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June 1, 2009JAMA news releases are made available to the public after 3 pm US Central time on the first 4 Tuesdays of each month. The Archives of Journals news releases are made available to the public after 3 pm Central time on Mondays. We also provide a list of previous news releases. THIS WEEK'S CONTENTS
ARCHIVES OF GENERAL PSYCHIATRY NEWS RELEASES
(Embargoed Until: 3 P.M. (CT), Monday, June 1, 2009)
ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE NEWS RELEASES
(Embargoed Until: 3 P.M. (CT), Monday, June 1, 2009)
INFORMATION CONTAINED IN THESE NEWS RELEASES IS PROTECTED BY COPYRIGHT. JOURNAL ATTRIBUTION IS REQUIRED. JOURNALISTS CAN NOW ACCESS EMBARGOED JAMA/ARCHIVES STUDIES ON-LINE. Go to www.jamamedia.org for more information and to apply for access. Please Note: The FOR THE MEDIA website now has a search feature to enable media to find previous JAMA/Archives news releases on specific medical topics. This search feature link is located on the home page at www.jamamedia.org
EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, June 1, 2009
Antidepressant Does Not Appear to Reduce Repetitive Behaviors in Children With Autism Spectrum Disorders
CHICAGO—The antidepressant citalopram does not appear to reduce the occurrence of repetitive behaviors in children and teens with autism spectrum disorders, according to a report in the June issue of Archives of General Psychiatry, one of the JAMA/Archives journals. Although the U.S. Food and Drug Administration has not approved any drugs to treat the core symptoms of autism and related disorders, medications are increasingly being used in this population, according to background information in the article. Citalopram belongs to a class of antidepressants known as selective serotonin reuptake inhibitors (SSRIs), which interfere with the way the brain regulates the neurotransmitter serotonin. "Because of suggested similarities between repetitive behavior in autism spectrum disorders and obsessive-compulsive disorder and the findings of serotonin system abnormalities in autism, anti-obsessional agents such as SSRIs have long been of interest," the authors write. Repetitive behaviors in children with autism—including inflexible routines and repetitive play—tend to persevere over time and predict the endurance of an early autism diagnosis. "Despite the relative dearth of evidence supporting their use, SSRIs are among the most frequently used medications for children with autism, partially because of their perceived safety." Bryan H. King, M.D., of Seattle Children's Hospital and the University of Washington, Seattle, and colleagues conducted a randomized controlled trial to determine the safety and efficacy of citalopram in children with autism spectrum disorders who had at least moderate levels of repetitive behavior. Of 149 children age 5 to 17 (average age 9.4) with autism spectrum disorders who participated, 73 were randomly assigned to receive citalopram (at an average dosage of 16.5 milligrams per day) and 76 to receive a placebo for 12 weeks. Most of the participants (82.6 percent) completed the 12-week trial. At the end of the treatment period, there were no differences between the treatment group and the placebo group in the number of children who demonstrated improvements on scales measuring repetitive behavior (32.9 percent vs. 34.2 percent). "Citalopram use was significantly more likely to be associated with adverse events, particularly increased energy level, impulsiveness, decreased concentration, hyperactivity, stereotypy [mechanical repetition of the same posture or movement], diarrhea, insomnia and dry skin or pruritis," the authors write.
"There is growing recognition that children and adolescents with autism spectrum disorders have serious behavioral problems and psychiatric symptoms that may be appropriate targets for pharmacotherapy," they continue. "To date, there are few large-scale trials to guide clinical practice, so clinicians are left to address these problems with inadequate information. The results of this trial indicate that citalopram is not an effective treatment for children having autism spectrum disorders with moderate or greater repetitive behavior. The results also highlight the urgent need for placebo-controlled trials of medications commonly used for children with autism spectrum disorders to determine whether the risks of specific drugs substantially outweigh their benefits."
Editor's Note: This work was funded by National Institutes of Health via STAART center contracts. All of the study medications were purchased using National Institutes of Health grant funds. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. Editorial: Data May Change Practice of Prescribing SSRIs to Children With Autism
"The use of selective serotonin reuptake inhibitors has prompted considerable interest regarding their possible application for treating children with autism," writes Fred R. Volkmar, M.D., of Yale Child Study Center, New Haven, Conn., in an accompanying editorial. "Previous double-blind, placebo-controlled studies in adults with autism showed a reduction in levels of repetitive behaviors," Dr. Volkmar writes. "Given the frequency of such behaviors in children with autism and their association with other features such as anxiety, depression and rigidity, selective serotonin reuptake inhibitors would seem to have, at least in theory, some therapeutic potential."
"Although the findings in the study by King et al were negative, the results are not difficult to interpret," Dr. Volkmar concludes. "The medication does not appear to be useful for repetitive behaviors in children with autism and related conditions. We need more studies of this kind to advance research and guide clinical practice."
Editor's Note: Dr. Volkmar reports book royalty income and grant support from the National Institute of Mental Health, the Eunice Kennedy Shriver National Institute of Child Health and Human Development and Autism Speaks. He is also compensated for serving as editor of the Journal of Autism and Developmental Disorders. Please see the article for additional information, including author contributions and affiliations, financial disclosures, funding and support, etc. For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org.
EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, June 1, 2009
Changing Residences Associated With Increased Risk of Suicidal Behavior Among Children
CHICAGO—Danish children who move frequently appear to have an increased risk of attempted or completed suicide between ages 11 and 17, according to a report in the June issue of Archives of General Psychiatry, one of the JAMA/Archives journals. Changes of residence occur frequently in modern society, and about half of children move at least once before their 10th birthday, according to background information in the article. Moving frequently is a burden to most people, including children, who typically move passively because of a parent's decision. "Whatever inspires the move, such experiences during childhood may be traumatic or psychologically distressing and, therefore, may affect a child's physical, mental, social and emotional well-being," the authors write. "Some children have difficulties coping with the change and may exhibit their distress as suicidal behavior, the last-resort response to the hardship and stress." Ping Qin, Ph.D., M.D., and colleagues at the University of Aarhus, Denmark, use data from Danish national registries to identify all children born between 1978 and 1995. Between 11 and 17 years of age, 4,160 of these children attempted suicide based on hospital records, and 79 completed suicide. For each suicide attempt or completion, the researchers selected 30 control children who were the same sex and age. Compared with the control children, those who attempted suicide were more likely to have changed residences frequently—55.2 percent of suicidal children and 32 percent of controls had moved more than three times, and 7.4 percent had moved more than 10 times (compared with 1.9 percent of controls). Frequent moves were also more common among children who completed suicide. A dose-response relationship was observed for both attempted and completed suicide, meaning that the more often a child changed addresses, the more likely he or she was to have attempted or completed suicide. The associations remained significant after the researchers controlled for other factors, such as birthplace and parents' mental health. "The breakdown of connections with peers, discontinuation of group activities, distress and worries related to the new environment are potentially psychologically distressing events for young children. Frequent exposures to these events can be stressful and confusing and may affect their psychosocial well-being, thus increasing their intention toward ending their life if they are unable to cope," the authors write. In addition, moving is stressful for parents and may result in their inability to attend to their children's emotional needs. "Children may feel ignored and have no one to communicate with. A suicide attempt may, to some extent, express the need for more attention from their parents."
"Although we could not distinguish whether frequent change of residence was a causal risk factor or merely an intermediate variable of other risk factors for suicidal behavior, the findings from this study suggest the importance of stability on children's psychosocial well-being," they conclude. The results raise questions for parents who move frequently, such as whether they have to move, how to minimize the effects of necessary moves on children and how to further involve children in the moving process. "Last, but not least, parents, caretakers and schools should be aware of the psychosocial needs of children who have recently moved and be ready to help them resolve their distress together or through professional assistance."
Editor's Note: This study was funded by the Danish Health Insurance Foundation, the Danish Ministry of Social Affairs and the Stanley Medical Research Institute. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org.
EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, June 1, 2009
FDA Warnings About Antidepressants Associated With Lasting, Unintended Changes in Diagnosis and Treatment
CHICAGO—Government warnings about suicidality among children taking antidepressants appear to be associated with unintended and persistent changes in the diagnosis and treatment of depression in children and adults, according to a report in the June issue of Archives of General Psychiatry, one of the JAMA/Archives journals. "In October 2003 the Food and Drug Administration (FDA) issued a Public Health Advisory about the risk of suicidality for pediatric patients taking antidepressants; a boxed warning, package insert and medication guide were implemented in February 2005," the authors write as background information in the article. "The warning was extended to young adults aged 18 to 24 years in May 2007. Immediately following the 2003 advisory, unintended declines in case finding and non–selective serotonin reuptake inhibitor substitute treatment were shown for pediatric patients, and spillover effects were seen in adult patients, who were not targeted by the warnings." To determine whether these unintentional consequences have persisted, Anne M. Libby, Ph.D., and colleagues at the University of Colorado Denver's School of Medicine analyzed patterns in a national integrated managed care claims database from July 1999 through June 2007. During this time period, 91,748 children (ages 5 to 18), 70,311 young adults (ages 19 to 24) and 630,748 adults (ages 25 to 89) were diagnosed with depression. Between 1999 and 2004, the rate of diagnosed episodes of depression increased steadily among each group. "After 2004 the observed national rate of pediatric case-finding fell significantly, with the post-advisory decline persisting such that the rate per 1,000 enrollees in 2007 (3.5) approached the 1999 level (3.2)," the authors write. "Based on the historical trend established in the five years prior to the advisory, the 2007 rate per 1,000 enrollees would have been 15.6 for young adults and 20.3 for adults; the actual observed rate was 9.6 for young adults and 12.4 for adults." In addition, primary care clinicians specifically continued to diagnose fewer cases of depression, with a 44 percent lower rate of diagnosis among pediatric patients, 37 percent lower among young adults and 29 percent lower among adults. This trend is particularly important because the general medical sector sees the largest proportion of patients seeking mental health care in the United States, the authors note. "Substitution of other forms of treatment might have been an expected outcome of a decrease in first-line treatment for the acute phase of depression," they write. "There was a small but significant increase in the proportion of new depression cases that received at least one visit for psychotherapy within 180 days of diagnosis for adults only. Antidepressant alternatives—atypical antipsychotics and anxiolytics—did not increase statistically or in clinically meaningful ways from their very low base rates in the pre-advisory period."
The findings suggest that initial unintended consequences of the FDA warnings have continued through 2007, the authors conclude. "Diagnosing decreases persist," they write. "Substitute care did not compensate in pediatric and young adult groups, and spillover to adults continued, suggesting that unintended effects are nontransitory, substantial and diffuse in a large national population. Policy actions are required to counter the unintended consequences of reduced depression treatment."
Editor's Note: Dr. Libby and co-authors Dr. Orton and Dr. Valuck report unrestricted investigator-initiated research grants from Eli Lilly and Company, Forest Pharmaceuticals, Lundbeck and the American Foundation for Suicide Prevention. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org. EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, June 1, 2009
TV Noise Associated With Fewer Verbal Interactions Between Infants and Parents
CHICAGO—For every hour they spend in the presence of an audible television, parents speak fewer words and infants are less likely to make vocalizations in response, according to a report in the June issue of Archives of Pediatrics & Adolescent Medicine, one of the JAMA/Archives journals. An increasing number of children are exposed to television during their early years, according to background information in the article. The American Academy of Pediatrics discourages television or video viewing before the age of 2, suggesting that parents focus on interactive play to foster child development. Critical developmental tasks occurring during this time period include language acquisition, which is promoted by interacting with adults. To test the hypothesis that hearing a television is associated with decreased parent and child interactions, Dimitri A. Christakis, M.D., M.P.H., studied 329 two- to 48-month-old children. The infants wore digital devices on random days for up to 24 months that recorded everything they heard or said. The recordings were then analyzed by a program featuring speech-recognition technology, which categorized the sounds and counted adult words, vocalizations by the children and conversational turns, or interactions between adults and children. Each additional hour of television exposure was associated with a decrease of 770 words (7 percent) the child heard from an adult during the recording session. Hours of television were also associated with a decrease in the number and length of child vocalizations and in the number of conversational turns. "Some of these reductions are likely due to children being left alone in front of the television screen, but others likely reflect situations in which adults, though present, are distracted by the screen and not interacting with their infant in a discernible manner. At first blush, these findings may seem entirely intuitive," the authors write. "However, these findings must be interpreted in light of the fact that purveyors of infant DVDs claim that their products are designed to give parents and children a chance to interact with one another, an assertion that lacks empirical evidence."
The results may help explain previously identified associations between television viewing and delayed language acquisition, the authors note. "Furthermore, our results highlight the need to conceptualize media exposure with consideration of more than just amount of exposure," they conclude. "Given the critical role that adult caregivers play in children's linguistic development, whether they talk to their child while the screen is on may be critical and explain the effects that are attributed to content or even amount of television watched. That is, whether parents talk less (or not at all) during some types of programs or at some times of the day may be as important in this age group as what is being watched."
Editor's Note: Co-authors Dr. Gilkerson, Dr. Xu, Dr. Gray, Dr. Yapanel and Mr. Richards were employed by the LENA Foundation. The LENA Foundation paid for the data collection. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org. EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, June 1, 2009
Many Children Held Back in Elementary School Do Not Receive Plan for Special Education Services
CHICAGO—Many children who are retained in kindergarten, first or third grade for academic reasons do not subsequently receive a document outlining the individualized special education services they should receive, according to a report in the June issue of Archives of Pediatrics & Adolescent Medicine, one of the JAMA/Archives journals. Each year, 5 percent to 10 percent of American students are retained at the same grade level, according to background information in the article. One in 10 students age 16 to 19 have repeated a grade. "Some of these students may require special education services at the time they are retained, in subsequent years or both," the authors write. "One approach to supporting a child with low academic achievement is the provision of special education services, as indicated in an Individualized Education Program (IEP). An IEP is a legally binding document describing a child's special education services and is developed after the child has undergone a special evaluation and has been determined eligible for services." Eligibility for an IEP varies from state to state, but under the Individuals With Disabilities Education Act, every American child has the right to an evaluation. Michael Silverstein, M.D., M.P.H., of Boston Medical Center, and colleagues studied 380 children nationwide who were retained in elementary school for academic reasons (300 in kindergarten or first grade and 80 in third grade). The children were followed up through fifth grade. Of the children retained in kindergarten or first grade, 40 (12.9 percent) had an IEP on record during the year they were held back, 60 (18.2 percent) received an IEP in the next one to five years and 210 (68.9 percent) never received an IEP. Twenty (18.9 percent) of the third-graders had an IEP during or before the year they were retained, 10 (8.8 percent) received one in the next one to two years and 60 (72.3 percent) never received one. Children retained in kindergarten and first grade were less likely to have an IEP if they had a high socioeconomic status or lived in the suburbs rather than rural areas. "Among kindergarten/first grade retainees with persistently low academic achievement in math and reading, as assessed by standardized testing, 38.2 percent and 29.7 percent, respectively, never received an IEP," the authors write.
"Although debates about the value of grade retention abound, the practice, in and of itself, has never been demonstrated to be an effective intervention relative to subsequent academic achievement or socioemotional adjustment," the authors write. "Therefore, some experts in the field believe that retention should be accompanied by focused individualized assessments of children's special education needs. Although our results do not definitely demonstrate that retained children have been denied their rights to such assessments, they raise the question of whether the potential special education needs of retained children, particularly those who demonstrate persistent academic difficulties, are being addressed consistently."
Editor's Note: This study was supported by a training grant from the Maternal Child Health Bureau. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org. EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, June 1, 2009
Many U.S. Children Have Inadequate Access to Pediatric Trauma Care
CHICAGO—Approximately 30 percent U.S. children live more than one hour away from a pediatric trauma center by ground or by air transportation, according to a report in the June issue of Archives of Pediatrics & Adolescent Medicine, one of the JAMA/Archives journals. More children between ages 1 and 14 die of injuries than of all other causes combined, according to background information in the article. Trauma centers have been shown to provide a survival benefit to severely injured adult and pediatric patients. Although a comprehensive inventory of adult trauma centers is regularly updated, no similar listing of pediatric trauma centers currently exists. Michael L. Nance, M.D., of the Children's Hospital of Philadelphia, and colleagues used information from national, state and local trauma systems authorities to create a catalog of verified pediatric trauma centers along with self-identified trauma centers. Using U.S. Census and Postal Service data, along with information about air medical services, the authors calculated access to age-specific trauma care services for American children younger than 15. A total of 170 verified pediatric trauma centers were identified, located in 41 states (including the District of Columbia). An estimated 71.5 percent of children younger than 15 were within 60 minutes of one of the centers by ground or by air transportation, whereas 43 percent were within 60 minutes if only ground transportation was considered. The authors estimate that 17.4 million U.S. children would not have access to a pediatric trauma center within 60 minutes. "Access ranged from 22.9 percent of the population in the most rural areas of the United States to 93.5 percent in the most urban," the authors write. Access also varied by state, ranging from more than 90 percent of children having access in 11 states to less than 25 percent having access in 12 states. "The addition of 24 candidate centers [not verified] increased coverage to 77.4 percent of the pediatric population being within 60 minutes of a pediatric trauma center." "While this study does not directly address outcome from injury as it relates to pediatric trauma care access, it stands to reason that limited access may equate to suboptimal trauma care and a lower likelihood of survival," the authors write. "Several authors have demonstrated superior outcomes for children treated in designated pediatric trauma centers." Adult-focused trauma centers may lack pediatric-specific personnel and equipment; however, most injured children are still treated at these facilities.
"Understanding the distribution of existing pediatric trauma centers and gaps in access will allow for more thoughtful trauma systems planning," they conclude. "The creation of an inventory of pediatric trauma care centers allowed us to perform these access calculations. A hospital's capacity to provide optimal care for injured children, however, is dynamic, and our inventory captures only a fixed moment in time. To optimize pediatric trauma care planning, the development of a thorough, standardized and continuously updated catalog of pediatric trauma care resources is necessary."
Editor's Note: This study was supported in part by funds available through the Josephine J. and John M. Templeton Jr. Endowed Chair in Pediatric Trauma. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org. |
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