Psychiatrist: Not Well Liked? Never Mind.

To actress Sally Field, being well-liked is really, really important, as evidenced by her emotional acceptance speech for an Oscar win in 1985.

Image via Flickr user Alan Light by Creative Commons License

But if you’re a psychiatrist treating patients with bipolar disorder, your likeability quotient shouldn’t be keeping you up at night.

What really matters in your business, according to a new study from Massachusetts General Hospital, is whether your patients feel understood, respected, and listened to. If they do, they’re more likely to take the medications you prescribe, as prescribed, a key factor in stablizing patients with the disorder.

Louisa G. Sylvia, Ph.D., associate director of psychological services at the hospital’s Bipolar Clinic and Research Program, examined the relationship between medication adherence and assessments of psychiatrists by 3,640 patients enrolled in the STEP-BD trial.

When patients felt they had a good working relationship with their psychiatrists and “meaningful exchanges,” they tended to stick close to the medication plan prescribed for them.

One important element of collaboration, for example, was being told that they had the right to refuse treatment.

“I interpret that as collaboration,” said Dr. Sylvia during a scientific presentation of her results at the annual meeting of the American Psychiatric Association. When a give-and-take discussion preceded prescribing, “They were actually more attached to the treatment.”

Liking the psychiatrist “as a person” was not a key factor associated with adherence, nor was a patient’s sense that the psychiatrist had experience in helping people.

But another key to success, perhaps a simple sign of respect, was promptness, according to the study. Patients kept waiting longer than 15 minutes beyond their appointment time were more likely than others to be nonadherent to their medications, Dr. Sylvia reported.

—Betsy Bates

“It’ll Be OK…” Or Will It? What Parents Do to Soothe

Much as parents would love to protect their children from pain — even the pinprick “ouch” of a routine immunization — it’s a fact of life in early childhood. Before a child’s 6th birthday, a glinty needle holding protection against dread diseases may find its mark dozens of times. Other children endure much more, requiring surgery, lumbar punctures, bone marrow aspirations, and other difficult medical procedures.

Helping kids to cope would seem to be high on the agenda of parents, pediatricians, and pain specialists alike. Indeed, anesthesiologist Zeev N. Kain of the University of California, Irvine, has devoted much of his professional life to a quest to reduce the anxiety of parents, children, and professionals during pediatric medical procedures. He is currently piloting a study aimed at training parents, nurses, surgeons, and anesthesiologists in the art of soothing a child, based on scientific evidence of what works.

Image via Flickr user BryanF by Creative Commons License

Ironically, the interventions to be included have long been known to researchers. Speaking at an  international conference on pediatric psychological trauma, Dr. Kain reviewed the  work of Dr. Ronald L. Blount, professor of psychiatry at the University of Georgia, Athens, who proved as early as 1989 that what calms children the most is distraction before the procedure (silliness and off-topic banter; playing with toys, being read stories) and prompts to ”breathe,” or “blow” during the procedure. (Puffing on a party blower is a perfect distracting, deep breathing tool, and cheap, too!)

What doesn’t work is also very clear and replicated numerous times in the literature. Not surprisingly, the list of ineffective interventions includes criticism, parental agitation, and bargaining. Childrens’ distress is also exacerbated when they are given control over when to start the procedure, and surprisingly, when parents and health professionals engage in that most intuitive of strategies, reassurance. Indeed, in Dr. Kain’s most recent sequential analysis of events in the operating room, reassuring statements to children seemed to be followed almost inevitably by an increase in crying, struggling, and other demonstrated expressions of distress.

So, instead of saying, “It’s OK,”  or “You’re going to be just fine,”  adults in Dr. Kain’s studies are learning how to distract kids even when the going gets tough and then to urge them to unfurl the crinkly party blower with gusto and a deep breath.

— Betsy Bates

Falls: The Humpty Dumpty Hypothesis

Image via Flickr user aturkus by Creative Common License

From the International Conference of Pediatric Psychological Trauma in Infants & Young Children in Los Angeles

Humpty Dumpty sat on a wall,

Humpty Dumpty had a great fall,

All the King’s horses and all the King’s men,

Couldn’t put Humpty together again.

Serious falls are among the most common injuries to children, representing 52% of injuries in infants and 43% of injuries in children aged 1-4, according to recent figures from the Centers for Disease Control and Prevention. Fortunately, most children who fall can be physically put together much better than hapless Humpty Dumpty, but new findings from Duke University suggest that their psychological sequelae may be harder to heal.

Dr. Helen Link Egger of the Center for Developmental Epidemiology in the Department of Psychiatry and Behavioral Sciences reported that preschool children (ages 2-5) who suffer any injury serious enough to require medical attention were 2.7 times more likely to meet criteria for separation anxiety disorder, based on findings of a longitudinal study of 666 children.

Those who suffered a fall were also 5.8 times more likely to meet criteria for depression.

“Now that’s a big odds ratio,” she said, explaining that the data translated into nearly 1 in 5 children who had fallen.

In well over half — 58%, the fall occurred prior to any depressive symptom.

The powerful link to depression was not seen in children who had endured other traumas, such as serious illnesses or injuries that required hospitalization. 

The chicken-and-egg question, which Dr. Egger said requires urgent research, is whether the falls themselves or the circumstances leading to the falls are most salient with regard to associations with depression.

“Are these children with depressed mothers? Children living in a household where no one is looking out for them?”

Even if it takes all of the King’s horses and all of the King’s men, it’s something we need to find out. 

—Betsy Bates

A Welcome Mat For Dads

In an upcoming “Behavioral Consult” column in Pediatric News, Johns Hopkins University pediatrician Barbara Howard talks about the many ways in which fathers uniquely contribute to their children’s health and well-being, and encourages pediatricians to make them feel comfortable and necessary during visits, right from the start.

Her many suggestions range from the utilitarian — offering Dad-friendly magazines and an extra chair in the exam room — to the insightful: emphasizing the infant’s strength and engagement during the well-baby exam and showing Dad how comfy his progeny feels in the “football hold.”

Image via Flickr user Narith5 by Creative Commons License

The discussion made me reflect on the fathers in my life and their connections with pediatricians. My own father seemed to know Dr. Snyder, but mostly from my mother’s amused recountings of our doctor’s dry wit and straight-faced pronouncements of medical truths (or falsehoods?) My husband, on the other hand, was a regular presence in the pediatrician’s office, always setting a bad example for the kids by playing with the blood pressure cuff or checking out the “knee hammers” in the drawer.

Where my husband’s great value lay was in negotiating the minor emergency phone line when one of our kids had a fever, gash, or cough. While my calls always seemed to be met with bored professionalism on the part of the triage nurse or the front desk assistant, we quickly realized that a call from DAD meant there must surely be an EMERGENCY. My hunch was that the voice of fatherhood was so unusual in the daily rhythm of the pediatric office that everyone took notice when a real dad was on the phone. The appointment was made pronto. The doctor called back immediately. We were no longer alone in our child crisis.

If pediatricians take Dr. Howard’s advice and brush off the welcome mat for Dads, I guess that eventually they’ll have to sit on hold just like moms have been doing for years.

— Betsy Bates

R U Plugged In?

From the annual meeting of the Society for Adolescent Medicine, Los Angeles

From Flickr Creative Commons user uberculture

Technology is all the rage at this meeting, themed “eTeens: Incorporating Technology and Health.” Adolescent medicine specialists have learned that     e-mail is becoming passé for kids, but text messages and social networking are in-in-in. They’ve learned the definition of “sexting” (sending compromising pictures in phone messages) and discovered that new research suggests teens’ online lives, habits, and friendships pretty much reflect their offline lives. They’ve heard how new technology is being used to offer teens free chlamydia screening and how text messages can remind them to take their oral contraceptives.

But when it comes to their own tech acumen, these docs may need to enroll in Cool School. Speaker Deborah Levine of the nonprofit Internet Sexuality Information Service, invited the California audience to take out their mobile phones and text the message “HOOKUP” to an isis site (365247) that responds by sending back a message about sexually transmitted diseases:  (“Meds cure chlamydia, gonorr & Syph… Herpes & HIV = viruses tt stay w/u 4eva. Text CLINIC + ur ZIP 4 CLINICS”).  A few brave souls clicked away, but hundreds of specialists just chuckled or stared avoidantly at their meeting programs.

“We [as health professionals] need to think of technology as part of [adolescents'] lives that we can use from [fostering] prevention all the way through to treatment,” said Ms. Levine.

But the first step, she said, is getting in touch with the forms of media that adolescents use every waking hour of the day.

“Get familiar with your cell phones!”  she exhorted, and stayed after the session to help specialists learn how to text.

— Betsy Bates