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Women in forensic psychiatry making progress but still have ways to go
AUSTIN, TEX. – Women are making progress in equal representation and leadership within the field of forensic psychiatry, but gender parity remains elusive, according to a presentation at the annual meeting of the American Academy of Psychiatry and the Law.
In the presentation, Kelly L. Coffman, MD, MPH, assistant professor of psychiatry and associate program director of the forensic psychiatry fellowship at Emory University, Atlanta, and Helen M. Farrell, MD, a lecturer at Harvard Medical School, Boston, discussed gender bias in the field and in medicine at large.
After reviewing a handful of Supreme Court cases since the 1970s establishing women’s rights to equal opportunities and harassment-free workplaces, Dr. Farrell noted a recent commentary in the New England Journal of Medicine illustrating the challenges women still face. In that commentary, Reshma Jagsi, MD, a professor of radiation oncology at the University of Michigan, Ann Arbor, and director of the Center for Bioethics and Social Sciences in Medicine, shared her own #MeToo experience within the context of such harassment narratives throughout academic medicine (N Engl J Med. 2018;378:209-11).
Harassment found in medicine
Dr. Jagsi had published a study in 2016 on workplace sexual harassment in medicine that surveyed 1,066 recipients of career development grants from the National Institutes of Health (JAMA. 2016;315:2120-1). The average age of respondents was 43 years, and 46% of respondents were women.
While only 22% of men reported perceiving gender bias in their careers, 70% of women reported such bias. Similarly, 66% of women said they had experienced gender bias in their careers, compared with 10% of men (P less than .001). Women also were substantially more likely to have experienced sexual harassment (30% vs. 4%).
Most women (92%) reporting those experiences described sexist remarks or behavior, 41% experienced unwanted sexual advances, and 9% experienced coercive advances.
“Although a lower proportion reported these experiences than in a 1995 sample, the difference appears large given that the women began their careers after the proportion of female medical students exceeded 40%,” Dr. Jagsi and her colleagues reported in the study.
The effects of those experiences were not minor: Among women who reported harassment, 59% said their confidence as professionals took a hit, and 47% said those experiences hurt their career advancement.
Women still underrepresented
One factor in those high rates might be the extent of existing power differentials: Women remain underrepresented in medical leadership despite accounting for more than half of all enrollees in U.S. medical schools in 2017, according to the Association of American Medical Colleges (AAMC). Female enrollment in medical schools hovered around 40% in the mid-90s, yet in 2015, the AAMC reported that women held 37% of all U.S. medical school faculty positions and 20% of full professorships.
“There’s also a large discrepancy in terms of specialties,” said Dr. Farrell, also a staff psychiatrist at Beth Israel Deaconess Medical Center, Boston. “Women tend to go into fields like pediatrics and ob.gyn. at much higher rates than men, and there are very low rates of women going into surgical fields like neurosurgery and orthopedics.”
Dr. Farrell then zeroed in on the field of forensic psychiatry in particular and various ways to consider how gender bias might manifest: opportunities for exposure to forensics in residency; fellowship applications vs. acceptances; experience in court; publications; invitations to present; large- and small-scale organizational leadership representation; and job placement across the settings of clinics, academics, prisons/institutions; and experience in private practice. Then there’s the perception of female forensic psychiatrists in court.
“There’s a really big question about the difference between how men and women are perceived by attorneys who hire us as experts, and by judges and juries in terms of our credibility when we’re testifying,” Dr. Farrell said.
Picking up where Dr. Farrell left off, Dr. Coffman noted that women always have faced an uphill battle – particularly within forensic psychiatry.
“Forensic psychiatry really is the global intersection of medicine, the criminal justice system, and the law – and traditionally, all three of these fields have really been male dominated,” Dr. Coffman said. “We were often told that women should not go into careers like medicine and the law, because if they work too hard, they might ruin their reproductive potential. They were also thought of as being weak and unable to handle seeing blood.”
Fortunately, however, she added: “That’s very different from how we think about things today.” For example,
Gender perceptions matter
Those numbers show progress, though “we’re a little bit behind the trends,” Dr. Coffman said. One reason for this probably is rooted in implicit biases that shape a person’s thinking, without a conscious realization of the sexist ideas about gender roles that have been internalized.
She presented two descriptions of an individual to make her point: one an accomplished scientist, tax attorney, and major political figure, and one a loving parent with a reputation for “always being well-coiffed and tastefully dressed.” Both depictions describe Margaret Thatcher, the first woman to become prime minister of the United Kingdom.
“There’s that real disconnect between the woman and the role, and that that’s where the prejudice lives,” Dr. Coffman said. “The greater the mismatch you see, the greater potential for prejudice.”
Research backs up those assertions. Dr. Coffman shared findings from a study that compared how male and female doctors introduced one another as speakers (J Womens Health [Larchmt]. 2017 May;26[5]:413-9).
Across 321 forms of address, women were more likely to use professional titles when “introducing any speaker during the first form of address, compared with male introducers (96.2% vs. 65.6%).” When the researchers drilled deeper, they found that women introduced others using their professional titles 97.8% of the time (45/46), while men used professional titles to introduce 72.4% of the time (110/152). A disparity was found in mixed-gender introductions: Women used professional titles when introducing men 95% of the time (57/60), but men did the same with women 49.2% of the time (31/63).
Research on perceptions of women as expert witnesses in court is more complicated. In one experiment, for example, mock jurors read a written summary of a civil case where the expert’s opinion was written by either a male or female automobile engineer. The jurors reached the same verdict just as often with female as male engineers – but awarded higher damages when the engineer was a woman.
But that was a written experiment. In similar research where mock jurors viewed video summaries involving cross-examination of a forensic mental health expert, men were found to be more “likable, believable, trustworthy, confident, and credible” than were women.
This and other research underscore a common dilemma for women, Dr. Coffman said: balancing the expectation of being warm and the need to appear competent – both of which can help and harm the way in which women are perceived. But the reality of perception sometimes can surprise.
She pointed to the double-edged sword of eye contact as an example: “If you don’t make eye contact, then you’re perceived as being weak. But if you make too much eye contact, then you’re perceived as being aggressive. So you really can’t win, right?”
Yet the women remained cautiously optimistic, especially noting the large proportion of men attending the session itself.
“It really takes everybody working together to keep the conversation going, finding out where women want to flourish and bloom, and having people to champion us and support that,” Dr. Farrell said.
Dr. Coffman and Dr. Farrell had no relevant conflicts of interest. They will be presenting an expanded version of the presentation at the International Academy of Law and Mental Health meeting in July 2019 in Rome.
AUSTIN, TEX. – Women are making progress in equal representation and leadership within the field of forensic psychiatry, but gender parity remains elusive, according to a presentation at the annual meeting of the American Academy of Psychiatry and the Law.
In the presentation, Kelly L. Coffman, MD, MPH, assistant professor of psychiatry and associate program director of the forensic psychiatry fellowship at Emory University, Atlanta, and Helen M. Farrell, MD, a lecturer at Harvard Medical School, Boston, discussed gender bias in the field and in medicine at large.
After reviewing a handful of Supreme Court cases since the 1970s establishing women’s rights to equal opportunities and harassment-free workplaces, Dr. Farrell noted a recent commentary in the New England Journal of Medicine illustrating the challenges women still face. In that commentary, Reshma Jagsi, MD, a professor of radiation oncology at the University of Michigan, Ann Arbor, and director of the Center for Bioethics and Social Sciences in Medicine, shared her own #MeToo experience within the context of such harassment narratives throughout academic medicine (N Engl J Med. 2018;378:209-11).
Harassment found in medicine
Dr. Jagsi had published a study in 2016 on workplace sexual harassment in medicine that surveyed 1,066 recipients of career development grants from the National Institutes of Health (JAMA. 2016;315:2120-1). The average age of respondents was 43 years, and 46% of respondents were women.
While only 22% of men reported perceiving gender bias in their careers, 70% of women reported such bias. Similarly, 66% of women said they had experienced gender bias in their careers, compared with 10% of men (P less than .001). Women also were substantially more likely to have experienced sexual harassment (30% vs. 4%).
Most women (92%) reporting those experiences described sexist remarks or behavior, 41% experienced unwanted sexual advances, and 9% experienced coercive advances.
“Although a lower proportion reported these experiences than in a 1995 sample, the difference appears large given that the women began their careers after the proportion of female medical students exceeded 40%,” Dr. Jagsi and her colleagues reported in the study.
The effects of those experiences were not minor: Among women who reported harassment, 59% said their confidence as professionals took a hit, and 47% said those experiences hurt their career advancement.
Women still underrepresented
One factor in those high rates might be the extent of existing power differentials: Women remain underrepresented in medical leadership despite accounting for more than half of all enrollees in U.S. medical schools in 2017, according to the Association of American Medical Colleges (AAMC). Female enrollment in medical schools hovered around 40% in the mid-90s, yet in 2015, the AAMC reported that women held 37% of all U.S. medical school faculty positions and 20% of full professorships.
“There’s also a large discrepancy in terms of specialties,” said Dr. Farrell, also a staff psychiatrist at Beth Israel Deaconess Medical Center, Boston. “Women tend to go into fields like pediatrics and ob.gyn. at much higher rates than men, and there are very low rates of women going into surgical fields like neurosurgery and orthopedics.”
Dr. Farrell then zeroed in on the field of forensic psychiatry in particular and various ways to consider how gender bias might manifest: opportunities for exposure to forensics in residency; fellowship applications vs. acceptances; experience in court; publications; invitations to present; large- and small-scale organizational leadership representation; and job placement across the settings of clinics, academics, prisons/institutions; and experience in private practice. Then there’s the perception of female forensic psychiatrists in court.
“There’s a really big question about the difference between how men and women are perceived by attorneys who hire us as experts, and by judges and juries in terms of our credibility when we’re testifying,” Dr. Farrell said.
Picking up where Dr. Farrell left off, Dr. Coffman noted that women always have faced an uphill battle – particularly within forensic psychiatry.
“Forensic psychiatry really is the global intersection of medicine, the criminal justice system, and the law – and traditionally, all three of these fields have really been male dominated,” Dr. Coffman said. “We were often told that women should not go into careers like medicine and the law, because if they work too hard, they might ruin their reproductive potential. They were also thought of as being weak and unable to handle seeing blood.”
Fortunately, however, she added: “That’s very different from how we think about things today.” For example,
Gender perceptions matter
Those numbers show progress, though “we’re a little bit behind the trends,” Dr. Coffman said. One reason for this probably is rooted in implicit biases that shape a person’s thinking, without a conscious realization of the sexist ideas about gender roles that have been internalized.
She presented two descriptions of an individual to make her point: one an accomplished scientist, tax attorney, and major political figure, and one a loving parent with a reputation for “always being well-coiffed and tastefully dressed.” Both depictions describe Margaret Thatcher, the first woman to become prime minister of the United Kingdom.
“There’s that real disconnect between the woman and the role, and that that’s where the prejudice lives,” Dr. Coffman said. “The greater the mismatch you see, the greater potential for prejudice.”
Research backs up those assertions. Dr. Coffman shared findings from a study that compared how male and female doctors introduced one another as speakers (J Womens Health [Larchmt]. 2017 May;26[5]:413-9).
Across 321 forms of address, women were more likely to use professional titles when “introducing any speaker during the first form of address, compared with male introducers (96.2% vs. 65.6%).” When the researchers drilled deeper, they found that women introduced others using their professional titles 97.8% of the time (45/46), while men used professional titles to introduce 72.4% of the time (110/152). A disparity was found in mixed-gender introductions: Women used professional titles when introducing men 95% of the time (57/60), but men did the same with women 49.2% of the time (31/63).
Research on perceptions of women as expert witnesses in court is more complicated. In one experiment, for example, mock jurors read a written summary of a civil case where the expert’s opinion was written by either a male or female automobile engineer. The jurors reached the same verdict just as often with female as male engineers – but awarded higher damages when the engineer was a woman.
But that was a written experiment. In similar research where mock jurors viewed video summaries involving cross-examination of a forensic mental health expert, men were found to be more “likable, believable, trustworthy, confident, and credible” than were women.
This and other research underscore a common dilemma for women, Dr. Coffman said: balancing the expectation of being warm and the need to appear competent – both of which can help and harm the way in which women are perceived. But the reality of perception sometimes can surprise.
She pointed to the double-edged sword of eye contact as an example: “If you don’t make eye contact, then you’re perceived as being weak. But if you make too much eye contact, then you’re perceived as being aggressive. So you really can’t win, right?”
Yet the women remained cautiously optimistic, especially noting the large proportion of men attending the session itself.
“It really takes everybody working together to keep the conversation going, finding out where women want to flourish and bloom, and having people to champion us and support that,” Dr. Farrell said.
Dr. Coffman and Dr. Farrell had no relevant conflicts of interest. They will be presenting an expanded version of the presentation at the International Academy of Law and Mental Health meeting in July 2019 in Rome.
AUSTIN, TEX. – Women are making progress in equal representation and leadership within the field of forensic psychiatry, but gender parity remains elusive, according to a presentation at the annual meeting of the American Academy of Psychiatry and the Law.
In the presentation, Kelly L. Coffman, MD, MPH, assistant professor of psychiatry and associate program director of the forensic psychiatry fellowship at Emory University, Atlanta, and Helen M. Farrell, MD, a lecturer at Harvard Medical School, Boston, discussed gender bias in the field and in medicine at large.
After reviewing a handful of Supreme Court cases since the 1970s establishing women’s rights to equal opportunities and harassment-free workplaces, Dr. Farrell noted a recent commentary in the New England Journal of Medicine illustrating the challenges women still face. In that commentary, Reshma Jagsi, MD, a professor of radiation oncology at the University of Michigan, Ann Arbor, and director of the Center for Bioethics and Social Sciences in Medicine, shared her own #MeToo experience within the context of such harassment narratives throughout academic medicine (N Engl J Med. 2018;378:209-11).
Harassment found in medicine
Dr. Jagsi had published a study in 2016 on workplace sexual harassment in medicine that surveyed 1,066 recipients of career development grants from the National Institutes of Health (JAMA. 2016;315:2120-1). The average age of respondents was 43 years, and 46% of respondents were women.
While only 22% of men reported perceiving gender bias in their careers, 70% of women reported such bias. Similarly, 66% of women said they had experienced gender bias in their careers, compared with 10% of men (P less than .001). Women also were substantially more likely to have experienced sexual harassment (30% vs. 4%).
Most women (92%) reporting those experiences described sexist remarks or behavior, 41% experienced unwanted sexual advances, and 9% experienced coercive advances.
“Although a lower proportion reported these experiences than in a 1995 sample, the difference appears large given that the women began their careers after the proportion of female medical students exceeded 40%,” Dr. Jagsi and her colleagues reported in the study.
The effects of those experiences were not minor: Among women who reported harassment, 59% said their confidence as professionals took a hit, and 47% said those experiences hurt their career advancement.
Women still underrepresented
One factor in those high rates might be the extent of existing power differentials: Women remain underrepresented in medical leadership despite accounting for more than half of all enrollees in U.S. medical schools in 2017, according to the Association of American Medical Colleges (AAMC). Female enrollment in medical schools hovered around 40% in the mid-90s, yet in 2015, the AAMC reported that women held 37% of all U.S. medical school faculty positions and 20% of full professorships.
“There’s also a large discrepancy in terms of specialties,” said Dr. Farrell, also a staff psychiatrist at Beth Israel Deaconess Medical Center, Boston. “Women tend to go into fields like pediatrics and ob.gyn. at much higher rates than men, and there are very low rates of women going into surgical fields like neurosurgery and orthopedics.”
Dr. Farrell then zeroed in on the field of forensic psychiatry in particular and various ways to consider how gender bias might manifest: opportunities for exposure to forensics in residency; fellowship applications vs. acceptances; experience in court; publications; invitations to present; large- and small-scale organizational leadership representation; and job placement across the settings of clinics, academics, prisons/institutions; and experience in private practice. Then there’s the perception of female forensic psychiatrists in court.
“There’s a really big question about the difference between how men and women are perceived by attorneys who hire us as experts, and by judges and juries in terms of our credibility when we’re testifying,” Dr. Farrell said.
Picking up where Dr. Farrell left off, Dr. Coffman noted that women always have faced an uphill battle – particularly within forensic psychiatry.
“Forensic psychiatry really is the global intersection of medicine, the criminal justice system, and the law – and traditionally, all three of these fields have really been male dominated,” Dr. Coffman said. “We were often told that women should not go into careers like medicine and the law, because if they work too hard, they might ruin their reproductive potential. They were also thought of as being weak and unable to handle seeing blood.”
Fortunately, however, she added: “That’s very different from how we think about things today.” For example,
Gender perceptions matter
Those numbers show progress, though “we’re a little bit behind the trends,” Dr. Coffman said. One reason for this probably is rooted in implicit biases that shape a person’s thinking, without a conscious realization of the sexist ideas about gender roles that have been internalized.
She presented two descriptions of an individual to make her point: one an accomplished scientist, tax attorney, and major political figure, and one a loving parent with a reputation for “always being well-coiffed and tastefully dressed.” Both depictions describe Margaret Thatcher, the first woman to become prime minister of the United Kingdom.
“There’s that real disconnect between the woman and the role, and that that’s where the prejudice lives,” Dr. Coffman said. “The greater the mismatch you see, the greater potential for prejudice.”
Research backs up those assertions. Dr. Coffman shared findings from a study that compared how male and female doctors introduced one another as speakers (J Womens Health [Larchmt]. 2017 May;26[5]:413-9).
Across 321 forms of address, women were more likely to use professional titles when “introducing any speaker during the first form of address, compared with male introducers (96.2% vs. 65.6%).” When the researchers drilled deeper, they found that women introduced others using their professional titles 97.8% of the time (45/46), while men used professional titles to introduce 72.4% of the time (110/152). A disparity was found in mixed-gender introductions: Women used professional titles when introducing men 95% of the time (57/60), but men did the same with women 49.2% of the time (31/63).
Research on perceptions of women as expert witnesses in court is more complicated. In one experiment, for example, mock jurors read a written summary of a civil case where the expert’s opinion was written by either a male or female automobile engineer. The jurors reached the same verdict just as often with female as male engineers – but awarded higher damages when the engineer was a woman.
But that was a written experiment. In similar research where mock jurors viewed video summaries involving cross-examination of a forensic mental health expert, men were found to be more “likable, believable, trustworthy, confident, and credible” than were women.
This and other research underscore a common dilemma for women, Dr. Coffman said: balancing the expectation of being warm and the need to appear competent – both of which can help and harm the way in which women are perceived. But the reality of perception sometimes can surprise.
She pointed to the double-edged sword of eye contact as an example: “If you don’t make eye contact, then you’re perceived as being weak. But if you make too much eye contact, then you’re perceived as being aggressive. So you really can’t win, right?”
Yet the women remained cautiously optimistic, especially noting the large proportion of men attending the session itself.
“It really takes everybody working together to keep the conversation going, finding out where women want to flourish and bloom, and having people to champion us and support that,” Dr. Farrell said.
Dr. Coffman and Dr. Farrell had no relevant conflicts of interest. They will be presenting an expanded version of the presentation at the International Academy of Law and Mental Health meeting in July 2019 in Rome.
REPORTING FROM THE AAPL ANNUAL MEETING
Biologics options for pediatric asthma continue to grow
ORLANDO – The goal of treatment is the same for all asthma cases, regardless of severity: “to enable a patient to achieve and maintain control over their asthma,” according to Stanley J. Szefler, MD, a professor of pediatrics at the University of Colorado at Denver, Aurora.
That goal includes “reducing the risk of exacerbations, emergency department visits, hospitalizations, and progression as well as reducing impairments, including symptoms, functional limitations, poor quality of life, and other manifestations of asthma,” Dr. Szefler, also director of the Children’s Hospital of Colorado pediatric asthma research program, told colleagues at the annual meeting of the American Academy of Pediatrics.
Severe asthma challenges
These aims are more difficult with severe asthma, defined by the World Health Organization as “the current level of clinical control and risks which can result in frequent severe exacerbations and/or adverse reactions to medications and/or chronic morbidity,” Dr. Szefler explained. Severe asthma includes untreated severe asthma, difficult-to-treat asthma, and treatment-resistant severe asthma, whether controlled on high-dose medication or not.
Allergen sensitization, viral respiratory infections, and respiratory irritants (such as air pollution and smoking) are common features of severe asthma in children. Also common are challenges specific to management: poor medication adherence, poor technique for inhaled medications, and undertreatment. Poor management can lead to repeated exacerbations, adverse effects from drugs, disease progression, possible development of chronic obstructive pulmonary disease (COPD), and early mortality.
The National Heart, Lung, and Blood Institute EPR-3 guidelines for treatment of pediatric asthma recommend a stepwise approach to therapy, starting with short-acting beta2-agonists as needed (SABA p.r.n.). The clinician then assesses the patient’s symptoms, exacerbations, side effects, quality of life, and lung function to determine whether the asthma is well managed or requires inhaled corticosteroids, or another therapy in moving through the steps. Each step also involves patient education, environmental control, and management of the child’s comorbidities.
It is not until steps 5 and 6 that the guidelines advise considering the biologic omalizumab for patients who have allergies. But other biologic options exist as well. Four biologics currently approved for treating asthma include omalizumab, mepolizumab, benralizumab, and reslizumab, but reslizumab is approved only for patients at least 18 years old.
Biologics for pediatric asthma
Omalizumab, which targets IgE, is appropriate for patients at least 6 years old in whom inhaled corticosteroids could not adequately control the symptoms of moderate to-severe persistent asthma. Dosing of omalizumab is a subcutaneous injection every 2-4 weeks based on pretreatment serum IgE and body weight using a dosing table that starts at 0.016 mg/kg/IgE (IU/mL). Maximum dose is 375 mg every 2 weeks in the United States and 600 mg every 2 weeks in the European Union.
The advantages of an anti-IgE drug are its use only once a month and its substantial effect on reducing exacerbations in a clearly identified population. However, these drugs are costly and require supervised administration, Dr. Szefler noted. They also carry a risk of anaphylaxis in less than 0.2% of patients, requiring the patient to be monitored after first administration and to carry an injectable epinephrine after omalizumab administration as a precaution for late-occurring anaphylaxis.
Mepolizumab is an anti–interleukin (IL)–5 drug used in patients at least 12 years old with severe persistent asthma that’s inadequately controlled with inhaled corticosteroids. Peripheral blood counts of eosinophilia determine if a patient has an eosinophilic phenotype, which has the best response to mepolizumab. People with at least 150 cells per microliter at baseline or at least 300 cells per microliter within the past year have shown a good response to mepolizumab. Dosing is 100 mg subcutaneously every 4 weeks.
For patients with atopic asthma, mepolizumab is effective in reducing the daily oral corticosteroid dose and the number of both annual exacerbations and exacerbations requiring hospitalization or an emergency visit. Other benefits of mepolizumab include increasing the time to a first exacerbation, the pre- and postbronchodilator forced expiratory volume in one second (FEV1) and overall quality of life.
Patient reductions in exacerbations while taking mepolizumab were associated with eosinophil count but not IgE, atopic status, FEV1 or bronchodilator response in the DREAM study (Lancet. 2012 Aug 18;380[9842]:651-9.).
Two safety considerations with mepolizumab include an increased risk of shingles and the risk of a preexisting helminth infection getting worse. Providers should screen for helminth infection and might consider a herpes zoster vaccination prior to starting therapy, Dr. Szefler said.
Benralizumab is an anti-IL5Ra for use in people at least 12 years old with severe persistent asthma and an eosinophilic phenotype (at least 300 cells per microliter). Dosing begins with three subcutaneous injections of 30 mg every 4 weeks, followed by administration every 8 weeks thereafter.
Benralizumab’s clinical effects include reduced exacerbations and oral corticosteroid use, and improved asthma symptom scores and prebronchodilator FEV1. Higher serum eosinophils and a history of more frequent exacerbations are both biomarkers for reduced exacerbations with benralizumab treatment.
Dupilumab: New kid on the block
The newest biologic for asthma is dupilumab, approved Oct. 19, 2018, by the Food and Drug Administration as the only asthma biologic that patients can administer at home. Dupilumab is an anti–IL-4 and anti–IL-13 biologic whose most recent study results showed a severe exacerbations rate 50% lower than placebo (N Engl J Med. 2018 Jun 28;378[26]:2486-96.). Patients with higher baseline levels of eosinophils had the best response, although some patients showed hypereosinophilia following dupilumab therapy.
The study had a low number of adolescents enrolled, however, and more data on predictive biomarkers are needed. Dupilumab also requires a twice-monthly administration.
“It could be potentially better than those currently available due to additional effect on FEV1,” Dr. Szefler said, but cost and safety may determine how dupilumab is recommended and used, including possible use for early intervention.
As development in biologics for pediatric asthma continues to grow, questions about best practices for management remain, such as what age is best for starting biologics, what strategies are most safe and effective, and what risks and benefits exist for each strategy. Questions also remain regarding the risk factors for asthma and what early intervention strategies might change the disease’s natural history.
“Look at asthma in children as a chronic disease that can result in potentially preventable adverse respiratory outcomes in adulthood,” Dr. Szefler said. He recommended monitoring children’s lung function over time and using “measures of clinical outcomes, lung function, and biomarkers to assess potential benefits of biologic therapy.”
Dr. Szefler has served on the advisory board for Regeneron and Sanofi, and he has consulted for AstraZeneca, Boehringer Ingelheim, Daiichi Sankyo, GlaxoSmithKline, Novartis, and Propeller Health.
ORLANDO – The goal of treatment is the same for all asthma cases, regardless of severity: “to enable a patient to achieve and maintain control over their asthma,” according to Stanley J. Szefler, MD, a professor of pediatrics at the University of Colorado at Denver, Aurora.
That goal includes “reducing the risk of exacerbations, emergency department visits, hospitalizations, and progression as well as reducing impairments, including symptoms, functional limitations, poor quality of life, and other manifestations of asthma,” Dr. Szefler, also director of the Children’s Hospital of Colorado pediatric asthma research program, told colleagues at the annual meeting of the American Academy of Pediatrics.
Severe asthma challenges
These aims are more difficult with severe asthma, defined by the World Health Organization as “the current level of clinical control and risks which can result in frequent severe exacerbations and/or adverse reactions to medications and/or chronic morbidity,” Dr. Szefler explained. Severe asthma includes untreated severe asthma, difficult-to-treat asthma, and treatment-resistant severe asthma, whether controlled on high-dose medication or not.
Allergen sensitization, viral respiratory infections, and respiratory irritants (such as air pollution and smoking) are common features of severe asthma in children. Also common are challenges specific to management: poor medication adherence, poor technique for inhaled medications, and undertreatment. Poor management can lead to repeated exacerbations, adverse effects from drugs, disease progression, possible development of chronic obstructive pulmonary disease (COPD), and early mortality.
The National Heart, Lung, and Blood Institute EPR-3 guidelines for treatment of pediatric asthma recommend a stepwise approach to therapy, starting with short-acting beta2-agonists as needed (SABA p.r.n.). The clinician then assesses the patient’s symptoms, exacerbations, side effects, quality of life, and lung function to determine whether the asthma is well managed or requires inhaled corticosteroids, or another therapy in moving through the steps. Each step also involves patient education, environmental control, and management of the child’s comorbidities.
It is not until steps 5 and 6 that the guidelines advise considering the biologic omalizumab for patients who have allergies. But other biologic options exist as well. Four biologics currently approved for treating asthma include omalizumab, mepolizumab, benralizumab, and reslizumab, but reslizumab is approved only for patients at least 18 years old.
Biologics for pediatric asthma
Omalizumab, which targets IgE, is appropriate for patients at least 6 years old in whom inhaled corticosteroids could not adequately control the symptoms of moderate to-severe persistent asthma. Dosing of omalizumab is a subcutaneous injection every 2-4 weeks based on pretreatment serum IgE and body weight using a dosing table that starts at 0.016 mg/kg/IgE (IU/mL). Maximum dose is 375 mg every 2 weeks in the United States and 600 mg every 2 weeks in the European Union.
The advantages of an anti-IgE drug are its use only once a month and its substantial effect on reducing exacerbations in a clearly identified population. However, these drugs are costly and require supervised administration, Dr. Szefler noted. They also carry a risk of anaphylaxis in less than 0.2% of patients, requiring the patient to be monitored after first administration and to carry an injectable epinephrine after omalizumab administration as a precaution for late-occurring anaphylaxis.
Mepolizumab is an anti–interleukin (IL)–5 drug used in patients at least 12 years old with severe persistent asthma that’s inadequately controlled with inhaled corticosteroids. Peripheral blood counts of eosinophilia determine if a patient has an eosinophilic phenotype, which has the best response to mepolizumab. People with at least 150 cells per microliter at baseline or at least 300 cells per microliter within the past year have shown a good response to mepolizumab. Dosing is 100 mg subcutaneously every 4 weeks.
For patients with atopic asthma, mepolizumab is effective in reducing the daily oral corticosteroid dose and the number of both annual exacerbations and exacerbations requiring hospitalization or an emergency visit. Other benefits of mepolizumab include increasing the time to a first exacerbation, the pre- and postbronchodilator forced expiratory volume in one second (FEV1) and overall quality of life.
Patient reductions in exacerbations while taking mepolizumab were associated with eosinophil count but not IgE, atopic status, FEV1 or bronchodilator response in the DREAM study (Lancet. 2012 Aug 18;380[9842]:651-9.).
Two safety considerations with mepolizumab include an increased risk of shingles and the risk of a preexisting helminth infection getting worse. Providers should screen for helminth infection and might consider a herpes zoster vaccination prior to starting therapy, Dr. Szefler said.
Benralizumab is an anti-IL5Ra for use in people at least 12 years old with severe persistent asthma and an eosinophilic phenotype (at least 300 cells per microliter). Dosing begins with three subcutaneous injections of 30 mg every 4 weeks, followed by administration every 8 weeks thereafter.
Benralizumab’s clinical effects include reduced exacerbations and oral corticosteroid use, and improved asthma symptom scores and prebronchodilator FEV1. Higher serum eosinophils and a history of more frequent exacerbations are both biomarkers for reduced exacerbations with benralizumab treatment.
Dupilumab: New kid on the block
The newest biologic for asthma is dupilumab, approved Oct. 19, 2018, by the Food and Drug Administration as the only asthma biologic that patients can administer at home. Dupilumab is an anti–IL-4 and anti–IL-13 biologic whose most recent study results showed a severe exacerbations rate 50% lower than placebo (N Engl J Med. 2018 Jun 28;378[26]:2486-96.). Patients with higher baseline levels of eosinophils had the best response, although some patients showed hypereosinophilia following dupilumab therapy.
The study had a low number of adolescents enrolled, however, and more data on predictive biomarkers are needed. Dupilumab also requires a twice-monthly administration.
“It could be potentially better than those currently available due to additional effect on FEV1,” Dr. Szefler said, but cost and safety may determine how dupilumab is recommended and used, including possible use for early intervention.
As development in biologics for pediatric asthma continues to grow, questions about best practices for management remain, such as what age is best for starting biologics, what strategies are most safe and effective, and what risks and benefits exist for each strategy. Questions also remain regarding the risk factors for asthma and what early intervention strategies might change the disease’s natural history.
“Look at asthma in children as a chronic disease that can result in potentially preventable adverse respiratory outcomes in adulthood,” Dr. Szefler said. He recommended monitoring children’s lung function over time and using “measures of clinical outcomes, lung function, and biomarkers to assess potential benefits of biologic therapy.”
Dr. Szefler has served on the advisory board for Regeneron and Sanofi, and he has consulted for AstraZeneca, Boehringer Ingelheim, Daiichi Sankyo, GlaxoSmithKline, Novartis, and Propeller Health.
ORLANDO – The goal of treatment is the same for all asthma cases, regardless of severity: “to enable a patient to achieve and maintain control over their asthma,” according to Stanley J. Szefler, MD, a professor of pediatrics at the University of Colorado at Denver, Aurora.
That goal includes “reducing the risk of exacerbations, emergency department visits, hospitalizations, and progression as well as reducing impairments, including symptoms, functional limitations, poor quality of life, and other manifestations of asthma,” Dr. Szefler, also director of the Children’s Hospital of Colorado pediatric asthma research program, told colleagues at the annual meeting of the American Academy of Pediatrics.
Severe asthma challenges
These aims are more difficult with severe asthma, defined by the World Health Organization as “the current level of clinical control and risks which can result in frequent severe exacerbations and/or adverse reactions to medications and/or chronic morbidity,” Dr. Szefler explained. Severe asthma includes untreated severe asthma, difficult-to-treat asthma, and treatment-resistant severe asthma, whether controlled on high-dose medication or not.
Allergen sensitization, viral respiratory infections, and respiratory irritants (such as air pollution and smoking) are common features of severe asthma in children. Also common are challenges specific to management: poor medication adherence, poor technique for inhaled medications, and undertreatment. Poor management can lead to repeated exacerbations, adverse effects from drugs, disease progression, possible development of chronic obstructive pulmonary disease (COPD), and early mortality.
The National Heart, Lung, and Blood Institute EPR-3 guidelines for treatment of pediatric asthma recommend a stepwise approach to therapy, starting with short-acting beta2-agonists as needed (SABA p.r.n.). The clinician then assesses the patient’s symptoms, exacerbations, side effects, quality of life, and lung function to determine whether the asthma is well managed or requires inhaled corticosteroids, or another therapy in moving through the steps. Each step also involves patient education, environmental control, and management of the child’s comorbidities.
It is not until steps 5 and 6 that the guidelines advise considering the biologic omalizumab for patients who have allergies. But other biologic options exist as well. Four biologics currently approved for treating asthma include omalizumab, mepolizumab, benralizumab, and reslizumab, but reslizumab is approved only for patients at least 18 years old.
Biologics for pediatric asthma
Omalizumab, which targets IgE, is appropriate for patients at least 6 years old in whom inhaled corticosteroids could not adequately control the symptoms of moderate to-severe persistent asthma. Dosing of omalizumab is a subcutaneous injection every 2-4 weeks based on pretreatment serum IgE and body weight using a dosing table that starts at 0.016 mg/kg/IgE (IU/mL). Maximum dose is 375 mg every 2 weeks in the United States and 600 mg every 2 weeks in the European Union.
The advantages of an anti-IgE drug are its use only once a month and its substantial effect on reducing exacerbations in a clearly identified population. However, these drugs are costly and require supervised administration, Dr. Szefler noted. They also carry a risk of anaphylaxis in less than 0.2% of patients, requiring the patient to be monitored after first administration and to carry an injectable epinephrine after omalizumab administration as a precaution for late-occurring anaphylaxis.
Mepolizumab is an anti–interleukin (IL)–5 drug used in patients at least 12 years old with severe persistent asthma that’s inadequately controlled with inhaled corticosteroids. Peripheral blood counts of eosinophilia determine if a patient has an eosinophilic phenotype, which has the best response to mepolizumab. People with at least 150 cells per microliter at baseline or at least 300 cells per microliter within the past year have shown a good response to mepolizumab. Dosing is 100 mg subcutaneously every 4 weeks.
For patients with atopic asthma, mepolizumab is effective in reducing the daily oral corticosteroid dose and the number of both annual exacerbations and exacerbations requiring hospitalization or an emergency visit. Other benefits of mepolizumab include increasing the time to a first exacerbation, the pre- and postbronchodilator forced expiratory volume in one second (FEV1) and overall quality of life.
Patient reductions in exacerbations while taking mepolizumab were associated with eosinophil count but not IgE, atopic status, FEV1 or bronchodilator response in the DREAM study (Lancet. 2012 Aug 18;380[9842]:651-9.).
Two safety considerations with mepolizumab include an increased risk of shingles and the risk of a preexisting helminth infection getting worse. Providers should screen for helminth infection and might consider a herpes zoster vaccination prior to starting therapy, Dr. Szefler said.
Benralizumab is an anti-IL5Ra for use in people at least 12 years old with severe persistent asthma and an eosinophilic phenotype (at least 300 cells per microliter). Dosing begins with three subcutaneous injections of 30 mg every 4 weeks, followed by administration every 8 weeks thereafter.
Benralizumab’s clinical effects include reduced exacerbations and oral corticosteroid use, and improved asthma symptom scores and prebronchodilator FEV1. Higher serum eosinophils and a history of more frequent exacerbations are both biomarkers for reduced exacerbations with benralizumab treatment.
Dupilumab: New kid on the block
The newest biologic for asthma is dupilumab, approved Oct. 19, 2018, by the Food and Drug Administration as the only asthma biologic that patients can administer at home. Dupilumab is an anti–IL-4 and anti–IL-13 biologic whose most recent study results showed a severe exacerbations rate 50% lower than placebo (N Engl J Med. 2018 Jun 28;378[26]:2486-96.). Patients with higher baseline levels of eosinophils had the best response, although some patients showed hypereosinophilia following dupilumab therapy.
The study had a low number of adolescents enrolled, however, and more data on predictive biomarkers are needed. Dupilumab also requires a twice-monthly administration.
“It could be potentially better than those currently available due to additional effect on FEV1,” Dr. Szefler said, but cost and safety may determine how dupilumab is recommended and used, including possible use for early intervention.
As development in biologics for pediatric asthma continues to grow, questions about best practices for management remain, such as what age is best for starting biologics, what strategies are most safe and effective, and what risks and benefits exist for each strategy. Questions also remain regarding the risk factors for asthma and what early intervention strategies might change the disease’s natural history.
“Look at asthma in children as a chronic disease that can result in potentially preventable adverse respiratory outcomes in adulthood,” Dr. Szefler said. He recommended monitoring children’s lung function over time and using “measures of clinical outcomes, lung function, and biomarkers to assess potential benefits of biologic therapy.”
Dr. Szefler has served on the advisory board for Regeneron and Sanofi, and he has consulted for AstraZeneca, Boehringer Ingelheim, Daiichi Sankyo, GlaxoSmithKline, Novartis, and Propeller Health.
EXPERT ANALYSIS FROM AAP 18
Autistic youth face higher risks from online child pornography
Prevention efforts include advising adolescent patients about puberty and sex.
AUSTIN, TEX. – It is important to understand the legislative and social lay of the land for child pornography and related issues, such as sexting and revenge porn, according to Nicole Sussman, MD.
Dr. Sussman of Cambridge (Mass.) Health Alliance provided an overview of the history of child pornography legislation before discussing the current landscape and the unique challenges and risks it presents to autistic youth at the annual meeting of the American Academy of Psychiatry and the Law.
History of U.S. child pornography laws
The Protection of Children Against Sexual Exploitation Act, passed in 1977, criminalized the act of forcing a child to engage in sexual activity. But it wasn’t widely cited. Little awareness existed around the issue until New York v. Ferber in 1982, which upheld a New York statute that outlawed distribution of material depicting children under 16 years of age engaged in sexual acts. The U.S. Supreme Court linked child porn to sexual abuse of a child and determined that the only way to control production of child pornography was to regulate distribution of it.
Shortly thereafter, the Child Protection Act of 1984 limited the production, distribution, and possession of “materials involving the sexual exploitation of minors even if the material is not found to be ‘obscene.’ ” The law also raised the age of a minor for the law’s purposes to anyone younger than age 18 years, removed the requirement that the materials be sold (free distribution was now also regulated), and authorized interception of communications to investigate offenses.
Two years later, the Child Sexual Abuse and Pornography Act and the Child Abuse Victims’ Rights Act strengthened child pornography laws; the first made it a federal offense to advertise “any product depicting sexually explicit conduct with a minor or the opportunity to engage in such conduct with a minor.”
More regulation followed with the Child Protection and Obscenity Enforcement Act of 1988, which added regulation of child pornography on computers, and the Child Pornography Prevention Act of 1996, which regulates all forms of online/virtual child pornography.
The first weakening of these laws came with Ashcroft v. Free Speech Coalition in 2002, which held that the 1996 law was overly broad, with the potential to violate free speech, since prohibition of images that “appear to be” or “convey the impression” of child pornography might not necessarily have actually involved child exploitation.
Finally, the Adam Walsh Child Protection and Safety Act of 2006 established the national sex offender registry and mandated convicted offender requirements for reporting their whereabouts based on the “tier” of their crime.
Today’s landscape: Internet use and pornography
With all that legislation as a backdrop, the intersection of growing use of mobile technology, online pornography and sexting can become thorny.
Recent data show that 95% of teens aged 13-17 years have access to a smartphone – independent of their race, sex, ethnicity, or socioeconomic status. Nearly half of teens (45%) report that they are online nearly constantly, Dr. Sussman said.
And pornography is free and easy to find online. A 2006 survey of New Hampshire college students found that 72% of them had seen porn before age 18 years – and that’s decade-old data.
A 2013-2014 survey of 16- and 17-year-olds in Boston found that about half (51%) reported watching porn at least weekly, and 54% watched porn to learn how to do something. Further, 30% of youth in that survey said porn was their primary source of sexual education, followed by parents, cited by 21%.
Put these realities together, and you encounter sexting, the act of sharing “sexually explicit images, videos, or messages through electronic media.” Research on the prevalence of sexting varies widely, with estimates up to 60% of teens. Though prevalence estimates depend on definitions, recent studies suggest that one in four teens send “sexts” and one in seven teens receive them, Dr. Sussman said.
But these figures should be considered alongside an understanding normal sexual development among adolescents. Sexting might simply represent a normal emerging component of sexual development within the context of today’s society, Dr. Sussman said. Sexting often is viewed by youth as a way to initiate and maintain relationships, she said.
Nevertheless, teens might not be able to fully appreciate the risks associated with sending or receiving sexually explicit texts. One in eight teens report being involved in nonconsensual sexting, whether as recipient of an unsolicited sext or as the subject of one.
Sexting also can take the form of “revenge porn” and “sextortion,” in which sexually explicit electronic images are distributed as a form of revenge or are threatened to be distributed.
Early legislation related to sexting has led to litigation, such as the case of 16-year-old A.H., who was charged with producing child pornography after she emailed her 17-year-old boyfriend images of the two of them engaged in sexual activity. She argued she had a right to privacy. But the court disagreed, finding the state had a compelling interest “in protecting children from sexual exploitation,” regardless of “whether the person sexually exploiting the child is an adult or a minor.”
By 2008-2009, about 4,000 cases involving minors sexting were making their way through the courts, demonstrating a “need for laws to evolve and to consider developmental context,” Dr. Sussman said. Punishment could be severe, including requirements for youth to register in the national sex offender registry. Today, however, 25 states have laws differentiating sexting from child pornography.
Child pornography and autistic youth
Teens with autism spectrum disorder might be particularly at higher risk for accessing child pornography and subsequent conviction. Autistic youth’s weaknesses in social skills make it difficult for them to understand the unwritten rules and subjectivity of dating. While their bodies and hormones are changing, their mental age might lag, and their weak interpersonal skills limit their ability to move a relationship in a romantic direction.
Meanwhile, autistic youth might feel more comfortable interacting with others on their computers. Paired with a difficulty in judging others’ age and a limited awareness or understanding of the potential outcomes of their actions, autistic youth can easily fall into a trap of accessing child pornography.
Porn might become a substitute for human interaction, and the accessibility of porn online makes it easy to discover child pornography whose “mere existence implies legality,” Dr. Sussman said. Further, youth are drawn toward images depicting people they personally identify with in terms of their social or emotional age.
Given that pornography typically is not discussed by parents or in sex education, “there have been some cases where people who have autism spectrum disorders have gotten in trouble,” Dr. Sussman said. Autistic youth also might struggle to make the connection between what’s wrong in real life versus what might appear abstract and more acceptable on a computer.
The realities of this special population have several implications courts should consider, Dr. Sussman said. For one, their actions may be misinterpreted as criminal when they might not pose the same level of danger to society as someone else who accesses child pornography. In general, criminal behavior is statistically lower among autistic individuals, but victimization of them is higher than average.
Yet it might be difficult for courts to perceive deficits in individuals with stronger (“high-functioning”) skills in some areas. Courts also should consider how an autistic person might fare in a correctional facility, where inability to understand and adhere to the prison environment’s social structure could prove fatal.
Autistic individuals might be more inclined to report those who break rules and might have an eagerness to please that makes them easily manipulated. Prison staff might misinterpret their behavior, and autistic inmates might be at risk for higher rates of isolation for their own protection.
Dr. Sussman said. Physicians should provide anticipatory guidance when it comes to puberty, sex, romantic interests, and masturbation, she said, and parents can us parental controls.
Youth, especially autistic youth, should be taught the difference between acceptable (“good”) touch, versus unacceptable (“bad”) touch, respect of personal space, and the difference between public and private behavior. Discussions of reality vs. fantasy – especially considering how unrealistic online porn often is – and the definition of consent are also vital preventive strategies.
Dr. Sussman had no conflicts of interest.
Prevention efforts include advising adolescent patients about puberty and sex.
Prevention efforts include advising adolescent patients about puberty and sex.
AUSTIN, TEX. – It is important to understand the legislative and social lay of the land for child pornography and related issues, such as sexting and revenge porn, according to Nicole Sussman, MD.
Dr. Sussman of Cambridge (Mass.) Health Alliance provided an overview of the history of child pornography legislation before discussing the current landscape and the unique challenges and risks it presents to autistic youth at the annual meeting of the American Academy of Psychiatry and the Law.
History of U.S. child pornography laws
The Protection of Children Against Sexual Exploitation Act, passed in 1977, criminalized the act of forcing a child to engage in sexual activity. But it wasn’t widely cited. Little awareness existed around the issue until New York v. Ferber in 1982, which upheld a New York statute that outlawed distribution of material depicting children under 16 years of age engaged in sexual acts. The U.S. Supreme Court linked child porn to sexual abuse of a child and determined that the only way to control production of child pornography was to regulate distribution of it.
Shortly thereafter, the Child Protection Act of 1984 limited the production, distribution, and possession of “materials involving the sexual exploitation of minors even if the material is not found to be ‘obscene.’ ” The law also raised the age of a minor for the law’s purposes to anyone younger than age 18 years, removed the requirement that the materials be sold (free distribution was now also regulated), and authorized interception of communications to investigate offenses.
Two years later, the Child Sexual Abuse and Pornography Act and the Child Abuse Victims’ Rights Act strengthened child pornography laws; the first made it a federal offense to advertise “any product depicting sexually explicit conduct with a minor or the opportunity to engage in such conduct with a minor.”
More regulation followed with the Child Protection and Obscenity Enforcement Act of 1988, which added regulation of child pornography on computers, and the Child Pornography Prevention Act of 1996, which regulates all forms of online/virtual child pornography.
The first weakening of these laws came with Ashcroft v. Free Speech Coalition in 2002, which held that the 1996 law was overly broad, with the potential to violate free speech, since prohibition of images that “appear to be” or “convey the impression” of child pornography might not necessarily have actually involved child exploitation.
Finally, the Adam Walsh Child Protection and Safety Act of 2006 established the national sex offender registry and mandated convicted offender requirements for reporting their whereabouts based on the “tier” of their crime.
Today’s landscape: Internet use and pornography
With all that legislation as a backdrop, the intersection of growing use of mobile technology, online pornography and sexting can become thorny.
Recent data show that 95% of teens aged 13-17 years have access to a smartphone – independent of their race, sex, ethnicity, or socioeconomic status. Nearly half of teens (45%) report that they are online nearly constantly, Dr. Sussman said.
And pornography is free and easy to find online. A 2006 survey of New Hampshire college students found that 72% of them had seen porn before age 18 years – and that’s decade-old data.
A 2013-2014 survey of 16- and 17-year-olds in Boston found that about half (51%) reported watching porn at least weekly, and 54% watched porn to learn how to do something. Further, 30% of youth in that survey said porn was their primary source of sexual education, followed by parents, cited by 21%.
Put these realities together, and you encounter sexting, the act of sharing “sexually explicit images, videos, or messages through electronic media.” Research on the prevalence of sexting varies widely, with estimates up to 60% of teens. Though prevalence estimates depend on definitions, recent studies suggest that one in four teens send “sexts” and one in seven teens receive them, Dr. Sussman said.
But these figures should be considered alongside an understanding normal sexual development among adolescents. Sexting might simply represent a normal emerging component of sexual development within the context of today’s society, Dr. Sussman said. Sexting often is viewed by youth as a way to initiate and maintain relationships, she said.
Nevertheless, teens might not be able to fully appreciate the risks associated with sending or receiving sexually explicit texts. One in eight teens report being involved in nonconsensual sexting, whether as recipient of an unsolicited sext or as the subject of one.
Sexting also can take the form of “revenge porn” and “sextortion,” in which sexually explicit electronic images are distributed as a form of revenge or are threatened to be distributed.
Early legislation related to sexting has led to litigation, such as the case of 16-year-old A.H., who was charged with producing child pornography after she emailed her 17-year-old boyfriend images of the two of them engaged in sexual activity. She argued she had a right to privacy. But the court disagreed, finding the state had a compelling interest “in protecting children from sexual exploitation,” regardless of “whether the person sexually exploiting the child is an adult or a minor.”
By 2008-2009, about 4,000 cases involving minors sexting were making their way through the courts, demonstrating a “need for laws to evolve and to consider developmental context,” Dr. Sussman said. Punishment could be severe, including requirements for youth to register in the national sex offender registry. Today, however, 25 states have laws differentiating sexting from child pornography.
Child pornography and autistic youth
Teens with autism spectrum disorder might be particularly at higher risk for accessing child pornography and subsequent conviction. Autistic youth’s weaknesses in social skills make it difficult for them to understand the unwritten rules and subjectivity of dating. While their bodies and hormones are changing, their mental age might lag, and their weak interpersonal skills limit their ability to move a relationship in a romantic direction.
Meanwhile, autistic youth might feel more comfortable interacting with others on their computers. Paired with a difficulty in judging others’ age and a limited awareness or understanding of the potential outcomes of their actions, autistic youth can easily fall into a trap of accessing child pornography.
Porn might become a substitute for human interaction, and the accessibility of porn online makes it easy to discover child pornography whose “mere existence implies legality,” Dr. Sussman said. Further, youth are drawn toward images depicting people they personally identify with in terms of their social or emotional age.
Given that pornography typically is not discussed by parents or in sex education, “there have been some cases where people who have autism spectrum disorders have gotten in trouble,” Dr. Sussman said. Autistic youth also might struggle to make the connection between what’s wrong in real life versus what might appear abstract and more acceptable on a computer.
The realities of this special population have several implications courts should consider, Dr. Sussman said. For one, their actions may be misinterpreted as criminal when they might not pose the same level of danger to society as someone else who accesses child pornography. In general, criminal behavior is statistically lower among autistic individuals, but victimization of them is higher than average.
Yet it might be difficult for courts to perceive deficits in individuals with stronger (“high-functioning”) skills in some areas. Courts also should consider how an autistic person might fare in a correctional facility, where inability to understand and adhere to the prison environment’s social structure could prove fatal.
Autistic individuals might be more inclined to report those who break rules and might have an eagerness to please that makes them easily manipulated. Prison staff might misinterpret their behavior, and autistic inmates might be at risk for higher rates of isolation for their own protection.
Dr. Sussman said. Physicians should provide anticipatory guidance when it comes to puberty, sex, romantic interests, and masturbation, she said, and parents can us parental controls.
Youth, especially autistic youth, should be taught the difference between acceptable (“good”) touch, versus unacceptable (“bad”) touch, respect of personal space, and the difference between public and private behavior. Discussions of reality vs. fantasy – especially considering how unrealistic online porn often is – and the definition of consent are also vital preventive strategies.
Dr. Sussman had no conflicts of interest.
AUSTIN, TEX. – It is important to understand the legislative and social lay of the land for child pornography and related issues, such as sexting and revenge porn, according to Nicole Sussman, MD.
Dr. Sussman of Cambridge (Mass.) Health Alliance provided an overview of the history of child pornography legislation before discussing the current landscape and the unique challenges and risks it presents to autistic youth at the annual meeting of the American Academy of Psychiatry and the Law.
History of U.S. child pornography laws
The Protection of Children Against Sexual Exploitation Act, passed in 1977, criminalized the act of forcing a child to engage in sexual activity. But it wasn’t widely cited. Little awareness existed around the issue until New York v. Ferber in 1982, which upheld a New York statute that outlawed distribution of material depicting children under 16 years of age engaged in sexual acts. The U.S. Supreme Court linked child porn to sexual abuse of a child and determined that the only way to control production of child pornography was to regulate distribution of it.
Shortly thereafter, the Child Protection Act of 1984 limited the production, distribution, and possession of “materials involving the sexual exploitation of minors even if the material is not found to be ‘obscene.’ ” The law also raised the age of a minor for the law’s purposes to anyone younger than age 18 years, removed the requirement that the materials be sold (free distribution was now also regulated), and authorized interception of communications to investigate offenses.
Two years later, the Child Sexual Abuse and Pornography Act and the Child Abuse Victims’ Rights Act strengthened child pornography laws; the first made it a federal offense to advertise “any product depicting sexually explicit conduct with a minor or the opportunity to engage in such conduct with a minor.”
More regulation followed with the Child Protection and Obscenity Enforcement Act of 1988, which added regulation of child pornography on computers, and the Child Pornography Prevention Act of 1996, which regulates all forms of online/virtual child pornography.
The first weakening of these laws came with Ashcroft v. Free Speech Coalition in 2002, which held that the 1996 law was overly broad, with the potential to violate free speech, since prohibition of images that “appear to be” or “convey the impression” of child pornography might not necessarily have actually involved child exploitation.
Finally, the Adam Walsh Child Protection and Safety Act of 2006 established the national sex offender registry and mandated convicted offender requirements for reporting their whereabouts based on the “tier” of their crime.
Today’s landscape: Internet use and pornography
With all that legislation as a backdrop, the intersection of growing use of mobile technology, online pornography and sexting can become thorny.
Recent data show that 95% of teens aged 13-17 years have access to a smartphone – independent of their race, sex, ethnicity, or socioeconomic status. Nearly half of teens (45%) report that they are online nearly constantly, Dr. Sussman said.
And pornography is free and easy to find online. A 2006 survey of New Hampshire college students found that 72% of them had seen porn before age 18 years – and that’s decade-old data.
A 2013-2014 survey of 16- and 17-year-olds in Boston found that about half (51%) reported watching porn at least weekly, and 54% watched porn to learn how to do something. Further, 30% of youth in that survey said porn was their primary source of sexual education, followed by parents, cited by 21%.
Put these realities together, and you encounter sexting, the act of sharing “sexually explicit images, videos, or messages through electronic media.” Research on the prevalence of sexting varies widely, with estimates up to 60% of teens. Though prevalence estimates depend on definitions, recent studies suggest that one in four teens send “sexts” and one in seven teens receive them, Dr. Sussman said.
But these figures should be considered alongside an understanding normal sexual development among adolescents. Sexting might simply represent a normal emerging component of sexual development within the context of today’s society, Dr. Sussman said. Sexting often is viewed by youth as a way to initiate and maintain relationships, she said.
Nevertheless, teens might not be able to fully appreciate the risks associated with sending or receiving sexually explicit texts. One in eight teens report being involved in nonconsensual sexting, whether as recipient of an unsolicited sext or as the subject of one.
Sexting also can take the form of “revenge porn” and “sextortion,” in which sexually explicit electronic images are distributed as a form of revenge or are threatened to be distributed.
Early legislation related to sexting has led to litigation, such as the case of 16-year-old A.H., who was charged with producing child pornography after she emailed her 17-year-old boyfriend images of the two of them engaged in sexual activity. She argued she had a right to privacy. But the court disagreed, finding the state had a compelling interest “in protecting children from sexual exploitation,” regardless of “whether the person sexually exploiting the child is an adult or a minor.”
By 2008-2009, about 4,000 cases involving minors sexting were making their way through the courts, demonstrating a “need for laws to evolve and to consider developmental context,” Dr. Sussman said. Punishment could be severe, including requirements for youth to register in the national sex offender registry. Today, however, 25 states have laws differentiating sexting from child pornography.
Child pornography and autistic youth
Teens with autism spectrum disorder might be particularly at higher risk for accessing child pornography and subsequent conviction. Autistic youth’s weaknesses in social skills make it difficult for them to understand the unwritten rules and subjectivity of dating. While their bodies and hormones are changing, their mental age might lag, and their weak interpersonal skills limit their ability to move a relationship in a romantic direction.
Meanwhile, autistic youth might feel more comfortable interacting with others on their computers. Paired with a difficulty in judging others’ age and a limited awareness or understanding of the potential outcomes of their actions, autistic youth can easily fall into a trap of accessing child pornography.
Porn might become a substitute for human interaction, and the accessibility of porn online makes it easy to discover child pornography whose “mere existence implies legality,” Dr. Sussman said. Further, youth are drawn toward images depicting people they personally identify with in terms of their social or emotional age.
Given that pornography typically is not discussed by parents or in sex education, “there have been some cases where people who have autism spectrum disorders have gotten in trouble,” Dr. Sussman said. Autistic youth also might struggle to make the connection between what’s wrong in real life versus what might appear abstract and more acceptable on a computer.
The realities of this special population have several implications courts should consider, Dr. Sussman said. For one, their actions may be misinterpreted as criminal when they might not pose the same level of danger to society as someone else who accesses child pornography. In general, criminal behavior is statistically lower among autistic individuals, but victimization of them is higher than average.
Yet it might be difficult for courts to perceive deficits in individuals with stronger (“high-functioning”) skills in some areas. Courts also should consider how an autistic person might fare in a correctional facility, where inability to understand and adhere to the prison environment’s social structure could prove fatal.
Autistic individuals might be more inclined to report those who break rules and might have an eagerness to please that makes them easily manipulated. Prison staff might misinterpret their behavior, and autistic inmates might be at risk for higher rates of isolation for their own protection.
Dr. Sussman said. Physicians should provide anticipatory guidance when it comes to puberty, sex, romantic interests, and masturbation, she said, and parents can us parental controls.
Youth, especially autistic youth, should be taught the difference between acceptable (“good”) touch, versus unacceptable (“bad”) touch, respect of personal space, and the difference between public and private behavior. Discussions of reality vs. fantasy – especially considering how unrealistic online porn often is – and the definition of consent are also vital preventive strategies.
Dr. Sussman had no conflicts of interest.
REPORTING FROM THE AAPL ANNUAL MEETING
Case shows clinical assessment supersedes psychological screening tools
AUSTIN, TEX. – Using psychological screenings for law enforcement employment decisions can be a worthwhile supplement to more traditional hiring procedures, but such tools should be used with caution, a recent case study suggests.
“Pre-employment psychological evaluations for police officers are increasingly utilizing self-reported personality assessments to identify attributes in candidates that have shown to correlate with job performance outcomes,” Ann Marie Mckenzie Cassidy, DO, of Icahn School of Medicine at Mount Sinai, New York, and her colleagues wrote in an abstract presented at the annual meeting of the American Academy of Psychiatry and the Law.
“As research supporting the predictive power of written self-reported measurements expands, the call for this empirically validated data to be weighted over clinician judgment is becoming more substantive,” the researchers wrote. “The following case exemplifies a psychological evaluation where test results were either inconclusive or strongly conflicted with the clinical picture of the candidate.”
The applicant was a 34-year-old male Army veteran who received an honorable discharge after three deployments. Though he had no relevant medical or formal psychiatric history or drug use, he said he did drink alcohol heavily for a short time after joining the Army. He also had four speeding citations and one drag racing citation.
His personal history revealed several problems, including a military write-up for yelling at a subordinate and a history of difficulties working with his supervisor.
“While working as a car mechanic, he was unable to resolve a conflict with a difficult customer” and quit his job without notice, leading his employer to say he would not hire the applicant again. Yet, the applicant “denied interpersonal issues at work” and said he did not recall the yelling incident. He also said the situation where he quit with only 2 hours’ notice was unfair.
The applicant reported stress, “feeling down and having a diminished interest in activities” following his deployment in Iraq, but he turned down treatment for his stress. He also “used unprofessional language during the examination, and, when asked to refrain from cursing, he did not express concern about this conduct.”
His psychological test results on the Minnesota Multiphasic Personality Inventory-2 (MMPI-2), however, suggested “a pattern of positive impression management and defensiveness that is not likely to accurately represent existing psychopathology,” the researchers reported. “Closer review suggests the applicant is apt to see himself as having high moral standards and not having aggressive impulses,” they wrote. Similarly, the applicant’s Sixteen Personality Factor Questionnaire results “reflected an individual who is tough-minded, with low anxiety, who is emotionally stable, deferential, and relaxed.”
These two tools’ findings conflicted with the applicant’s history and presentation, and the examiner deemed him “psychologically unsuitable for hire.”
The researchers said this case reinforces the importance of investigating how empirical data – even with tools such as the MMPI-2, whose predictive power has been validated in several studies – are weighted and used with clinical psychological assessments.
the researchers concluded. “Until there is greater exploration of divergent or complementary testing findings and clinical judgment, test data should not be weighted over clinical judgment in psychological evaluations.”
AUSTIN, TEX. – Using psychological screenings for law enforcement employment decisions can be a worthwhile supplement to more traditional hiring procedures, but such tools should be used with caution, a recent case study suggests.
“Pre-employment psychological evaluations for police officers are increasingly utilizing self-reported personality assessments to identify attributes in candidates that have shown to correlate with job performance outcomes,” Ann Marie Mckenzie Cassidy, DO, of Icahn School of Medicine at Mount Sinai, New York, and her colleagues wrote in an abstract presented at the annual meeting of the American Academy of Psychiatry and the Law.
“As research supporting the predictive power of written self-reported measurements expands, the call for this empirically validated data to be weighted over clinician judgment is becoming more substantive,” the researchers wrote. “The following case exemplifies a psychological evaluation where test results were either inconclusive or strongly conflicted with the clinical picture of the candidate.”
The applicant was a 34-year-old male Army veteran who received an honorable discharge after three deployments. Though he had no relevant medical or formal psychiatric history or drug use, he said he did drink alcohol heavily for a short time after joining the Army. He also had four speeding citations and one drag racing citation.
His personal history revealed several problems, including a military write-up for yelling at a subordinate and a history of difficulties working with his supervisor.
“While working as a car mechanic, he was unable to resolve a conflict with a difficult customer” and quit his job without notice, leading his employer to say he would not hire the applicant again. Yet, the applicant “denied interpersonal issues at work” and said he did not recall the yelling incident. He also said the situation where he quit with only 2 hours’ notice was unfair.
The applicant reported stress, “feeling down and having a diminished interest in activities” following his deployment in Iraq, but he turned down treatment for his stress. He also “used unprofessional language during the examination, and, when asked to refrain from cursing, he did not express concern about this conduct.”
His psychological test results on the Minnesota Multiphasic Personality Inventory-2 (MMPI-2), however, suggested “a pattern of positive impression management and defensiveness that is not likely to accurately represent existing psychopathology,” the researchers reported. “Closer review suggests the applicant is apt to see himself as having high moral standards and not having aggressive impulses,” they wrote. Similarly, the applicant’s Sixteen Personality Factor Questionnaire results “reflected an individual who is tough-minded, with low anxiety, who is emotionally stable, deferential, and relaxed.”
These two tools’ findings conflicted with the applicant’s history and presentation, and the examiner deemed him “psychologically unsuitable for hire.”
The researchers said this case reinforces the importance of investigating how empirical data – even with tools such as the MMPI-2, whose predictive power has been validated in several studies – are weighted and used with clinical psychological assessments.
the researchers concluded. “Until there is greater exploration of divergent or complementary testing findings and clinical judgment, test data should not be weighted over clinical judgment in psychological evaluations.”
AUSTIN, TEX. – Using psychological screenings for law enforcement employment decisions can be a worthwhile supplement to more traditional hiring procedures, but such tools should be used with caution, a recent case study suggests.
“Pre-employment psychological evaluations for police officers are increasingly utilizing self-reported personality assessments to identify attributes in candidates that have shown to correlate with job performance outcomes,” Ann Marie Mckenzie Cassidy, DO, of Icahn School of Medicine at Mount Sinai, New York, and her colleagues wrote in an abstract presented at the annual meeting of the American Academy of Psychiatry and the Law.
“As research supporting the predictive power of written self-reported measurements expands, the call for this empirically validated data to be weighted over clinician judgment is becoming more substantive,” the researchers wrote. “The following case exemplifies a psychological evaluation where test results were either inconclusive or strongly conflicted with the clinical picture of the candidate.”
The applicant was a 34-year-old male Army veteran who received an honorable discharge after three deployments. Though he had no relevant medical or formal psychiatric history or drug use, he said he did drink alcohol heavily for a short time after joining the Army. He also had four speeding citations and one drag racing citation.
His personal history revealed several problems, including a military write-up for yelling at a subordinate and a history of difficulties working with his supervisor.
“While working as a car mechanic, he was unable to resolve a conflict with a difficult customer” and quit his job without notice, leading his employer to say he would not hire the applicant again. Yet, the applicant “denied interpersonal issues at work” and said he did not recall the yelling incident. He also said the situation where he quit with only 2 hours’ notice was unfair.
The applicant reported stress, “feeling down and having a diminished interest in activities” following his deployment in Iraq, but he turned down treatment for his stress. He also “used unprofessional language during the examination, and, when asked to refrain from cursing, he did not express concern about this conduct.”
His psychological test results on the Minnesota Multiphasic Personality Inventory-2 (MMPI-2), however, suggested “a pattern of positive impression management and defensiveness that is not likely to accurately represent existing psychopathology,” the researchers reported. “Closer review suggests the applicant is apt to see himself as having high moral standards and not having aggressive impulses,” they wrote. Similarly, the applicant’s Sixteen Personality Factor Questionnaire results “reflected an individual who is tough-minded, with low anxiety, who is emotionally stable, deferential, and relaxed.”
These two tools’ findings conflicted with the applicant’s history and presentation, and the examiner deemed him “psychologically unsuitable for hire.”
The researchers said this case reinforces the importance of investigating how empirical data – even with tools such as the MMPI-2, whose predictive power has been validated in several studies – are weighted and used with clinical psychological assessments.
the researchers concluded. “Until there is greater exploration of divergent or complementary testing findings and clinical judgment, test data should not be weighted over clinical judgment in psychological evaluations.”
REPORTING FROM THE AAPL ANNUAL MEETING
Death row executions raise questions about competence
AUSTIN, TEX. – More than one-quarter of inmates executed during a recent 7-year period had a history confirming or suggesting they had a mental illness that might have called their competence for execution into question, according to new research.
Capital punishment remains legal in 31 U.S. states. In Ford v. Wainwright, the U.S. Supreme Court ruled in 1986 that executing a person lacking competence violates the Eighth Amendment, yet many people with a history of mental illness have been executed, said Paulina Riess, MD, of the BronxCare Health System in New York, and her colleagues.
The question of appropriately determining whether someone is competent enough to be executed also is controversial, Dr. Riess and her colleagues noted in their research abstract at the annual meeting of the American Academy of Psychiatry and the Law. “The decision of whether one is competent ultimately falls into the hands of a forensic evaluator whose opinion should represent a clear and detailed explanation of a prison’s understanding, awareness, and comprehension of the pending execution.”
They also collected data on inmates’ age, race, instant offense, method of execution, and years spent on death row.
When the authors searched the literature for an evidence-based tool to provide “information regarding any history of mental illness pertaining to executed prisoners,” they found none and therefore relied on media coverage for their data on history of mental illness or disability or psychotropic medication treatment.
They found that 26% had a history of psychiatric illness, mental disability, or treatment with psychiatric medications.
Among 273 people executed from 2010-2017, all but 5 were men. Texas had the most executions at 80, followed by Florida (27), Georgia (23), Ohio (22), Oklahoma (21), and Alabama (17). Other states in the analysis included Arizona, Arkansas, Idaho, Louisiana, Mississippi, South Carolina, South Dakota, Utah, and Virginia.
Five of the inmates were aged older than 70 years, and seven were under 30 years old. Most were aged 31-40 years (73 inmates) or 40-50 years (108 inmates). The racial breakdown was 147 whites, 90 blacks, 35 Hispanics, and 1 Native American.
Lethal injection was the method of execution for all – except one who died by firing squad and two who died by electrocution. Seven inmates had been convicted for mass murder or serial killing (one of whom also had a robbery conviction). The others all had homicide convictions, 61 of whom had at least one other conviction in addition to homicide – predominantly robbery or rape.
Of those with information available, 117 inmates spent 11-20 years on death row, 64 spent 21-30 years, and 15 spent 31-40 years. Only five inmates spent fewer than 5 years on death row, and 49 inmates spent 5-10 years.
The need to rely on media reports for data collection is a limitation of the study. “While gathering demographic information, team members unanimously reported a history of trauma in a large portion of those executed during the 7-year span examined,” the authors reported. “This is another limitation as trauma history could have been included as a separate variable.”
No disclosures were reported.
AUSTIN, TEX. – More than one-quarter of inmates executed during a recent 7-year period had a history confirming or suggesting they had a mental illness that might have called their competence for execution into question, according to new research.
Capital punishment remains legal in 31 U.S. states. In Ford v. Wainwright, the U.S. Supreme Court ruled in 1986 that executing a person lacking competence violates the Eighth Amendment, yet many people with a history of mental illness have been executed, said Paulina Riess, MD, of the BronxCare Health System in New York, and her colleagues.
The question of appropriately determining whether someone is competent enough to be executed also is controversial, Dr. Riess and her colleagues noted in their research abstract at the annual meeting of the American Academy of Psychiatry and the Law. “The decision of whether one is competent ultimately falls into the hands of a forensic evaluator whose opinion should represent a clear and detailed explanation of a prison’s understanding, awareness, and comprehension of the pending execution.”
They also collected data on inmates’ age, race, instant offense, method of execution, and years spent on death row.
When the authors searched the literature for an evidence-based tool to provide “information regarding any history of mental illness pertaining to executed prisoners,” they found none and therefore relied on media coverage for their data on history of mental illness or disability or psychotropic medication treatment.
They found that 26% had a history of psychiatric illness, mental disability, or treatment with psychiatric medications.
Among 273 people executed from 2010-2017, all but 5 were men. Texas had the most executions at 80, followed by Florida (27), Georgia (23), Ohio (22), Oklahoma (21), and Alabama (17). Other states in the analysis included Arizona, Arkansas, Idaho, Louisiana, Mississippi, South Carolina, South Dakota, Utah, and Virginia.
Five of the inmates were aged older than 70 years, and seven were under 30 years old. Most were aged 31-40 years (73 inmates) or 40-50 years (108 inmates). The racial breakdown was 147 whites, 90 blacks, 35 Hispanics, and 1 Native American.
Lethal injection was the method of execution for all – except one who died by firing squad and two who died by electrocution. Seven inmates had been convicted for mass murder or serial killing (one of whom also had a robbery conviction). The others all had homicide convictions, 61 of whom had at least one other conviction in addition to homicide – predominantly robbery or rape.
Of those with information available, 117 inmates spent 11-20 years on death row, 64 spent 21-30 years, and 15 spent 31-40 years. Only five inmates spent fewer than 5 years on death row, and 49 inmates spent 5-10 years.
The need to rely on media reports for data collection is a limitation of the study. “While gathering demographic information, team members unanimously reported a history of trauma in a large portion of those executed during the 7-year span examined,” the authors reported. “This is another limitation as trauma history could have been included as a separate variable.”
No disclosures were reported.
AUSTIN, TEX. – More than one-quarter of inmates executed during a recent 7-year period had a history confirming or suggesting they had a mental illness that might have called their competence for execution into question, according to new research.
Capital punishment remains legal in 31 U.S. states. In Ford v. Wainwright, the U.S. Supreme Court ruled in 1986 that executing a person lacking competence violates the Eighth Amendment, yet many people with a history of mental illness have been executed, said Paulina Riess, MD, of the BronxCare Health System in New York, and her colleagues.
The question of appropriately determining whether someone is competent enough to be executed also is controversial, Dr. Riess and her colleagues noted in their research abstract at the annual meeting of the American Academy of Psychiatry and the Law. “The decision of whether one is competent ultimately falls into the hands of a forensic evaluator whose opinion should represent a clear and detailed explanation of a prison’s understanding, awareness, and comprehension of the pending execution.”
They also collected data on inmates’ age, race, instant offense, method of execution, and years spent on death row.
When the authors searched the literature for an evidence-based tool to provide “information regarding any history of mental illness pertaining to executed prisoners,” they found none and therefore relied on media coverage for their data on history of mental illness or disability or psychotropic medication treatment.
They found that 26% had a history of psychiatric illness, mental disability, or treatment with psychiatric medications.
Among 273 people executed from 2010-2017, all but 5 were men. Texas had the most executions at 80, followed by Florida (27), Georgia (23), Ohio (22), Oklahoma (21), and Alabama (17). Other states in the analysis included Arizona, Arkansas, Idaho, Louisiana, Mississippi, South Carolina, South Dakota, Utah, and Virginia.
Five of the inmates were aged older than 70 years, and seven were under 30 years old. Most were aged 31-40 years (73 inmates) or 40-50 years (108 inmates). The racial breakdown was 147 whites, 90 blacks, 35 Hispanics, and 1 Native American.
Lethal injection was the method of execution for all – except one who died by firing squad and two who died by electrocution. Seven inmates had been convicted for mass murder or serial killing (one of whom also had a robbery conviction). The others all had homicide convictions, 61 of whom had at least one other conviction in addition to homicide – predominantly robbery or rape.
Of those with information available, 117 inmates spent 11-20 years on death row, 64 spent 21-30 years, and 15 spent 31-40 years. Only five inmates spent fewer than 5 years on death row, and 49 inmates spent 5-10 years.
The need to rely on media reports for data collection is a limitation of the study. “While gathering demographic information, team members unanimously reported a history of trauma in a large portion of those executed during the 7-year span examined,” the authors reported. “This is another limitation as trauma history could have been included as a separate variable.”
No disclosures were reported.
REPORTING FROM THE AAPL ANNUAL MEETING
Child gun deaths lowest in states with strictest firearm laws
ORLANDO – and laws restricting children’s access to firearms are linked to reduced pediatric firearm suicide rates, according to research.
“State-level legislation could play an important role in reducing pediatric firearm-related deaths,” concluded Jordan S. Taylor, MD, of Stanford (Calif.) University and his colleagues.
Dr. Taylor earned top honors among the American Academy of Pediatrics (AAP) Council on Injury, Violence and Poison Prevention research abstracts when he presented his findings at the annual meeting of the American Academy of Pediatrics.
Firearm injuries account for the second leading cause of death among U.S. children: 3,155 youth ages 19 years and younger died from gunshot injuries in 2016, and more than 17,000 were injured. Yet state laws governing the purchase, ownership, carriage, and storage of guns vary widely across the country. Dr. Taylor and his colleagues conducted two studies to assess the effects of firearm legislation on firearm-related injuries and deaths in U.S. children.
In their first study, they analyzed pediatric inpatient admissions for firearm injuries in 2012 relative to the stringency of state firearm legislation. They relied on five data sources for the analysis: the Kids’ Inpatient Database (KID), the Healthcare Cost and Utilization Project, the Agency for Healthcare Research and Quality, the U.S. Census Bureau, and the 2013 Brady scorecard.
The Brady scorecard provides scores for each state based on the presence and strictness of firearm-related laws, including legislation on background checks, ability of dangerous individuals to purchase guns, trafficking laws, and laws governing the sales, carrying, and purchasing of firearms.
The 10 states with the strictest laws (highest Brady scores) are California, Connecticut, Delaware, Hawaii, Illinois, Maryland, Massachusetts, New Jersey, New York, and Rhode Island. The 10 states with the lowest scores (least-strict legislation) are Alaska, Arizona, Arkansas, Florida, Kentucky, Louisiana, Montana, Nevada, Virginia, and Wyoming.
Among the 6,941 youth (aged 0-20 years) hospitalized in 2012 for firearm injuries, 7% died. More than a third of these (36%) occurred in the South, 25% in the Midwest, 22% in the West, and 17% in the Northeast.
Children most likely to be injured were boys, older children, black and Latino children, and children living in low-income zip codes.
The Midwest and South, which have lower average Brady scores (more lax legislation on guns), had 8.30 injuries per 100,000 children, compared with 7.54 injuries per 100,000 children in the Northeast and West, which have higher average Brady scores (more stringent gun laws). This was a difference of 0.76 injuries per 100,000 children (95% confidence interval, 0.38-1.13; P less than 0.001).
Then the researchers conducted a second analysis that looked specifically at firearm mortality within the context of both child access prevention (CAP) laws and states’ Brady scores. CAP laws include safe storage laws and gun lock laws, for example.
This analysis used the Web-Based Injury Statistics Query and Reporting System to capture pediatric firearm deaths from 2014-2015 and compared these to the 2014 Brady scores and CAP laws.
An estimated 2,715 child gun deaths occurred during the study period, of which 62% were homicides and 31% were suicides. The researchers identified “a significant negative correlation between states’ firearm legislation stringency and pediatric firearm mortality (Spearman correlation coefficient = –0.66) and between presence of CAP laws and firearm suicide rates (Spearman correlation coefficient = –0.56).”
Dr. Taylor said in an interview, “states that have both types of child access prevention laws [had] suicide rates four times lower than states that did not have either of those.”
Positive correlations also showed up between unemployment rate and firearm homicide rate (Spearman correlation coefficient = 0.55) and teen tobacco use and firearm suicide rate (Spearman correlation coefficient = 0.50).
The association between Brady scores and pediatric mortality from firearms remained significant after adjustment for poverty, unemployment, and substance abuse (P less than .01). Similarly, the association between the pediatric firearm suicide rate and CAP laws remained significant after controlling for socioeconomic factors and other firearm legislation (P less than .01).
In a video interview, Dr. Taylor discussed his research findings and their importance in clinical practice.
“It’s absolutely important for pediatricians to talk to families about firearms in their home and also in the homes of their friends that they visit,” Dr. Taylor said. “We try to approach it as a public health issue similar to seat belts and car seats.”
No external funding was used, and Dr. Taylor reported no conflicts of interest.
ORLANDO – and laws restricting children’s access to firearms are linked to reduced pediatric firearm suicide rates, according to research.
“State-level legislation could play an important role in reducing pediatric firearm-related deaths,” concluded Jordan S. Taylor, MD, of Stanford (Calif.) University and his colleagues.
Dr. Taylor earned top honors among the American Academy of Pediatrics (AAP) Council on Injury, Violence and Poison Prevention research abstracts when he presented his findings at the annual meeting of the American Academy of Pediatrics.
Firearm injuries account for the second leading cause of death among U.S. children: 3,155 youth ages 19 years and younger died from gunshot injuries in 2016, and more than 17,000 were injured. Yet state laws governing the purchase, ownership, carriage, and storage of guns vary widely across the country. Dr. Taylor and his colleagues conducted two studies to assess the effects of firearm legislation on firearm-related injuries and deaths in U.S. children.
In their first study, they analyzed pediatric inpatient admissions for firearm injuries in 2012 relative to the stringency of state firearm legislation. They relied on five data sources for the analysis: the Kids’ Inpatient Database (KID), the Healthcare Cost and Utilization Project, the Agency for Healthcare Research and Quality, the U.S. Census Bureau, and the 2013 Brady scorecard.
The Brady scorecard provides scores for each state based on the presence and strictness of firearm-related laws, including legislation on background checks, ability of dangerous individuals to purchase guns, trafficking laws, and laws governing the sales, carrying, and purchasing of firearms.
The 10 states with the strictest laws (highest Brady scores) are California, Connecticut, Delaware, Hawaii, Illinois, Maryland, Massachusetts, New Jersey, New York, and Rhode Island. The 10 states with the lowest scores (least-strict legislation) are Alaska, Arizona, Arkansas, Florida, Kentucky, Louisiana, Montana, Nevada, Virginia, and Wyoming.
Among the 6,941 youth (aged 0-20 years) hospitalized in 2012 for firearm injuries, 7% died. More than a third of these (36%) occurred in the South, 25% in the Midwest, 22% in the West, and 17% in the Northeast.
Children most likely to be injured were boys, older children, black and Latino children, and children living in low-income zip codes.
The Midwest and South, which have lower average Brady scores (more lax legislation on guns), had 8.30 injuries per 100,000 children, compared with 7.54 injuries per 100,000 children in the Northeast and West, which have higher average Brady scores (more stringent gun laws). This was a difference of 0.76 injuries per 100,000 children (95% confidence interval, 0.38-1.13; P less than 0.001).
Then the researchers conducted a second analysis that looked specifically at firearm mortality within the context of both child access prevention (CAP) laws and states’ Brady scores. CAP laws include safe storage laws and gun lock laws, for example.
This analysis used the Web-Based Injury Statistics Query and Reporting System to capture pediatric firearm deaths from 2014-2015 and compared these to the 2014 Brady scores and CAP laws.
An estimated 2,715 child gun deaths occurred during the study period, of which 62% were homicides and 31% were suicides. The researchers identified “a significant negative correlation between states’ firearm legislation stringency and pediatric firearm mortality (Spearman correlation coefficient = –0.66) and between presence of CAP laws and firearm suicide rates (Spearman correlation coefficient = –0.56).”
Dr. Taylor said in an interview, “states that have both types of child access prevention laws [had] suicide rates four times lower than states that did not have either of those.”
Positive correlations also showed up between unemployment rate and firearm homicide rate (Spearman correlation coefficient = 0.55) and teen tobacco use and firearm suicide rate (Spearman correlation coefficient = 0.50).
The association between Brady scores and pediatric mortality from firearms remained significant after adjustment for poverty, unemployment, and substance abuse (P less than .01). Similarly, the association between the pediatric firearm suicide rate and CAP laws remained significant after controlling for socioeconomic factors and other firearm legislation (P less than .01).
In a video interview, Dr. Taylor discussed his research findings and their importance in clinical practice.
“It’s absolutely important for pediatricians to talk to families about firearms in their home and also in the homes of their friends that they visit,” Dr. Taylor said. “We try to approach it as a public health issue similar to seat belts and car seats.”
No external funding was used, and Dr. Taylor reported no conflicts of interest.
ORLANDO – and laws restricting children’s access to firearms are linked to reduced pediatric firearm suicide rates, according to research.
“State-level legislation could play an important role in reducing pediatric firearm-related deaths,” concluded Jordan S. Taylor, MD, of Stanford (Calif.) University and his colleagues.
Dr. Taylor earned top honors among the American Academy of Pediatrics (AAP) Council on Injury, Violence and Poison Prevention research abstracts when he presented his findings at the annual meeting of the American Academy of Pediatrics.
Firearm injuries account for the second leading cause of death among U.S. children: 3,155 youth ages 19 years and younger died from gunshot injuries in 2016, and more than 17,000 were injured. Yet state laws governing the purchase, ownership, carriage, and storage of guns vary widely across the country. Dr. Taylor and his colleagues conducted two studies to assess the effects of firearm legislation on firearm-related injuries and deaths in U.S. children.
In their first study, they analyzed pediatric inpatient admissions for firearm injuries in 2012 relative to the stringency of state firearm legislation. They relied on five data sources for the analysis: the Kids’ Inpatient Database (KID), the Healthcare Cost and Utilization Project, the Agency for Healthcare Research and Quality, the U.S. Census Bureau, and the 2013 Brady scorecard.
The Brady scorecard provides scores for each state based on the presence and strictness of firearm-related laws, including legislation on background checks, ability of dangerous individuals to purchase guns, trafficking laws, and laws governing the sales, carrying, and purchasing of firearms.
The 10 states with the strictest laws (highest Brady scores) are California, Connecticut, Delaware, Hawaii, Illinois, Maryland, Massachusetts, New Jersey, New York, and Rhode Island. The 10 states with the lowest scores (least-strict legislation) are Alaska, Arizona, Arkansas, Florida, Kentucky, Louisiana, Montana, Nevada, Virginia, and Wyoming.
Among the 6,941 youth (aged 0-20 years) hospitalized in 2012 for firearm injuries, 7% died. More than a third of these (36%) occurred in the South, 25% in the Midwest, 22% in the West, and 17% in the Northeast.
Children most likely to be injured were boys, older children, black and Latino children, and children living in low-income zip codes.
The Midwest and South, which have lower average Brady scores (more lax legislation on guns), had 8.30 injuries per 100,000 children, compared with 7.54 injuries per 100,000 children in the Northeast and West, which have higher average Brady scores (more stringent gun laws). This was a difference of 0.76 injuries per 100,000 children (95% confidence interval, 0.38-1.13; P less than 0.001).
Then the researchers conducted a second analysis that looked specifically at firearm mortality within the context of both child access prevention (CAP) laws and states’ Brady scores. CAP laws include safe storage laws and gun lock laws, for example.
This analysis used the Web-Based Injury Statistics Query and Reporting System to capture pediatric firearm deaths from 2014-2015 and compared these to the 2014 Brady scores and CAP laws.
An estimated 2,715 child gun deaths occurred during the study period, of which 62% were homicides and 31% were suicides. The researchers identified “a significant negative correlation between states’ firearm legislation stringency and pediatric firearm mortality (Spearman correlation coefficient = –0.66) and between presence of CAP laws and firearm suicide rates (Spearman correlation coefficient = –0.56).”
Dr. Taylor said in an interview, “states that have both types of child access prevention laws [had] suicide rates four times lower than states that did not have either of those.”
Positive correlations also showed up between unemployment rate and firearm homicide rate (Spearman correlation coefficient = 0.55) and teen tobacco use and firearm suicide rate (Spearman correlation coefficient = 0.50).
The association between Brady scores and pediatric mortality from firearms remained significant after adjustment for poverty, unemployment, and substance abuse (P less than .01). Similarly, the association between the pediatric firearm suicide rate and CAP laws remained significant after controlling for socioeconomic factors and other firearm legislation (P less than .01).
In a video interview, Dr. Taylor discussed his research findings and their importance in clinical practice.
“It’s absolutely important for pediatricians to talk to families about firearms in their home and also in the homes of their friends that they visit,” Dr. Taylor said. “We try to approach it as a public health issue similar to seat belts and car seats.”
No external funding was used, and Dr. Taylor reported no conflicts of interest.
REPORTING FROM AAP 2018
Key clinical point: Stricter state firearm legislation was associated with reduced firearm-related pediatric mortality.
Major finding: 8.3 injuries per 100,000 children occurred in the Midwest and South, compared with 7.5 injuries per 100,000 children in the Northeast and West.
Study details: The findings are based on two separate analyses that analyzed state Brady scores along with 6,941 firearm-related hospitalizations in 2012 and 2,715 pediatric deaths from firearms in 2014-2015.
Disclosures: No external funding was used, and Dr. Taylor reported no conflicts of interest.
Sofa and bed injuries very common among young children
ORLANDO – Injuries related to beds and sofas in children aged under 5 years occur more than twice as frequently than injuries related to stairs, according to new research.
“Findings from our analysis reveal that it is an important source of injury to young children and a leading cause of trauma to infants,” concluded David S. Liu, of Baylor College of Medicine, Houston, who presented the findings at the annual meeting of the American Academy of Pediatrics.
“The rate of bed- and sofa-related injuries is increasing, which underscores the need for increased prevention efforts, including parental education and improved safety design, to decrease soft furniture injuries among young children,” Mr. Liu and his colleagues wrote.
The researchers used the National Electronic Injury Surveillance System of the U.S. Consumer Product Safety Commission to conduct a retrospective analysis of injuries related to sofas and beds from 2007 to 2016.
They found that an estimated 2.3 million children aged under 5 years were treated for injuries related to soft furniture during those years, an average of 230,026 injuries a year, or 115 injuries per 10,000 children. To the surprise of the researchers, injuries related to beds and sofas were the most common types of accidental injury in that age group, occurring 2.5 times more often than stair-related injuries, which occurred at a rate of 47 per 10,000 population.
Boys were slightly more likely to be injured, making up 56% of all the cases. Soft tissue/internal organ injuries were most common, comprising 28% of all injuries, followed by lacerations in 24% of cases, abrasions in 15%, and fractures in 14%.
More than half the children (61%) sustained injuries to the head or face, and 3% were hospitalized for their injuries. Although infants (under 1 year old) only accounted for 28% of children injured, they were twice as likely to be hospitalized than older children.
The researchers also identified increases in injuries over the time period studied. Bed-related injuries increased 17% from 2007 to 2016, and sofa/couch-related injuries increased 17% during that period.
Although the vast majority of children were treated and released, approximately 4% of children were admitted or treated and transferred to another facility. Overall, an estimated 3,361 children died during the 9-year period, translating to a little over 370 children a year.
In a video interview, Mr. Liu discussed the implications of these findings.
“We know how dangerous car accidents and staircases are, and we often recommend car seats and stair gates for those,” Mr. Liu said. “Obviously we can’t put a gate or a barrier on every single sofa, couch, and bed in America, so as clinicians and parents, the best we can do is keep aware of how dangerous these items are. Just because of their soft nature doesn’t mean they’re inherently safer.”
The researchers reported no disclosures and the research received no external funding.
ORLANDO – Injuries related to beds and sofas in children aged under 5 years occur more than twice as frequently than injuries related to stairs, according to new research.
“Findings from our analysis reveal that it is an important source of injury to young children and a leading cause of trauma to infants,” concluded David S. Liu, of Baylor College of Medicine, Houston, who presented the findings at the annual meeting of the American Academy of Pediatrics.
“The rate of bed- and sofa-related injuries is increasing, which underscores the need for increased prevention efforts, including parental education and improved safety design, to decrease soft furniture injuries among young children,” Mr. Liu and his colleagues wrote.
The researchers used the National Electronic Injury Surveillance System of the U.S. Consumer Product Safety Commission to conduct a retrospective analysis of injuries related to sofas and beds from 2007 to 2016.
They found that an estimated 2.3 million children aged under 5 years were treated for injuries related to soft furniture during those years, an average of 230,026 injuries a year, or 115 injuries per 10,000 children. To the surprise of the researchers, injuries related to beds and sofas were the most common types of accidental injury in that age group, occurring 2.5 times more often than stair-related injuries, which occurred at a rate of 47 per 10,000 population.
Boys were slightly more likely to be injured, making up 56% of all the cases. Soft tissue/internal organ injuries were most common, comprising 28% of all injuries, followed by lacerations in 24% of cases, abrasions in 15%, and fractures in 14%.
More than half the children (61%) sustained injuries to the head or face, and 3% were hospitalized for their injuries. Although infants (under 1 year old) only accounted for 28% of children injured, they were twice as likely to be hospitalized than older children.
The researchers also identified increases in injuries over the time period studied. Bed-related injuries increased 17% from 2007 to 2016, and sofa/couch-related injuries increased 17% during that period.
Although the vast majority of children were treated and released, approximately 4% of children were admitted or treated and transferred to another facility. Overall, an estimated 3,361 children died during the 9-year period, translating to a little over 370 children a year.
In a video interview, Mr. Liu discussed the implications of these findings.
“We know how dangerous car accidents and staircases are, and we often recommend car seats and stair gates for those,” Mr. Liu said. “Obviously we can’t put a gate or a barrier on every single sofa, couch, and bed in America, so as clinicians and parents, the best we can do is keep aware of how dangerous these items are. Just because of their soft nature doesn’t mean they’re inherently safer.”
The researchers reported no disclosures and the research received no external funding.
ORLANDO – Injuries related to beds and sofas in children aged under 5 years occur more than twice as frequently than injuries related to stairs, according to new research.
“Findings from our analysis reveal that it is an important source of injury to young children and a leading cause of trauma to infants,” concluded David S. Liu, of Baylor College of Medicine, Houston, who presented the findings at the annual meeting of the American Academy of Pediatrics.
“The rate of bed- and sofa-related injuries is increasing, which underscores the need for increased prevention efforts, including parental education and improved safety design, to decrease soft furniture injuries among young children,” Mr. Liu and his colleagues wrote.
The researchers used the National Electronic Injury Surveillance System of the U.S. Consumer Product Safety Commission to conduct a retrospective analysis of injuries related to sofas and beds from 2007 to 2016.
They found that an estimated 2.3 million children aged under 5 years were treated for injuries related to soft furniture during those years, an average of 230,026 injuries a year, or 115 injuries per 10,000 children. To the surprise of the researchers, injuries related to beds and sofas were the most common types of accidental injury in that age group, occurring 2.5 times more often than stair-related injuries, which occurred at a rate of 47 per 10,000 population.
Boys were slightly more likely to be injured, making up 56% of all the cases. Soft tissue/internal organ injuries were most common, comprising 28% of all injuries, followed by lacerations in 24% of cases, abrasions in 15%, and fractures in 14%.
More than half the children (61%) sustained injuries to the head or face, and 3% were hospitalized for their injuries. Although infants (under 1 year old) only accounted for 28% of children injured, they were twice as likely to be hospitalized than older children.
The researchers also identified increases in injuries over the time period studied. Bed-related injuries increased 17% from 2007 to 2016, and sofa/couch-related injuries increased 17% during that period.
Although the vast majority of children were treated and released, approximately 4% of children were admitted or treated and transferred to another facility. Overall, an estimated 3,361 children died during the 9-year period, translating to a little over 370 children a year.
In a video interview, Mr. Liu discussed the implications of these findings.
“We know how dangerous car accidents and staircases are, and we often recommend car seats and stair gates for those,” Mr. Liu said. “Obviously we can’t put a gate or a barrier on every single sofa, couch, and bed in America, so as clinicians and parents, the best we can do is keep aware of how dangerous these items are. Just because of their soft nature doesn’t mean they’re inherently safer.”
The researchers reported no disclosures and the research received no external funding.
REPORTING FROM AAP 2018
Key clinical point: Injuries from beds and sofas/couches are common in children aged under 5 years, occurring 2.5 times more frequently than stairs-related injuries.
Major finding: An estimated 115 bed/sofa-related injuries per 10,000 children occur every year.
Study details: The findings are based on a retrospective analysis of injuries related to sofas and beds from 2007 to 2016.
Disclosures: The researchers reported no disclosures and the research received no external funding.
Substance use increases likelihood of psychiatric hold in pregnancy
AUSTIN, TEX. – Providers are no more likely to put an involuntary psychiatric hold on someone who is pregnant than not unless she is using substances, recent research shows.
“This raises a question regarding who psychiatrists consider to be their patients: the mother, the unborn child, or both?” Samuel J. House, MD, of the University of Arkansas, Little Rock, said at the annual meeting of the American Academy of Psychiatry and the Law (AAPL).
Dr. House sent out a survey to members of the AAPL to learn their attitudes toward involuntary psychiatric holds on pregnant women, with and without evidence of substance use, and he presented the results at the meeting.
“We know that the rates of involuntary hospitalizations very widely” across different jurisdictions and practice settings, Dr. House said, but research has shown that age, unmarried status, psychotic symptoms, aggression, and a low level of social function are associated with involuntary commitment. He wanted to explore where pregnancy fit.
Dr. House became interested in clinicians’ perspectives on this issue when he realized how few psychiatric holds he saw among pregnant women during the 4 years he spent at a university hospital’s level 1 trauma center. He included questions about substance use in his survey because of the “recent push to criminalize substance use during pregnancy, mainly in response to the significant impact substance use during pregnancy can have on the fetus or developing child,” he said.
Dr. House received 68 survey responses from AAPL members, most of whom were male with an average age of 47 years. The 7-question survey presented various clinical scenarios and asked what the respondent would do.
The first question concerned being called to the emergency department to evaluate a 28-year-old white woman with clinical signs of depression, history of a suicide attempt, and a mother who had committed suicide when the patient was 15. However, she states during evaluation: “I could never actually kill myself. My family would be too upset, and I would go to hell.”
Two-thirds of respondents (67.6%) said they would admit the woman to an inpatient unit for stabilization, and the others would discharge her with close follow-up.
The second question asked what the clinician would do if the patient declined admission: 41.2% would discharge, and 58.8% would place the woman on a psychiatric hold.
The third question introduced a positive pregnancy test for the woman, but none of the respondents said they would cancel the psychiatric hold. Most were split between proceeding with a hold (42.6%) or proceeding with a discharge (47.1%), though 10.3% would cancel the discharge and place the patient on a hold. Ultimately, respondents were no more likely to put the woman on a hold whether she was pregnant or not.
Then the survey repeated the scenario, but instead of a positive pregnancy test, the question asked what clinicians would do if her drug screen were positive after she had refused admission. In that scenario, the woman reported daily methamphetamine use to the emergency physician.
Among respondents, 48.5% would proceed with a psychiatric hold, 42.6% would proceed with a discharge, and 8.8% would cancel the discharge and put the patient on a hold.
The final question asks clinicians’ course of action if the woman’s pregnancy test were positive after the positive drug screen. Now, only a little over a quarter of respondents (26.5%) would proceed with a discharge and follow-up. More than half (57.4%) would proceed with a hold, and 16.2% would cancel the discharge and place a psychiatric hold.
Therefore, 73.6% of clinicians would place a pregnant woman with a history of substance use on a psychiatric hold, compared with 52.9% if the woman were pregnant but not using methamphetamine.
Laws on pregnancy, substance use
Dr. House considered those findings within the context of current laws governing substance use during pregnancy., with prosecution usually requiring detection of the substance at birth or during pregnancy, or evidence of risk to the child’s health.
Tennessee is unique in considering substance abuse in pregnancy assault if the child is born with dependence or other harm from the drug use. Women in Minnesota, South Dakota, and Wisconsin can be subject to civil commitment, including required inpatient drug treatment, for substance abuse during pregnancy (Am J Psychiatry. 2016 Nov 1;173[11]:1077-80).
Mandatory reporting laws for suspected substance abuse during pregnancy exist in 15 states, mostly in the Southwest, northern Midwest, and states around the District of Columbia. And four states – Kentucky, Iowa, Minnesota, and North Dakota – require pregnant women suspected of substance abuse to be tested.
Yet, most major relevant medical associations oppose criminalization of substance use during pregnancy, including the American Psychiatric Association, the American Academy of Addiction Psychiatry, the American Medical Association, and the American College of Obstetricians and Gynecologists.
“They are generally for increasing access for people, like voluntary screening, but against criminalization because it creates a barrier to accessing prenatal care,” Dr. House explained.
Aside from the question of whom psychiatrists consider their patients – the woman, her fetus, or both – the results raise another question, Dr. House said: “While studies have shown that criminalizing substance use during pregnancy discourages mothers from seeking prenatal care, does the threat of an involuntary psychiatric admission have a similar consequence?” That’s a question for further research.
No external funding was used. Dr. House was a clinical investigator without compensation for Janssen Pharmaceuticals from 2015 to 2017.
AUSTIN, TEX. – Providers are no more likely to put an involuntary psychiatric hold on someone who is pregnant than not unless she is using substances, recent research shows.
“This raises a question regarding who psychiatrists consider to be their patients: the mother, the unborn child, or both?” Samuel J. House, MD, of the University of Arkansas, Little Rock, said at the annual meeting of the American Academy of Psychiatry and the Law (AAPL).
Dr. House sent out a survey to members of the AAPL to learn their attitudes toward involuntary psychiatric holds on pregnant women, with and without evidence of substance use, and he presented the results at the meeting.
“We know that the rates of involuntary hospitalizations very widely” across different jurisdictions and practice settings, Dr. House said, but research has shown that age, unmarried status, psychotic symptoms, aggression, and a low level of social function are associated with involuntary commitment. He wanted to explore where pregnancy fit.
Dr. House became interested in clinicians’ perspectives on this issue when he realized how few psychiatric holds he saw among pregnant women during the 4 years he spent at a university hospital’s level 1 trauma center. He included questions about substance use in his survey because of the “recent push to criminalize substance use during pregnancy, mainly in response to the significant impact substance use during pregnancy can have on the fetus or developing child,” he said.
Dr. House received 68 survey responses from AAPL members, most of whom were male with an average age of 47 years. The 7-question survey presented various clinical scenarios and asked what the respondent would do.
The first question concerned being called to the emergency department to evaluate a 28-year-old white woman with clinical signs of depression, history of a suicide attempt, and a mother who had committed suicide when the patient was 15. However, she states during evaluation: “I could never actually kill myself. My family would be too upset, and I would go to hell.”
Two-thirds of respondents (67.6%) said they would admit the woman to an inpatient unit for stabilization, and the others would discharge her with close follow-up.
The second question asked what the clinician would do if the patient declined admission: 41.2% would discharge, and 58.8% would place the woman on a psychiatric hold.
The third question introduced a positive pregnancy test for the woman, but none of the respondents said they would cancel the psychiatric hold. Most were split between proceeding with a hold (42.6%) or proceeding with a discharge (47.1%), though 10.3% would cancel the discharge and place the patient on a hold. Ultimately, respondents were no more likely to put the woman on a hold whether she was pregnant or not.
Then the survey repeated the scenario, but instead of a positive pregnancy test, the question asked what clinicians would do if her drug screen were positive after she had refused admission. In that scenario, the woman reported daily methamphetamine use to the emergency physician.
Among respondents, 48.5% would proceed with a psychiatric hold, 42.6% would proceed with a discharge, and 8.8% would cancel the discharge and put the patient on a hold.
The final question asks clinicians’ course of action if the woman’s pregnancy test were positive after the positive drug screen. Now, only a little over a quarter of respondents (26.5%) would proceed with a discharge and follow-up. More than half (57.4%) would proceed with a hold, and 16.2% would cancel the discharge and place a psychiatric hold.
Therefore, 73.6% of clinicians would place a pregnant woman with a history of substance use on a psychiatric hold, compared with 52.9% if the woman were pregnant but not using methamphetamine.
Laws on pregnancy, substance use
Dr. House considered those findings within the context of current laws governing substance use during pregnancy., with prosecution usually requiring detection of the substance at birth or during pregnancy, or evidence of risk to the child’s health.
Tennessee is unique in considering substance abuse in pregnancy assault if the child is born with dependence or other harm from the drug use. Women in Minnesota, South Dakota, and Wisconsin can be subject to civil commitment, including required inpatient drug treatment, for substance abuse during pregnancy (Am J Psychiatry. 2016 Nov 1;173[11]:1077-80).
Mandatory reporting laws for suspected substance abuse during pregnancy exist in 15 states, mostly in the Southwest, northern Midwest, and states around the District of Columbia. And four states – Kentucky, Iowa, Minnesota, and North Dakota – require pregnant women suspected of substance abuse to be tested.
Yet, most major relevant medical associations oppose criminalization of substance use during pregnancy, including the American Psychiatric Association, the American Academy of Addiction Psychiatry, the American Medical Association, and the American College of Obstetricians and Gynecologists.
“They are generally for increasing access for people, like voluntary screening, but against criminalization because it creates a barrier to accessing prenatal care,” Dr. House explained.
Aside from the question of whom psychiatrists consider their patients – the woman, her fetus, or both – the results raise another question, Dr. House said: “While studies have shown that criminalizing substance use during pregnancy discourages mothers from seeking prenatal care, does the threat of an involuntary psychiatric admission have a similar consequence?” That’s a question for further research.
No external funding was used. Dr. House was a clinical investigator without compensation for Janssen Pharmaceuticals from 2015 to 2017.
AUSTIN, TEX. – Providers are no more likely to put an involuntary psychiatric hold on someone who is pregnant than not unless she is using substances, recent research shows.
“This raises a question regarding who psychiatrists consider to be their patients: the mother, the unborn child, or both?” Samuel J. House, MD, of the University of Arkansas, Little Rock, said at the annual meeting of the American Academy of Psychiatry and the Law (AAPL).
Dr. House sent out a survey to members of the AAPL to learn their attitudes toward involuntary psychiatric holds on pregnant women, with and without evidence of substance use, and he presented the results at the meeting.
“We know that the rates of involuntary hospitalizations very widely” across different jurisdictions and practice settings, Dr. House said, but research has shown that age, unmarried status, psychotic symptoms, aggression, and a low level of social function are associated with involuntary commitment. He wanted to explore where pregnancy fit.
Dr. House became interested in clinicians’ perspectives on this issue when he realized how few psychiatric holds he saw among pregnant women during the 4 years he spent at a university hospital’s level 1 trauma center. He included questions about substance use in his survey because of the “recent push to criminalize substance use during pregnancy, mainly in response to the significant impact substance use during pregnancy can have on the fetus or developing child,” he said.
Dr. House received 68 survey responses from AAPL members, most of whom were male with an average age of 47 years. The 7-question survey presented various clinical scenarios and asked what the respondent would do.
The first question concerned being called to the emergency department to evaluate a 28-year-old white woman with clinical signs of depression, history of a suicide attempt, and a mother who had committed suicide when the patient was 15. However, she states during evaluation: “I could never actually kill myself. My family would be too upset, and I would go to hell.”
Two-thirds of respondents (67.6%) said they would admit the woman to an inpatient unit for stabilization, and the others would discharge her with close follow-up.
The second question asked what the clinician would do if the patient declined admission: 41.2% would discharge, and 58.8% would place the woman on a psychiatric hold.
The third question introduced a positive pregnancy test for the woman, but none of the respondents said they would cancel the psychiatric hold. Most were split between proceeding with a hold (42.6%) or proceeding with a discharge (47.1%), though 10.3% would cancel the discharge and place the patient on a hold. Ultimately, respondents were no more likely to put the woman on a hold whether she was pregnant or not.
Then the survey repeated the scenario, but instead of a positive pregnancy test, the question asked what clinicians would do if her drug screen were positive after she had refused admission. In that scenario, the woman reported daily methamphetamine use to the emergency physician.
Among respondents, 48.5% would proceed with a psychiatric hold, 42.6% would proceed with a discharge, and 8.8% would cancel the discharge and put the patient on a hold.
The final question asks clinicians’ course of action if the woman’s pregnancy test were positive after the positive drug screen. Now, only a little over a quarter of respondents (26.5%) would proceed with a discharge and follow-up. More than half (57.4%) would proceed with a hold, and 16.2% would cancel the discharge and place a psychiatric hold.
Therefore, 73.6% of clinicians would place a pregnant woman with a history of substance use on a psychiatric hold, compared with 52.9% if the woman were pregnant but not using methamphetamine.
Laws on pregnancy, substance use
Dr. House considered those findings within the context of current laws governing substance use during pregnancy., with prosecution usually requiring detection of the substance at birth or during pregnancy, or evidence of risk to the child’s health.
Tennessee is unique in considering substance abuse in pregnancy assault if the child is born with dependence or other harm from the drug use. Women in Minnesota, South Dakota, and Wisconsin can be subject to civil commitment, including required inpatient drug treatment, for substance abuse during pregnancy (Am J Psychiatry. 2016 Nov 1;173[11]:1077-80).
Mandatory reporting laws for suspected substance abuse during pregnancy exist in 15 states, mostly in the Southwest, northern Midwest, and states around the District of Columbia. And four states – Kentucky, Iowa, Minnesota, and North Dakota – require pregnant women suspected of substance abuse to be tested.
Yet, most major relevant medical associations oppose criminalization of substance use during pregnancy, including the American Psychiatric Association, the American Academy of Addiction Psychiatry, the American Medical Association, and the American College of Obstetricians and Gynecologists.
“They are generally for increasing access for people, like voluntary screening, but against criminalization because it creates a barrier to accessing prenatal care,” Dr. House explained.
Aside from the question of whom psychiatrists consider their patients – the woman, her fetus, or both – the results raise another question, Dr. House said: “While studies have shown that criminalizing substance use during pregnancy discourages mothers from seeking prenatal care, does the threat of an involuntary psychiatric admission have a similar consequence?” That’s a question for further research.
No external funding was used. Dr. House was a clinical investigator without compensation for Janssen Pharmaceuticals from 2015 to 2017.
REPORTING FROM THE AAPL ANNUAL MEETING
Key clinical point: Women are more likely to receive a psychiatric hold if they are pregnant and using a substance.
Major finding: Almost 53% of clinicians would place a suicidal pregnant woman on a psychiatric hold, but 73.6% would do so if she were using methamphetamines.
Study details: The findings are based on an Internet survey of 68 members of the American Academy of Psychiatry and the Law.
Disclosures: No external funding was used. Dr. House was a clinical investigator without compensation for Janssen Pharmaceuticals from 2015 to 2017.
A paradigm shift in medical research is necessary
ORLANDO – What doctors think they know to be true in medicine has changed dramatically in the past several decades and will be different again in the decades to come, leaving them with a dilemma, according to Kevin T. Powell, MD, PhD, a pediatric hospitalist in St. Louis. If half of what doctors teach or know in medicine today will ultimately end up not being true, how do they know what to believe or accept?
While there is not a single satisfactory answer to that question, researchers can select research that gets doctors closer to reliable findings and steer them away from the barrage of poor-quality research that emerges from the current publish-or-perish system, Dr. Powell told his colleagues at the annual meeting of the American Academy of Pediatrics.
During his talk, Dr. Powell discussed the challenges and flaws with medical research as it is currently conducted, citing Doug Altman’s writings on these problems as early as 1994.
“The poor quality of much medical research is widely acknowledged, yet disturbingly the leaders of the medical profession seem only minimally concerned about the problem and make no apparent effort to find a solution,” wrote Mr. Altman, an English medical statistician (BMJ. 1994;308:283).
“We need less research, better research, and research done for the right reasons,” Mr. Altman concluded. “Abandoning using the number of publications as a measure of ability would be a start.”
In an interview, Dr. Powell described an unfortunate consequence of the publish-or-perish pressure in academic medicine: A glut of short-term, small studies with little clinical utility that researchers can complete in 1 or 2 years rather than the large, multicenter studies that take several years – and produce higher-quality findings – but cannot be turned into as many publications.
“We’re generating a lot of medical research findings that end up being false,” he said. “It’s a random walk in terms of getting to the truth rather than having an accurate process of getting to truth through evidence-based medicine.”
But he was hopeful, not cynical, about the way forward. By persuading people that medical research has changed for the worse over time and can change into something better, Dr. Powell saw potential for future research resulting in the same sort of public health achievements that research produced in the past, such as big reductions in smoking or sudden infant death syndrome.
Dr. Powell concluded his talk with a riff on Martin Luther’s 95 Theses, the 9.5 Theses, for a reformation of evidence-based medicine that together address the various shortcomings he discussed.
1. Recognize academic promotion as a bias, just like drug money.
2. Don’t confound statistically significant and clinically significant.
3. Use only significant figures.
4. Use the phrase “we did not DETECT a difference” and include power calculations.
5. Use confidence intervals instead of P values.
6. Use number needed to harm and number needed to treat instead of relative risk.
7. Absence of proof is not proof of absence. When there is insufficient randomized, controlled trial evidence, have an independent party estimate an effect based on non-RCT articles.
8. Any article implying clinical practice should change must include a counterpoint and a benefit cost analysis. Consider both effectiveness and safety.
9. Use postmarketing peer review.
9.5. Beware of research based on surveys.
Dr. Powell reported no relevant financial disclosures.
ORLANDO – What doctors think they know to be true in medicine has changed dramatically in the past several decades and will be different again in the decades to come, leaving them with a dilemma, according to Kevin T. Powell, MD, PhD, a pediatric hospitalist in St. Louis. If half of what doctors teach or know in medicine today will ultimately end up not being true, how do they know what to believe or accept?
While there is not a single satisfactory answer to that question, researchers can select research that gets doctors closer to reliable findings and steer them away from the barrage of poor-quality research that emerges from the current publish-or-perish system, Dr. Powell told his colleagues at the annual meeting of the American Academy of Pediatrics.
During his talk, Dr. Powell discussed the challenges and flaws with medical research as it is currently conducted, citing Doug Altman’s writings on these problems as early as 1994.
“The poor quality of much medical research is widely acknowledged, yet disturbingly the leaders of the medical profession seem only minimally concerned about the problem and make no apparent effort to find a solution,” wrote Mr. Altman, an English medical statistician (BMJ. 1994;308:283).
“We need less research, better research, and research done for the right reasons,” Mr. Altman concluded. “Abandoning using the number of publications as a measure of ability would be a start.”
In an interview, Dr. Powell described an unfortunate consequence of the publish-or-perish pressure in academic medicine: A glut of short-term, small studies with little clinical utility that researchers can complete in 1 or 2 years rather than the large, multicenter studies that take several years – and produce higher-quality findings – but cannot be turned into as many publications.
“We’re generating a lot of medical research findings that end up being false,” he said. “It’s a random walk in terms of getting to the truth rather than having an accurate process of getting to truth through evidence-based medicine.”
But he was hopeful, not cynical, about the way forward. By persuading people that medical research has changed for the worse over time and can change into something better, Dr. Powell saw potential for future research resulting in the same sort of public health achievements that research produced in the past, such as big reductions in smoking or sudden infant death syndrome.
Dr. Powell concluded his talk with a riff on Martin Luther’s 95 Theses, the 9.5 Theses, for a reformation of evidence-based medicine that together address the various shortcomings he discussed.
1. Recognize academic promotion as a bias, just like drug money.
2. Don’t confound statistically significant and clinically significant.
3. Use only significant figures.
4. Use the phrase “we did not DETECT a difference” and include power calculations.
5. Use confidence intervals instead of P values.
6. Use number needed to harm and number needed to treat instead of relative risk.
7. Absence of proof is not proof of absence. When there is insufficient randomized, controlled trial evidence, have an independent party estimate an effect based on non-RCT articles.
8. Any article implying clinical practice should change must include a counterpoint and a benefit cost analysis. Consider both effectiveness and safety.
9. Use postmarketing peer review.
9.5. Beware of research based on surveys.
Dr. Powell reported no relevant financial disclosures.
ORLANDO – What doctors think they know to be true in medicine has changed dramatically in the past several decades and will be different again in the decades to come, leaving them with a dilemma, according to Kevin T. Powell, MD, PhD, a pediatric hospitalist in St. Louis. If half of what doctors teach or know in medicine today will ultimately end up not being true, how do they know what to believe or accept?
While there is not a single satisfactory answer to that question, researchers can select research that gets doctors closer to reliable findings and steer them away from the barrage of poor-quality research that emerges from the current publish-or-perish system, Dr. Powell told his colleagues at the annual meeting of the American Academy of Pediatrics.
During his talk, Dr. Powell discussed the challenges and flaws with medical research as it is currently conducted, citing Doug Altman’s writings on these problems as early as 1994.
“The poor quality of much medical research is widely acknowledged, yet disturbingly the leaders of the medical profession seem only minimally concerned about the problem and make no apparent effort to find a solution,” wrote Mr. Altman, an English medical statistician (BMJ. 1994;308:283).
“We need less research, better research, and research done for the right reasons,” Mr. Altman concluded. “Abandoning using the number of publications as a measure of ability would be a start.”
In an interview, Dr. Powell described an unfortunate consequence of the publish-or-perish pressure in academic medicine: A glut of short-term, small studies with little clinical utility that researchers can complete in 1 or 2 years rather than the large, multicenter studies that take several years – and produce higher-quality findings – but cannot be turned into as many publications.
“We’re generating a lot of medical research findings that end up being false,” he said. “It’s a random walk in terms of getting to the truth rather than having an accurate process of getting to truth through evidence-based medicine.”
But he was hopeful, not cynical, about the way forward. By persuading people that medical research has changed for the worse over time and can change into something better, Dr. Powell saw potential for future research resulting in the same sort of public health achievements that research produced in the past, such as big reductions in smoking or sudden infant death syndrome.
Dr. Powell concluded his talk with a riff on Martin Luther’s 95 Theses, the 9.5 Theses, for a reformation of evidence-based medicine that together address the various shortcomings he discussed.
1. Recognize academic promotion as a bias, just like drug money.
2. Don’t confound statistically significant and clinically significant.
3. Use only significant figures.
4. Use the phrase “we did not DETECT a difference” and include power calculations.
5. Use confidence intervals instead of P values.
6. Use number needed to harm and number needed to treat instead of relative risk.
7. Absence of proof is not proof of absence. When there is insufficient randomized, controlled trial evidence, have an independent party estimate an effect based on non-RCT articles.
8. Any article implying clinical practice should change must include a counterpoint and a benefit cost analysis. Consider both effectiveness and safety.
9. Use postmarketing peer review.
9.5. Beware of research based on surveys.
Dr. Powell reported no relevant financial disclosures.
EXPERT ANALYSIS FROM AAP 18
Sandy Hook Promise: Four programs help people recognize signs of a threat
ORLANDO – “The caretaker of all living things” – that was the good-natured moniker 7-year-old Daniel Barden had earned from his family – according to his dad, Mark Barden. Daniel would pick up black ants and take them outside “to be with their families,” even when the ant bit his fingers.
A walk down the sidewalk after a rain would take three times longer than it should because Daniel stopped to pick up every worm on the pavement and put it in the grass, lest it dry out in the sun, Mr. Barden said with a chuckle at the annual meeting of the American Academy of Pediatrics.
Daniel was his youngest and full of pure joy, Mr. Barden said, but that ended with his son’s murder during the Sandy Hook Elementary mass shooting Dec. 14, 2012. To honor his son and work to reduce the likelihood of similar mass shootings, Mr. Barden, now the managing director of Sandy Hook Promise in Newtown, Conn., shared with the pediatrician audience the work of the organization formed by Sandy Hook parents to attempt to prevent gun violence before it happens.
“We’re moms and dads and a couple of families who have lost loved ones in that tragedy, and we are growing as an organization,” Mr. Barden said. “Our basic, most fundamental objective is to prevent other families from living with the pain I will live with for the rest of my life.”
Their mission involves “creating a culture engaged and committed to identifying, intervening, and getting help for individuals who may be at risk of hurting themselves or others,” Mr. Barden said.
Sandy Hook Promise accomplishes this goal by educating and empowering communities through their four programs: Start with Hello, SOS Suicide Prevention Program, SaySomething, and Safety Assessment & Intervention. The organization delivers these programs through multiple platforms, including national and local trainers, digital curriculum downloads, interactive online training videos, and using multilingual presenters and English and Spanish materials.
The organization also especially works with schools and student’s clubs to change their culture and feel empowered to speak up and do their part to prevent gun violence too.
These programs resulted from extensive qualitative and quantitative research that Sandy Hook Promise conducted after the shooting with academic researchers, law enforcement, educators, school administrators, mental health professionals, and social movement experts.
“As we see these stories play themselves out over and over again, we start to reveal the story of somebody who didn’t just snap overnight,” Mr. Barden said. Signs that a person may be at risk for committing mass violence include suicidality, preoccupation with weapons, talking about committing violent acts, and general signs of depression and anxiety. “If we can train people how to not only recognize but to look for those signs, we can make a sustainable difference,” he said.
Most mass shootings are planned at least 6 months in advance, he said. About 80% of school shooters tell someone about their plans, and 69% tell multiple people. Similarly, up to 70% of people who die by suicide tell someone they plan to do it or give some other warning sign.
Further, more than a third of violent threats and bullying occurs electronically, so students are well equipped to watch for the signs and report them if they know how and feel comfortable doing so.
Mr. Barden outlined the goals of each of the four Sandy Hook Promise programs.
Start With Hello
This program “teaches youth how to identify and minimize social isolation, marginalization, and rejection in order to create an inclusive, connected community,” Mr. Barden explained. The goals of the program are to reduce bullying, foster socialization, increase engagement, and change a culture from within.
SOS Signs of Suicide
This is Sandy Hook Promise’s newest program and is built on a program developed by the Federal Bureau of Investigation following the Virginia Tech shooting and adapted for school-based applications.
“It also develops a multidisciplinary team within the school who acts as various touch points who know how to recognize a potential warning sign and then triage that information and take steps to get to the root cause of that behavior and not just bandage the wound,” Mr. Barden explained.
SaySomething
The organization’s flagship program does the most to recruit student involvement in recognizing the signs of a potential threat, particularly in social media, and report the individual and their behavior to a trusted adult or through Sandy Hook Promise’s Anonymous Reporting System.
“The kids take this one, and they run with it and do amazing things with it,” Mr. Barden said, noting that it particularly helps students recognize warning signs on social media. “We have growing evidence of kids following this model, and we’ve already prevented mass shootings and numerous suicides with this.”
Safety Assessment & Intervention (SAI) program
This program “trains a multidisciplinary team how to identify, assess, and respond to threats and observed at-risk behaviors,” Mr. Barden said. SAI aims to create a safer, more open school environment with less violence, bullying, and threats. That includes reducing educators’ fear and anxiety, and leading students to have a more positive view of teachers and staff.
Students can report tips to the Anonymous Reporting System through the website, calling the hot line or via a free mobile app. Regardless of the method, the anonymous tips go to a 24/7 multilingual crisis center and, if needed, law enforcement. The crisis center contacts the appropriate school official via text, email, or a phone call, and the case is tracked in real time until it’s addressed, resolved, and closed.
All of these programs are freely available to any school or institution who wants to use them, Mr. Barden said, because the organization does not want cost to get in the way of any school or community that is taking advantage of tools to reduce the risk of violence.
In fact, more than 3.5 million youth and adults in more than 7,000 schools in every state have been trained in these programs, helping hundreds of youth access mental health and wellness help, he said. The program has reduced truancy, bullying, and other forms of violence and victimization, and it has intervened in multiple school shooting plans across the United States.
Mr. Barden wrapped up his address with his gratitude for pediatricians’ willingness to be partners in reducing gun violence.
“I want to tell you how much it means to me that you took the time to come here and listen to my story and the work I’m doing,” he said, “and how proud I am to be able to share it with you, and how proud I am to be able to honor that little kid who truly was the caretaker of all living things and to continue that spirit in his honor and in his absence.”
ORLANDO – “The caretaker of all living things” – that was the good-natured moniker 7-year-old Daniel Barden had earned from his family – according to his dad, Mark Barden. Daniel would pick up black ants and take them outside “to be with their families,” even when the ant bit his fingers.
A walk down the sidewalk after a rain would take three times longer than it should because Daniel stopped to pick up every worm on the pavement and put it in the grass, lest it dry out in the sun, Mr. Barden said with a chuckle at the annual meeting of the American Academy of Pediatrics.
Daniel was his youngest and full of pure joy, Mr. Barden said, but that ended with his son’s murder during the Sandy Hook Elementary mass shooting Dec. 14, 2012. To honor his son and work to reduce the likelihood of similar mass shootings, Mr. Barden, now the managing director of Sandy Hook Promise in Newtown, Conn., shared with the pediatrician audience the work of the organization formed by Sandy Hook parents to attempt to prevent gun violence before it happens.
“We’re moms and dads and a couple of families who have lost loved ones in that tragedy, and we are growing as an organization,” Mr. Barden said. “Our basic, most fundamental objective is to prevent other families from living with the pain I will live with for the rest of my life.”
Their mission involves “creating a culture engaged and committed to identifying, intervening, and getting help for individuals who may be at risk of hurting themselves or others,” Mr. Barden said.
Sandy Hook Promise accomplishes this goal by educating and empowering communities through their four programs: Start with Hello, SOS Suicide Prevention Program, SaySomething, and Safety Assessment & Intervention. The organization delivers these programs through multiple platforms, including national and local trainers, digital curriculum downloads, interactive online training videos, and using multilingual presenters and English and Spanish materials.
The organization also especially works with schools and student’s clubs to change their culture and feel empowered to speak up and do their part to prevent gun violence too.
These programs resulted from extensive qualitative and quantitative research that Sandy Hook Promise conducted after the shooting with academic researchers, law enforcement, educators, school administrators, mental health professionals, and social movement experts.
“As we see these stories play themselves out over and over again, we start to reveal the story of somebody who didn’t just snap overnight,” Mr. Barden said. Signs that a person may be at risk for committing mass violence include suicidality, preoccupation with weapons, talking about committing violent acts, and general signs of depression and anxiety. “If we can train people how to not only recognize but to look for those signs, we can make a sustainable difference,” he said.
Most mass shootings are planned at least 6 months in advance, he said. About 80% of school shooters tell someone about their plans, and 69% tell multiple people. Similarly, up to 70% of people who die by suicide tell someone they plan to do it or give some other warning sign.
Further, more than a third of violent threats and bullying occurs electronically, so students are well equipped to watch for the signs and report them if they know how and feel comfortable doing so.
Mr. Barden outlined the goals of each of the four Sandy Hook Promise programs.
Start With Hello
This program “teaches youth how to identify and minimize social isolation, marginalization, and rejection in order to create an inclusive, connected community,” Mr. Barden explained. The goals of the program are to reduce bullying, foster socialization, increase engagement, and change a culture from within.
SOS Signs of Suicide
This is Sandy Hook Promise’s newest program and is built on a program developed by the Federal Bureau of Investigation following the Virginia Tech shooting and adapted for school-based applications.
“It also develops a multidisciplinary team within the school who acts as various touch points who know how to recognize a potential warning sign and then triage that information and take steps to get to the root cause of that behavior and not just bandage the wound,” Mr. Barden explained.
SaySomething
The organization’s flagship program does the most to recruit student involvement in recognizing the signs of a potential threat, particularly in social media, and report the individual and their behavior to a trusted adult or through Sandy Hook Promise’s Anonymous Reporting System.
“The kids take this one, and they run with it and do amazing things with it,” Mr. Barden said, noting that it particularly helps students recognize warning signs on social media. “We have growing evidence of kids following this model, and we’ve already prevented mass shootings and numerous suicides with this.”
Safety Assessment & Intervention (SAI) program
This program “trains a multidisciplinary team how to identify, assess, and respond to threats and observed at-risk behaviors,” Mr. Barden said. SAI aims to create a safer, more open school environment with less violence, bullying, and threats. That includes reducing educators’ fear and anxiety, and leading students to have a more positive view of teachers and staff.
Students can report tips to the Anonymous Reporting System through the website, calling the hot line or via a free mobile app. Regardless of the method, the anonymous tips go to a 24/7 multilingual crisis center and, if needed, law enforcement. The crisis center contacts the appropriate school official via text, email, or a phone call, and the case is tracked in real time until it’s addressed, resolved, and closed.
All of these programs are freely available to any school or institution who wants to use them, Mr. Barden said, because the organization does not want cost to get in the way of any school or community that is taking advantage of tools to reduce the risk of violence.
In fact, more than 3.5 million youth and adults in more than 7,000 schools in every state have been trained in these programs, helping hundreds of youth access mental health and wellness help, he said. The program has reduced truancy, bullying, and other forms of violence and victimization, and it has intervened in multiple school shooting plans across the United States.
Mr. Barden wrapped up his address with his gratitude for pediatricians’ willingness to be partners in reducing gun violence.
“I want to tell you how much it means to me that you took the time to come here and listen to my story and the work I’m doing,” he said, “and how proud I am to be able to share it with you, and how proud I am to be able to honor that little kid who truly was the caretaker of all living things and to continue that spirit in his honor and in his absence.”
ORLANDO – “The caretaker of all living things” – that was the good-natured moniker 7-year-old Daniel Barden had earned from his family – according to his dad, Mark Barden. Daniel would pick up black ants and take them outside “to be with their families,” even when the ant bit his fingers.
A walk down the sidewalk after a rain would take three times longer than it should because Daniel stopped to pick up every worm on the pavement and put it in the grass, lest it dry out in the sun, Mr. Barden said with a chuckle at the annual meeting of the American Academy of Pediatrics.
Daniel was his youngest and full of pure joy, Mr. Barden said, but that ended with his son’s murder during the Sandy Hook Elementary mass shooting Dec. 14, 2012. To honor his son and work to reduce the likelihood of similar mass shootings, Mr. Barden, now the managing director of Sandy Hook Promise in Newtown, Conn., shared with the pediatrician audience the work of the organization formed by Sandy Hook parents to attempt to prevent gun violence before it happens.
“We’re moms and dads and a couple of families who have lost loved ones in that tragedy, and we are growing as an organization,” Mr. Barden said. “Our basic, most fundamental objective is to prevent other families from living with the pain I will live with for the rest of my life.”
Their mission involves “creating a culture engaged and committed to identifying, intervening, and getting help for individuals who may be at risk of hurting themselves or others,” Mr. Barden said.
Sandy Hook Promise accomplishes this goal by educating and empowering communities through their four programs: Start with Hello, SOS Suicide Prevention Program, SaySomething, and Safety Assessment & Intervention. The organization delivers these programs through multiple platforms, including national and local trainers, digital curriculum downloads, interactive online training videos, and using multilingual presenters and English and Spanish materials.
The organization also especially works with schools and student’s clubs to change their culture and feel empowered to speak up and do their part to prevent gun violence too.
These programs resulted from extensive qualitative and quantitative research that Sandy Hook Promise conducted after the shooting with academic researchers, law enforcement, educators, school administrators, mental health professionals, and social movement experts.
“As we see these stories play themselves out over and over again, we start to reveal the story of somebody who didn’t just snap overnight,” Mr. Barden said. Signs that a person may be at risk for committing mass violence include suicidality, preoccupation with weapons, talking about committing violent acts, and general signs of depression and anxiety. “If we can train people how to not only recognize but to look for those signs, we can make a sustainable difference,” he said.
Most mass shootings are planned at least 6 months in advance, he said. About 80% of school shooters tell someone about their plans, and 69% tell multiple people. Similarly, up to 70% of people who die by suicide tell someone they plan to do it or give some other warning sign.
Further, more than a third of violent threats and bullying occurs electronically, so students are well equipped to watch for the signs and report them if they know how and feel comfortable doing so.
Mr. Barden outlined the goals of each of the four Sandy Hook Promise programs.
Start With Hello
This program “teaches youth how to identify and minimize social isolation, marginalization, and rejection in order to create an inclusive, connected community,” Mr. Barden explained. The goals of the program are to reduce bullying, foster socialization, increase engagement, and change a culture from within.
SOS Signs of Suicide
This is Sandy Hook Promise’s newest program and is built on a program developed by the Federal Bureau of Investigation following the Virginia Tech shooting and adapted for school-based applications.
“It also develops a multidisciplinary team within the school who acts as various touch points who know how to recognize a potential warning sign and then triage that information and take steps to get to the root cause of that behavior and not just bandage the wound,” Mr. Barden explained.
SaySomething
The organization’s flagship program does the most to recruit student involvement in recognizing the signs of a potential threat, particularly in social media, and report the individual and their behavior to a trusted adult or through Sandy Hook Promise’s Anonymous Reporting System.
“The kids take this one, and they run with it and do amazing things with it,” Mr. Barden said, noting that it particularly helps students recognize warning signs on social media. “We have growing evidence of kids following this model, and we’ve already prevented mass shootings and numerous suicides with this.”
Safety Assessment & Intervention (SAI) program
This program “trains a multidisciplinary team how to identify, assess, and respond to threats and observed at-risk behaviors,” Mr. Barden said. SAI aims to create a safer, more open school environment with less violence, bullying, and threats. That includes reducing educators’ fear and anxiety, and leading students to have a more positive view of teachers and staff.
Students can report tips to the Anonymous Reporting System through the website, calling the hot line or via a free mobile app. Regardless of the method, the anonymous tips go to a 24/7 multilingual crisis center and, if needed, law enforcement. The crisis center contacts the appropriate school official via text, email, or a phone call, and the case is tracked in real time until it’s addressed, resolved, and closed.
All of these programs are freely available to any school or institution who wants to use them, Mr. Barden said, because the organization does not want cost to get in the way of any school or community that is taking advantage of tools to reduce the risk of violence.
In fact, more than 3.5 million youth and adults in more than 7,000 schools in every state have been trained in these programs, helping hundreds of youth access mental health and wellness help, he said. The program has reduced truancy, bullying, and other forms of violence and victimization, and it has intervened in multiple school shooting plans across the United States.
Mr. Barden wrapped up his address with his gratitude for pediatricians’ willingness to be partners in reducing gun violence.
“I want to tell you how much it means to me that you took the time to come here and listen to my story and the work I’m doing,” he said, “and how proud I am to be able to share it with you, and how proud I am to be able to honor that little kid who truly was the caretaker of all living things and to continue that spirit in his honor and in his absence.”
EXPERT ANALYSIS FROM AAP 18