A JAACAP PUBLICATION
JAACAP ConnectFALL 2017 • VOLUME 4 • ISSUE 4
A Recommitment Ceremony 3 Oliver M. Stroeh, MD ...... Lab to Smartphone 4 David Rettew, MD ...... Boys’ Club: Sexual Dimorphism in Autism Spectrum Disorder 6 Emily A. Slat, BSc, Anne L. Glowinski, MD, MPE ...... The Challenge of Bullying Victimization for Adolescents With Autism Spectrum Disorder 9 Marcus A. Harrison, BS, Gerrit van Schalkwyk, MBChB ...... The Boy Who Lived: Harry Potter, Suicide, and an Opportunity for Mental Health Literacy 13 Mark Sinyor, MSc, MD, FRCPC ...... Review of Possible Etiologies and Treatment Options in a Teen With Coprophagia 17 Candace L. Giles, MD ......
PROMOTING DEVELOPMENT OF TRANSLATIONAL SKILLS AND PUBLICATION AS EDUCATION 2018 Pediatric Psychopharmacology Update Institute
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January 26-27, 2018 Laurence L. Greenhill, MD and Jeremy M. Veenstra-VanderWeele, MD, Co-Chairs New York Marriott at the Brooklyn Bridge—Brooklyn, NY Registration opens in September at www.aacap.org/psychopharm-2018. Questions? Email [email protected].
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Welcome to JAACAP Connect!
What is JAACAP Connect? mentors when necessary, and work as a team to create All are invited! JAACAP Connect is an online companion the final manuscripts. to the Journal of the American Academy of Child and What are the content requirements for Adolescent Psychiatry (JAACAP), the leading journal JAACAP Connect articles? focused exclusively on psychiatric research and treat- JAACAP Connect is interested in any topic relevant to ment of children and adolescents. A core mission of pediatric mental health that bridges scientific findings JAACAP Connect is to engage trainees and practi- with clinical reality. As evidenced by our first edition, the tioners in the process of lifelong learning via readership, topic and format can vary widely, from neuroscience to authorship, and publication experiences that emphasize teen music choices. translation of research findings into the clinical practice of child and adolescent psychiatry. How can JAACAP Connect help with my educational requirements? Why do we need JAACAP Connect? Motivated by the ACGME/ABPN Psychiatry Milestone The field of child and adolescent psychiatry is Project©, JAACAP Connect aims to promote the devel- rapidly changing, and translation of scientific liter- opment of the skillset necessary for translating scientific ature into clinical practice is a vital skillset that takes research into clinical practice. The process of science- years to develop. JAACAP Connect engages clini- based publication creates a vital set of skills that is rarely cians in this process by offering brief articles based acquired elsewhere, and models the real-life thought on trending observations by peers, and by facilitating process of translating scientific findings into clinical development of lifelong learning skills via mentored care. To bring this experience to more trainees and authorship experiences. providers, JAACAP Connect aims to enhance mastery of translating scientific findings into clinical reality by Who reads JAACAP Connect? encouraging publishing as education.
All students, trainees, and clinicians who are interested JAACAP Connect combines education and skill acqui- in child and adolescent mental health will benefit from sition with mentorship and guidance to offer new expe- reading JAACAP Connect, available online at www. riences in science-based publication. We will work jaacap.com/content/connect. AACAP members will with students, trainees, early career, and seasoned receive emails announcing new quarterly issues. physicians, regardless of previous publication experi- ence, to develop brief science-based and skill-building Who writes JAACAP Connect? articles. Opportunities for increasing knowledge and You do! We seek highly motivated students, trainees, skills through publishing as education will be available early career, and seasoned clinicians and researchers through continued contributions and direct involve- from all disciplines with compelling observations about ment with the JAACAP Connect editorial team, using an child and adolescent psychiatry. We pair authors with apprenticeship model.
Start Thinking About Authorship With JAACAP Connect What trends have you observed that deserve a closer look? Can you envision reframing key research findings into clinical care? Do you want to educate others on a broader scale, thereby improving the health of children around the country, the world? We encourage all levels of practitioners and researchers, from students to attendings, to join in and participate. All are welcome, and you are invited.
2 Fall 2017 www.jaacap.com/content/connect BACK TO TABLE OF CONTENTS 13% of youth ages 8-15 have a mental illness severe enough to cause significant impairment 13% in day-to-day living
79% of children ages 6-17 with mental illnesses do not receive treatment 79%
Nearly 50% of students age 14+ with mental illness drop out of high school (the highest rate of 50% any disability group)
More than 4,600 youth die by suicide annually, yet experts believe nearly 80% are preventable 4,600
Studies indicate on average the delay between first onset of symptoms and 8-10 treatment is 8 to 10 years
50% of all lifetime cases of mental illness are diagnosed by age 14 50%
ON OUR BIKE RIDE ACROSS THE NATION AND HELP US JOIN US BREAK THE CYCLE OF CHILDREN’S MENTAL ILLNESSES Children’s mental illnesses are REAL, COMMON, and TREATABLE. Yet today in the United States, this vulnerable population is caught in a vicious cycle of limited access to care, delayed treatment, and worsening illnesses. Join us on our ride to Break the Cycle, raising awareness and support to (1) fund new research initiatives, (2) increase the number of child and adolescent psychiatrists, and (3) help ensure that children suffering in silence get the treatment they need.
Visit BREAKTHECYCLE.AACAP.ORG and make a donation, take the pledge, or sign up to be a rider.
Break Cyclethe
infographic flyer.indd 1 1/26/2017 2:13:56 PM JAACAP Connect A JAACAP PUBLICATION
A Recommitment Ceremony
s I and many clinicians, researchers, and educa- Underscoring the JAACAP Connect mission to engage tors in our field prepare for the 64th Annual clinicians in learning throughout the lifespan via experi- AMeeting of the American Academy of Child and ences that emphasize translation of research into clinical Adolescent Psychiatry (AACAP) in Washington, DC, I practice, the authors who have contributed articles find my excitement building. Since I first attended the to this issue represent multiple stages of professional AACAP Annual Meeting as a trainee, I have viewed it as development (trainees in MD, MD/PhD, and clinical an opportunity to immerse myself in the past, present, fellowship programs, early career psychiatrists, and and future of our field—in its clinical wisdom, its rapidly established clinicians, researchers, and educators) and expanding science, and its passionate community. As a address a variety of topics of clinical pertinence. Slat card-carrying introvert, I appreciate the intimacy of both and Glowinski (p. 6) address the clinical and biological our field and our community, though I also recognize factors that contribute to an observed sexual dimor- the sobering fact that there aren’t enough of us to meet phism in youth with autism spectrum disorder (ASD). the demand for our clinical expertise and that we must Harrison and van Schalkwyk (p. 9) review the problem of resist any tendencies towards insularity and continue to adolescents with ASD being bullied, the current limita- advocate on behalf of those we serve. Each year, I leave tions to better understanding this problem, and several the Annual Meeting re-energized and recommitted to ways that this bullying can be addressed. Building on a learning, educating, advocating, and delivering the best previous JAACAP Connect article, Sinyor (p. 13) high- possible clinical care to our patients and their families. lights the potential utility of J.K. Rowling’s Harry Potter series as a message of hope and resilience in the face of This issue of JAACAP Connect represents for me a trauma and suicidal impulses. Closing this issue, Giles similar experience of recommitment, as it reflects beau- (p. 17) reviews coprophagia, a high-risk complex behav- tifully the purpose and mission with which this publi- ioral disorder that can have various etiologies and, as a cation was established. In recognition of the rapidly result, be difficult to treat. changing field of child and adolescent psychiatry and in support of the skill development necessary to criti- As I approach the second half of my term as Editor, I cally appraise the scientific literature and translate high- am particularly grateful for both the spirit with which quality science into clinical practice, I am thrilled to JAACAP Connect continues and the authors, Edito- introduce the inaugural column of what will be a regular rial Board members, and JAACAP staff who make it recurring series by David Rettew, MD. His column, possible. I very much look forward to joining many of titled “Lab to Smartphone,” will tackle hot-topic issues you in Washington, DC, and to (re)affirming our commit- within the field, including those controversies that ments to one another, our profession, and the vital work stem from the all-too-common pseudo-science that that still needs to be done. potentially confuses us and our patients/families, alike. Read his column (p. 4), and consider joining him in the Oliver M. Stroeh, MD “lab-to-smartphone” movement! Editor
3 Fall 2017 www.jaacap.com/content/connect BACK TO TABLE OF CONTENTS Your AACAP membership includes access to JAACAP, JAACAP Connect, and 4 more Elsevier pediatrics and psychiatry journals
Log in at www.aacap.org and click on JAACAP under Member Resources or register at www.jaacap.org to claim your subscription.
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Lab to Smartphone
David Rettew, MD
elcome to the first column of “Lab to Smart- With these principles in mind, the two primary goals of phone,” a new and regular feature of JAACAP “Lab to Smartphone” can be summarized as follows. The WConnect that is devoted to educating and first is to provide dependable and useful information on engaging our child psychiatry community on practical, a variety of child mental health topics that are of current contemporary, and controversial topics that are on interest and are often not covered by more traditional the minds of both child psychiatrists and the greater journal formats. Many of these topics will relate to contro- public at large. Let’s face it: child psychiatry is poorly versies that are being debated outside of the proverbial understood and often profoundly misrepresented in the ivory tower. Potential topics could include psychiatry’s role media. While I could be wrong about this, my sense is in being true mental health professionals rather than just that the annual meetings of, say, dermatology organi- mental illness professionals, the new world of open-ac- zations generally don’t attract nearly the number of cess journals and conferences, or why so many people protesters that we do. And though it certainly is true that don’t believe ADHD actually exists. These columns will at our profession has made some missteps along the way, times challenge and confront not only groups that seek much of this antagonism comes from our allowing of to undermine child psychiatry, but ourselves, as well. The other groups to define us. second goal of this column, frankly, will be to encourage other child psychiatrists, and especially trainee and junior- Ironically, in this age of endless information, people are more confused than ever, especially when it comes level folks, to “get out there” and engage the broader to a topic as complex as the developing human brain. community in both spreading reliable and helpful infor- Yes, there are fascinating and cutting-edge research mation about child mental health while refuting nonsense studies being conducted worldwide every day, with wherever it is found. As part of that effort, this column some of them appearing in JAACAP, but what good is encourages especially less-experienced writers to a groundbreaking article on attention-deficit/hyperac- contribute to “Lab to Smartphone” by either co-writing a tivity disorder (ADHD) going to do for a family that has column with me or with another senior mentor. Informa- been convinced that ADHD doesn’t exist? How is a new tion about how to do this is at the end of this article. evidence-based approach to psychotherapy going to How did I get this gig? That’s a good question, and reach the patient who has just seen an antidepressant I’m not sure I completely know the answer. Like many commercial and now believes that getting well involves child psychiatrists, my career has taken some turns. I no more than taking a pill to correct their “chemical started out primarily as a researcher, doing studies in imbalance”? child temperament and the associations with psycho- The ability to translate behavioral science into useful pathology. My colleagues and I published a number of and operational knowledge challenges even those what we thought were pretty interesting studies, but few of us in practice for many years. For trainees such as people seemed to be reading them, and the ones that psychiatry residents and child psychiatry fellows, it can were already knew a lot about the subject. Originally, I had be especially difficult to distinguish between substance thought that my job ended once a paper was published; and hype, the limits of psychiatry’s knowledge from the now I realize that the work is just beginning. The people limits of your knowledge, or between the topics that are I really wanted to reach—the parent trying to do right controversial among the public versus the topics that by their kid, the pediatrician drowning in patient mental are controversial within the field. health problems, the child psychiatrist too busy to read
4 Fall 2017 www.jaacap.com/content/connect BACK TO TABLE OF CONTENTS Lab to Smartphone
through an entire journal article—were finding answers to is understandable and compelling. Unfortunately, there their questions but in other places, namely blogs, social are not enough child psychiatrists around to be able to media, websites, and the occasional trade book.1 The have these direct professional relationships with all the problem with that was that much of that information was patients and families who need them. This means that simply wrong and often written by people with little expe- to extend our reach to the broader population, we have rience in either research or patient care. Some of these to go beyond the office, the scholarly journal, and the online experts were terrific, but too often the focus was scientific conference to the places where people are less about translating science and more about selling a actually looking for information and encouragement. new type of untested psychotherapy, nutritional supple- In Vermont, like in many other states, there is a strong ment, or book about how horrible psychiatry is.2 farm-to-table movement that strives to provide an inte- About 5 years ago, I was invited to write a blog for grated system of getting food from a local source to primary care clinicians as part of my day job at the the consumer with maximum efficiency and minimal University of Vermont Larner College of Medicine. This processing and manipulation. When it comes to the flow led to being asked to write a blog for the general public of reliable science-based information from the lab to an on the Psychology Today website called “ABCs of Child individual’s smartphone (and then to their brain, hope- Psychiatry,” which now has been viewed close to a fully), much of that hard-earned evidence is unfortunately quarter of a million times. From there, I found myself lingering at the farm or with a few interested neighbors doing more and more media appearances for radio and while hungry diners elsewhere are gobbling down the television, now including a monthly segment on our scientific equivalent of Twinkies. It’s my hope that this local news. While I’m far from being anything close to column will be a small step towards improving that distri- a celebrity, this exposure has generated quite a bit of bution network, and I invite you to be a part of it. positive and grateful responses, as well as my fair share References of trolls and detractors. 1. Fox S, Duggan M. Health Online 2013. Washington, DC: Overall, this attempt to represent child psychiatry to Pew Research Center Internet and Technology American Life Center; 2013. the public and explain what is actually known about 2. Rettew DC. Celebrity psychiatrists and science: time improving mental health has been a fascinating to close the gap. J Am Acad Child Adolesc Psychiatry. journey, but we need to increase our numbers. In my 2015;54:243-244. 20-plus years working in psychiatry, perhaps the most important lesson I have learned is this: the most chal- Participate in the Lab to Smartphone Column lenging part of our work is not coming up with a plan To suggest a topic for this column or to inquire about that will help a patient and their family get better; it is co-writing a Lab to Smartphone column with Dr. motivating, inspiring, and supporting them to enact that Rettew or another child psychiatry mentor, please plan. To accomplish this requires connection, trust, and send an email to [email protected]. an ability to articulate what we know into language that
About the Author David Rettew, MD, is program director of the child and adolescent psychiatrist fellowship program at the University of Vermont Medical Center and an associate professor of psychiatry and pediatrics at the University of Vermont Larner College of Medicine. He is the author of the book Child Psychiatry: New Thinking About the Boundary Between Traits and Illness and the “ABCs of Child Psychiatry” blog on the Psychology Today website. He is on Twitter as @PediPsych.
Disclosure: Dr. Rettew has received royalties for his blog for Psychology Today.
5 Fall 2017 www.jaacap.com/content/connect BACK TO TABLE OF CONTENTS Calling all leaders! AACAP offers resources and programs to nurture a new AACAP AWARD SPOTLIGHT: genera on of child and adolescent psychiatrist leaders. Visit the AACAP website at Myo Thwin Myint, MD www.aacap.org/awards to discover opportuni es available for you!
2013 AACAP JUNIOR SCHOLAR AWARD I enjoy the opportunity to learn, reconnect with mentors, as well as collaborate and exchange ideas with colleagues at each Annual Mee ng. I received the award as a result of being accepted to give an oral presenta on at the Resident as Teacher, a program tailored for trainees. The luncheon was great and allowed me to engage and learn about the amazing interests of other AACAP Junior members.
2012 AACAP ADVOCACY DAY TRAVEL SCHOLARSHIP (now known as the AACAP Legisla ve Conference)
This award showed me the importance of advocacy and sparked my commitment to a end the legisla ve conference each year. AACAP staff prepared us so well that we were able to stay on message and advocate effec vely. I’ve been a ending the legisla ve conference almost each year since then, and con nue to encourage my colleagues, fellows, residents, ABOUT DR. MYINT students, pa ents and families to a end the conference. More than ever, our advocacy is essen al! JOINED AACAP: JULY 2010 WORKS AT: 2011 AACAP EDUCATIONAL OUTREACH PROGRAM FOR CAP RESIDENTS TULANE UNIVERSITY The Annual mee ng is a great forum to learn, meet other colleagues to share ideas, mentor POSITION: and be mentored. A ending the Mentorship Program, the Career Development Forum, as ASSISTANT PROFESSOR; PROGRAM DIRECTOR OF well as encouragement to a end Resident as Teacher along with AACAP Commi ee TRIPLE BOARD RESIDENCY mee ngs, propelled me to get more involved in AACAP. Without this award, I’m unsure if I AND CAP FELLOWSHIP would have found all that Annual Mee ng has to offer, including support to not only be TRAINING PROGRAMS involved in planning many of those ac vi es for subsequent mee ngs, but also the privilege INTERESTS: of leading most of them. TRAINING AND EDUCATION, LGBTQ HEALTH AACAP AFFILIATIONS: TRAINING AND EDUCATION COMMITTEE MEMBER; AACAP ALLIANCE FOR LEARNING AND INNOVATION GROUP LEADER; 2017 SUMMER MEDICAL STUDENT FELLOWSHIP MENTOR JAACAP Connect A JAACAP PUBLICATION
Boys’ Club: Sexual Dimorphism in Autism Spectrum Disorder
Emily A. Slat, BSc, Anne L. Glowinski, MD, MPE
utism spectrum disorder (ASD) is a complex may help to correct for this bias. This baseline difference and heterogeneous disorder of development. in reciprocal social behavior between the sexes may AIts heterogeneity presents a challenge for the explain part of the sex difference seen in ASD-diagnosed creation of diagnostic criteria that will encompass all populations, but it is clear that other factors contribute to affected individuals without misdiagnosing other devel- the sexual dimorphism of this complex disorder. opmental disorders, or missing individuals entirely. Our current definition recognizes a spectrum of persistent The female protective effect (FPE) is a widely held theory deficits in socialization, communication, and restricted that females are inherently protected from certain ASD interests/repetitive behaviors.1 Even though DSM guide- traits, leading to reduced rates of ASD diagnosis in lines for diagnosis of autism have changed over time, females. Genetic studies support this theory by revealing there is a persistent sexual dimorphism in the ASD a higher burden of de novo mutations in females with ASD 8,9 population, with far more males receiving the diagnosis compared to males with ASD. Constantino et al. used than females. Sex ratios vary from one study to the ASD multiplex families (i.e. two or more family members next, with an average 4:1 male-to-female ratio across meeting criteria for ASD diagnosis) to look at whether common allelic variations in the pseudoautosomal the spectrum.2 However, there is great variation in this region of the X chromosome might serve as protective sex ratio when patients with ASD are subdivided based factors for females (relative to males) when present in a on level of function. The high-functioning ASD popula- homozygous state. No single allele met a threshold for tion, formerly diagnosed with Asperger’s disorder, has genome-wide significance for such a protective function. a male-to-female ratio of 10:1,3 while children with intel- Constantino et al. were able to demonstrate a sex differ- lectual disability in addition to ASD have male-to-female ence in the distribution of autistic trait scores among ratios much closer to 1:1.3,4 Many explanations for this siblings of affected individuals in multiplex families. Their sexual dimorphism have been proposed, but no single work revealed a bimodal distribution in the female ASD factor can account for this phenomenon. population, in contrast to a unimodal distribution among When trying to understand what may underlie the sexual males, demonstrating that a protective effect may exist dimorphism of ASD, we must look at sexual dimorphism among multiplex females.10 Similar bimodal distributions within the general population. The Social Responsiveness of affected females have been identified in other research Scale (SRS) surveys quantitatively measure deficits in in ASD multiplex families, reproducibly demonstrating two reciprocal social behavior.5 Across multiple studies, SRS distinct populations of females, separating an affected scores from unaffected and affected individuals demon- group from an unaffected group.11 The nature of sex-spe- strated a mean score 3 points higher for males (0.17 SD) cific reduction in phenotypic expression of genetic than females.6,7 This difference may seem trivial, but a susceptibility to autism is further qualified by findings small shift toward the pathological end of the spectrum in of Dworzynski et al., which demonstrated a significantly males combined with an absolute threshold for diagnosis higher rate of ASD diagnosis in girls when they also had of ASD across both sexes creates a significant difference intellectual disability or behavioral problems.12 These in the number of males diagnosed with ASD relative to data suggest that some highly deleterious genetic influ- females. Normalizing the data based on sex differences ences may override the protective phenomenon unique
6 Fall 2017 www.jaacap.com/content/connect BACK TO TABLE OF CONTENTS Sexual Dimorphism in Autism Spectrum Disorder
to females. Further research will be required to elucidate biopsychosocial diagnostic assessment to limit clinical the specific biological mechanisms that protect females; bias and subjectivity of diagnosis. Second, acknowledge discovery of such mechanisms may aid in the develop- that male and female populations do not have equal ment of more effective diagnostic tools and therapeutic distributions of ASD traits and use sex-normed thresh- interventions in the future. olds for diagnosis based on the distribution of autistic traits for each sex. Third, continue to study the roles of Familial inheritance of autistic traits supports the exis- biological mechanisms that contribute to ASD inheri- tence of a strong genetic component to ASD, but we must tance or protection from inheritance. By increasing our also acknowledge the impact of clinical practice on diag- understanding of the biological and clinical factors that nosis. The higher rate of ASD diagnosis among males may contribute to the sexual dimorphism of ASD, we can be influenced by a community diagnostic bias against improve the accuracy of diagnosis and develop novel females. Dworzynski et al. demonstrated that boys with therapeutic treatments, thus improving outcomes for all ASD have a higher rate of comorbid behavioral abnor- people along the autism spectrum. malities, thus preferentially bringing more boys with ASD to clinical attention than girls with the same level of ASD symptom burden.12 Even after controlling for symptom Take Home Summary burden, boys were more likely to be given a community On average, boys outnumber girls 4:1 in the diag- 10,13 diagnosis of ASD compared to girls. Addressing this nosis of autism spectrum disorders (ASD). This is bias is not likely to lead to complete resolution of this likely due in part to sexual dimorphism at the level sex difference, but it is important to acknowledge and of basic biology. However, it is also likely influenced address its contribution. by biases that exist in the way ASD is clinically diag- To address the issue of community diagnostic bias nosed. Understanding the clinical and biological against female diagnosis of ASD, a number of studies have factors that contribute to this sexual dimorphism in attempted to identify and quantify differences between ASD prevalence among boys and girls will help us male and female ASD phenotypes. Some studies demon- improve the accuracy of diagnosis. strate higher rates of restricted interests and repetitive behaviors among males14,15 or greater social deficits in References males.16 In contrast, other studies demonstrate no statis- 1. American Psychiatric Association. Diagnostic and Statis- tically significant differences between ASD phenotypes tical Manual of Mental Disorders – Fifth edition. Wash- 17-19 of males versus females. This inconsistency across ington, DC: American Psychiatric Publishing; 2013. studies may reflect the heterogeneity of ASD and subse- 2. Baird G, Simonoff E, Pickles A, et al. Prevalence of disor- quent differences in the populations studied by each ders of autism spectrum in a population cohort of children research group; however, it is more likely that the diffi- in South Thames: the special needs and autism project (SNAP). Lancet. 2006;368:210-215. culty to identify unique “feminine” or “masculine” autistic 3. Fombonne E. Epidemiology of pervasive developmental traits reflects an absence of genuine subtypes based disorders. Pediatr Res. 2009;65:591-598. on sex. Therefore, efforts to create ASD criteria that are 4. Yeargin-Allsopp M, Rice C, Karapurkar T, Doernberg N, unique to each sex may not be particularly helpful. Boyle C, Murphy C. Prevalence of autism in a US metro- politan area. JAMA. 2003;289:49-55. Instead, we are more likely to diagnose ASD with higher 5. Constantino J, Gruber C. The Social Responsiveness specificity and sensitivity by acknowledging that this Scale-2 manual. Torrance, CA: Western Psychological disorder spans a heterogeneous spectrum, and following Services; 2012. a few simple guidelines. First, increase the use of quan- 6. Constantino JN, Todd RD. Autistic traits in the general population: a twin study. Arch Gen Psychiatry. titative measures in the context of multidisciplinary, 2003;60:524-530.
7 Fall 2017 www.jaacap.com/content/connect BACK TO TABLE OF CONTENTS JAACAP Connect A JAACAP PUBLICATION
7. Kamio Y, Inada N, Kuroda M, et al. Quantitative autistic 14. Sipes M, Matson JL, Worley JA, Kozlowski AM. Gender traits ascertained in a national survey of 22 529 Japanese differences in symptoms of autism spectrum disorders in school children. Acta Psychiatr Scand. 2013;128:45-53. toddlers. Res Autism Spectr Disord. 2011;5:1465-1470. 8. Jaquemont S, Coe BP, Hersch M, et al. A higher muta- 15. Nicholas JS, Charles JM, Carpenter LA, King LB, tional burden in females supports “female protective Jenner W, Spratt EG. Prevalence and characteristics of model” in neurodevelopmental disorders. Am J Hum children with autism-spectrum disorders. Ann Epidemiol. Genet. 2014;94:415-425. 2008;18:130-136. 9. Dong S, Walker MF, Carriero NJ, et al. De novo insertions 16. McLennan O, Lord C, Schopler E. Sex differences in and deletions of predominantly paternal origin are associ- higher functioning people with autism. J Autism Devel ated with autism spectrum disorder. Cell Rep. 2014;9:16-23. Disord. 1993;23:217-227. 10. Constantino JN, Zhang Y, Frazier T, Abbacchi AM, Law 17. Mayes SD, Calhoun SL, Murray MJ, et al. Comparison of P. Sibling recurrence and the genetic epidemiology of scores on Checklist for Autism Spectrum Disorder, Child- autism. Am J Psychiatry. 2010;167:1349-1356. hood Autism Rating Scale (CARS), and Gilliam Asperger’s 11. Virkud YV, Todd RD, Abbacchi AM, Zhang Y, Constan- disorder scale (GADS) for children with low functioning tino JN. Familial aggregation of quantitative autistic traits autism, high functioning autism or Asperger’s disorder, in multiplex versus simplex autism. Am J Med Genet B ADHD and typical development. J Autism Devel Disord. Neuropsychiatr Genet. 2009;150B:328-334. 2009;39:1682-1693. 12. Dworzynski K, Ronald A, Bolton P, Happe F. How different 18. Szatmari P, Georgiades S, Bryson S, et al. Investigating are girls and boys above and below the diagnostic the structure of restricted, repetitive behaviors and threshold for autism spectrum disorder? J Am Acad Child interests domain of autism. J Child Psychol Psychiatry. Adolesc Psychiatry. 2012;51:788-797. 2006;47:582-590. 13. Russell G, Steer C, Golding J. Social and demo- 19. Duvekot J, van der Ende J, Verhulst FC, et al. Factors influ- graphic factors that influence the diagnosis of autistic encing the probability of diagnosis of autism spectrum spectrum disorders. Soc Psychiatry Psychiatr Epidemiol. disorder in girls versus boys. Autism. [Epub ahead of print] 2011;46:1283-1293. 2016 Dec 9. DOI: 10.1177/1362361316672178
About the Authors Emily A. Slat, BSc, is an MD/PhD candidate in the Medical Scientist Training Program at Washington University School of Medicine in St. Louis. She plans to pursue an academic research career in child and adolescent psychiatry.
Anne L. Glowinski, MD, MPE, a member of the JAACAP editorial board, is a professor and directs the educa- tion and training program in child and adolescent psychiatry at Washington University School of Medicine in St. Louis. She is a member of the Psychiatry Residency Review Committee (2014-2020) and is a passionate educator involved in the training of medical or research students, as well as postgraduate MD, MPH, or PhD students.
The authors would like to acknowledge John N. Constantino, MD, Washington University School of Medicine, for scientific guidance and intellectual discussions pertaining to the content of this article.
Disclosure: Dr. Glowinski and Ms. Slat report no biomedical financial interests or potential conflicts of interest.
8 Fall 2017 www.jaacap.com/content/connect BACK TO TABLE OF CONTENTS AACAP: Your One Stop for MOC Resources www.aacap.org/moc
Lifelong Learning Modules Earn one year’s worth of both CME and self-assessment credit from one ABPN-approved source. Learn from approximately 35 journal articles, chosen by the Lifelong Learning Committee, on important topics and the latest research. Visit www.aacap.org/moc/modules to find out more about availability, credits, and pricing.
Improvement in Medical Practice Tools (FREE and available to members only) AACAP’s Lifelong Learning Committee has developed a series of ABPN- approved checklists and surveys to help fulfill the PIP component of your MOC requirements. Choose from over 20 clinical module forms and patient and peer feedback module forms. Patient forms also available in Spanish. AACAP members can download these tools at www.aacap.org/pip.
Questions? Contact Elizabeth Hughes, Live Meetings (www.aacap.org/cme) Deputy Director of Pediatric Psychopharmacology Institute — Up to 12.5 CME Credits Education and Douglas B. Hansen, MD, Annual Review Course — Up to 18 CME Credits Recertification, at Annual Meeting — Up to 50 CME Credits [email protected]. • Annual Meeting Self-Assessment Exam — 8 self-assessment CME Credits • Annual Meeting Self-Assessment Workshop — 8 self-assessment CME Credits • Lifelong Learning Institute featuring the latest module
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The Challenge of Bullying Victimization for Adolescents With Autism Spectrum Disorder
Marcus A. Harrison, BS, Gerrit van Schalkwyk, MBChB
ullying victimization is defined as a repetitive and limitations of such approaches and suggestions for aggressive behavior that can be physically, socially, future research. and emotionally harmful towards the victim.1 Prior B Scope of the Problem research has identified that youth who lack positive peer interactions and have poor social skills are at Roughly one out of every 68 children born in the United greater risk of being bullied.2 However, there has been States will be diagnosed with a form of ASD.6 According limited study regarding the nature of bullying specifically to Sterzing, Shattuck, and Narendorf, adolescents among children with autism spectrum disorder (ASD). diagnosed with ASD experience a victimization rate of ASD is a psychiatric diagnosis characterized by impair- 46.3%, while the typically developing adolescent popu- ments in communication and in social interaction and lation has an estimated victimization rate of 10.6%.1 In reciprocity, and youth with ASD have been found to have this research, the term “victimization” included name- significant challenges in building and maintaining friend- calling, teasing, other verbal forms of harassment, and ships.3 Perhaps unsurprisingly given these challenges, being forced to do things like give lunch money. In a children with ASD are about four times more likely to parent-report study composed of 192 parents of youth experience bullying in their lifetimes when compared with ASD between the ages of 5-21 years old, 77% to their typically developing peers.2,4 It is therefore vital identified their children as victims of bullying specifi- 2 that clinicians have an understanding of how to assess cally occurring within the prior month. Out of the 77% and address the problem of bullying in this vulnerable of parents who identified their children as victims, 20% population of youth. reported that these children experienced some form of bullying exceeding a month, and 54% reported bullying Beyond the clinical importance, the topic of bullying in exceeding a year. Similarly, in a self-report study adolescents with ASD is one that needs to be studied consisting of 30 adolescents diagnosed with ASD, 73% in greater depth, such that we might understand not of these adolescents reported victimization or bullying only that being bullied is more common, but also what by their peers in their lifetime.5 Regardless of the sample the specific risk factors might be and how these youth size, both the parent-reported and self-reported victim- can best be supported. Existing research is mainly ization percentages are between 70-80% and about 4-7 cross-sectional in nature and reliant on parent report. times higher than typically developing individuals. As Little is known about the types of interventions that may previously mentioned, this victimization ratio between support these individuals.5 typically developing adolescents and those diagnosed with ASD likely is attributable to their different social In this article, we will begin by discussing in further detail abilities in a general class setting, which may lead to the epidemiology of bullying among youth with ASD. We isolation of students with ASD from their typically devel- then will outline challenges associated with assessing oping peers. Taken together, bullying victimization is whether individuals in this subgroup are being bullied. both a prevalent phenomenon and one with unique Finally, we will describe some current approaches taken determinants in youth with ASD, and thus warrants to reduce bullying risk in those with ASD, as well as the specific attention and research.
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Recognizing What We Don’t Know and Why We that would affect both self-report and second-person Don’t Know More report methodologies. In a study completed by Fisher Key deficiencies in our understanding of bullying in and Taylor (N = 30), adolescents with ASD tended to youth with ASD can be attributed to the methods of reduce the seriousness of their peer victimization expe- measurement and assessment most often utilized rience as evidenced by the tone and phrases they used in extant studies. In the existing literature, the most to explain a specific bullying experience.5 Furthermore, commonly used method of measurement is a second- in the same study, some participants with ASD provided person reporting system or survey completed by a idiosyncratic examples of physical forms of bullying, parent, guardian, teacher, or some person other than including poking, staring, and tying shoelaces together, the direct victim.5 However, utilization of second-person suggesting that youth with ASD may experience different report as a form of measurement has many limitations. forms of bullying than typically developing peers. For instance, parents’ abilities to report their children’s It is therefore important that an assessment of bullying experiences with bullying may be impacted by devel- in youth with ASD take into account these limitations opmental level. Parents tend to be more informed and and challenges. Efforts are also needed to design and involved in their children’s lives during earlier periods.2 validate surveys for use in children with ASD that take As youth begin to reach their teenage years, they less into account the potential for concrete interpretation of commonly disclose their social experiences and interac- bullying experience. tions to their parents. Because the peak bullying period for adolescents extends from middle school through the What We Can Do Now transition to high school, parents of children within this age group likely provide less accurate data compared to Supporting the social experience of youth with ASD parents of elementary school-aged children.2 Parents’ and reducing their risk of bullying relies on the key reports of their children’s experiences with bullying may interventions of a modified educational environment, be further influenced by parents’ own biases. Parents peer supports and education, adult supervision, and, have been shown to be less likely to report bullying that where appropriate, clinical treatment. Schools typi- may be occurring at home by a sibling or other family cally support youth with ASD by providing educa- members.6 More broadly, it has been shown that parents tion in specialized classroom settings. This practice of victims of bullying are more likely to participate in is supported by the finding that there are higher rates studies of bullying, as compared to those parents who of bullying in general education classes compared to 1 have no prior knowledge of their children being bullied.6,7 special education. On the other hand, in the United States, federal law promotes educational inclusion While second-person report methodology presents and requires school districts to educate students with particular challenges to our understanding of the disabilities alongside their typically developing peers problem of bullying among youth with ASD, charac- to the maximum extent deemed appropriate. Relatedly, teristics specific to youth with ASD also directly limit although rates of bullying tend to be lower in specialized a greater understanding of this problem. The experi- classrooms, inclusive classrooms promote the develop- ence of being bullied or victimized by a peer is highly ment of social skills and communication with typically personal. Thus, to achieve the highest validity, such developing peers, which is especially important for experiences are best explained by the victims, them- students with ASD and other communicative or devel- selves.2 However, difficulties in communication and in opmental disabilities.1 It is also expected that integrated social interaction and reciprocity—universal among general education classrooms increase acceptance those with an ASD diagnosis—may impede a child’s of students with disabilities by providing non-disabled ability both to detect bullying (particularly if subtle) students exposure to peers with a disability, and the and report the bullying to someone else, challenges opportunity for mutually beneficial friendships.
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Peer support may increase the likelihood that an It is also important to consider that youth with ASD instance of bullying will come to an end. Schools may who have been victimized by bullying may benefit from consider implementing peer support groups in which clinical support. In particular, children who experience typically developing students along with disabled chronic peer victimization and their families should be students learn to support and advocate for students referred to a mental health clinician who specializes diagnosed with a disability and then take that same in the treatment of youth with ASD.2 One goal of the knowledge and utilize it throughout the school day, referral would be for the mental health professional to especially in the classroom.5 In a study composed fully explore in a developmentally appropriate manner of students with a diverse set of moderate to severe the extent and nature of the youth’s experience with disabilities (n = 152) and typically developing peers bullying. Furthermore, a mental health professional may (n = 53) across 6 different schools within an urban school help the youth develop a framework for relationship district, a similar peer support intervention called the building and healthy social interactions. For example, Peer Buddy Program was implemented, and typically Fisher and Taylor suggest the use of videos to help developing students reported feeling more comfortable children with autism identify different forms of bullying, and confident to intervene and advocate for their peers a technique that could also be very useful in facilitating with disabilities directly following their participation in self-reporting.5 Combining both visual and verbal or the Peer Buddy Program.8 written explanations is an additional approach by which to ensure that children with ASD have a full under- Beyond peer support, directive support from adults is standing. Ultimately, an important goal for clinicians is of importance when tackling bullying generally, but it to help adolescents better understand what bullying is crucial when considering bullying amongst children looks and feels like, such that they may be better able to with ASD. Parents and teachers have a major responsi- identify and report when they are being victimized. bility in the intervention of bullying in autism. First and foremost, parents are responsible for establishing an In Conclusion optimal home environment that promotes their child’s Bullying of adolescents with ASD is a prominent clinical overall social and communicational development.2 challenge. Seemingly as a result of their difficulties with Teachers play an equally important role by promoting communication and social interaction, youth with ASD peer support in both social functioning and education. are at greater risk of being bullied. Furthermore, the Typically developing students’ interpretation of their communication and interpersonal deficits associated disabled peers is based on their knowledge about a with ASD limit our current understanding of the problem. disability or lack thereof.4 Teachers may act to create Adolescents with ASD may not recognize when they are an inclusive environment and provide students with the being bullied and also may struggle to report it when knowledge and confidence to avoid becoming a perpe- it does happen. As a result of these and other factors trator of peer victimization, and to act as an ally and described in this article, the current self-report and intervene.5 It is also the teacher’s duty to report any second-person report methodologies frequently used bullying incident that he or she has seen or that has to study bullying in this population are inadequate. been reported, as well as provide direct support to the victim. According to Fisher and Taylor, youth do not feel Although further research is required, common-sense supported by teachers after a bullying incident, which interventions include careful consideration of the prompts victims to have increased internalized emotions educational setting, a home environment that fosters or the desire for retaliation.5 Students with autism need development of social skills, and clinical intervention both immediate and long-term support when dealing when indicated. Further, peer support programs show with bullying, and it is important that teachers actively early promise in empirical studies and should be imple- listen to reports of bullying. mented whenever possible.
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2. Cappadocia MC, Weiss JA, Pepler D. Bullying experi- ences among children and youth with autism spectrum Take Home Summary disorders. J Autism Dev Disord. 2012;42:266-277. 77 Adolescents with ASD are at greater risk for 3. Mazurek MO, Shattuck PT, Wagner M, Cooper BP. Prev- bullying victimization. alence and correlates of screen-based media use among youths with autism spectrum disorders. J Autism Dev 77 Adult support is vital for reducing the risk of Disord. 2011;42:1757-1767. bullying and promoting positive social develop- 4. Maïano C, Normand CL, Salvas M-C, Moullec G, Aimé A. ment and interaction in adolescents with ASD. Prevalence of School Bullying Among Youth with Autism Spectrum Disorders: A Systematic Review and Meta-Anal- 77 Lack of knowledge and research on the topic ysis. Autism Res. 2016;9:601-615. of bullying in adolescents with ASD makes 5. Fisher MH, Taylor JL. Let’s talk about it: Peer victimiza- it challenging to collect accurate data and tion experiences as reported by adolescents with autism implement the most effective and appropriate spectrum disorder. Autism. 2016;20:402-411. intervention methods. 6. Pfeffer RD. Childhood Victimization in a National Sample of Youth with Autism Spectrum Disorders. J Policy Pract Intellect Disabil. 2016;13:311-319. 7. Adams R, Taylor J, Duncan A, Bishop S. Peer victimiza- References tion and educational outcomes in mainstreamed adoles- 1. Sterzing PR, Shattuck PT, Narendorf SC, Wagner M, cents with autism spectrum disorder (ASD). J Autism Dev Cooper BP. Bullying involvement and autism spectrum Disord. 2016;46:3557-3566. disorders: prevalence and correlates of bullying involve- 8. Copeland SR, Hughes C, Carter EW, et al. Increasing ment among adolescents with an autism spectrum access to general education: perspectives of participants disorder. Arch Pediatr Adolesc Med. 2012;166:1058-1064. in a high school peer support program. Remedial Spec Educ. 2004;25:342-352.
About the Authors Marcus A. Harrison, BS, is with Center of Excellence in Primary Care, VA Connecticut Health Care System, and Yale School of Medicine.
Gerrit van Schalkwyk, MBChB, is with Butler Hospital, Providence, RI.
Disclosure: Dr. van Schalkwyk and Mr. Harrison report no biomedical financial interests or potential conflicts of interest.
12 Fall 2017 www.jaacap.com/content/connect BACK TO TABLE OF CONTENTS Mission: To educate, support, and elect candidates for Congress who advocate for child and adolescent psychiatry and child mental health. For more information, visit www.aacap-pac.com
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The Boy Who Lived: Harry Potter, Suicide, and an Opportunity for Mental Health Literacy
Mark Sinyor, MSc, MD, FRCPC
Of course this is happening inside your head, Harry, for me is its hidden function as a meditation on suicide but why on earth should that mean that it is not real? from the perspective of someone with lived experience. – Albus Dumbledore, Harry Potter Viewing the books with this in mind, it quickly becomes and the Deathly Hallows1(p579) apparent that suicide not only appears in the Harry Potter books but could be considered a major theme in t has been 20 years since the first of the Harry Potter the series. I’d like to focus the rest of this article on the books was published. In the interim, they have been theme of suicide in Harry Potter, which may be just as translated into 73 languages and sold more than I important and similarly unrecognized as the themes of 450 million copies. It seems everyone knows Harry, depression and therapy. even within the notoriously restrictive Guantanamo Bay prison.2 When I first read the books, I thought I knew Rowling has said that her books “are largely about Harry too, but I was missing something important that death.”5 On a superficial level, this is self-evident, as has significance for our field. many characters die in the series, while those who survive, most importantly Harry, are left to manage As our group recently published in JAACAP Connect, their grief and loss. Given that Harry spends most of the third book in the series, Harry Potter and the Prisoner the series fighting an evil antagonist, Lord Voldemort, to of Azkaban, presents Harry metaphorically overcoming stay alive, one may rightly ask where suicide comes into depression using cognitive-behavioral therapy (CBT) play. A literal reading of the text points to Voldemort, skills mirroring J.K. Rowling’s own experiences in real and Harry’s other antagonists, as an external evil that life.3-4 In the book, Harry’s de facto CBT therapist, has been compared to the Nazis.6 But what if we were Professor Lupin, deploys cognitive restructuring, fear to take a more interpretive stance and imagine the death hierarchies, behavioral activation, and core belief work to impulse represented by Voldemort as existing within help Harry overcome the dementors and his symptoms Harry himself? That is, if Harry embodies Rowling’s of depression.4 Azkaban is arguably the most fulsome depression as she has stated, it seems fair to question depiction of psychotherapy skills in children’s literature.4 whether his character also contains an allegory for Yet, despite the book’s ubiquity for nearly two decades, suicidal ideation. There is at least some evidence to it has remained an untapped resource for teaching CBT support this notion. As the story progresses, the bound- skills to youth. A framework for implementing a mental aries between Harry and Voldemort become increas- health literacy program based on the book is outlined in ingly blurry, and Voldemort is presented as a kind of alter our previous paper, and more than 500 middle school ego for Harry. In the final book, Professor Dumbledore students in Ontario, Canada are receiving a pilot curric- reveals that “In the case of Harry and Lord Voldemort, ulum in which they learn CBT skills along with Harry. to speak of one is to speak of the other…Part of Lord When I noticed that J.K. Rowling had embedded Voldemort lives inside Harry.”1(pp549-551) In this conceptu- depression in her books, I wondered whether she might alization, Voldemort can be viewed not only as perpe- have done the same for the suicidal thoughts she has trator but also as residue of Harry’s original trauma. said she experienced while depressed.3 As a suicide Harry is, quite literally, scarred by the childhood loss of researcher, the most surprising aspect of the series his parents, an important risk factor for eventual death
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by suicide.7 One potential interpretation of his struggle fundamental question of this chapter is in which direction against Voldemort could be as a metaphorical struggle Harry will fly, towards death or away from it. Summoning to determine whether he will be able to overcome his strength from his bond with Dumbledore, his teachers, past trauma or if it will set him on a path to destruction. friends, and parents, he chooses to affirm life and in so doing, Rowling makes a powerful statement about the A careful read reveals numerous pieces of evidence ability of love and comradery to overcome what at times supporting this interpretation. For example, Voldemort’s has seemed like intolerable pain. school house of Slytherin is connected to suicide. The Bloody Barron, house ghost and mascot of Slytherin, Schools have a rich tradition of using popular fiction, dies in a murder-suicide.1 Voldemort’s gift of a silver novels like Animal Farm, The Great Gatsby, and Lord of hand to one of his devoted followers is ultimately used the Flies, to teach youth about history and fundamental by its owner to choke himself to death.1 Voldemort’s truths of the human condition. Fantasy novels are often return to power and deepening connection with Harry dismissed as offering little educational value. However, in the fifth book coincides with Harry experiencing what The Lord of the Rings, the quintessential work in this appears to be suicidal ideation. In one scene, Voldemort genre, was a parable for J.R.R. Tolkien’s experiences in enters Harry’s mind directly, and he reacts with a desire the trenches of World War I.9 The core message of that to be dead: “Let the pain stop, thought Harry … Let him series was that the friendship and bravery exhibited by kill us.”8(p720) In another, Harry discovers a stone archway his soldier comrades was the only foil against the human that represents a boundary between the living world impulse for power that threatened to destroy the world. and death and feels “a very strong inclination to climb From wise old wizards to Dark Lords to dangerous up…and walk through it.”8(p682) When instead his godfa- magical objects, J.K. Rowling borrowed liberally from ther dies by falling through the archway, Harry finds Tolkien.10 In my view, the genius of Rowling, generally the suffering unbearable, yelling “I’VE HAD ENOUGH, overlooked, is that she coopted many of the tropes I’VE SEEN ENOUGH, I WANT OUT, I WANT IT TO END, Tolkien used to convey his geopolitical message and I DON’T CARE ANYMORE.”8(p726) He fantasizes about repurposed them to deliver a highly personal reflection being dead so that he can join his godfather. These on how someone suffering from depression, hopeless- suicidal impulses are resolved in The Deathly Hallows, ness, and suicidal ideation can find a path to resilience. the final book in the series. It introduces the resurrec- tion stone, a “hallow” that Harry most covets since it When I speak to the middle school students who are has the power to reunite him with his dead parents. The learning CBT skills by studying Harry Potter, a few legend of the resurrection stone, however, is that it led notable themes emerge: they strongly identify with its original owner to an ill-fated reunion with his dead Harry, and they are able to see how his struggles are lover after which, “driven mad with hopeless longing, similar to theirs and their peers’. They are also univer- [he] killed himself so as truly to join her.”1(p332) The implicit sally surprised that the books have something to teach question is whether Harry will suffer a similar fate. The them about mental wellbeing. An emerging scholarly novel culminates in a final battle between Harry and literature suggests that mental health literacy, taught Voldemort. Notably, the entire penultimate chapter and in schools, has the potential to improve knowledge, arguable centerpiece of that struggle takes place as an decrease stigma, and even diminish suicidal ideation internal dialogue within Harry’s head between himself and behavior.11 Examples of resilience in the face of and his dead mentor, Albus Dumbledore.1 The discus- mental illness are an important component of these sion is set in a train station where Harry is given the efforts. In 2010, my colleague Thomas Niederkroten- option to go one way or the other: he can return to his thaler and his group demonstrated that media reports body and continue fighting or take a train away from emphasizing “mastery” of suicidal crises, that is suicidal life.1 In French, Voldemort means “flight of death.” The ideation followed by positive outcomes such as help
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seeking rather than suicidal behavior, were associated 12 with fewer subsequent suicide deaths in Austria. While Take Home Summary we know that suicide can be contagious through the 77 Suicide may be an under-recognized theme in well-known “Werther effect,” put simply, resilience may the Harry Potter novels. be contagious too. We need both youth and adult role models to teach positive coping strategies, and in Harry 77 The series can be read to convey a powerful Potter and J.K. Rowling, we have one of each. When message of hope and resilience in the face Rowling herself was depressed and contemplated of trauma and suicidal impulses mirroring the suicide, she has told reporters that “the thing that made author’s lived experience. me go for help was probably my daughter.”4 Clearly, Rowling was able to draw on her own strengths and reasons for living to overcome her illness, and that is an References important message for readers. By failing to highlight 1. Rowling JK. Harry Potter and the Deathly Hallows. London: Bloomsbury; 2007. her story and its commonality with Harry’s, our field and 2. Pindar R. ‘Harry Potter is most popular book in youth educators are missing an opportunity to teach Guantánamo Bay’. The Telegraph. 2009. http://www. mental health literacy. telegraph.co.uk/culture/books/booknews/6151383/Harry- Potter-is-most-popular-book-in-Guantanamo-Bay.html. It is a misconception that primary prevention of suicide Accessed December 16, 2016. entails education about suicide. To the contrary, school- 3. Johnson S. JK Rowling contemplated suicide. The Tele- based suicide prevention should focus on resilience graph. March 28, 2008. http://www.telegraph.co.uk/news/ uknews/1582552/JK-Rowling-contemplated-suicide.html. education. However, in an era when youth may be Accessed April 25, 2016. exposed to graphic portrayals of suicide such as in the 4. Sinyor M, Fefergrad M, Cheung AH, Selchen S, Zaretsky show 13 Reasons Why,13-14 teachers need better tools A. The Boy Who Lived Well: Harry Potter as a Novel Tool to communicate more realistic and helpful messages for Teaching Cognitive-Behavioral Therapy Skills to Youth. about suicide. Schools, especially those struggling to JAACAP Connect. 2017;4(2):15-20. manage questions about suicide, could create literature 5. Greig G. ‘There would be so much to tell her...’ The Telegraph. 2006. http://www.telegraph.co.uk/news/ units specifically asking students to think about Harry uknews/1507438/There-would-be-so-much-to-tell-her.... Potter as an allegory about suicide and to teach J.K. html. Accessed December 16, 2016. Rowling’s personal story of resilience as a model to 6. Lacassagne A. War and peace in the Harry Potter series. be emulated. Eur J Cultur Stud. 2016;19:318-334. 7. Guldin MB, Li J, Pedersen HS, et al. Incidence of suicide The Harry Potter books and Rowling’s accompanying among persons who had a parent who died during their story are a largely untapped resource for teaching childhood: a population-based cohort study. JAMA Psychiatry. 2015;72:1227-1234. mental health literacy, positive coping skills, and resil- 8. Rowling JK. Harry Potter and the Order of the Phoenix. ience in the face of trauma, hopelessness, and suicidal London: Bloomsbury; 2003. ideation. After 20 years, the Harry Potter novels have 9. Loconte J. How J.R.R. Tolkien Found Mordor on the rightfully earned their status as literary classics. Western Front. The New York Times. 2016. http://www. Teachers and schools should give them the attention nytimes.com/2016/07/03/opinion/sunday/how-jrr-tolkien- they deserve and, like all great books, use them to teach found-mordor-on-the-western-front.html?_r=0. Accessed December 16, 2016. children about life.
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10. Guanio-Uluru L. Ethics and form in fantasy literature: 13. Ayers JW, Althouse BM, Leas EC, Dredze M, Allem JP. Tolkien, Rowling and Meyer. Basingstoke, UK: Palgrave Internet Searches for Suicide Following the Release of 13 Macmillan; 2015. Reasons Why. JAMA Intern Med. 2017 Jul 31. doi: 10.1001/ 11. Wasserman D, Hoven CW, Wasserman C, et al. jamainternmed.2017.3333. [Epub ahead of print]. School-based suicide prevention programmes: the 14. O’Brien KHM, Knight JR Jr, Harris SK. A Call for Social SEYLE cluster-randomised, controlled trial. Lancet. Responsibility and Suicide Risk Screening, Prevention, 2015;385:1536-1544. and Early Intervention Following the Release of the Netflix 12. Niederkrotenthaler T, Voracek M, Herberth A, et al. Role of Series 13 Reasons Why. JAMA Intern Med. 2017 Jul 31. media reports in completed and prevented suicide: Werther doi: 10.1001/jamainternmed.2017.3388. [Epub ahead of v. Papageno effects. Br J Psychiatry. 2010;197:234-243. print].
About the Author Mark Sinyor, MSc, MD, FRCPC, is an assistant professor in the Department of Psychiatry, University of Toronto, and a psychiatrist with Sunnybrook Health Sciences Centre, Toronto.
Disclosure: Dr. Sinyor has received grant support from the American Foundation for Suicide Prevention, the Physicians’ Services Incorporated Foundation, the Dr. Brenda Smith Bipolar Fund, the University of Toronto Department of Psychiatry Excellence Fund, and the Innovation Fund of the Alternative Funding Plan from the Academic Health Sciences Centres of Ontario.
JAACAP – November 2017 Issue
It is November of 2017, and the Journal has nearly finished what is, at this point, a year-long transition in editorial leadership. Editor-Elect Douglas K. Novins fully assumes the responsibilities of outgoing Editor- in-Chief Andrés Martin with the January 2018 issue, although this handoff has been in the works for some months now. Dr. Martin’s tenure has been marked by his dedication to mentorship, and to building a pipeline of future editors, reviewers, and authors, not to mention record impact factors and the expansion of features such as cover art, podcasting, and continuing medical education opportunities. In his editor’s report from December 2016, Dr. Martin wrote of his successor, “Doug is a stellar scholar, clinician, educator, and administrator, and he is a kind, fair, and wise man…a truly inspired choice in a field of so many talented and worthy applicants. Doug is the perfect person for the job and will be superb at it” (2016;55:1099). As Dr. Martin passes the baton to Dr. Novins, readers of the Journal can look for the hallmarks of the publication to remain the same— continued coverage of groundbreaking science and incisive research, clinical, and policy translation—while also noting the advent of exciting new content and features. The flagship publication of AACAP is in good 16 Fall 2017 hands. www.jaacap.com/content/connect BACK TO TABLE OF CONTENTS Douglas B. Hansen, MD, rd ANNUAL43 REVIEW COURSE
CO-CHAIRS: New for Gabrielle A. 2018: Carlson, MD Comprehensive ANNUAL Shawn S. Sidhu, MD review for all levels of clinical applications. REVIEW COURSE DA COURSE TES: March 2 – CME credit offered ENTIRELY April 13, 2018 ONLINE!
Join us for the first ever ONLINE Douglas B. Hansen, MD, Annual Review Course, one of the newest online education programs available from AACAP. Over a 6-week period, our newly redesigned course will allow you to connect with colleagues, interact with experts, and learn about the most sought-after topics in the field — all on your own schedule, in your home or office. Registration will open early December. www.aacap.org/ReviewCourse-2018 QUESTIONS? Email [email protected] JAACAP Connect A JAACAP PUBLICATION
Review of Possible Etiologies and Treatment Options in a Teen With Coprophagia
Candace L. Giles, MD
Case: An 18-year-old, single, unemployed Bahamian male with a diagnosis of new-onset schizophrenia was treated with risperidone (Risperdal) on the inpatient unit, then discharged home to his family. Later that day, he became physically aggressive when family members attempted to prevent him from eating his own feces. They physically restrained him until police arrived, after which he was brought to a different hospital, given family members’ continued concerns that the patient was a danger to himself. At the hospital, the patient demonstrated signs of psychosis, including disorganized behaviors, internal preoccupation, and thought blocking. He was laughing and smiling as he spoke both of eating his own feces and of his earlier aggression towards his family members. Given his clinical presentation and concern at that time that he presented an acute danger both to himself and others, the treatment team decided that he required involuntary admission to a psychiatric inpatient unit.
oprophagia, of which there are few reported but it is unclear if homo sapiens have ever routinely cases, is a complex behavioral disorder that can engaged or still engage in coprophagia.3 have various etiologies, each of which might C Although coprophagia represents normal biological warrant a different treatment or management approach. functioning in some vertebrates, it currently is consid- Coprophagia comes from the Greek copros, feces, ered abnormal behavior in humans, particularly given and phagein, to eat. It is the act of consuming feces, the risks associated with this behavior. Coprophagia in whether directly from the same individual (autoco- humans can result in E. coli infection, hepatitis A, hepa- prophagy), other individuals (allocoprophagic), or other titis E, influenza, pneumonia, polio, chronic gingival species (heterospecific), and is considered normal infections, chronic lesions of vestibule mucosa, infec- behavior amongst certain invertebrate and vertebrate tions of the salivary glands (sialadenitis), intestinal para- animal species. Invertebrates such as dung beetles, sitosis, and gastrointestinal obstruction (which can worms, and flies often consume and redigest the feces cause death).1,4,5 Although fecal matter has been used of large animals.1 Termites consume one another’s feces in humans for fecal bacteriotherapy (patients suffering as a means of aiding digestion.1 There are some verte- from intractable diarrhea caused by Clostridium diffi- brate herbivores (e.g., rabbits, hamsters, guinea pigs, cile—bacteria that affects the gastrointestinal tract—can mole rats, horses, tortoises, gorillas, etc.) that need to undergo fecal microbiota transplantation), in instances consume their own feces to help digest their food and such as these, the fecal matter is administered via naso- extract sufficient nutrients such as vitamins.2 Some gastric tube, enema, or in a capsule form to decrease 6 vertebrate mothers eat the feces of their newborn young the risks associated with oral fecal ingestion. 1 to prevent alerting potential predators of their location. The literature available to guide clinicians to appropriate Other vertebrates (e.g., the young of elephants, pandas, treatment for patients with coprophagia is limited, due in hippopotamuses, koalas, etc.) are born with a sterile part to its complexity and the relatively small number of gastrointestinal system, and they obtain the necessary occurrences. Understanding coprophagia in humans is bacteria by eating the feces of others in their herd in critical—particularly given the potential negative health order to digest vegetation.1 Coprophagia has also been sequelae of this complex behavior. This article reviews reported in dogs, chimpanzees, and even early humans, possible etiologies, key work-up strategies, and several
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treatment options to consider when working with [TIBC], and serum ferritin) for causes of iron deficiencies, patients with coprophagia. comprehensive metabolic panel (CMP) and urinalysis (UA) for abnormalities causing cognitive impairment, Coprophagia and Its Comorbidities thyroid stimulating hormone (TSH) for causes of affec- Coprophagia in humans is typically associated with tive instability, urine toxicology for causes of decision either a medical or psychiatric disorder. Frequent impairment, brain imaging for any malformations, comorbidities of coprophagia include mineral defi- and electroencephalogram (EEG) in cases of seizure ciency, neurological dysfunction, disorders of develop- history. If the patient’s medical work-up comes back ment, intellectual disabilities, psychosis, anxiety, and within normal limits, then consideration of psychiatric affective instability.7 Coprophagia commonly is consid- causes is warranted. To help guide clinicians in diag- ered a variant of pica (the persistent and developmen- nostic clarity, it is recommended to conduct an in-depth tally inappropriate eating of nonnutritive substances),8 search for collateral information to better understand which itself is frequently associated with either a medical the timeline and presentation of the coprophagia. If the disorder (e.g., iron-deficiency anemia) or psychiatric patient is communicative and medically stable, then disorder (e.g., autism spectrum disorder and intellec- neuropsychological testing can be helpful to determine tual disability9). Haoui et al. found that the majority of the patient’s IQ score as well as to detect any psychi- psychiatrically hospitalized patients who demonstrated atric disorders. Although the medical and psychiatric pica also were diagnosed with either a disability of work-up of coprophagia can be extensive, the findings mental impairment (48%) or developmental delays are often negative or contribute minimally to under- (26%).10 Sharma et al. found that coprophagia and other standing the etiology in most cases. forms of pica occur in individuals with mild to moderate dementia and mixed (iron deficiency and macrocytic) Treatment 11 anemia. Josephs et al. conducted a medical record In general, effective diagnosis and treatment of under- review at Mayo Clinic from 1995-2015 that identified 12 lying medical and/or psychiatric conditions is the priority, adult patients with coprophagia; half of the patients had because coprophagia often resolves with the improve- neurodegenerative dementia, two had developmental ment of other comorbid symptoms. Ing et al. (2011) delay, and one each had a history of seizures, steroid completed a functional analysis in a six-year-old female psychosis, frontal lobe tumor, and schizoaffective with autism and demonstrated that her coprophagia 12 disorder. Individual case reports also have suggested was driven by automatic reinforcement (the behavior 13-15 associations between coprophagia and psychosis, itself produces its own reinforcement); providing obsessive-compulsive disorder (OCD),16 mood disor- noncontingent access to alternative stimuli decreased ders,7 personality disorders,17 and paraphilias.18 coprophagia for her.19
Work-Up of Coprophagia In cases where coprophagia is secondary to mineral Treatment modalities are constructed to address the deficiencies such as iron, altering the diet of the patient underlying etiology for a disorder (see Table 1). As just to include the missing nutrients has been shown to described, deciphering the etiology of coprophagia can resolve the secondary behavior. Bugle and Robin (1993) be a difficult task depending on the patient’s cognitive wrote about three cases of individuals with profound limitation and presentation. All patients should receive intellectual disabilities, coprophagia, and nutritional a thorough medical work-up upon admission to rule deficiencies. In each case, the individual was given twice out any medical causes. Tests that should be ordered the doses of a daily oral supplement of an “elemental include complete blood count (CBC) with differential and diet,” which would provide all the nutrients necessary iron studies (e.g., serum iron, total iron binding capacity for sustenance. The frequency of coprophagia was
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Table 1: Tools to Help Guide Diagnostic Formulation and Treatment Planning TOOLS DEFINITION SCORING SYSTEMS Full-scale IQ Designed to measure intelligence and 130 and above = very superior cognitive ability by verbal scales (i.e., general 120–129 = superior knowledge, language, reasoning, and memory 110–119 = high average skills) and performance scales (i.e., spatial, 90–109 = average sequencing, and problem-solving skills) 80–89 = low average 70–79 = borderline 69 and below = extremely low Beck’s Depression Inventory (BDI) BDI is a 21-item, self-report rating inventory 0–9 = minimal depression that measures characteristic attitudes and 10–18 = mild depression symptoms of depression 19–29 = moderate depression 30–63 = severe depression Thematic Apperception Test A projective test designed to reveal a person’s 1. Defense Mechanisms Manual social drives or needs by their interpretation of (DMM) a series of pictures of emotionally ambiguous 2. Social Cognition and Object situations Relations (SCOR) 3. Personal Problem-Solving System–Revised (PPSS-R) Rorschach A psychological test in which a person’s Exner scoring system, also known interpretations of a series of standard inkblots as the Rorschach Comprehensive are analyzed as an indication of personality System (RCS) traits, preoccupations, and conflicts Minnesota Multiphasic Personality A standardized psychometric test of adult Analysis compares relative elevation Inventory (MMPI) personality and psychopathology of factors to the different norm groups studied decreased in all three cases when they received the cial, as well. A Pardini et al. (2010) study showed improve- supplemental nutrients as compared to when they were ment in a 29-year-old male with high-functioning autism maintained on a balanced institutional diet alone.20 on aripripazole 15 mg daily dose after 4 weeks.13 Similarly, antipsychotics have been used to treat coprophagia in When coprophagia is caused by mood and anxiety disor- patients with schizophrenia. A Lingeswaran et al. (2009) ders, treatment of the underlying depression or anxiety study showed complete resolution of symptoms for a can resolve the coprophagia. Beck and Frohberg (2005) 19-year-old South Indian male with schizophrenia on olan- did a case report on a 77-year-old male with mild intel- zapine 10 mg daily with no relapse 3 months after initial lectual disability who was evaluated for sudden-onset evaluation.14 Another study conducted by Harada et al. of coprophagia, which revealed an underlying depres- (2006) described resolution of symptoms for a patient with sion that responded to sertraline 25 mg daily with reso- schizophrenia who suffered from medication-refractory lution of symptoms.7 A Zeitlyn and Polivy (1995) case coprophagia on perospirone.15 report showed that an adult male with normal cognitive functioning but who suffered from severe posttraumatic The goal of any treatment plan is for the resolution of symptoms. If the various treatment modalities prove inef- stress disorder and compensatory OCD behaviors fective to decrease coprophagic behaviors, then consid- could have remission in coprophagic behavior with the eration for long-term placement for continued treatment treatment of his OCD. The male had remission after initi- should be discussed with the patient and family. ation with a behavioral treatment program comprised of exposure and response prevention.16 Conclusion Pharmacotherapy to treat comorbid conditions other than Coprophagia is a variant form of pica that, despite being mood and anxiety disorders has been shown to be benefi- necessary for survival in other species, can be harmful
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in humans, causing diseases and infections in the body. 2. VetSci. Comparative Digestion. http://vetsci. It requires immediate assessment to determine the root co.uk/2010/05/14/comparative-digestion/. May 14, 2010. Accessed February 18, 2016. cause of the behavior, which is either medical or psychi- 3. Langley L. National Geographic. Why Do Animals— atric in nature. A full work-up will reveal if there are any Including Your Dog—Eat Poop? http://news. disorders or deficiencies that can explain the coprophagia nationalgeographic.com/2015/05/150509-animals-dogs- and lead to a treatment plan. Although coprophagia feces-health-science-dung-beetles-food/. May 9, 2015. literature is limited, it appears to be related to mental Accessed June 14, 2017. illness, neurodevelopmental disorders, or mental impair- 4. Donnellan CA, Player JR. A case of coprophagia presenting with sialadenitis. Age Ageing. 1999;28:233-234. ments because cognitive limitations prevent individuals 5. Byard RW. Coprophagic Café Coronary. Am J Forensic with these conditions from understanding the risks of Med Pathol. 2001;22:96-99. coprophagia. In these instances, treatment involves 6. Borody TJ, Paramsothy S, Agrawal G. Fecal Microbiota a comprehensive analysis to construct a behavioral Transplantation: Indications, Methods, Evidence, and management plan that will decrease the coprophagia Future Directions. Curr Gastroenterol Rep. 2013;15:337. and replace it with a positive behavior. Additionally, 7. Beck DA, Frohberg NR. Coprophagia in an elderly man: a case report and review of the literature. Int J Psychiatry coprophagia can be present in individuals with schizo- Med. 2005;35:417-427. phrenia, which is a psychotic process that also affects 8. Ellis CR, Schnoes CJ. Eating disorder: Pica. www.emed- executive functioning, reasoning, and decision making. icine.com/ped/topic1798.htm. 2005. Retrieved April 1, Psychotic disorders are best treated with antipsychotics 2014. and have been proven to decrease coprophagia in prior 9. Matson JL, Hattier MA, Belva B, Matson ML. Pica in case reports. Coprophagia is a critical abnormal behavior persons with developmental disabilities: approaches to treatment. Res Dev Disabil. 2013;34:2564-2571. that should be investigated emergently to provide treat- 10. Haoui R, Gautie L, Puisset F. Pica: A descriptive study ment. In cases where the mainstay of treatment does of patients in a speciality medical center. Encephale. not provide improvement on an inpatient unit, individuals 2003;29:415-424. may need a longer course of treatment in state facilities 11. Sharma TR, Kavuru B, Aly M. Coprophagia and pica in prior to reintegration into the community. individuals with mild to moderate dementia and mixed (iron deficiency and macrocytic) anemia. J Am Geriatr Soc. 2011;59:2375-2377. Take Home Summary 12. Josephs KA, Whitwell JL, Parisi JE, Lapid MI. Coprophagia in neurologic disorders. J Neurol. 2016;263:1008-1014. Coprophagia is a variant form of pica where individ- 13. Pardini M, Guida S, Gialloreti LE. Aripiprazole treatment uals will consume feces. It is a complex behavioral for coprophagia in autistic disorder. J Neuropsychiatry disorder that can have various etiologies; because Clin Neurosci. 2010;22:451-s.e33-451.e33. there are few reported cases, it presents a chal- 14. Lingeswaran A, Vijayakumar V, Dinesh J. Entomophagy lenge in putting together an appropriate treatment and coprophagy in undifferentiated schizophrenia. Indian J Psychol Med. 2009;31:52-53. plan. However, it is critical to determine a treat- 15. Harada KI, Yamamoto K, Saito T. Effective treatment of ment plan because coprophagia is a dangerous coprophagia in a patient with schizophrenia with the novel behavior that can lead to infections and medical atypical antipsychotic drug perospirone. Pharmacopsy- complications that can result in death. chiatry. 2006;39:113. 16. Zeitlin SB, Polivy J. Coprophagia as a manifestation of obsessive-compulsive disorder: a case report. J Behav Ther Exp Psychiatry. 1995;26:57-63. References 17. Blasco-Fontecilla H, García-Nieto R, Álvarez-García R, et 1. World Heritage Encyclopedia. Coprophagia. http://www. al. Coprophagia in a patient with borderline personality worldlibrary.org/articles/coprophagia. Accessed February disorder. Eur J Psychiatry. 2015;29:211-214. 18, 2016.
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18. Wise TN, Goldberg RL. Escalation of a fetish: coprophagia 20. Bugle C, Rubin HB. Effects of a nutritional supplement in a nonpsychotic adult of normal intelligence. J Sex on coprophagia: a study of three cases. Res Dev Disabil. Marital Ther. 1995;21:272-275. 1993;14:445-456. 19. Ing AD, Roane HS, Veenstra RA. Functional Analysis and Treatment of Coprophagia. J Appl Behav Anal. 2011;44:151-155.
About the Author Candace L. Giles, MD, is board-certified in general psychiatry. She holds memberships in APA, AACAP, and AAPL. She is currently completing her forensic psychiatry fellowship at Emory University and was previously with Johns Hopkins Hospital, Child and Adolescent Psychiatry.
Disclosure: Dr. Giles reports no biomedical financial interests or potential conflicts of interest.
Check out the Scientific Proceedings of AACAP's 64th Annual Meeting in this special online- only issue of JAACAP
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21 Fall 2017 www.jaacap.com/content/connectusing the DOI BACK TO TABLE OF CONTENTS AACAP’s Legislative Conference and Assembly Meeting April 8-9, 2018
AACAP’s Legislative Conference and Assembly Meeting will take place in Washington, DC, from April 8-9, 2018. Join us for both events to advocate for children’s mental health.
AACAP Legislative Conference AACAP Assembly Meeting
On April 8 and 9, 2018, learn about the On April 8, AACAP’s Assembly of Regional legislative process and public policy issues Organizations will meet to discuss the impacting child and adolescent psychiatry. issues facing your state and region. The AACAP’s Government Affairs team will Assembly consists of AACAP member provide you with advocacy materials to help develop and deliver the most effective representatives from across the nation message. Once again, family advocates and is always looking for more voices and will be invited to join AACAP members on advocates like you to join the discussion. Capitol Hill. Join us and make your voice heard as we advocate for children’s mental health. Visit www.aacap.org/Assembly for more Visit www.aacap.org/LegislativeConference information or contact Megan Levy, for more information or contact Zachary Executive Office Manager, at Kahan, Advocacy & PAC Manager, at [email protected] or 202.966.1994. [email protected] or 202.587.9669. A JAACAP PUBLICATION
Editorial Board Author Guidelines Editor JAACAP Connect is interested in any topic relevant to pediatric mental health that bridges scientific findings with clinical reality. As evidenced by our previous Oliver M. Stroeh, MD editions, the topic and format can vary widely, from neuroscience to teen music choices. What trends have you observed that deserve a closer look? Can you Associate Editor envision reframing key research findings into clinical care? Do you want to educate Justin Schreiber, DO, MPH others on a broader scale, thereby improving the health of children around the country, the world? We encourage all levels of practitioners and researchers, from Deputy Editors students to attendings, to join in and participate.
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