said in an interview. “Right now we have nothing to offer those individuals other than an occasional referral to an overtaxed mental health system. The only rational strategy is a mass dissemination model, which is going to have to be technology.”
The CATCH-IT program is aimed at teens showing early signs of depression or predepressive symptoms as determined through screening during well checks or other visits for acute or chronic concerns. The study uses multiple screening tools in selecting participants, but Dr. Van Voorhees estimates that screening in practice would require about 1-2 minutes of a medical assistant’s or nurse’s time, followed by 1-2 minutes of the practitioner’s time for positive screens – “and one in five of those screens is going to be positive,” he said.
“The thing we want to convey to primary care practitioners is that these individuals are coming through your office every day, we’re doing nothing for them, and in some ways we are ignoring their enormous future potential adverse trajectory toward mental disorders,” he said.
The program includes 14 modules drawing on cognitive behavioral therapy, behavioral activation, interpersonal psychotherapy, and community resiliency. Six archetypal teens – such as teen living with a single mom or one whose parents are divorcing – are featured in each of the modules to demonstrate six ways of applying the strategies taught in that module. The archetypal teens are around 14-15 years old, but the program is aimed at teens aged 13-18 years, with a reading level at about grade 6, Dr. Van Voorhees said.
Two and a half years after those teens used the CATCH-IT intervention, they showed “a sustained reduction in automatic negative thoughts and educational impairment,” but no difference in their perceptions of support from family or friends. The lack of a control group in that pilot limits what conclusions can be drawn about the program’s effectiveness, but the researchers did learn that motivational interviewing led to greater engagement with the program, compared with teens who received a brief recommendation of it.
Therefore, in the subsequent – and still ongoing – study, physicians used motivational interviewing when offering teens the opportunity to join the program. That study does include a control group, in which participants are assigned a generic health education program online instead of CATCH-IT, and the randomized participants have been stratified by site, gender, and depression risk level.
The researchers first assessed the baseline characteristics of the population, recruited from 38 clinics in two cities. The study enrolled 369 teens aged 13-18 years – 248 in Chicago and 121 in Boston. All were identified as high risk for depression based on elevated scores on the Center for Epidemiological Studies Depression (CES-D) scale or the Kiddie Schedule for Affective Disorders Scale (K-SADS). Two thirds (68%) of participants are female, and most (63%) are in high school. About a third (34%) are in middle school. The racial/ethnic breakdown of the sample is 21% Hispanic, 26% black, 43% white, 4% Asian, 6% multiracial, and 1% other (which adds up to 101% due to rounding). More than half of the participants’ mothers (60%) and fathers (53%) were college graduates.
The teens completed the CES-D, the Screen for Child Related Anxiety Disorders (SCARED), the Beck Hopelessness Scale (BHS), the CRAFFT screening for adolescent substance misuse and the Disruptive Behaviors Disorder Scale (DBD-A). A parent of each teen also filled out the CES-D and DBD-A.
The baseline results did not suggest any concerns about substance use, hopelessness, or disruptive behaviors such as ADHD or conduct disorder. But the average scores on the CES-D and SCARED sat just at the threshold for a potential depressive or anxiety disorders. A CES-D score of at least 16 suggests a possible depressive disorder, and a SCARED score of at least 25 suggests a possible anxiety disorder. The mean scores on the teens’ CES-D were 17.7 in the Chicago cohort, 15.4 in the Boston cohort and 16.9 for the whole group. Similarly, the SCARED mean scores were 26.3 in the Chicago cohort, 23.5 in the Boston cohort and 25.3 overall.
Scores from K-SADS showed subthreshold levels of depressed mood in 36% of teens in both cities, and a nearly identical subthreshold level of irritability. Subthreshold anhedonia was identified in 20% of the overall population. One percent of the overall population had current suicidal ideation.
The next steps are to analyze outcomes among the participants, as the team is doing currently. They have just passed the 1-year anniversary of the trial and are analyzing the data they collected over the past year. The study will run an additional year for longer-term data collection.
One of the abstracts presented at PAS explored the economic implications of incorporating CATCH-IT in primary care.
“The cost for implementation is where the challenge is,” Dr. Van Voorhees said. “Screening takes time, and calling people takes time.” But when spread across a practice’s overall clientele in a year, the costs drop considerably, he said, and savings from effective identification and depression prevention may outweigh costs. The researchers have not yet conducted a cost-effectiveness study because they still are analyzing data on outcomes.
But Dr. Van Voorhees is optimistic about the possibilities of the program.
“What this entire model is about is, how do we understand what’s going on in the environment of the primary care clinic to find these people, identify them, and motivate them, and how can we give them something relevant enough to actually complete,” Dr. Van Voorhees said in the interview. “Then, let’s actually see if it changes their behavioral trajectory.”
The National Institute of Mental Health funded the research. Dr. Van Voorhees has consulted for Prevail Health Solutions, Mevident, Social Kinetics, and Hong Kong University on development of Internet-based interventions.
AT PAS 17
SAN FRANCISCO – One in eight teenagers experienced at least one major depressive episode in 2015, according to the National Institute for Mental Health. Yet the recent uptick in teen suicide rates suggests that U.S. mental health care services are not meeting their needs.
A team at the University of Illinois in Chicago, led by Benjamin Van Voorhees, MD, MPH, hopes so, and they have spent the past several years developing and testing such a program with a National Institute of Mental Health (NIMH) grant.
“Adolescents are in a really plastic moment in their psychobehavioral repertoire and brain development as they program themselves to adapt to adult life,” Dr. Van Voorhees said in an interview. “Right now we have nothing to offer those individuals other than an occasional referral to an overtaxed mental health system. The only rational strategy is a mass dissemination model, which is going to have to be technology.”
The CATCH-IT program is aimed at teens showing early signs of depression or predepressive symptoms as determined through screening during well checks or other visits for acute or chronic concerns. The study uses multiple screening tools in selecting participants, but Dr. Van Voorhees estimates that screening in practice would require about 1-2 minutes of a medical assistant’s or nurse’s time, followed by 1-2 minutes of the practitioner’s time for positive screens – “and one in five of those screens is going to be positive,” he said.
“The thing we want to convey to primary care practitioners is that these individuals are coming through your office every day, we’re doing nothing for them, and in some ways we are ignoring their enormous future potential adverse trajectory toward mental disorders,” he said.
The program includes 14 modules drawing on cognitive behavioral therapy, behavioral activation, interpersonal psychotherapy, and community resiliency. Six archetypal teens – such as teen living with a single mom or one whose parents are divorcing – are featured in each of the modules to demonstrate six ways of applying the strategies taught in that module. The archetypal teens are around 14-15 years old, but the program is aimed at teens aged 13-18 years, with a reading level at about grade 6, Dr. Van Voorhees said.
Two and a half years after those teens used the CATCH-IT intervention, they showed “a sustained reduction in automatic negative thoughts and educational impairment,” but no difference in their perceptions of support from family or friends. The lack of a control group in that pilot limits what conclusions can be drawn about the program’s effectiveness, but the researchers did learn that motivational interviewing led to greater engagement with the program, compared with teens who received a brief recommendation of it.
Therefore, in the subsequent – and still ongoing – study, physicians used motivational interviewing when offering teens the opportunity to join the program. That study does include a control group, in which participants are assigned a generic health education program online instead of CATCH-IT, and the randomized participants have been stratified by site, gender, and depression risk level.
The researchers first assessed the baseline characteristics of the population, recruited from 38 clinics in two cities. The study enrolled 369 teens aged 13-18 years – 248 in Chicago and 121 in Boston. All were identified as high risk for depression based on elevated scores on the Center for Epidemiological Studies Depression (CES-D) scale or the Kiddie Schedule for Affective Disorders Scale (K-SADS). Two thirds (68%) of participants are female, and most (63%) are in high school. About a third (34%) are in middle school. The racial/ethnic breakdown of the sample is 21% Hispanic, 26% black, 43% white, 4% Asian, 6% multiracial, and 1% other (which adds up to 101% due to rounding). More than half of the participants’ mothers (60%) and fathers (53%) were college graduates.
The teens completed the CES-D, the Screen for Child Related Anxiety Disorders (SCARED), the Beck Hopelessness Scale (BHS), the CRAFFT screening for adolescent substance misuse and the Disruptive Behaviors Disorder Scale (DBD-A). A parent of each teen also filled out the CES-D and DBD-A.
The baseline results did not suggest any concerns about substance use, hopelessness, or disruptive behaviors such as ADHD or conduct disorder. But the average scores on the CES-D and SCARED sat just at the threshold for a potential depressive or anxiety disorders. A CES-D score of at least 16 suggests a possible depressive disorder, and a SCARED score of at least 25 suggests a possible anxiety disorder. The mean scores on the teens’ CES-D were 17.7 in the Chicago cohort, 15.4 in the Boston cohort and 16.9 for the whole group. Similarly, the SCARED mean scores were 26.3 in the Chicago cohort, 23.5 in the Boston cohort and 25.3 overall.
Scores from K-SADS showed subthreshold levels of depressed mood in 36% of teens in both cities, and a nearly identical subthreshold level of irritability. Subthreshold anhedonia was identified in 20% of the overall population. One percent of the overall population had current suicidal ideation.
The next steps are to analyze outcomes among the participants, as the team is doing currently. They have just passed the 1-year anniversary of the trial and are analyzing the data they collected over the past year. The study will run an additional year for longer-term data collection.
One of the abstracts presented at PAS explored the economic implications of incorporating CATCH-IT in primary care.
“The cost for implementation is where the challenge is,” Dr. Van Voorhees said. “Screening takes time, and calling people takes time.” But when spread across a practice’s overall clientele in a year, the costs drop considerably, he said, and savings from effective identification and depression prevention may outweigh costs. The researchers have not yet conducted a cost-effectiveness study because they still are analyzing data on outcomes.
But Dr. Van Voorhees is optimistic about the possibilities of the program.
“What this entire model is about is, how do we understand what’s going on in the environment of the primary care clinic to find these people, identify them, and motivate them, and how can we give them something relevant enough to actually complete,” Dr. Van Voorhees said in the interview. “Then, let’s actually see if it changes their behavioral trajectory.”
The National Institute of Mental Health funded the research. Dr. Van Voorhees has consulted for Prevail Health Solutions, Mevident, Social Kinetics, and Hong Kong University on development of Internet-based interventions.
AT PAS 17
SAN FRANCISCO – One in eight teenagers experienced at least one major depressive episode in 2015, according to the National Institute for Mental Health. Yet the recent uptick in teen suicide rates suggests that U.S. mental health care services are not meeting their needs.
A team at the University of Illinois in Chicago, led by Benjamin Van Voorhees, MD, MPH, hopes so, and they have spent the past several years developing and testing such a program with a National Institute of Mental Health (NIMH) grant.
“Adolescents are in a really plastic moment in their psychobehavioral repertoire and brain development as they program themselves to adapt to adult life,” Dr. Van Voorhees said in an interview. “Right now we have nothing to offer those individuals other than an occasional referral to an overtaxed mental health system. The only rational strategy is a mass dissemination model, which is going to have to be technology.”
The CATCH-IT program is aimed at teens showing early signs of depression or predepressive symptoms as determined through screening during well checks or other visits for acute or chronic concerns. The study uses multiple screening tools in selecting participants, but Dr. Van Voorhees estimates that screening in practice would require about 1-2 minutes of a medical assistant’s or nurse’s time, followed by 1-2 minutes of the practitioner’s time for positive screens – “and one in five of those screens is going to be positive,” he said.
“The thing we want to convey to primary care practitioners is that these individuals are coming through your office every day, we’re doing nothing for them, and in some ways we are ignoring their enormous future potential adverse trajectory toward mental disorders,” he said.
The program includes 14 modules drawing on cognitive behavioral therapy, behavioral activation, interpersonal psychotherapy, and community resiliency. Six archetypal teens – such as teen living with a single mom or one whose parents are divorcing – are featured in each of the modules to demonstrate six ways of applying the strategies taught in that module. The archetypal teens are around 14-15 years old, but the program is aimed at teens aged 13-18 years, with a reading level at about grade 6, Dr. Van Voorhees said.
Two and a half years after those teens used the CATCH-IT intervention, they showed “a sustained reduction in automatic negative thoughts and educational impairment,” but no difference in their perceptions of support from family or friends. The lack of a control group in that pilot limits what conclusions can be drawn about the program’s effectiveness, but the researchers did learn that motivational interviewing led to greater engagement with the program, compared with teens who received a brief recommendation of it.
Therefore, in the subsequent – and still ongoing – study, physicians used motivational interviewing when offering teens the opportunity to join the program. That study does include a control group, in which participants are assigned a generic health education program online instead of CATCH-IT, and the randomized participants have been stratified by site, gender, and depression risk level.
The researchers first assessed the baseline characteristics of the population, recruited from 38 clinics in two cities. The study enrolled 369 teens aged 13-18 years – 248 in Chicago and 121 in Boston. All were identified as high risk for depression based on elevated scores on the Center for Epidemiological Studies Depression (CES-D) scale or the Kiddie Schedule for Affective Disorders Scale (K-SADS). Two thirds (68%) of participants are female, and most (63%) are in high school. About a third (34%) are in middle school. The racial/ethnic breakdown of the sample is 21% Hispanic, 26% black, 43% white, 4% Asian, 6% multiracial, and 1% other (which adds up to 101% due to rounding). More than half of the participants’ mothers (60%) and fathers (53%) were college graduates.
The teens completed the CES-D, the Screen for Child Related Anxiety Disorders (SCARED), the Beck Hopelessness Scale (BHS), the CRAFFT screening for adolescent substance misuse and the Disruptive Behaviors Disorder Scale (DBD-A). A parent of each teen also filled out the CES-D and DBD-A.
The baseline results did not suggest any concerns about substance use, hopelessness, or disruptive behaviors such as ADHD or conduct disorder. But the average scores on the CES-D and SCARED sat just at the threshold for a potential depressive or anxiety disorders. A CES-D score of at least 16 suggests a possible depressive disorder, and a SCARED score of at least 25 suggests a possible anxiety disorder. The mean scores on the teens’ CES-D were 17.7 in the Chicago cohort, 15.4 in the Boston cohort and 16.9 for the whole group. Similarly, the SCARED mean scores were 26.3 in the Chicago cohort, 23.5 in the Boston cohort and 25.3 overall.
Scores from K-SADS showed subthreshold levels of depressed mood in 36% of teens in both cities, and a nearly identical subthreshold level of irritability. Subthreshold anhedonia was identified in 20% of the overall population. One percent of the overall population had current suicidal ideation.
The next steps are to analyze outcomes among the participants, as the team is doing currently. They have just passed the 1-year anniversary of the trial and are analyzing the data they collected over the past year. The study will run an additional year for longer-term data collection.
One of the abstracts presented at PAS explored the economic implications of incorporating CATCH-IT in primary care.
“The cost for implementation is where the challenge is,” Dr. Van Voorhees said. “Screening takes time, and calling people takes time.” But when spread across a practice’s overall clientele in a year, the costs drop considerably, he said, and savings from effective identification and depression prevention may outweigh costs. The researchers have not yet conducted a cost-effectiveness study because they still are analyzing data on outcomes.
But Dr. Van Voorhees is optimistic about the possibilities of the program.
“What this entire model is about is, how do we understand what’s going on in the environment of the primary care clinic to find these people, identify them, and motivate them, and how can we give them something relevant enough to actually complete,” Dr. Van Voorhees said in the interview. “Then, let’s actually see if it changes their behavioral trajectory.”
The National Institute of Mental Health funded the research. Dr. Van Voorhees has consulted for Prevail Health Solutions, Mevident, Social Kinetics, and Hong Kong University on development of Internet-based interventions.
Office visit conversations are clues to teens’ predepressive symptoms
SAN FRANCISCO – if you know what to look for, suggest the findings of a qualitative study on teens’ sub-threshold symptoms of depression.
“Probing with sensitive questioning and understanding can help providers assess teens’ risks for depression,” said study coauthor Huma Khan, MD, of the University of Illinois Children’s Hospital in Chicago. “Furthermore, close follow-up with teens who mention certain topics, such as losing interest in activities or the loss of a loved one, also may help providers redirect the trajectory of depressive symptoms.”
To better understand ways in which teens may manifest sub-threshold depressive symptoms and possible coping mechanisms, Dr. Khan’s team conducted a qualitative analysis of 37 hour-long interviews with a subsample of teens enrolled in a larger study for adolescents at risk for depression. The teens, recruited from urban and suburban pediatric clinics, were aged 13-18 years and included 12 from Boston and 25 from Chicago. Ten were Hispanic, 15 were African American, and 12 were white.
The participants qualified for the study based on assessments using the Center for Epidemiological Studies Depression (CESD) scale and two questions about anhedonia and/or a depressed or irritable mood for at least 2 weeks. Teens with a current diagnosis of major depressive disorder or currently receiving therapy for depression were excluded.
Starting without a priori assumptions regarding potential findings, the researchers each independently used codes to identify key concepts in the transcripts and then categorized the codes. During regular meetings, they compared findings and continued until patterns in the content emerged.
The findings revealed that teens often express sadness in ways that don’t necessarily immediately call to mind a risk for depression.
“Our participants rarely described themselves as ‘depressed’ and instead used less specific terms such as ‘stressed’ or ‘down,’ ” Dr. Khan said. “Adolescents spoke of topics including unhappiness with school or family relationships that could be attributed to normal teenage angst by some. However, with further probing, adolescents revealed – in their own words – how profoundly impacted they were by their symptoms in various aspects of their lives.”
The research identified themes in three areas: external negative sources of stress, expressions of sadness, and coping practices. The three main sources of external stress identified included school pressure, family discord, and death of a close friend or family member.
The school pressures included difficulty understanding the material, completing work, passing classes, and achieving set goals. Problems with family ranged from tension and fighting to verbal and emotional abuse as well as stress from specific changes, such as divorce or frequent moves.
The researchers identified four main categories of sadness expression:
• Feeling stressed, sad, or down, often involving crying and interfering with their lives.
• Anger and irritability, often directed at others: One teen said, “Little things annoy me that used not to annoy me.”
• New feelings of apathy: One teen said, “I can still do the stuff I want to do, I just don’t feel like it. I used to love, love singing. Now, I sing, but I don’t really... it’s not all that.”
• Problems sleeping, including difficulty falling or staying asleep or sleeping too much.
“In contrast to the depression screening scales that only indicated sub-threshold depression, adolescents – with further questioning – spoke of significant symptoms of unhappiness, loss of interest in activities, and anger/irritability,” Dr. Khan said. “Some teens had little insight into their feelings.”
For example, statements made by the teens included, “They don’t understand why I’m upset. Sometimes I don’t either,” and “I just got really sad. I don’t know. You cry, but you don’t really know why you’re crying. You’re just crying.”
The adolescents told the researchers that spending time with friends was a major way of dealing with their feelings. In addition, two-thirds of the participants had a health issue that led them to visit their primary care provider or the emergency department. These conditions included asthma, allergies, thyroid issues, attention-deficit/hyperactivity disorder, migraines and headaches, arthritis, ulcers, abdominal pain, colonoscopy, fainting, acne, needing birth control pills, and panic attacks.
The researchers concluded that you need to tune into the feelings teens have through conversations about seemingly innocuous topics, whether it’s an annual check-up or an appointment for a specific concern. The statements and feelings expressed by the teens cut across ethnicities, indicating a possible “universality of symptoms for teens with predepression,” the researchers noted.
“The take-away message of our study is that adolescent providers can play an important role in the prevention of major depressive episodes by heavily relying on individual interviews with patients,” Dr. Khan said. “These conversations are powerful tools in uncovering psychological disturbances that may progress to debilitating depressive episodes if gone unnoticed.”
The research was funded by the National Institutes of Mental Health. Dr. Khan had no relevant financial disclosures.
SAN FRANCISCO – if you know what to look for, suggest the findings of a qualitative study on teens’ sub-threshold symptoms of depression.
“Probing with sensitive questioning and understanding can help providers assess teens’ risks for depression,” said study coauthor Huma Khan, MD, of the University of Illinois Children’s Hospital in Chicago. “Furthermore, close follow-up with teens who mention certain topics, such as losing interest in activities or the loss of a loved one, also may help providers redirect the trajectory of depressive symptoms.”
To better understand ways in which teens may manifest sub-threshold depressive symptoms and possible coping mechanisms, Dr. Khan’s team conducted a qualitative analysis of 37 hour-long interviews with a subsample of teens enrolled in a larger study for adolescents at risk for depression. The teens, recruited from urban and suburban pediatric clinics, were aged 13-18 years and included 12 from Boston and 25 from Chicago. Ten were Hispanic, 15 were African American, and 12 were white.
The participants qualified for the study based on assessments using the Center for Epidemiological Studies Depression (CESD) scale and two questions about anhedonia and/or a depressed or irritable mood for at least 2 weeks. Teens with a current diagnosis of major depressive disorder or currently receiving therapy for depression were excluded.
Starting without a priori assumptions regarding potential findings, the researchers each independently used codes to identify key concepts in the transcripts and then categorized the codes. During regular meetings, they compared findings and continued until patterns in the content emerged.
The findings revealed that teens often express sadness in ways that don’t necessarily immediately call to mind a risk for depression.
“Our participants rarely described themselves as ‘depressed’ and instead used less specific terms such as ‘stressed’ or ‘down,’ ” Dr. Khan said. “Adolescents spoke of topics including unhappiness with school or family relationships that could be attributed to normal teenage angst by some. However, with further probing, adolescents revealed – in their own words – how profoundly impacted they were by their symptoms in various aspects of their lives.”
The research identified themes in three areas: external negative sources of stress, expressions of sadness, and coping practices. The three main sources of external stress identified included school pressure, family discord, and death of a close friend or family member.
The school pressures included difficulty understanding the material, completing work, passing classes, and achieving set goals. Problems with family ranged from tension and fighting to verbal and emotional abuse as well as stress from specific changes, such as divorce or frequent moves.
The researchers identified four main categories of sadness expression:
• Feeling stressed, sad, or down, often involving crying and interfering with their lives.
• Anger and irritability, often directed at others: One teen said, “Little things annoy me that used not to annoy me.”
• New feelings of apathy: One teen said, “I can still do the stuff I want to do, I just don’t feel like it. I used to love, love singing. Now, I sing, but I don’t really... it’s not all that.”
• Problems sleeping, including difficulty falling or staying asleep or sleeping too much.
“In contrast to the depression screening scales that only indicated sub-threshold depression, adolescents – with further questioning – spoke of significant symptoms of unhappiness, loss of interest in activities, and anger/irritability,” Dr. Khan said. “Some teens had little insight into their feelings.”
For example, statements made by the teens included, “They don’t understand why I’m upset. Sometimes I don’t either,” and “I just got really sad. I don’t know. You cry, but you don’t really know why you’re crying. You’re just crying.”
The adolescents told the researchers that spending time with friends was a major way of dealing with their feelings. In addition, two-thirds of the participants had a health issue that led them to visit their primary care provider or the emergency department. These conditions included asthma, allergies, thyroid issues, attention-deficit/hyperactivity disorder, migraines and headaches, arthritis, ulcers, abdominal pain, colonoscopy, fainting, acne, needing birth control pills, and panic attacks.
The researchers concluded that you need to tune into the feelings teens have through conversations about seemingly innocuous topics, whether it’s an annual check-up or an appointment for a specific concern. The statements and feelings expressed by the teens cut across ethnicities, indicating a possible “universality of symptoms for teens with predepression,” the researchers noted.
“The take-away message of our study is that adolescent providers can play an important role in the prevention of major depressive episodes by heavily relying on individual interviews with patients,” Dr. Khan said. “These conversations are powerful tools in uncovering psychological disturbances that may progress to debilitating depressive episodes if gone unnoticed.”
The research was funded by the National Institutes of Mental Health. Dr. Khan had no relevant financial disclosures.
SAN FRANCISCO – if you know what to look for, suggest the findings of a qualitative study on teens’ sub-threshold symptoms of depression.
“Probing with sensitive questioning and understanding can help providers assess teens’ risks for depression,” said study coauthor Huma Khan, MD, of the University of Illinois Children’s Hospital in Chicago. “Furthermore, close follow-up with teens who mention certain topics, such as losing interest in activities or the loss of a loved one, also may help providers redirect the trajectory of depressive symptoms.”
To better understand ways in which teens may manifest sub-threshold depressive symptoms and possible coping mechanisms, Dr. Khan’s team conducted a qualitative analysis of 37 hour-long interviews with a subsample of teens enrolled in a larger study for adolescents at risk for depression. The teens, recruited from urban and suburban pediatric clinics, were aged 13-18 years and included 12 from Boston and 25 from Chicago. Ten were Hispanic, 15 were African American, and 12 were white.
The participants qualified for the study based on assessments using the Center for Epidemiological Studies Depression (CESD) scale and two questions about anhedonia and/or a depressed or irritable mood for at least 2 weeks. Teens with a current diagnosis of major depressive disorder or currently receiving therapy for depression were excluded.
Starting without a priori assumptions regarding potential findings, the researchers each independently used codes to identify key concepts in the transcripts and then categorized the codes. During regular meetings, they compared findings and continued until patterns in the content emerged.
The findings revealed that teens often express sadness in ways that don’t necessarily immediately call to mind a risk for depression.
“Our participants rarely described themselves as ‘depressed’ and instead used less specific terms such as ‘stressed’ or ‘down,’ ” Dr. Khan said. “Adolescents spoke of topics including unhappiness with school or family relationships that could be attributed to normal teenage angst by some. However, with further probing, adolescents revealed – in their own words – how profoundly impacted they were by their symptoms in various aspects of their lives.”
The research identified themes in three areas: external negative sources of stress, expressions of sadness, and coping practices. The three main sources of external stress identified included school pressure, family discord, and death of a close friend or family member.
The school pressures included difficulty understanding the material, completing work, passing classes, and achieving set goals. Problems with family ranged from tension and fighting to verbal and emotional abuse as well as stress from specific changes, such as divorce or frequent moves.
The researchers identified four main categories of sadness expression:
• Feeling stressed, sad, or down, often involving crying and interfering with their lives.
• Anger and irritability, often directed at others: One teen said, “Little things annoy me that used not to annoy me.”
• New feelings of apathy: One teen said, “I can still do the stuff I want to do, I just don’t feel like it. I used to love, love singing. Now, I sing, but I don’t really... it’s not all that.”
• Problems sleeping, including difficulty falling or staying asleep or sleeping too much.
“In contrast to the depression screening scales that only indicated sub-threshold depression, adolescents – with further questioning – spoke of significant symptoms of unhappiness, loss of interest in activities, and anger/irritability,” Dr. Khan said. “Some teens had little insight into their feelings.”
For example, statements made by the teens included, “They don’t understand why I’m upset. Sometimes I don’t either,” and “I just got really sad. I don’t know. You cry, but you don’t really know why you’re crying. You’re just crying.”
The adolescents told the researchers that spending time with friends was a major way of dealing with their feelings. In addition, two-thirds of the participants had a health issue that led them to visit their primary care provider or the emergency department. These conditions included asthma, allergies, thyroid issues, attention-deficit/hyperactivity disorder, migraines and headaches, arthritis, ulcers, abdominal pain, colonoscopy, fainting, acne, needing birth control pills, and panic attacks.
The researchers concluded that you need to tune into the feelings teens have through conversations about seemingly innocuous topics, whether it’s an annual check-up or an appointment for a specific concern. The statements and feelings expressed by the teens cut across ethnicities, indicating a possible “universality of symptoms for teens with predepression,” the researchers noted.
“The take-away message of our study is that adolescent providers can play an important role in the prevention of major depressive episodes by heavily relying on individual interviews with patients,” Dr. Khan said. “These conversations are powerful tools in uncovering psychological disturbances that may progress to debilitating depressive episodes if gone unnoticed.”
The research was funded by the National Institutes of Mental Health. Dr. Khan had no relevant financial disclosures.
AT PAS 17
Key clinical point: Dialogue with teens at each visit may reveal predepressive symptoms indicating an opportunity for depression prevention.
Major finding: The research identified themes in three areas: external negative sources of stress, expressions of sadness, and coping practices. The three main sources of external stress identified included school pressure, family discord, and death of a close friend or family member.
Data source: The findings are based on a qualitative analysis of 37 K-SADS interviews with teens aged 13-18 years from Chicago and Boston community pediatric clinics.
Disclosures: The research was funded by the National Institutes of Mental Health. Dr. Khan had no relevant financial disclosures.