Inpatient Docs: STOP "diagnosing" kids with ASD and expecting the outpatient doc treat it

[smalltownpsych]

No study has ever showed increased suicide, or even suicide attempts on SSRIs. Some have shown increased suicidal thoughts, leading to the BBW, which then led to some very interesting chances at research to have an abrupt change in prescribing of SSRIs which is absolutely of interest to anyone who knows/cares about public health.

re: ADHD, I am not sure who the heck told you there is no evidence for improvement but that is such a patently incorrect summary of the literature. There are literally like 100 articles on this, many of which were done in other countries that have methodological advantages to research that could even be conducted in the US and is really the gold standard for long-term studies. Here is 1 review but is not even close to exhaustive of the literature.

http://bmcmedicine.biomedcentral.com/articles/10.1186/1741-7015-10-99

Re: psychosis there has been admittedly early studies re: omega 3's in high risk youth, which is child psych. Also, there is now evidence of harm (that is earlier) psychosis with stimulants in kids with parents that had schizophrenia. I attempt to ameliorate that harm using non-stimulant tx for ADHD after it's started by other prescribers.

I'm a bit too busy with personal life to post 50 articles, but this anti-child psychiatry stance from a lot of SDN is really quite toxic to the field. I am not sure how people get off so much on bashing CAP and the only reason I even wrote this is for prospective medical students/residents.

Just want to point out that without random assignment the groups of kids with ADHD with treatment and those without are not the same. Several alternative variables come to mind when thinking about these two groups. Besides ADHD isn't an either or so perhaps the most benefit is for the most severe. There are negative aspects of treatment that are also not looked at in many of the studies. Especially important is the misdiagnosing that occurs in the real world as this is automatically excluded from the studies.

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[Merovinge]

im not sure why you tend to fly on the defensive, i am not sure I, nor anyone else has been particularly disparaging of child psych, I am certainly no more anti-child psych than I am antipsychiatry in general. it's all a bit precious and this kind of reaction is not going to endear med students into the profession. rather, I asked reasonable questions out of genuine inquiry and when you react in this kind of way it suggests you aren't so interested in discussing the evidence.

People are disparaging child psych all the time on these boards, sometimes for reasonable things, but often not. I heard it constantly throughout adult residency where it was a badge of honor to be uncomfortable with kids or do poorly on a child rotation, much like I have heard surgeons give bumps to med students who did poorly on a psych rotation. It's unfortunately germane to my daily living, like at the meeting the chair of our department had with our child chair this past week where he was making not nice remarks about CAP. I have near zero insight into why this schism exists which is what makes it more frustrating.

I stand up for CAP because I would have never gone into the field without my medical school experience and mentors. My adult residency had me not wanting to follow my plans to be honest, but its been one of the best decisions of my life to do so. I meet a lot of medical students interest in the area, which is one of, if not the most, undeserved areas of medicine and I think future kids/generations need to see people who actually stick up for the field.

Reading what you said about not thinking evidence supported improved long-term outcomes in ADHD seemed a bit absurd to me since you know the literature so well and this is one of the few areas of CAP that has good to great research. I have had nearly every attending I have worked with in medical school, residency, and fellowship either casually acknowledge, discuss this patients, or go over articles related to this, so I was originally finding it hard to believe that was not your experience.

thanks for the link will have a read. most early psychosis programs are run by general psychiatrists even though the population is under-18s. I am familiar with the omega-3 research as I mentioned but it is not common for psychiatrists to prescribe omega-3s to these ARMS kids.

Im not sure what you mean about Omega 3's not being used by CAP, given the risk/benefit ratio they make a lot of sense when they can be covered/acquired and the right age for intervention is in the CAP ages. Historically they have not been used but this research is new. If it gets any more positive replication I have little doubt it will become more widespread.

you are of course correct about SRIs not being associated with suicide, but misleading in stating they have not been associated with increased suicide attempts, which they have been (and here). I was taught by and worked with some of the leading public health researchers on suicide, and they were quite clear that the claims about increased suicides being related to the BBW were incredibly dubious and misleading. A trend being "of interest" and being of significance are quite different things altogether. In fact, the spike in suicides could not be related to the black box warning in any significant way since that warning came at the end of 2004 (so could not really account for the suicides for 2004), and SRI prescriptions have been consistently increasing and are higher than 2004 levels now and suicide rates are even greater in youth than they were at the time of the BBW.

So your generalized description is not what I mean. The analysis for public health measures is not just overall population suicide rate over time versus SSRI rate over time, although that is what initial studies looked at (which I agree is a course measure and not helpful). Good research looks to see what areas had what differential in change in prescriptions and how suicide rate changed compared to that differential. I'll do my best to get an article or two for you on this.

 

[Merovinge]

Just want to point out that without random assignment the groups of kids with ADHD with treatment and those without are not the same. Several alternative variables come to mind when thinking about these two groups. Besides ADHD isn't an either or so perhaps the most benefit is for the most severe. There are negative aspects of treatment that are also not looked at in many of the studies. Especially important is the misdiagnosing that occurs in the real world as this is automatically excluded from the studies.

Certainly your first statement is true, and is included in any population analysis as best as it can be. No strictly population based studies can 100% control for this (there are certainly matching based statistics that can help) but there have been some RCT followup data that suggest similar findings. Negative aspects of treatment are (thankfully) relative minor to date with stimulant or non-stimulant tx of ADHD. Positive findings however include things such: decreased rate of car accidents, increase HS graduation rate, decreased rate of ending up in prison, decreased (possibly) rate of future substance abuse, decreased oppositionality and more . This includes European data where the general onus is to not treat children with psychotropics and yet even their researchers are waving the flag and suggesting treatment.

At this point, it's a lot like saying that treating kids with asthma is concerning. The negative aspects of treatment are rarely accounted for those kids (interestingly asthma tx has similar SE to ADHD tx) and sometimes they are misdiagnosed when they do not have PFTs!

 

[DD214_DOC]

I haven't really encountered what you guys are talking about regarding CAP. From my experience, CAP had a bad reputation mostly because of the type of work involved and how frustrating and stressful/overwhelming it can get. Also because a lot of parents just really suck.

However, I can understand WHY some people would have a generally negative opinion of CAP psychiatrists, and I fault my reckless colleagues -- although I wouldn't necessarily refer to such types as colleagues -- for a large portion of this. As I have said many times, it takes a special type of personality to do CAPs well, otherwise you're at great risk of falling into the trap of aligning yourself with the parental pathology and missing the real issue or, worse, knowingly never addressing the real issues because the thought of an angry parent yelling at you creates too much anxiety. That's fine if you're the highly-anxious conflict-avoidant type, but you have no business being in CAPs.

CAPs does, I gather, have the reputation of unnecessarily medicating children and of lots of off-label use with minimal supporting evidence. Although, almost everything we use is off-label. There is a lot of truth in this, unfortunately. But, there are also a ton of dynamics at play to which the non-CAP types are completely oblivious. Sometimes, that 8 year old isn't on Seroquel for behavioral problems because the CAP psychiatrist is too lazy to do the, "real work" of therapy and parent education, or because they're stupid. It just might be possible that the parents, despite countless efforts by the psychiatrist, continue to refuse to follow recommendations for therapy or be compliant with this aspect of treatment. Rather than allow the child to continue being stuck in the middle of it all, the best option is to control the behaviors with medications so that his unemotional, unattached, critical and vindictive parent/s -- who were constantly screaming at him and telling him how he's a worthless POS and the cause of all their problems -- won't continue ruining him. It breaks the cycle, even if the method isn't the most ideal.

It's unfortunate, really, that more don't go into CAPS, if only for the additional training. In retrospect, I really wish I would have had the additional knowledge in development and systems theory back when I saw adults. It would have been really helpful.

 

[smalltownpsych]

Certainly your first statement is true, and is included in any population analysis as best as it can be. No strictly population based studies can 100% control for this (there are certainly matching based statistics that can help) but there have been some RCT followup data that suggest similar findings. Negative aspects of treatment are (thankfully) relative minor to date with stimulant or non-stimulant tx of ADHD. Positive findings however include things such: decreased rate of car accidents, increase HS graduation rate, decreased rate of ending up in prison, decreased (possibly) rate of future substance abuse, decreased oppositionality and more . This includes European data where the general onus is to not treat children with psychotropics and yet even their researchers are waving the flag and suggesting treatment.

At this point, it's a lot like saying that treating kids with asthma is concerning. The negative aspects of treatment are rarely accounted for those kids (interestingly asthma tx has similar SE to ADHD tx) and sometimes they are misdiagnosed when they do not have PFTs!

The message that the kid internalizes if diagnosed as ADHD and need medication is completely different from something like asthma. I actually believe that there is less of a problem with CAP when it comes to this because they are more likely to be accurate in the diagnosis and look at other factors than would the majority of prescribers. I could see why better outcomes might occur in Europe as they are not so focused on medications first and foremost so more likely to be more severe cases with correct dx. I would be less negative about ADHD treatment if not for the fact that about half the kids I see who are being prescribed stimulants don't have ADHD. I am not antipsychiatry by any means as many of my patients do benefit from these life saving medications, just anti the quick fix mentality in our society that leads to incorrect treatments and poorer outcomes.

 

[Merovinge]

The message that the kid internalizes if diagnosed as ADHD and need medication is completely different from something like asthma. I actually believe that there is less of a problem with CAP when it comes to this because they are more likely to be accurate in the diagnosis and look at other factors than would the majority of prescribers. I could see why better outcomes might occur in Europe as they are not so focused on medications first and foremost so more likely to be more severe cases with correct dx. I would be less negative about ADHD treatment if not for the fact that about half the kids I see who are being prescribed stimulants don't have ADHD. I am not antipsychiatry by any means as many of my patients do benefit from these life saving medications, just anti the quick fix mentality in our society that leads to incorrect treatments and poorer outcomes.

Absolutely reasonable that 1/2 the kids you prescribed stims don't have ADHD, but again due to lack of CAP providers, the overwhelming majority of stims are prescribed by peds/FM/NPs and not CAP physicians. These folks have a lot of pressure to see patients in 5-10 minutes and if the parents "forget" to bring in the Vanderbilt's (which already have some problems if taken as gospel), then good luck making the best of that situation.

I can also believe that a kid internalizes a diagnosis of ADHD differently than asthma but I don't think that's correct or ideal. I actually like my random analogy even more when I think about it because they are both conditions which people frequently grow out of the clinical phenotype and then have sub-syndromic difficulties in adulthood. Treatment for both simply ameliorates the sx and is not disease modifying. Both have quick on and quick off treatment that can sometimes suffer from poor compliance but have relatively large effect sizes when used and low incidents of serious SE. Not exercising because you have asthma leads to lots of long term complications, just like not learning because you have ADHD.

 

[SeniorWrangler]

Rather than allow the child to continue being stuck in the middle of it all, the best option is to control the behaviors with medications so that his unemotional, unattached, critical and vindictive parent/s -- who were constantly screaming at him and telling him how he's a worthless POS and the cause of all their problems -- won't continue ruining him. It breaks the cycle, even if the method isn't the most ideal.

This is pretty chilling.