HERE

IN THIS ISSUE

T his month’s Journal features articles focusingon two important topics: medication adherenceand familial influences on psychopathology.

John March gets the ball rolling with a special 50thanniversary Journal article (p. 427) highlighting thePreschool Attention-Deficit/Hyperactivity DisorderTreatment Study as the culmination of 25 years ofpediatric psychopharmacology trials, which willusher in a new era of interventions translated fromdevelopmental neuroscience.

Woldu and colleagues (p. 490) evaluated the rela-tion among antidepressant treatment adherence, clin-ical response, and suicidal events in the Treatment ofResistant Depression in Adolescents study. Thisstudy randomized adolescents who remained de-pressed after 8 weeks of treatment with a selectiveserotonin reuptake inhibitor to four treatment arms:switch to another selective serotonin reuptake inhib-itor alone, venlafaxine alone, or a selective serotoninreuptake inhibitor or venlafaxine plus cognitive be-havioral therapy. Nonadherence was defined by vari-ation in dose-adjusted plasma levels and by clinicianpill counts. There was a low concordance betweenplasma levels and pill counts, but nonadherence wascommon (50.8% by pill count). Overall response wasrelated to pill counts, but not to plasma levels. Neithermethod of adherence was related to suicidal eventoccurrence or pace of patients’ decline. The investiga-tors conclude that nonadherence is a common andsignificant source of treatment nonresponse.

Marcus and Durkin (p. 480) tested whether stim-ulant medication adherence was associated with im-provement in grade point average in children withattention-deficit/hyperactivity disorder. They corre-lated Medicaid claims with academic records fromfirst through eighth graders in Philadelphia (3,543students across 29,992 marking periods). Adherencewas a disappointing 18.6%. Importantly, grade pointaverage was significantly higher during stimulantadherent versus nonadherent periods (2.18 versus1.99). This relation was stronger in those with comor-bid disruptive behavior disorders. Adherence wasassociated with grade point average increases of 0.106point in boys, 0.111 in girls, 0.078 in elementarystudents, and 0.118 in middle school students.

Murray and colleagues (p. 460) examined the linkbetween maternal and child depression by conduct-

ing a prospective longitudinal study of offspring of

JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY

VOLUME 50 NUMBER 5 MAY 2011

postnatally depressed and nondepressed mothers as-sessed from infancy to 16 years of age. Children ofdepressed mothers were at greater risk of developingdepression by age 16 than were children of nonde-pressed mothers (41.5% versus 12.5%, odds ratio4.99). The investigators suggest that routine screeningfor, and treatment of, maternal postpartum depres-sion might subsequently decrease adolescent depres-sion.

Lewis and colleagues (p. 451) explored environ-mental links between maternal depression and child-hood depression/anxiety. To account for inheritedeffects, they compared 852 families with a child bornby assisted conception, including genetically unre-lated (egg or embryo donation) and genetically re-lated (homologous in vitro fertilization and spermdonation) mother/child pairs. Genetically related andunrelated mother/child and father/child pairs hadsignificant associations between parent/child symp-toms. The investigators conclude that depression canbe transmitted environmentally, independent of in-herited effects, and is not accounted for by sharedadversity measurements.

Morcillo and colleagues (p. 471) probed the rela-tion between parental familism (i.e., strong values ofattachment to nuclear and extended family) and an-tisocial behaviors in Puerto Rican children 5 to 13years of age in the South Bronx and Puerto Rico.Parental familism was protective against antisocialbehavior in girls 5 to 13 years old, but only in boys 5to 9 years old. The investigators suggest that pro-grams targeting antisocial behaviors should incorpo-rate familism.

Vidair and colleagues (p. 441) evaluated parentalpsychiatric symptoms in those bringing their child forpsychiatric evaluation among 801 mothers, 182 fa-thers, and 848 children 6 to 18 years of age. Roughly18% of mothers and fathers reported increased psy-chiatric symptoms. Maternal symptoms were signifi-cantly associated with children’s overall functioningand symptoms of depression, anxiety, and opposi-tional/conduct problems (but not attention-deficit/hyperactivity disorder). In contrast, paternal symp-toms were not significantly associated with overallfunctioning or diagnoses. Maternal and paternalsymptoms were associated with children’s internaliz-ing and externalizing symptoms. The investigatorsconclude that screening parents for psychopathology

should be part of a child’s psychiatric evaluation.

425www.jaacap.org

THERE

ABSTRACT THINKING

rtopb

Access to Care: Start at the Very Beginning

P sychiatric treatment for children involvesmany factors, including adherence and familyfactors, as discussed in this month’s Journal.

Starting at the very beginning, recent updatesfocus on the most fundamental treatment ingredi-ent: access to child and adolescent psychiatrists.

Sarvet and colleagues1 reported data from theMassachusetts Child Psychiatry Access Project, apublically funded program that created six regionalteams to provide primary care clinicians (PCCs) inMassachusetts with rapid access to child psychiatricexpertise, education, and referral assistance. Specifi-cally, Massachusetts Child Psychiatry Access Projectteams provided immediate informal telephone con-sultation to PCCs regarding mental health needs ofchildren in primary care settings and timely formaloutpatient consultations to children referred by PCCs.Each of the six regional teams consisted of one full-time equivalent child psychiatrist, one psychothera-pist, and one care coordinator; the duties of each wereoften rotated among personnel from the host regionalacademic center.

Sarvet et al. showed that from 2005 through 2008the six regional teams enrolled 1,341 PCCs in 353practices covering 95% of Massachusetts’ youths.There was a mean of 12 encounters per quarter forissues including diagnostic questions (34%), identify-ing community resources (27%), and medication con-sultations (27%). PCCs reported an increase in theirability to meet the needs of their psychiatric patients(from 8% to 63%). The investigators concluded thatsuch state-supported programs can be an importantcollaboration among pediatricians, child psychiatrists,and state governments to improve access to childpsychiatric consultation.

Myers and colleagues2 evaluated the use of tele-psychiatry to address lack of access to child psychia-try. Examining service utilization for telepsychiatry

services provided by Seattle Children’s Hospital, they

Project. Pediatrics. 2010;126:1191-1200.2. Myers KM, Vander SA, McCarty CA, et al. Child and adolescent

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eported that 701 patients were treated from 2001hrough 2007 by five psychiatrists and four psychol-gists. They received a mean of 2.8 appointments peratient. They concluded that telepsychiatry is a feasi-le way to improve access to psychiatric care.

Dingle3 explored how medical students are ex-posed to child and adolescent psychiatry at U.S. andCanadian medical schools. Surveys were distributedto medical student education directors at 142schools, with an 81% response rate. Althoughmore than 95% of schools required child andadolescent psychiatry education, the averagenumber of hours was 7.4 in the preclinical yearsand 4.3 hours in the clinical years. Furthermore,some of these didactics were folded into othercourses, such as neuroscience minors or problem-based learning cases, or options, such as for doctor–patient relationship curricula. With respect to clinicalrotations, 62.5% of responding schools had child andadolescent psychiatry clinical rotations, and 25.7%required it. From this, the investigator concluded thatthis survey is consistent with other similar studiesshowing that early exposure of medical students tochild and adolescent psychiatry is minimal andshould be considered in addressing practitionershortages.

Relatedly, the National Residency Matching Pro-gram (http://www.NRMP.org) recently publisheddata from the 2011 Child and Adolescent PsychiatryFellowship match. Of 331 slots at certified programs,85% were filled.

Daniel P. Dickstein, M.D., F.A.A.P.Daniel_Dickstein@Brown.edu

E.P. Bradley HospitalAlpert Medical School, Brown University

Providence, RIDOI:10.1016/j.jaac.2011.02.008

Disclosure: Dr. Dickstein receives research support from the National

Institutes of Health and the American Foundation for Suicide Prevention.

REFERENCES1. Sarvet B, Gold J, Bostic JQ, et al. Improving access to mental health

care for children: the Massachusetts Child Psychiatry Access

telepsychiatry: variations in utilization, referral patterns andpractice trends. J Telemed Telecare. 2010;16:128-133.

3. Dingle AD. Child psychiatry: what are we teaching medicalstudents? Acad Psychiatry. 2010;34:175-182.

AL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY

VOLUME 50 NUMBER 5 MAY 2011