Monday, October 21, 2013

Psychotropic drugs commonly prescribed to children with ASD

Psychotropic medications, singly and in combination, are commonly prescribed for children with autism spectrum disorders (ASD), according to research published online Oct. 21 in Pediatrics.

Donna Spencer, Ph.D., of OptumInsight in Eden Prairie, Minn., and colleagues reviewed claims data from 2001 to 2009 for 33,565 children with ASD to assess rates and predictors of psychotropic use.

The researchers found that 64 percent of children with ASD had filled a prescription for at least one psychotropic medication.

Polypharmacy was evident, with concurrent medication fills across at least two drug classes in 35 percent and across at least three classes in 15 percent.

Factors associated with greater risk of psychotropic use and multiclass polypharmacy included older age; psychiatrist visit; and evidence of comorbid conditions such as seizures, attention-deficit disorders, anxiety, bipolar disorder, or depression.

"Despite minimal evidence of the effectiveness or appropriateness of multidrug treatment of ASD, psychotropic medications are commonly used, singly and in combination, for ASD and its co-occurring conditions," the authors write.

More information: Psychotropic Medication Use and Polypharmacy in Children With Autism

ADHD: Do sunny climates reduce the symptoms of ADHD?

Attention-deficit/hyperactivity disorder, or ADHD, is the most common childhood psychiatric disorder.

ADHD is more and more believed to have a genetic element but other risk factors have also been identified, including premature birth, low birth weight, a mother's use of alcohol or tobacco during pregnancy, and environmental exposures to toxins like lead.

ADHD is characterized by an inability to focus, poor attention, hyperactivity, and impulsive behavior, and the normal process of brain maturation is delayed in children with ADHD.

Many individuals with ADHD also report sleep-related difficulties and disorders. In fact, sleep disorder treatments and chronobiological interventions intended to restore normal circadian rhythms, including light exposure therapy, claim to improve ADHD symptoms.

Estimates suggest that the average worldwide prevalence of ADHD ranges from about 5 to 7%, but it also varies greatly by country and region.

A simple visual comparison of data maps released by the U.S. Centers for Disease Control and Prevention and the U.S. Department of Energy that display ADHD prevalence rates by state and solar intensities (sunlight) across the country, respectively, reveals an interesting pattern indicative of an association.

So does this mean that there could be an identifiable relationship between ADHD prevalence rates and the sunlight intensity levels of particular regions?

The accumulation of these points led Dr. Martijn Arns and his colleagues to systematically and scientifically investigate this question.

They collected and analyzed multiple data-sets from the United States and 9 other countries.

Reporting their findings in the current issue of Biological Psychiatry, they did find a relationship between solar intensity and ADHD prevalence.

Even after controlling for factors that are known to be associated with ADHD, both U.S. and non-U.S. regions with high sunlight intensity have a lower prevalence of ADHD, suggesting that high sunlight intensity may exert a 'protective' effect for ADHD.

To further validate their work, they also looked at this same relationship with autism and major depressive disorder diagnoses.

They found that the findings were specific to ADHD, with no associations observed between the other two disorders.

Dr. John Krystal
"The reported association is intriguing, but it raises many questions that have no answers," commented Dr. John Krystal, Editor of Biological Psychiatry.

"Do sunny climates reduce the severity or prevalence of ADHD and if so, how? Do people, who are prone to develop ADHD, tend to move away from sunny climates and if so, why?"

As with all scientific research, further work is necessary, including a prospective replication of these findings.

It is also important to realize that this data reflects only an association - not a causation - between ADHD and solar intensity levels so worried parents should not start planning cross-country moves.

However, these findings do have significant implications, explains Dr. Arns.

"From the public health perspective, manufacturers of tablets, smartphones and PCs could investigate the possibility of time-modulated color-adjustment of screens, to prevent unwanted exposure to blue light in the evening."

"These results could also point the way to prevention of a sub-group of ADHD, by increasing the exposure to natural light during the day in countries and states with low solar intensity.

For example, skylight systems in classrooms and scheduling playtime in line with the biological clock could be explored further."

More information: The article is "Geographic Variation in the Prevalence of Attention-Deficit/Hyperactivity Disorder: The Sunny Perspective" by Martijn Arns, Kristiaan B. van der Heijden, L. Eugene Arnold, and J. Leon Kenemans (DOI: 10.1016/j.biopsych.2013.02.010). The article appears in Biological Psychiatry, Volume 74, Issue 8 (October 15, 2013)

Sunday, October 20, 2013

Moving on to solids: Raising an adventurous eater

Dinner that evening (anchovy crostini, burrata drizzled with olive oil, and prosciutto-topped Neapolitan pizza) was already stimulating and shaping our child's tastes.

So was the vegetable burrito, drenched in hot sauce, she had eaten for lunch.

Julie Mennella
"Learning about food occurs long before the first taste of food," says Julie Mennella, a biopsychologist at the Monell Chemical Senses Centre in Philadelphia, where she studies how we learn and accept flavours.

"The flavours of the mother's diet get into the amniotic fluid." The same thing happens when the mother breastfeeds, she says.

We had already decided that Indira would be breastfed, and because her diet is nearly as varied as my own, she'd expose our child to a panoply of cuisines.

Born in January, Zephyr was a healthy little boy with a full head of hair and a ravenous hunger.

The next few months were a happy blur, and it wasn't long before we were talking about adding solid foods to his diet.

Though I have rudimentary cooking skills, I'm no culinary maestro. Before Zephyr was born, Indira did most of the cooking, but now the opposite was true. Because I work from home, I had more time to spend in the kitchen.

Still, I needed help crafting the purées that could be the bridge to more complex solids. After consulting our paediatrician, I contacted Tucker Yoder, the executive chef of the Clifton Inn in Charlottesville, Virginia, and a father of three. He agreed to come and teach me a few tricks.

Yoder and his wife have a few simple rules for feeding their children. "We try to give them what we're having," he says, "and we'll try giving them anything."

The children enjoy a wide variety of food, including kale-fortified breakfast smoothies and omelettes filled with freshly foraged mushrooms.

His next rule sounds identical to one that my mother enforced. "If it's on your plate, you've got to try it," he says.

"For me, it's if you don't eat it, you go to bed hungry." The couple shop seasonally and locally, and draw on their own garden for tomatoes, greens, herbs and root vegetables.

Placing Zephyr in his high chair that evening, I mentally crossed my fingers as I dipped his spoon into the pineapple-mango mixture and fed him solids for the first time. He looked confused for a moment.

Then his eyes lit up, he worked his jaw, and he swallowed. He pulled the spoon toward his mouth for seconds.

In his haste, Zephyr managed to smear most of the mixture on his hands, chin and bib, but another smidgeon made it into his mouth.

Trying the strawberry-beetroot purée the next evening, I experienced similarly success. Two days later, however, when I picked Zephyr up from nursery, they told me: "He didn't like the sweet potatoes. He spat them out."

I shouldn't have been surprised. Maybe we got too cocky putting crushed red pepper flakes in there, though it was just a few specks.

Indira has an insatiable appetite for spicy food, and I thought Zephyr might have inherited it but his palate wasn't ready.

Jenny Carenco
"They're not going to eat everything," Jenny Carenco, the author of Bébé Gourmet: 100 French-Inspired Baby Food Recipes for Raising an Adventurous Eater and the former owner of the French frozen baby food manufacturer Les Menus Bébé, reassured me. "My kids don't eat everything. My daughter hates courgettes."

Repetition is the key to winning children over to new tastes, says Carenco. "Just keep serving it and make it a positive experience," she says.

"The mistake is to stop serving it. If they don't like peas, it's not going to kill you to cook up and throw away a spoonful of peas after every meal. Serve them at every meal. And if they have one, it's a victory. Then they'll have two."

Heather Stouffer, the founder and chief executive of US company Mom Made Foods, agrees. "You've got to be patient, consistent and a good role model," she says.

The company launched in 2006, selling organically certified frozen puréed baby foods at a farmers market, though it has phased out those products. ("It was too niche a market," explains Stouffer.)

Now it produces frozen meals and snacks for children aged from two to 10 that are available in US grocery stores.

Stouffer is conscious of what she feeds her own children, eight-year-old Emory and three-year-old Audrey, and her pint-sized customers.

"I'm a huge believer in starting kids out from their very first bite through childhood with healthy, real foods," she says.

Like Yoder, she believes in feeding the children the same meal that she and her husband are eating, in a slightly modified form.

To see how that is accomplished, we met at my house to cook a tilapia fajita dinner with mango salsa and guacamole, then puréed some of the fruit and fish plus spinach for Zephyr.

Mashing some of the leftover avocado with a little water yielded him a small bowl of guacamole, too. Both were a hit, though his bib looked like a Jackson Pollock when he was finished.

As my wife and I laughed over his reaction while eating our own dinner, I thought back on something his paediatrician had said: "Make eating enjoyable, and do it as a family as much as you can."

This was just the beginning of Zephyr's appreciation for food, but so far, so good.

I was still smiling as I went to store the remainder of the peaches and cream. When I opened our refrigerator, the second shelf was filled with a rainbow of purées – not one of them beige.

Wednesday, October 16, 2013

Older Mothers favour one child, always

Similarities in personal values and beliefs between an adult child and an older mother is what keeps that child in favor over the long-term, and that preference can have practical applications for mother's long-term care, according to a Purdue University study.

Jill Suitor
"Favouritism matters because it affects adult sibling relationships and caregiving patterns and outcomes for mothers, and now we know that who a mother favours is not likely to change," said Jill Suitor, professor of sociology, who has been studying older parent relationships with adult children for nearly 30 years.

"Knowing that favoritism, particularly regarding caregiving, is relatively stable will be helpful for practitioners when designing arrangements that are going to work best for moms."

Approximately three-quarters of the mothers identified that the child who they favored as their preferred caregiver at the start of the study was the same child they favoured seven years later.

Megan Gilligan
"One of the biggest predictors of who remained the favourite was mother's perception of similarity between herself and her child," said Megan Gilligan, an assistant professor in human development and family studies at Iowa State University and a former Purdue graduate student who is a collaborator on the project.

"Mothers were likely to continue to prefer children who they perceived were similar to them in their beliefs and values, as well as to prefer children who had cared for them before."

Their research, co-authored with Karl Pillemer, professor of human development in the College of Human Ecology at Cornell University, is published in the Journal of Marriage and Family.

The findings are based on the Within-Family Differences Study in which data were collected seven years apart from the same 406 mothers, ages 65-75. The study is funded by the National Institute on Aging.

Karl Pillemer
Gender similarity also was a consistent factor to show long-term favoritism, which is not surprising because the mother-daughter connection has been shown in previous research to typically be the strongest, closest and most supportive parent-child relationship.

In addition to looking at the similarity of personal values, the researchers also looked at whether a child's financial independence, adult roles as a spouse or parent themselves, consistent employment, and lawful behaviour influenced which child remained the favorite.

What was surprising is that whether a child was married, divorced or achieved independence, mattered much less than sharing personal values, said Suitor, who is a member of the Center on Aging and the Life Course.

"These mothers are saying that if I can't make my own decisions involving my life than who can best make these decisions for me? Who thinks like I do?" Suitor said.

"Who has the same vision in life that I do, has a pretty good sense of what I would do? This is incredibly important with issues related to caregiving, and that is why understanding these family dynamics is so important."

While the importance similarity played in explaining why a mother's favorite child remained the same across the study, it was much harder to identify what drove changes when a child fell out of favour.

"One of the few predictors of changes was when children stopped engaging in deviant behaviours, such as substance abuse, during the seven years, and then their mothers were more likely to choose them as the children to whom they were most emotionally close," Gilligan said.

Suitor said, "This is an interesting change because if a child engaged in deviant behaviours seven years ago but then stopped they were even more likely to be chosen than were siblings who never engaged in deviant behaviours."

Suitor, Pillemer and Gilligan are planning to extend the Within-Family Differences Study to include interviewing the Baby Boomers about their own adult children.

More information: Continuity and Change in Mothers' Favoritism Toward Offspring in Adulthood, J. Jill Suitor, Megan Gilligan, Karl Pillemer, Journal of Marriage and Family, 2013.

Tuesday, October 1, 2013

Clinician observations of preschoolers' behavior help to predict ADHD at school age

Don't rely on one source of information about your preschoolers' inattention or hyperactivity. Rather, consider how your child behaves at home as well as information from his or her teacher and a clinician.

This advice comes from Sarah O'Neill, of The City College of New York, based on research she conducted at Queens College (CUNY), in an article published in Springer's Journal of Abnormal Child Psychology.

The study examines how well parent, teacher, and clinician ratings of preschoolers' behavior are able to predict severity and diagnosis of attention deficit hyperactivity disorder (ADHD) at age six.

Characterized by developmentally inappropriate levels of inattention, hyperactivity, and impulsivity, ADHD is one of the most frequently diagnosed childhood psychiatric disorders.

Although many studies focusing on school-aged children have shown that parents and teachers—rather than clinician observations alone—are more likely to assess ADHD accurately, scant evidence exists to support similar conclusions with preschoolers.

To fill this gap in the research, O'Neill and colleagues followed a group of 104 hyperactive and/or inattentive three- and four-year-olds for a period of two years. Both parents and teachers rated the preschoolers' behaviour.

In addition, clinicians, who were blind to parent and teacher reports, completed ratings of preschoolers' behavior during a psychological testing session.

By the time the children reached age six, more than half (53.8 percent) had been diagnosed with ADHD.

The likelihood of such a diagnosis increased when all three informants had rated the child as high on symptoms at age three or four.

Furthermore, after analyzing the reports separately, the research team found that parents' reports were critical, particularly when combined with either teacher or clinician reports.

Teacher reports alone were not as useful, and the research team ascribed the relative inability of educators' reports to predict a child's ADHD status over time to possible situational variables.

Preschoolers may initially have difficulty adjusting to the structured classroom setting, but this disruptive behavior is time-limited to the transition to school.

Teachers' perceptions of "difficult" behaviour may also be affected by factors such as classroom setting and size as well as their expectations of children's behaviour.

As a result of the study findings, O'Neill and her team emphasize the importance of using information from multiple informants who have seen the child in different settings.

Parent reports of preschoolers' behaviour appear to be crucial, but these alone are not sufficient. Augmenting the parent report with that of the teacher and/or clinician is necessary.

Also important are clinician observations of preschoolers during psychological testing, which are predictive of an ADHD diagnosis and its severity over time.

Being able to identify children at risk for poorer outcomes may help educators and clinicians to plan appropriate interventions.

"Consider a preschool child's behaviour in different contexts," O'Neill emphasized. "Although parents' reports of preschoolers' inattention, hyperactivity, or impulsivity are very important, ideally we would not rely solely on them. At least for young children, the clinician's behavioural observations appear to hold prognostic utility."

More information: O'Neill, S. et al. (2013). Reliable Ratings or Reading Tea Leaves: Can Parent, Teacher, and Clinician Behavioral Ratings of Preschoolers Predict ADHD at Age Six? Journal of Abnormal Child Psychology. DOI: 10.1007/s10802-013-9802-4