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What does the child who can’t say goodbye to a parent without breaking down have in common with the child who is cripplingly terrified of dogs and the one who gets a bad stomach ache reliably on Monday morning?
Anxieties and worries of all kinds are common in children, necessarily part of healthy development, but also, when they interfere with the child’s functioning, the most common pediatric mental health problems. From separation anxiety to social anxiety to school avoidance to phobias to generalized anxiety disorder, many children’s lives are at some point touched by anxiety that gets out of hand.
“I often tell parents, anxiety and fears are totally a normal and healthy part of growing up,” said Dr. Sabrina Fernandez, an assistant professor of pediatrics at the University of California, San Francisco, who has written about strategies for primary care doctors to use in dealing with anxiety disorders. “I worry that it’s becoming something more when it interferes with the child’s ability to do their two jobs: to learn in school and to make friends.”
Children whose lives are being seriously derailed by their anxieties often get psychotherapy or medication, or both. And a meta-analysis published in November in JAMA looked at the two best-studied treatments for anxiety disorders, cognitive behavioral therapy and psychotropic medication. The technique of a meta-analysis allows scientists to pull in a whole range of different studies, weight the results according to the size and rigor of the research, and then consider the wider array of data gleaned from multiple investigations.
“We included panic disorder, social anxiety disorder, specific phobias, generalized anxiety disorder and separation anxiety,” said the lead author, Zhen Wang, an associate professor of health services research at the Mayo Clinic College of Medicine and Science (they did not include children with post-traumatic stress disorder or obsessive-compulsive disorder). The study looked at the effectiveness of treatments in reducing the symptoms of anxiety, and at ending the anxiety disorder state. And they also looked at any reports of adverse events associated with the treatments, from sleep disturbances to suicide.
The authors examined 115 different studies, for a total of 7,719 patients, and concluded that certain kinds of antidepressant medications – especially the selective serotonin reuptake inhibitors, or S.S.R.I.s – were effective in reducing anxiety symptoms in children; the mean age of the children in the study was 9.2 years, with a range of 5 to 16.
There were only a few studies that directly compared them, but they suggest that cognitive behavioral therapy may be even more effective at reducing symptoms and at resolving the anxiety disorders, and that the combination of medication and C.B.T. may be better than either was alone. The drugs were associated with a variety of adverse events, though they did not find the association with suicide attempts that has led to a black box warning on S.S.R.I.s. Still, they have not ruled out those dangers: “The difference may be due to underreporting and monitoring of suicide attempts in clinical trials,” Dr. Wang said.
Dr. Stephen P.H. Whiteside, the director of the Pediatric Anxiety Disorders Clinic at the Mayo Clinic, who was one of the authors of the meta analysis, said, “if your child has difficulties with anxiety, first of all, it’s treatable. There are a variety of interventions that can be helpful.”
So which of those children – the parent-clinger, the dog-fearer, the school-avoider – needs psychotherapy or psychopharmacology?
“Anxiety happens in kids,” said Dr. Christopher K. Varley, a professor in the department of psychiatry at the University of Washington School of Medicine in Seattle. “It does not always need treatment.” And it does not always look exactly like what adults think of as anxiety, he said. Kids can have physical symptoms, or become disruptive; headaches and stomachaches and tantrums can all mean that a child is anxious.
“The important questions to me are, is this a problem, is it getting in the way of functioning, is it creating stress for the child and the family, is it causing pain and suffering?” he said.
“A big thing for families is that sometimes anxiety can lead to avoidance behavior in social settings and in school,” Dr. Fernandez said. But staying away from school is only going to make the problem worse, she said. “As a parent, all you want to do is make your child feel safe and feel comfortable, and if they’re saying, I only feel safe and comfortable home with my door shut, that can only exacerbate the problem.”
The most helpful form of therapy, Dr. Whiteside said, according to the evidence, is exposure-based cognitive behavioral therapy, which involves helping kids face their fears in a supportive environment. “If they’re afraid of dogs, they have to practice petting dogs; if they’re afraid of talking to people, practice talking to people.” That seems to be of greater value for children with these problems than, for example, therapies based on changing thought patterns, or distractions, or even therapy aimed at deeper insight into the fears.
The message of exposure therapy, Dr. Whiteside said, is that the situations the child is avoiding are not as dangerous as the child’s anxiety would suggest, and that the child can cope with the anxiety. “It’s an uncomfortable feeling that you can handle,” he said, and the more the child handles it, the more proficient the child will become.
But this takes skill and experience on the therapist’s part, and an investment of time and resources by the family. “We found that C.B.T. reports the most consistent outcomes compared to placebo, but it’s time-consuming and sometimes in rural areas it’s not available,” Dr. Wang said.
The question of medication may arise for children with moderate to severe anxiety, and perhaps ideally for a child who is already getting psychotherapy. But of course, not everyone has access to the experts, or to the recommended forms of therapy. Psychotropic medications are often prescribed by primary care doctors, pediatricians or family physicians, doing their best to help their patients, sometimes getting guidance from a psychiatrist by phone.
“Even though it’s a common problem and there are treatments that work, there are still profound problems in the United States with access to psychotherapists who are versed in psychotherapy techniques that have been demonstrated to help,” Dr. Varley said. “And there clearly is a paucity of child psychiatrists.”
In an editorial accompanying the recent meta-analysis, researchers hailed the large numbers of children included, but warned that many children don’t respond fully to treatment, and that children who suffer from one form of anxiety disorder are often at high risk to develop another.
“The good news is I’ve had lots of patients who’ve had much better experiences and were able to deal with those ups and downs of life, who went to therapy and learned tools to deal, or needed a little help with medication,” said Dr. Fernandez.
By Perri Klass
11 December 2017
A new nationwide Danish study suggests that the high risk of health problems common among homeless populations can span generations, and increase the likelihood of psychiatric disorders in their children.
Researchers assessed more than 1 million children and adolescents aged 0 to 16 years and found that children with at least one parent who had a history of homelessness were more than twice as likely to have a psychiatric disorder as those whose parents had not been homeless (15.1 cases per 1000 person-years [95% CI] versus 6.0 cases per 1000 person-years [95% CI], respectively).
“These findings have important implications for public health and policy because they suggest a need for improvement in the support of socially marginalized families to help prevent psychiatric illness in offspring,” the authors, led by Sandra Feodor Nilsson, MSc, of the University of Copenhagen, wrote.
Data suggested that similar incidence rate ratios (IRR) of psychiatric disorders were found in children who had two parents or only a father with a history of homelessness. However, IRR was higher when a child’s mother had a history of homelessness, versus when just their father had the same history.
Parental history of homelessness was also associated with a high risk of substance abuse disorders in offspring, again, with higher IRRs in children whose mothers had a history of homelessness. In addition to attachment and substance abuse disorders, the risk of psychosis and attention-deficit hyperactivity disorder (ADHD) in the fully adjusted model were also found to be higher when only the mother had a history of homelessness than when only the father had the same history.
If both parents had a history of homelessness, the child was most likely to have a high IRR for attachment disorder. After adjustment for parental psychiatric disorders, increased risks were found for most psychiatric outcomes, including autism spectrum disorders, mental retardation, tics and Tourette’s disorders. Notable exceptions included affective disorders and eating disorders, according to the authors.
“There are many reasons why parental homelessness would increase the risk of mental disorders in offspring,” wrote Wayne Hall, of the Centre for Youth Substance Abuse Research at the University of Queensland, Australia, in a response letter, published in The Lancet.
“Homelessness makes parenting difficult and it is usually accompanied by social adversity and poverty. Unstable housing interferes with children’s schooling and prevents them from developing friendships and social relationships with peers. There could also be genetic risks of developing mental disorders that increase the risk of parental homelessness and their offspring’s risk of developing these disorders,” Hall added.
The study adds to mounting evidence that adversity, especially early on in life, can have lingering effects, and in some cases can even span generations.
According to the authors, the study’s strengths lie in its basis on a nationwide and almost complete cohort of children and adolescents with accurate linkage to their parents’ use of public homeless shelters. As such, the cohort is likely generalizable to children younger than 16 years old in other high-income countries with well-developed social support systems, the authors wrote.
“Denmark has a well-developed social welfare system; the predicament of children with homeless parents is likely to be much worse in countries that have radically cut social welfare and health services in times of austerity,” Hall wrote.
On the other hand, the study was restricted in its ability to control for important confounders like availability of alternative family support, undiagnosed mental disorders in parents, and the parents’ and children’s pre-existing risks for developing psychiatric disorders.
“Nonetheless, the study findings clearly show that the children of homeless parents are at increased risk of developing attachment and substance use disorders,” Hall wrote. “These mental disorders are likely to further diminish the life chances of these children by reducing their educational attainments and subsequent employment opportunities.”
The study, Risk of psychiatric disorders in offspring of parents with a history of homelessness during childhood and adolescence in Denmark: a nationwide, register-based, cohort study, was published December, 2017 in The Lancet.
11 December 2017
By Thomas Castles
A fresh look at a federally sponsored 2012 national study shows a significant link between parent's behaviors and thoughts of suicide among adolescents, according to a presentation given by two University of Cincinnati professors at the 2017 American Public Health Association conference.
UC professors Keith King and Rebecca Vidourek performed a follow-up data analysis of results from the "2012 National Survey on Drug Use and Health," which provides national- and state-level data on the use of tobacco, alcohol, illicit drugs – including nonmedical use of prescription drugs – and mental health in the United States.
Their findings showed that children between the ages of 12 and 17 are significantly more likely to contemplate, plan and attempt suicide when their parents do not engage in certain behaviors that demonstrate to their children that they care about them. "Kids need to know that someone's got their back, and unfortunately, many of them do not. That's a major problem," King said.
Startlingly, the findings showed that the age group most significantly impacted by parenting behaviors was 12- and 13-year-old children. Children in that age group with parents who never or rarely told them they were proud of them were nearly five times more likely to have suicidal thoughts, nearly seven times more likely to formulate a suicide plan and about seven times more likely to attempt suicide than their peers. Similarly, 12- and 13 year olds with parents who rarely or never told them they did a good job or helped them with their homework were at excessively high risk for suicide.
"Parents ask us all the time, 'What can we do?'" said King, who coordinates UC's health promotion and education doctoral program and serves as Director of the Center for Prevention Science. "You can tell them you're proud of them, that they did a good job, get involved with them, and help them with their homework."
"A key is to ensure that children feel positively connected to their parents and family," added Vidourek, who serves as Co-Director of the Center for Prevention Science.
The risk of suicidal behaviors among high school-aged teens, though lower than among 12- and 13-year-olds, is still significantly higher when their parents aren't emotionally involved. For example, 16- and 17-year-olds whose parents rarely or never told the children they are proud of them are about three times more likely to have suicidal thoughts and almost four times more likely to make a suicide plan and attempt suicide than peers whose parents sometimes or often did.
That may seem promising when compared to the youngest age group, but the decrease in the odds of suicidal behavior among children ages 14 and above may partially stem from teens finding other coping mechanisms to deal with their lack of parental engagement, such as involvement in drug use and high-risk sexualy behaviors, King said. "It follows through consistently, regardless of gender, regardless of race – it's all across the board," he said.
5 December 2017
Source: University of Cincinnati
Punishment – or the threat of it – is generally considered an effective way to shape human behavior; it is, after all, the foundation of our criminal justice system. But what if there’s a subset of the population for whom this paradigm simply doesn’t apply? New research suggests that there is such a group: survivors of childhood trauma.
University of Wisconsin-Madison psychology professor Seth Pollak worked with over 50 people around the age of 20, and found that those who had experienced extreme stress as kids were hampered in their ability to make good decisions as adults. Simply put, childhood trauma – due to circumstances like neglect or exposure to violence – created young adults fundamentally unable to correctly consider risk and make healthy life decisions – and no threat of punishment was likely to be effective in changing this deficit. For cities where fears of juvenile violence have transfixed residents and flummoxed city leaders, Pollak’s results suggest that demands for stiffer sentences on youthful offenders are likely to be counterproductive.
The study’s participants were already known to Pollak: He had worked with them as eight-year-olds, when he measured their stress levels as part of a study on the effects of stress hormones on children’s development. The kids, from Madison and its environs, ranged from middle-class children who had experienced no trauma to kids who had dealt with extreme circumstances like abuse or a parent killed by gunfire. Extreme poverty tends to be associated with these traumatizing environments: Economic uncertainty puts parents under stress, which trickles down to children; food and housing insecurity can further exacerbate these stresses.
In revisiting the group, Pollak enlisted those who as children were at the ends of the trauma spectrum, either experiencing very little stress or copious amounts. The study had the now-adults engage in tasks such as gambling simulations, designed to assess their response to risk-taking, reward, and punishment. “We would give them clues as to outcomes,” said Pollak, “such as ‘When you see this shape, you’re at risk of losing $5.’” Pollak scanned the participants’ brain activity while they completed the activities.
The people who did not have stressful childhoods tended to pay attention to the clues and gamble wisely; those who had suffered severe trauma did not. They would, for instance, choose the shape that they had been warned against – and make the mistake again and again. They also took a great deal of time agonizing over decisions, and when they lost they became markedly upset.
The brain scans of this group showed less-than-usual brain activity during the period of decision making, and more-than-usual activity during the aftermath. “It makes sense,” said Pollak. “If you didn’t pay attention to the cues indicating that you’re about to lose, you’re more surprised and then upset when you do.”
The study also explored the subjects’ behavior in real life. They filled out a simple questionnaire about their propensity to drive without a seatbelt, avoid the doctor while ill, and other risky behaviors. The results mirrored the results of the games: The participants who made poor gambling decisions also made poor life decisions.
Pollak stressed that the findings aren’t related to intelligence or IQ. “It’s more like a learning disability,” he said. “The people were ignoring the signs that most people were taking as a warning. The information isn’t getting processed.”
Most of the participants who had experienced trauma as children were now facing problems like criminal records, joblessness, and obesity – though a few had succeeded. “We even found one person who was studying at an Ivy League university,” said Pollak. But the research showed that regardless of current circumstances and stress levels, it was the experience of childhood trauma that determined how well the participants assessed risk.
Though it’s well documented that children who experience high stress are at risk for behavioral problems, the neurobiological processes that contribute to this are poorly understood. Pollak’s experiment addressed this by suggesting that altered brain activation leads to poor judgment in decision making. “Something about the stress of early childhood is changing the brain systems that allow us to attend to information that might signal potential risk or loss,” he said.
The study’s findings also suggest that for cities, building more jails and ramping up punishments for juvenile offenders will do little to deter future crime. Research shows that the majority of youth involved in the criminal justice system – up to 90 percent – have experienced trauma. On these kids and young adults, the threat of inflicting further punishment won’t have its desired effect. “It’s like disciplining a child with something that’s not meaningful to them,” said Pollak. “But we still hold them responsible for making the same mistakes.”
Instead, Pollak suggested training programs that foster the development of the brain’s ability to make better decisions. “If we can teach people to do math, we can probably teach them to attend to things that might get them into trouble,” he said.
The research also points to a more effective way to decrease urban crime: limiting exposure to childhood trauma. Pollak noted the importance of social safety nets that shield children from stress, such as affordable housing, nutrition assistance, and health insurance. While these programs may seem costly, such expenses are dwarfed by the social costs of dealing with adults who who enter society and the workforce unable to attain education, hold down jobs, and maintain families and relationships. “This is powerful evidence that the problems of early life lead to other problems that don’t go away,” Pollak said.
One silver lining? Because his research focuses on the developing brain – which transcends ideology, economic class, racial or ethnic groupings, and other potentially politically charged elements – Pollak holds out hope that those across the political spectrum will pay attention to his findings. “There’s something about showing a biological effect in children that makes these policy issues nonpartisan,” he said.
By Mimi Kirk
4 December 2017
Girls who had experienced childhood violence were 24 percent more likely to drop out, while boys who had experienced violence were 26 percent more likely to drop out than their peers.
One in five people in the United States drop out of high school before graduation, which decreases their lifetime earning potential by 20 percent. Yet there has been little previous research into the link between being a victim of violence before the age of 16 and dropping out of high school.
The study, "Child Abuse, Sexual Assault, Community Violence and High School Graduation," was published in the November issue of the journal Review of Behavioral Economics.
The researchers used data from the National Comorbidity Survey Replication and the National Survey of American Life to create a sample set of 5,370 females and 3,522 males. The sample was restricted to people born in the United States to create a more consistent data set.
Within the sample of more than 8,800 respondents, 34 percent of women and 29 of men reported being the victim of some sort of violence before age 16. Twenty-one percent of women reported sexual assault as opposed to 6 percent of men.
"Actually, we were stunned by the magnitude of the violence directed against young women and young men," said William A. Darity, professor at Duke's Sanford School of Public Policy, director of the Samuel DuBois Cook Center on Social Equity and a co-author of the study.
"Moreover, these assaults are not confined to any social class, racial, or ethnic group," he said. "This is authentically an American problem. One of its manifestations is the negative effect on persistence in school for many of the victims."
Because most states require compulsory education until age 16, the study focused on the association of dropout with violence experienced between the ages of 1 and 15.
Dropout rates for people who experienced any type of violence before age 16 were compared with the rates for people who did not experience violence during the same time frame.
The researchers categorized violent experiences into three kinds: child abuse, sexual assault and community violence. Community violence was defined as violence experienced outside the home, such as being mugged or beaten by anyone other than parents. Sexual assault included violence both within the home and in the community.
They found significant differences between men and women for the three types of violence experienced. Men suffered more from community violence, 12 percent versus 3 percent for women, while more women experienced sexual assault, at 21 percent versus 6 percent for men.
Women who suffered a combination of both sexual assault and child abuse were the most likely to dropout. Among men, the highest dropout rate was highest for those who were victims of both child abuse and community violence.
Male and female victims of home violence also left school early at a higher rate than their peers who did not report experiencing violence.
Surprisingly, victims of sexual assault who experienced no other violence were no more likely to drop out than their peers who were not victims. This held true among both males and females.
The study suggests that policies to reduce violence against children or assist children in coping with violence will have the additional benefit of lowering the national dropout rate.
1 December 2017
Source: Duke University
Parents and teachers are painfully aware that it's nearly impossible to get a teenager to focus on what you think is important. Even offering them a bribe or issuing a stern warning will typically fail. There may be many reasons for that, including the teenager's developing sense of independence and social pressure from friends.
Now a new study, published in Nature Communications, shows that this behaviour may actually be down to how the adolescent brain is wired.
Adolescence is defined as the period of life that starts with the biological changes of puberty and ends when the individual attains a stable, independent role in society. (This definition may leave some readers wistfully pondering the second half of that equation). We now know that it is also a time of tremendous brain reorganisation, which we are only just beginning to understand.
At this point, the brain's grey matter, which has been growing exuberantly since birth, starts to thin. This is probably due to a system of synaptic pruning, ridding the brain of unnecessary nerve cell connections and resulting in boosted neural efficiency. This thinning occurs from the back to the front of the brain, with the prefrontal cortex, responsible for executive functions such as cognitive control and decision-making, being the last to be tidied up.
Associated with this maturing process are "upgrades" of key structural and functional networks – a shift from local connections to more widespread global links between different parts of the brain.
You don't need to be a neuroscientist to know that adolescence is also a time of greatly increased impulsivity, sensation-seeking and risk-taking. One aspect of risk behaviour in adolescents appears to be an apparent inability to match their behaviour to the likely rewards (or punishments) that might follow.
A mature brain is quite good at predicting the necessary balance between effort and reward. It does this by using links between the cognitive control systems, found in the highly evolved prefrontal cortex, and the reward circuitry, made up of evolutionarily older sub-cortical structures, which controls motivation and "wanting". These include the striatum and the anterior cingulate cortex.
Psychologists would describe this skill as the ability to adjust one's cognitive performance to environmental demands, whereas business gurus would refer to it as "cost-benefit analysis". Colloquially we might decide whether or not "the game is worth the candle".
So is it possible that the adolescent brain organisation is not yet up to the task of this careful balancing act? This would come from an unsophisticated reward system, which has not yet been dampened by input from a more conservative, forward-planning prediction system based on cognition.
High versus low stakes
The new study shows that this really is the case – looking at the brains of individuals from 13-20 years old. They did this by collecting data from functional magnetic resonance imaging, which measures brain activity indirectly by tracking changes in blood flow, from participants while they played a video game. This was a cognitive test giving players either high or low financial rewards or punishments in return for correctly sorting pictures of planets.
In this kind of task, you would expect to see improved performance when there are higher stakes involved. But the study showed that this was only the case for older participants (19-20 years old). Younger players were less efficient at the task whether the stakes were high or low. The defining characteristic of brain activity in the better performers was increased use of the prefrontal areas and, perhaps crucially, more powerful connections between the prefrontal cortex and the sub-cortical striatal areas.
Effectively, this study demonstrates the emerging efficiency of a "cool" cognitive control system moderating a "hot" motivational assessment system, resulting in the appropriate balance between the rewards offered and the actions required to maximise performance. If your brain is younger, you are simply not very good at matching what you need to do with what you will gain if you get it right or lose if you get it wrong. This is indeed evidence of an adolescent lack of the necessary fine-tuning in the reward system which (thankfully) appears to emerge with age.
Interestingly, this is different from brain activity linked to adult impulsivity and sensation-seeking – which is associated with general under-responsiveness of the reward system rather than a simultaneous lack of connectivity with the control system.
Knowing about this effect could be of value in educational and training fields. Just increasing any reward/bribe you might be tempted to offer to get a teenager to do something may not have the desired effect. Instead, try to give young adolescents as much information as possible about an upcoming decision – this could help redress the imbalance between cognition and motivation.
For example, instead of bribing them to apply to a certain university, taking them on multiple visits to university open days might just be worthwhile. That said, it may not be easy. There's also the risk that you'll be faced with another aspect of adolescent behaviour – a refusal to listen to adult words of wisdom.
We also need to acknowledge that this kind of behaviour is not always a bad thing. There is an evolutionary take that a newly emerging adult needs to take risks, with youthful enthusiasm and excitement unfettered by worthy cognitive controls. As author William Faulkner said: "You cannot swim for new horizons until you have courage to lose sight of the shore."
By Gina Rippon
29 November 2017
Care leavers in English higher education are significantly more likely to drop out of university courses than otherwise similar students, according to the first national study on the topic.
New research found that care leavers – young people who are in the care of their local authority at the age of 16 or over – were about 38 per cent more likely to withdraw from their university course and not return, compared with peers with similar demographic profiles and qualification levels.
Their reasons for withdrawal were similar to those of other students, with academic issues being the most common, followed by emotional and mental health issues and financial problems. However, care leavers who did complete a degree were as likely to achieve a first or upper second-class degree as otherwise similar students.
The study explored the educational pathways of all young people in England who were 16 in 2008, tracking whether or not they entered higher education by 2015. It found that 12 per cent of care leavers had entered higher education by the age of 23 – double the previous estimate of 6 per cent.
However, this still represents a substantially lower proportion than that for other young people (42 per cent). This was largely due to the lower qualifications that care leavers were able to achieve in school, according to the research.
The research was conducted by Neil Harrison, associate professor of education policy at the University of the West of England, on behalf of the National Network for the Education of Care Leavers. It used combined data from the National Pupil Database and the Higher Education Statistics Agency, covering 650,220 young people, of whom 6,470 were care leavers.
Dr Harrison said that Department for Education data track care leavers only up until the age of 21, meaning that previous figures were “masking” the high number of care leavers who enrol in higher education when they are older.
He added that universities could work closer with local authorities and increase their outreach activity with young people who have left school to ensure that the “door to higher education” remains open to care leavers, and to improve the transition period between care and higher education.
Universities also needed to offer “long-term therapeutic support” if they want to make sure that “care leavers are thriving in higher education”, Dr Harrison said.
The Moving On Up report, which was launched at the House of Commons on 29 November, also included interviews with 212 students currently in higher education, who had previously been in care.
More than half these interviewees said that they had considered leaving higher education, with one in five having done so often.
Some of the interviewees reported being actively discouraged from pursuing higher education, while others said that they had difficulty getting advice about applications or practical help with accommodation or financial issues.
Students also reported that some universities were not able to provide adequate support for the long-term mental health issues deriving from childhood trauma.
November 29, 2017
By Ellie Bothwell