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There has been lots of attention on concussions in youth, especially from sports, over the past few years. It’s good that we are paying more attention to concussions. As the stories of prior National Football League players show us, concussions can lead to lifelong problems.
The problem for doctors, parents, and coaches has been that while we want to do the right thing when a child gets a concussion, we haven’t known what that right thing is. So it’s great news that the Centers for Disease Control and Prevention (CDC) has reviewed all the research and made recommendations to help guide us as we care for children with concussions.
The recommendations reflect the fact that every child who has a concussion is different. Every injury is different, obviously, but it’s more than that. Some children are more likely to have trouble, such as those who have had prior concussions or have learning problems, mental health problems, or neurological problems. Interestingly, children whose families are stressed for reasons such as poverty can take a longer time to recover from concussions. And there is a bit of a wild card factor too: sometimes children unexpectedly take a long time to recover – or, conversely, recover very quickly.
Overview of new concussion care recommendations
Most children with concussions don’t need CT or MRI scans. If there was a severe injury or the child is having severe or unusual symptoms, then it’s worth doing to be sure there isn’t internal bleeding, a fracture, or some other injury. Most of the time with concussions, there is nothing to see – and it’s not worth the risk or expense involved in these studies.
Use the right tool to make the diagnosis. There are some symptoms we associate with concussion, like bad headache, dizziness, loss of memory of the accident. But because it isn’t always clear, it’s helpful to use a checklist or questionnaire that is “validated,” meaning that it’s been shown to accurately pick out those with a concussion from those who simply have a bad clunk to the head and not a concussion. The CDC lists some tools that are recommended.
When a child has a concussion, assess for risk factors for a prolonged recovery. As I said above, some children take longer to get better – and while we can never predict for sure, it’s important to think about that at the time of the injury. This can help doctors.
Provide education for parents and caregivers about concussions and what to expect. Most people with concussions get completely better within one to three months. It’s important that patients, families, and coaches know what all the symptoms are after a concussion – and know not only what’s normal, but also what is a sign of a problem. For example, trouble sleeping, dizziness, and moodiness can be normal, but if any of those symptoms are getting worse, it’s important to call the doctor.
Help children return gradually to normal activities after a concussion. Rest – of not just the body but the mind too – is important for the first two to three days after a concussion, but after that it’s important to start getting back to normal. When people rest completely for longer than that, it actually takes them longer to get better!
Getting back to normal after a concussion
Gradual is the key word for returning to exercise and school – and this is where families, doctors, schools, and coaches need to work together. The basic idea is to start slow and see how the child does. If they do okay, they can do a bit more schoolwork or exercise. If they don’t do okay, meaning they have more symptoms, that’s where the education comes in – they should do less and go more slowly. The process of getting back to normal life can take a few days, or a few months. It has to be tailored to each child and each situation, which is why collaboration is so important. It’s also really important not to rush the process, especially when it comes to returning to a sport where concussions are common, such as football, hockey, or soccer. If a child gets another concussion while they are still recovering, it will take them much longer to get better and put them at risk of permanent disabilities.
Treating concussions is important, but preventing them is even more important. To learn more about what everyone can do to help prevent brain injury, visit the CDC’s Heads Up page.
By Claire McCarthy
Source: Harvard Health Publishing
9 October 2018
Violent video game play by adolescents is associated with increases in physical aggression over time, according to a Dartmouth meta-analysis published in the Proceedings of the National Academy of Sciences (PNAS).
Although most researchers on the subject agree that playing violent video games appears to increase physical aggression, a vocal minority continues to dispute this. To examine issues raised by the counterclaims on this topic, Dartmouth researchers conducted a meta-analysis of 24 studies from around the world from 2010 to 2017 with over 17,000 participants, ages nine to 19 years-old. The studies all examined how violent video game play affected changes in real-world physical aggression over time, ranging from three months to four years. Examples of physical aggression included incidents such as hitting someone or being sent to the principal's office for fighting, and were based on self-reports by children, parents, teachers and peers.
Dartmouth's study examined three specific critiques of the literature on video game play and aggression:
To address claims that previous meta-analyses overestimate the association of violent video game play and aggression because they include "non-serious" measures of aggression, this meta-analysis was limited to studies that measured reports of overt, physical aggression over time. Despite this more stringent criterion, findings supported the hypothesis that playing violent games is associated with subsequent increases in physical aggression.
To investigate claims that effects are often inflated because many studies do not take into account other variables predictive of aggressive behavior, Dartmouth researchers compared analyses that included or did not include information on such variables and found that taking these data into account had only a minor effect on the size of the observed relation between violent video game play and aggression.
To evaluate claims that the estimated effect of violent game play on aggression is inflated because of a bias against publishing studies that fail to find a relation of violent game play and aggression, Dartmouth researchers conducted a variety of different tests and found no evidence of publication bias.
In addition to providing evidence that violent video game play is associated with increased aggression over time, the study also reports that this effect appears to be significantly different for various ethnic groups: the largest effect was observed among white participants, with some effect noted among Asians and no effect observed among Hispanics.
Although speculative, the authors suggest that this effect may reflect a greater emphasis on maintaining empathy toward victims of aggression among Eastern and Hispanic cultures in contrast to an emphasis on "rugged individualism" in Western cultures.
"Although no single research project is definitive, our research aims to provide the most current and compelling responses to key criticisms on this topic. Based on our findings, we feel it is clear that violent video game play is associated with subsequent increases in physical aggression," said lead author Jay G. Hull, the Dartmouth Professor of Psychological and Brain Sciences, and associate dean of faculty for the social sciences at Dartmouth.
"The most notable critic of the violent video game aggression literature conducted studies in primarily Hispanic populations and found no evidence of this association. If all of my studies showed null findings, I too, would be skeptical," said co-author James D. Sargent, the Scott M. and Lisa G. Stuart Professor of Pediatric Oncology and director of the C. Everett Koop Institute at Dartmouth. "I hope our findings prompt skeptics to reevaluate their position, especially since some of our other research indicates that violent video game play may increase deviance with implications for multiple risk behaviors," added Sargent.
The study builds on the research team's growing body of work that investigates the impact of video games on children's behavior, including the link between mature-rated, risk-glorifying video games and deviant behavior (e.g., smoking, drinking, and risky sex) and the association between playing these type of video games and reckless driving among teens.
1 October 2018
Source: Dartmouth College
Anxiety disorders, the most common mental health problems in children
and adolescents, often go untreated while children suffer, even though
there are effective treatments available, according to a new report on
anxiety in children and adolescents from the Child Mind Institute in New
York. Anxiety may be missed because it doesn’t necessarily declare
itself with attention-getting disruptive behaviors; in fact, symptoms
may keep some children quiet and inhibited, though in other children,
alternatively, anxiety may be misunderstood as oppositional behavior.
Adults may also assume that anxiety in a child is just a phase to be outgrown. A certain amount of anxiety is a normal aspect of development for young children – consider separation anxiety, for example – and it can even be protective, since children need to learn to keep themselves safe and anticipate certain kinds of dangers. But when worrying or avoiding possible threats gets in the way of a child’s functioning or a child’s enjoyment, it should be a signal to parents that help is needed, not just watching and waiting, not arranging the child’s life to avoid the occasions of anxiety.
Kathleen Merikangas, the senior investigator and chief of the Genetic Epidemiology Research Branch at the National Institute of Mental Health, said, “To me, anxiety is one of the most underrecognized or under-treated conditions of childhood and adolescence.” These children can get missed, she said, because they may seem to be functioning well; many don’t have the kinds of developmental problems or attention issues that draw attention in school, though they may be suffering.
Consider the child whose anxiety about speaking in public gets in the way of participating in class. The child may be silent out of a fear of being laughed at or otherwise rejected, Dr. Merikangas said, but to the teacher, it may look like the child is just not interested. Environmental modifications can really help these children thrive in school, she said; for example, working in small groups with children they know.
The new report, released in September, summarizes the evidence that early temperament in children predicts their later behavior patterns around anxiety; toddlers who show what are called “behaviorally inhibited” behaviors, which parents are likely to perceive as extreme shyness, or anxiety around new people, are more likely to develop social anxiety later on. That doesn’t mean that shyness is pathological (as with all varieties of temperament, there’s a wide range of function), but it does suggest how important it is to help a child with this temperament who develops difficulties.
The tendency toward anxiety – and toward some specific forms of anxiety, like phobias – may persist throughout childhood and adolescence and into adulthood. And anxiety is closely tied to depression, Dr. Merikangas said. Although there have been reports that anxiety rates among American teenagers have soared, she cited evidence that the international rates of the underlying disorders had stayed consistent from 1998 to 2013; there is no global “epidemic” of clinical anxiety disorders, she said.
But with rates of suicide and suicidal ideation on the rise, it’s particularly important to provide information to schools and to parents about recognizing anxiety and getting children help.
Dr. Harold Koplewicz, the president of the Child Mind Institute, said that when anxiety disorders in children are left untreated, anxiety can inhibit their lives, making standard daily activities difficult, from attending school to sleeping in their own beds, and lead to many extra visits to the school nurse or the pediatrician.
But beyond that, he said, “people underestimate that this is a gateway disorder.” If children don’t get help with these disorders, they may be at risk to develop other mental health problems; the child with severe separation anxiety may develop panic disorder, he said; the child with untreated general anxiety may be at greater risk for depression.
Dr. Merikangas was a co-investigator on a national study of mental disorders in adolescents, which has shown both that anxiety disorders were the most common mental health problems in adolescents in the United States, and also the problems that showed up earliest in those children’s lives – the mean age of onset for anxiety disorders was 6. But many adolescents had never received treatment. That makes it essential to get the word out, Dr. Merikangas said, that anxiety is “one of the most treatable symptoms and syndromes, we can really change their lives with minimal intervention.”
“All these disorders are remarkably treatable,” Dr. Koplewicz said. There are highly effective behavioral and psychosocial therapies, including cognitive behavioral therapies, to help children cope with the demands of daily life. For children who don’t respond to psychosocial therapies, he said, medications can be added.
But perhaps because anxiety is a normal response, parents often believe that even severe and disabling anxiety symptoms are just a phase, and on average, there is a two-year lag between the time children develop anxiety and the time they get help. “It’s bad for these children’s brains,” he said. “Having your brain’s thermostat miss-set is not good for your brain.”
“Anxiety can manifest itself along a continuum,” said Rachel Busman, the senior director of the anxiety disorders center at the Child Mind Institute. The report shows that there is some overlap with physical illnesses, such as chronic headaches or stomach aches, often coordinated with school. “That could be a kid’s way of saying, ‘I’m anxious,’” she said.
And when a child who is having a lot of difficulty with separation gets into the classroom, Dr. Busman said, that child may start throwing things, or running and hiding, and that “bad behavior” may represent the fight or flight response of anxiety. “We’ve also seen kids who have intense social anxiety and their way of managing it is to be class clown,” she said.
Treating children with anxiety always means working with their parents. Jerry Bubrick, senior clinical psychologist at the anxiety disorders center of the Child Mind Institute, said that when children are little, it’s normal for parents to operate in “fix-it mode,” blocking the staircase so a toddler doesn’t tumble down, averting problems before they happen.
As children get older, parents normally pull back, helping children find solutions of their own. “But anxious parents of anxious children remain in fix-it mode,” he said, helping their children avoid the situations that make them anxious. Therapy involves exposing children to those situations and helping them develop strategies to manage them; with treatment, Dr. Bubrick said, parents can “let the child experience the anxiety and learn to tolerate and overcome it on their own.”
“If you see things you’re not sure about, talk to the preschool, talk to the pediatrician, be open to the idea that maybe there is anxiety,” even in a young child, Dr. Busman said. Separation anxiety can be a problem even in children who are able to go to school, she said. Parents should pay attention if a child can’t be left with a babysitter, a child can’t sleep alone at home. “These are the kids, they go into the bathroom, and they’re like, are you still there?” she said. “We do see really young anxious children.”
“If your child is suffering distress and dysfunction, reach out to your pediatrician,” Dr. Koplewicz said. When you get to a mental health professional, “make sure you ask the right questions,” he said, including asking whether that person has specific experience with treating anxiety and how long the treatment is expected to take.
“You want a professional who understands what they’re doing and can explain to you what they’re doing.”
By Perry Klass
1 October 2018
Youth with a history of institutional rearing assigned to early foster care intervention had less problematic trajectories of psychopathology from childhood to adolescence, study findings revealed.
“Early foster care placement has been shown to partially mitigate the negative psychiatric outcomes of institutionally reared children,” Mark Wade, PhD, division of developmental medicine, Boston Children’s Hospital, Harvard Medical School, and colleagues wrote. “Little is known about the mental health trajectories of institutionalized children, in part because there are so few longitudinal studies in this field.”
In this longitudinal, intent-to-treat randomized clinical study, researchers evaluated the trajectories of latent psychopathology factors – general, internalizing and externalizing – among children with a history of institutional rearing. They also examined whether randomization to foster care was tied to reductions in psychopathology from age 8 years through adolescence.
Children from Romania residing in six institutions underwent baseline testing and then were randomly allocated to a care as usual group or a foster care group. A matched sample of never-institutionalized children served as the comparison group. Participants were followed up at 8, 12 and 16 years. Wade and colleagues examined participants’ psychopathology via the MacArthur Health and Behavior Questionnaire and teacher/caregiver-reported symptoms.
In total, 220 children, 119 of whom had histories of institutional rearing, were included in the analysis. According to the results, children in the care as usual group and in the foster care group experienced higher general psychopathology compared with never-institutionalized children at ages 8, 12 and 16 years.
The care as usual and foster care groups did not differ on their level of general psychopathology at age 8 years; however, differences started emerging by age 12 years. By age 16 years, children in the foster care group had significantly lower general psychopathology factors than those in the care as usual group. Wade and colleagues indicated that these group differences were likely driven by the finding that foster care children showed modest declines in general psychopathology from age 8 years to age 16 years, while care as usual children remained high.
Although the care as usual and foster care groups showed increasing divergence in externalizing psychopathology factors over time, demonstrating that the foster care intervention lead to fewer problems than care as usual by age 16 years, the results showed no internalizing differences.
“This study provides strong evidence that the beneficial effects of foster care grow incrementally over time and may promote healthy adaptation during a formative period of neurophysiological reorganization,” the investigators wrote. “Elucidating how these neurophysiological systems map onto long-term trajectories of psychopathology is a crucial area for future research.”
The results presented by Wade and colleagues support the importance of early interventions for institutionalized children, Jonathan D. Schaefer, MA, from the department of psychology and neuroscience, Duke University, wrote in an accompanying editorial.
“Their results also underscore the notion that hierarchical models of psychopathology will continue to be important organizing structures in understanding not only patterns of comorbidity among disorders, but also how the liability to these conditions is shaped by environmental influences,” Schaefer concluded.
By Savannah Demko
2 October 2018
Negative views of looked-after children are commonplace among teachers, with many labelling them "problem children", a survey has found.
Among more than 400 teachers surveyed, 87 per cent said they had heard at least one colleague express a negative view about looked-after children in their schools, with a third saying they heard such views often.
Three quarters had heard a colleague say that children in care are less likely to succeed in life, while 70 per cent had heard them referred to as "problem children".
Nearly half or those surveyed reported hearing a teacher say that children in care are less academically able and 13 per cent had heard a colleague say that it is the child's fault they are in care.
The survey has been carried out by children in care charities Become and Voices From Care Cymru for their report Teachers Who Care.
The report calls for better training for school staff to improve their understanding of the distinct needs of children in care, such as trauma and attachment issues. This training should also address what care is like and how to work with virtual school heads.
The survey found that the vast majority of teachers received no training about looked-after children before they qualified as a teacher, and a quarter had not had any training around looked-after children issues either before or after they qualified.
"As charities who work with young people in care every day, we know that looked-after children worry about what their teachers think of them, and fear being written off as 'difficult' or unlikely to succeed in life," states the report.
"Children in care can struggle at school because of their circumstances, whether that be pre-care trauma, or the disruption and instability of placement moves, and they know that sometimes teachers do not understand what they're going through.
"Teachers therefore need to be supportive and understanding, while also being ambitious for looked-after children and seeing that they have inherent potential equal to their peers."
The survey also reveals that teachers are keen to see more support from children's services in helping looked-after children in their school - 31 per cent said there was not enough support from social workers and 16 per cent said they'd like more help from children's services.
Among recommendations made by the two charities is for schools to invite social workers to meet with staff to explain their work and create opportunities for closer collaboration and information sharing.
The Department for Education's What Works Centre for Children's Social Care is currently involved in an initiative to test out placing social workers in schools.
By Joe Lepper
28 September 2018