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Monday, December 11, 2017

Watching for Signs of Psychosis in Teens

From the Child Mind Institute

By Juliann Garey
December 4, 2017

There are fewer more frightening or challenging psychiatric conditions for a family to face than psychosis, an extreme mental state in which impaired thinking and emotions cause a person to lose contact with reality.

This could mean hearing or seeing things that aren’t there (hallucinations), or believing things that aren’t true (delusions).

The illness most often associated with psychosis, schizophrenia, usually doesn’t show up until very late adolescence or early adulthood. Recently, however, experts in the field have been working to identify high-risk kids who show symptoms that could serve as early warning signs of psychosis, and several academic centers have been set up to focus on this crucial period when it may be possible to change the trajectory of mental illness.


Not all the kids who are identified with what experts call “prodromal” symptoms will progress, or “convert” to full-blown psychotic illness. But early intervention has been shown to improve outcomes for those who do. And since psychotic symptoms cause disruption across a teenager’s life, from school to friendships to family, researchers are hoping quick action can prevent impairment and prolong typical functioning.

What’s more, some of the approaches that show promise in delaying onset of psychosis or mitigating symptoms include fairly simple lifestyle changes like stress reduction and sleep hygiene, and managing co-occurring disorders like anxiety. The key: identifying at-risk kids earlier when these low-impact measures are still effective.

What are “prodromal” symptoms?

Prodromal symptoms are “attenuated” or weak symptoms of psychosis. Moreover, “they are a warning sign,” says Dr. Christoph Correll, the medical director of the Recognition and Prevention Program (RAP) at Zucker Hillside Hospital in Queens, N.Y., which specializes in diagnosing and treating early symptoms of mental illness in teenagers and young adults.

“These signs can happen in people who don’t go on to develop psychosis—but if we follow these people who are in the risk state based on these watered-down versions, one third will probably go on to develop psychosis. That’s a lot more than in the general population.”

Prodromal symptoms occur on a spectrum from very, very mild to severe and can include:

  • Withdrawing from friends and family/feeling suspicious of others
  • Changes in sleeping or eating patterns
  • Less concern with appearance, clothes or hygiene
  • Difficulty organizing thoughts or speech
  • Loss of usual interest in activities or of motivation and energy
  • Development of unusual ideas or behaviors
  • Unusual perceptions, such as visions or hearing voices (or even seeing shadows)
  • Feeling like things are unreal
  • Change in personality
  • Feelings of grandiosity (belief he has a superpower, etc.)

In some cases, these symptoms represent the early stages of a disorder, and will eventually convert. In others, the symptoms actually fade or remain mild. Dr. Tiziano Colibazzi is a psychiatrist at Columbia Presbyterian’s COPE clinic (Center for Prevention and Evaluation), which was established to research and treat prodromal symptoms.

“We can identify a group of people that are at clinically high risk,” says Dr. Colibazzi. “What we can’t do is narrow that group down further to identify the 30 percent who will convert.”

First Step If You Feel Your Child is at Risk: An Evaluation

The right treatment for prodromal symptoms depends entirely on how severe they are when they are diagnosed. The first step is a proper and complete diagnosis by a mental health professional with experience in assessing psychotic illness.

If you see marked changes in motivation, thinking, and/or behavior in your child, the first place to start is with her pediatrician to rule out a medical illness. Substance use also needs to be ruled out as the cause of any behavior changes in adolescents. After that, you’re going to want to have your child evaluated by a qualified psychiatrist or psychologist. This in itself might be a multi-step process.

“You can’t just look at the kid once and get a bit of a history and then know what’s going on, ” says Dr. Correll. “Kids develop; symptoms develop. And the trajectory—how things change, get better or worse, what other symptoms add on to it—will be highly informative in telling us something about the prognosis, what we expect to happen.”


One aid to predicting the evolution and severity of symptoms, notes Dr. Colibazzi, is the patient’s ability to doubt his symptoms. If your child retains the self-awareness to know that it’s his mind that is playing tricks on him, it’s an indication that symptoms are still in the very early stages. As symptoms become more severe, the patient’s beliefs (whether paranoid, grandiose or hallucinatory) become increasingly difficult to challenge.

Lifestyle and Mental Health Options

Psychotic symptoms and illnesses have been shown to vary quite a bit depending on the environment—the health of our bodies, our interpersonal relationships, our mindsets. As with any illness, but particularly important in at-risk youth, healthy living is key.

Regardless of the severity of prodromal symptoms, Dr. Correll says that your child’s outcome can be improved by making sure your kid sticks to a routine that includes:
  • Eating well
  • Getting regular exercise
  • Adhering to a regular sleep schedule
  • Reducing stress as much as possible
  • Staying away from drugs—particularly marijuana, which can interact with prodromal symptoms and increase the risk for psychosis significantly

Also, don’t forget to address depression and anxiety. According to Dr. Correll, “adults who eventually developed schizophrenia identified a three to five year period during which they experienced depression or anxiety before developing the prodromal symptoms of psychosis and then developed full-blown psychosis.”

“So, treating the depression early,” he says, “might actually interrupt the progression from depression to psychosis in some patients.”

Treatment for Prodromal Psychotic Symptoms

Dr. Correll recommends trying several approaches. Mild symptoms call for more low-key treatments including:

  • Psycho-education: teaching both the kid and the family more about the symptoms and the illness.
  • Therapy, particularly cognitive behavioral therapy: “CBT can be good to change one’s thinking patterns,” says Correll, “and also to address developing self-esteem. We have to be careful that kids with a psychiatric diagnosis don’t self-stigmatize and get into a hopeless or negative mode where they feel they can’t achieve.”
  • Lifestyle adjustments: Assessing whether the current school environment is best for the child. Perhaps a therapeutic social group to help the child cope.
  • Reducing Stress: Stress is often a trigger for symptoms, so reducing stress in these kids’ lives is crucial and may prevent or delay conversion to psychotic illness.

Understanding prodromal symptoms and monitoring kids who are at high risk for psychotic illness means that parents can do more for their kids than wait for symptoms to get worse or merely hope for the best. Early monitoring and intervention can give high-risk kids an advantage, which researchers hope will eventually change the odds when it comes to psychotic illness.


“The duration of untreated psychosis does actually seem to affect the course of the illness,” Dr. Colibazzi says. The longer the illness goes untreated, the greater the chance that it will cause serious disruption in all areas of the patient’s life. “So it is reasonable to think that just following someone very closely and treating them very early, as soon as they develop symptoms, would be helpful.”

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Pregnant Women Who Need Medications Face a Risky Guessing Game. A Federal Task Force is Now Trying to Help

From STAT News

By Megan Thielking

December 5, 2017

So many women face wrenching decisions about using medication during their pregnancies. Now, federal officials are finally inviting them to tell their stories. And they’re not holding back:

“I was on Zoloft for many years before I became pregnant with my first. Both my psychiatrist and OB/GYN would not give me an answer about if I should continue to take it.”

“For every condition that couldn’t be addressed with acetaminophen or antacids, I was out of luck. Several months later, when I forgot to take that list of medications on vacation with me and came down with a cold, I sweated bullets trying to recall whether medicated cough drops had been on the list.”

“I wish I came off the meds while I was pregnant but what was done was done.”

Their fears and frustrations are slowly stirring change. Congress last year created a task force through the National Institutes of Health to study why so few women can get reliable answers on medication use during pregnancy — and to recommend solutions. Members have been holding public meetings and reviewing the women’s comments. Experts say it’s long overdue.

Few drugs have been approved as safe and effective to use during pregnancy, and most of those are for conditions specific to pregnancy. As a result, almost every medicine given to a pregnant woman, from prescription antacids for acid reflux to biologic drugs to prevent epileptic seizures, is considered an off-label use. Some doctors even take women off medications as basic and important as those that help control blood pressure, because there’s no way of knowing if they’re safe.

The research “is pretty impressively minimal,” said Dr. Catherine Spong, an obstetrician who is leading the federal task force.

Another wrinkle: Because the body changes so much during pregnancy, standard doses might be too high, or too low, for an expectant mother, depending on how a specific medication is distributed and absorbed in the body. There’s very little research on how to compensate for such shifts.

That’s left doctors and patients playing a dicey guessing game.

“It’s a risk-risk analysis,” said Adrienne Griffin, a mother of three who decided to take an antidepressant during pregnancy. “There’s risk to not being medicated, and there may be risks to being medicated."

STAT interviewed pregnant women and mothers, doctors, ethicists, and federal officials and reviewed hours of testimony to the federal task force to understand the scope of the problem.

The drug industry has long steered clear of research on pregnant women. Past tragedies loom large — starting with thalidomide, which was widely prescribed for morning sickness in the late 1950s only to cause devastating limb deformities in at least 10,000 babies.

Regulations, too, have long discouraged research on pregnant women out of caution. Researchers have to meet specific requirements to include them in experimental studies – and often don’t. And pregnant women are currently listed as an example of a “vulnerable population” in research, along with prisoners and people with diminished mental capacity.

It’s a designation designed to protect people who might be at risk of being pressured into participating in a trial. They’re set to be removed from that list in January.

There’s deep concern over the ethics of exposing pregnant women to drugs that haven’t been proven safe for them or their fetuses. Just last week, in testimony before Congress, NIH Director Francis Collins laid out the dilemma. “This area of research is vital,” he said, “but it is absolutely critical that we carefully consider intentional exposures in this potentially vulnerable time of life.”

Doctors get that. Yet they point out that since so little research has been done, millions of women each year are already getting exposed to potentially risky drugs.

“Because we haven’t done that research, women are faced with those kinds of questions every day in the clinic,” said Dr. Anne Lyerly, a bioethicist at University of North Carolina, Chapel Hill. “They’re exposed to untested medications necessarily every day.”
Pregnant and panicking, women search for data

Julie Cerrone found out she was pregnant in July. Her first thought?

“Oh, shit. I’m on this medication,” she said.

A 32-year-old health advocate and blogger in Pittsburgh, Cerrone was taking the drug Otezla for her psoriatic arthritis. The condition — a type of inflammatory arthritis that can flare up and then subside — leaves her sapped of energy and overcome with aches. Her hands are often wrought with pain. Her knees sometimes swell so much it’s difficult to walk. At a friend’s baby shower last year, she realized she could never open gifts in front of her friends and family. It would be too hard on her hands.


Her symptoms got a bit better when she started the drug. So when she found out she was nearly two months pregnant, she panicked and called her physician.

“He said, ‘Well, this drug hasn’t been shown to be detrimental,’” she recalled. “I was like, ‘Well, it hasn’t been shown to be safe.’”

She talked to her gynecologist, rheumatologist, and dermatologist. Their consensus: Don’t take any medications unless you absolutely need them. There just wasn’t enough data to show whether the biologic would affect her fetus. She researched the drug on her own online, but came up essentially empty-handed. So Cerrone stopped taking Otezla and hoped for the best.

“It was really, ‘Well, I hope I’m doing the right thing,’” she said.

So far, her arthritis has been bearable; she hasn’t experienced a major flare-up. But Cerrone has heard from other women online that the condition often gets worse after giving birth. She’s concerned that if that happens, she’ll need to go back on the medication and won’t be able to breastfeed. There isn’t safety data on nursing while on Otezla, either.

“[Pregnant women are] exposed to untested medications necessarily every day.”

Cerrone also faced another common problem during pregnancy: morning sickness.

“Except it was all-day sickness. I couldn’t keep my head up. I couldn’t function as a person,” she said. Her doctor prescribed Zofran, a common anti-nausea medication. It’s frequently used to treat morning sickness, but when Cerrone did her own research, she found conflicting anecdotes.

It’s a familiar theme: Pregnant women often turn to Facebook support groups and other online forums for advice — but rarely get a complete picture. After all, people are far more likely to report negative outcomes than positive ones. And they report correlations, not causation. About 3 percent of all newborns have some kind of birth defect; without rigorously controlled trials, it’s impossible to know whether a pregnant woman’s medication use affected her baby’s health.

“What people report are the bad things,” said Spong, the obstetrician who leads the federal task force, which is coordinated by the National Institute of Child Health and Human Development. “If someone’s on a medication during pregnancy and nothing untoward happens, you don’t report it. It’s not news."


Cerrone ultimately decided to take Zofran — and continued to do so for two months — because she couldn’t keep any food down. She didn’t have a firm answer about the drug’s safety, but she knew for sure that not getting enough nutrition wouldn’t be good for the fetus.

She hopes there are no long-term implications for her baby. She’s due in March.
Doctors struggle to decide: Is a medication truly necessary?

Physicians face their own challenges in trying to advise pregnant patients.

“When I’m talking to patients, my advice is, if she doesn’t need the drug, don’t take it,” said Dr. Daniela Carusi, an OB-GYN at Brigham and Women’s Hospital in Boston.

But that involves a tough decision: When is a medication absolutely necessary? Pregnant women often find it hard to make that judgment call.

“They feel like their baby is an innocent bystander,” Carusi said. “But you can’t have a sick mother and expect a healthy baby.”

“When I’m talking to patients, my advice is, if she doesn’t need the drug, don’t take it.”

Doctors do what they can. They look at the limited observational studies. They look at the data from pharmacokinetics studies on pregnant rabbits and mice. In many cases, they stick to older medicines when possible. They assume that if drugs have been on the market for decades, we’d know if they caused major problems for pregnant women.

“Often that’s the best that we can do,” Carusi said.

But that approach can raise additional thorny questions. Dr. Alison Cahill, a maternal-fetal medicine specialist, said she sometimes treats patients who’ve run through the gamut of drugs to treat their chronic disease before finding one that works.

If such a patient gets pregnant, Cahill has to weigh whether to keep her on the effective drug — which may be too new to have much of a track record in pregnant women — or switch her to an older medication that hasn’t worked for her in the past.

“Then, you have the drug exposure for a drug that isn’t working, and you have the fetus exposed to an untreated disease,” said Cahill, who practices in Missouri.

Many pregnant women talk about literally drawing up pro/con lists as they go through the agonizing internal debate.

“[My doctor] said, ‘Well, this drug hasn’t been shown to be detrimental.’ I was like, ‘Well, it hasn’t been shown to be safe.’”

Griffen, the mother of three in Arlington, Va., experienced severe anxiety and depression after her second child was born. She started taking antidepressants, but wasn’t sure what to do when she decided to have another child.

Her doctors didn’t have a clear answer, either.

They left it to her to decide.

“They were silent on the subject. They said, ‘Do whatever you think is best,’” she recalled.

Griffen felt she needed to stay on the medication: “I could not be a basket case with a 2-year-old and a 4-year-old,” she said. So she pored over studies on her own, checking to see if they were well-controlled and parsing out the relative risk of birth defects.


There’s been a fair amount of observational research on antidepressant use during pregnancy — but the findings from those studies don’t always point in the same direction. In some cases, the findings in a single study are contradictory.

One study in 2015 looked at 850,000 births in Finland and found that there were more short-term complications in newborns whose mothers took antidepressants during pregnancy. But that study also found there was a lower risk of preterm birth among women who took antidepressants compared to women with psychiatric disorders who didn’t take medication during pregnancy.

Or consider the confusion over a potential link between antidepressant use during pregnancy and autism spectrum disorder in children.

One study, published in April in the Journal of the American Medical Association, found that use of common antidepressants during pregnancy wasn’t associated with a significantly increased risk of autism spectrum disorder. The authors suggested that the link between the two — which had been reported in many other studies — might actually be explained by other factors, like genetics.

A study published in the BMJ three months later, however, concluded that the link might not solely be due to those other factors.

“It’s a risk-risk analysis. There’s risk to not being medicated, and there may be risks to being medicated.”

In short, nothing’s definitive. And media coverage can make the decision even more confusing, frustrating, and frightening for pregnant women.

One publication ran a story about the April study with the headline “Anti-depressant use before, during pregnancy tied to autism risk.” Another publication ran a story about the same study with the headline “Studies find no evidence for autism link to antidepressant use.” The July study received similarly contradictory coverage.

Ultimately, Griffen decided to stay on her antidepressant, Zoloft. But she knows not every woman has the education — or the time — to do the kind of research that made her comfortable with that decision.

Women with Chronic Disease Face Even Tougher Choices

For pregnant women with chronic diseases like sickle cell anemia, Crohn’s disease, or epilepsy, decisions about medication use grow exceedingly complicated.

Clair Cobbold, 32, was diagnosed with epilepsy when she was 18. When she decided to have a family, her epilepsy specialist walked her through the research on anti-seizure medication in pregnancy and the risk of birth defects, which is elevated with some anti-seizure medications.

“She was honest with me about that and allowed me to make my own mind up,” Cobbold said.

At that point, she was taking a drug called lamotrigine and was having about one major seizure a year. “I was on one of the safest [drugs] they could see,” she said.


But Cobbold knew “one of the safest” doesn’t guarantee “safe.” She weighed her options. There’s no warning when she’s about to have a seizure — they sneak up on her and she drops to the floor. She worried that if she had a seizure while on the stairs, she might fall and harm the fetus.

“Epilepsy is always a bit of trial and error. But I felt by taking the medication, it was safer than me having a seizure,” she said.

She did have a seizure early on in her pregnancy. Cobbold’s doctor increased her dose, hoping that would help keep the seizures in check. Her daughter was born healthy, without any major birth defects.

Between her daughter’s birth in 2012 and her son’s birth in 2015, Cobbold’s seizures became more frequent. Her physicians decided lamotrigine wasn’t going to cut it anymore. They switched her to a drug sold under the brand name Keppra. There wasn’t a solid answer on whether it was safe to take during pregnancy — but she knew she needed the medication. Pregnant and in charge of an active toddler, she couldn’t risk falling from a seizure.

“There wasn’t the option of me not being on medication,” she said. “It was the safest of all my options.” She made it through her pregnancy without a seizure, and gave birth to a healthy boy.

But her decision to stay on the seizure medications during pregnancy still nags at her.

Cobbold has been trying for three years to potty-train her daughter, who has an overactive bladder. It’s not a complication that’s ever been tied to anti-seizure medication use during pregnancy. But she has heard similar stories in Facebook support groups from other moms who took the same medication while pregnant.

She asked her neurologist, who first walked her through the decision to take the medication during pregnancy. He told her there’s no way to know whether the drug is connected to her daughter’s bladder issues. There isn’t any research.

Read Part II Here

Sunday, December 10, 2017

So Tired Teens Can Sleep In, Boston School Committee Votes To Make Classes Start Later

From NPR's WBUR 90.9 FM

By Max Larkin
December 7, 2017

The Boston School Committee voted unanimously Wednesday night to approve a new system-wide schedule that will allow most teenagers in the district to sleep in a bit next year.

Under the new framework, most high schools will start at or after 8 a.m. Presently, about half of the district's public schools start class at or before 7:30 a.m. And whenever possible, younger children will be dismissed before 4 p.m., in part to prevent them from running out of steam late in the day — or walking home in the dark.

Exceptions will be made for schools enrolling many students with autism or medical conditions. Schools and families will be notified of the precise changes to the schedule as early as Thursday morning.

Switching up high schoolers' schedules has been a district priority for some time, due in large part to a growing convergence of sleep science and educational activism.

The Centers for Disease Control and Prevention recommends teens get between eight to 10 hours of sleep each night, but most get fewer than that. Many sleep researchers, like Wendy Troxel, have blamed what they call an "epidemic" of teenage sleep deprivation on high-school schedules, arguing they aren’t built around students’ internal clocks.

“Adolescent biology is unique compared to any other stage of life," Troxel, a senior behavioral scientist at the RAND Corporation, said. "Their sleep-wake biology is shifted by about two hours.”

She likened teenage sleep patterns to being permanently jet-lagged. Troxel and others believes that early start times don't just rob students of the benefits — like better mood and memory — that come with a good night's rest. They can trigger or exacerbate problems associated with adolescent learners: irritability, distraction, even anxiety and depression.

Troxel has argued that high school classes should start at 8:30 a.m or later. But she told WBUR that schedule changes like the one passed in Boston are steps in the right direction.

To arrive at a systemwide plan for next school year's start times, the district’s operations team turned to the same MIT engineers who plotted this year’s bus routes (with mixed early results). The engineers developed another algorithm that has churned through — the district announced with pride — 1.8 octodecillion possible school-day schedules, whittling them down to a few ahead of Wednesday's meeting.

The district still has not released a full picture of how the systemwide plan will work. But whatever happens next will look like a flip of this year's schedule. Buses will drop young children — who are often wide awake at 6 a.m. — at school earlier, while older students keep dreaming.

(Max Larkin/WBUR)

Several other Massachusetts districts, notably Monomoy School Districts on Cape Cod, have been trying out a similar schedule of late. More than a dozen districts in-state have responded to activism from groups like Start School Later.

There weren't many criticisms presented by the public or school committee members before the unanimous vote. Some said they have heard from some older students who warned against starting school too late, citing work and childcare responsibilities in the afternoon.

Jessica Tang, president of the Boston Teachers' Union, says most of the educators she knows are in support of more high-quality learning time with more wakeful students. But she added that some teachers do worry about juggling their own childcare and commutes under the new schedule.

Earlier this year, Boston polled teachers, families and staff, letting them rank 11 possible start times ranging from 7:30 a.m. to 9 a.m. The thousands of responses didn’t square perfectly with sleep science.

Families and teachers of elementary students tended to cluster around later start times — as late as 8:30 a.m. At high schools, stakeholders aimed for 8 a.m. or earlier. Few respondents of any group, other than some families of high school students, expressed much interest in 9 a.m. or later start times.

But Mary Hamaker, who leads the Start School Later initiative in Massachusetts, explains those poll results as a sign of predictable wariness of something new and disruptive. She and others hope that the new schedule in Boston will win over even the most reluctant as its benefits become clearer.

The significance of the change remains to be seen. What is clear is that, as of next fall, the times — they are a-changing.

The Constitutional Right to Education Is Long Overdue

From The Conversation
via the Education Law Prof Blog

By Derek Black
December 5, 2017

Public school funding has shrunk over the past decade. School discipline rates reached historic highs. Large achievement gaps persist. And the overall performance of our nation’s students falls well below our international peers.

These bleak numbers beg the question: Don’t students have a constitutional right to something better?

Many Americans assume that federal law protects the right to education. Why wouldn’t it? All 50 state constitutions provide for education. The same is true in 170 other countries. Yet, the word “education” does not appear in the United States Constitution, and federal courts have rejected the idea that education is important enough that it should be protected anyway.

After two decades of failed lawsuits in the 1970s and ‘80s, advocates all but gave up on the federal courts. It seemed the only solution was to amend the Constitution itself. But that, of course, is no small undertaking. So in recent decades, the debate over the right to education has mostly been academic.

The summer of 2016 marked a surprising turning point. Two independent groups – Public Counsel and Students Matter – filed lawsuits in Michigan and Connecticut. They argue that federal law requires those states to provide better educational opportunities for students. In May, 2017, the Southern Poverty Law Center filed a similar suit in Mississippi.

At first glance, the cases looked like long shots. However, my research shows that these lawsuits, particularly in Mississippi, may be onto something remarkable. I found that the events leading up to the 14th Amendment – which explicitly created rights of citizenship, equal protection and due process – reveal an intent to make education a guarantee of citizenship. Without extending education to former slaves and poor whites, the nation could not become a true democracy.

Why a Federal Right to Education Matters

Even today, a federal constitutional right to education remains necessary to ensure all children get a fair shot in life. While students have a state constitutional right to education and it has made a real difference in many states, too many state courts have been ineffective in protecting those rights. Some courts claim they lack the authority to demand reform. Others simply struggle to cajole legislative compliance with court orders.

Without a federal check, education policy tends to reflect politics more than an effort to deliver quality education. In many instances, states have done more to cut taxes than to support needy students.

And a federal right is necessary to prevent random variances between states. For instance, New York spends US $18,100 per pupil, while Idaho spends $5,800. New York is wealthier than Idaho, and its costs are of course higher, but New York still spends a larger percentage on education than Idaho.

Tennessee and Kentucky make the point even clearer. Kentucky is a little poorer than Tennessee, but spends far more on education—$8500 per pupil compared to Tennessee’s $7300. In other words, geography and wealth are important factors in school funding, but so is the effort a state is willing to make to support education.

And many states are exerting less and less effort. Recent data show that 31 states spend less on education now than before the recession – as much as 23 percent less.

States often makes things worse by dividing their funds unequally among school districts. In Pennsylvania, the poorest districts have 33 percent less per pupil than wealthy districts. Half of the states follow a similar, although less extreme, pattern.

Studies indicate these inequities deprive students of the basic resources they need, particularly quality teachers. Reviewing decades of data, a 2014 study found that a 20 percent increase in school funding, when maintained, results in low-income students completing nearly a year of additional education. This additional education wipes out the graduation gap between low- and middle-income students.

A Kansas legislative study showed that “a 1 percent increase in student performance was associated with a .83 percent increase in spending.”

These findings are just detailed examples of the scholarly consensus: Money matters for educational outcomes.

The New Lawsuits

While normally the refuge for civil rights claims, federal courts have refused to address these educational inequalities. In 1973, the Supreme Court explicitly rejected education as a fundamental right. Later cases asked the court to recognize some narrower right in education, but the court again refused.

After a long hiatus, new lawsuits are now offering new theories in federal court. In Michigan, plaintiffs argue that if schools do not ensure students’ literacy, students will be consigned to a permanent underclass. In Connecticut, plaintiffs emphasize that a right to a “minimally adequate education” is strongly suggested in the Supreme Court’s past decisions. In Mississippi, plaintiffs argue that Congress required Mississippi to guarantee education as a condition of its readmission to the Union after the Civil War.

While none of the lawsuits explicitly state it, all three hinge on the notion that education is a basic right of citizenship in a democratic society. Convincing a court, however, requires more than general appeals to the value of education in a democratic society. It requires hard evidence. Key parts of that evidence can be found in the history of the 14th Amendment itself.

The Original Intent to Ensure Education

Immediately after the Civil War, Congress needed to transform the slave-holding South into a working democracy and ensure that both freedmen and poor whites could fully participate in it. High illiteracy rates posed a serious barrier. This led Congress to demand that all states guarantee a right to education.

In 1868, two of our nation’s most significant events were occurring: the readmission of southern states to the Union and the ratification of the 14th Amendment. While numerous scholars have examined this history, few, if any, have closely examined the role of public education.

The most startling thing is how much persuasive evidence is in plain view. Scholars just haven’t asked the right questions: Did Congress demand that southern states provide public education, and, if so, did that have any effect on the rights guaranteed by the 14th Amendment? The answers are yes.

Poster with text from the reconstructed Constitution depicting African-American leaders
in Louisiana. At center is a full-length portrait of Oscar J. Dunn, lieutenant governor of
Louisiana, seated at a desk. Surrounding him are 29 portraits of African-American
delegates to the Louisiana Constitutional Convention of 1868. Know Louisiana

As I describe in the Constitutional Compromise to Guarantee Education, Congress placed two major conditions on southern states’ readmission to the Union: Southern states had to adopt the 14th Amendment and rewrite their state constitutions to conform to a republican form of government. In rewriting their constitutions, Congress expected states to guarantee education. Anything short was unacceptable.

Southern states got the message. By 1868, nine of 10 southern states seeking admission had guaranteed education in their constitutions. Those that were slow or reluctant were the last to be readmitted. The last three states – Virginia, Mississippi and Texas – saw Congress explicitly condition their readmission on providing education.

The intersection of southern readmissions, rewriting state constitutions and the ratification of the 14th Amendment helps to define the meaning of the 14th Amendment itself. By the time the 14th Amendment was ratified in 1868, state constitutional law and congressional demands had cemented education as a central pillar of citizenship.

In other words, for those who passed the 14th Amendment, the explicit right of citizenship in the 14th Amendment included an implicit right to education.

The reasoning of both Congress and the state conventions was clear: “Education is the surest guarantee of the … preservation of the great principles of republican liberty.”

The rest is history. Our country went from one in which fewer than half of states guaranteed education prior to the war to one in which all 50 state constitutions guarantee education today.

The new cases before the federal courts offer an opportunity to finish the work first started during Reconstruction – to ensure that all citizens receive an education that equips them to participate in democracy. The nation has made important progress toward that goal, but I would argue so much more work remains.

The time is now for federal courts to finally confirm that the United States Constitution does, in fact, guarantee students the right to quality education.

Saturday, December 9, 2017

What Parents Should Know About Risperdal

From the Child Mind Institute

By Caroline Miller
December 4, 2017

Pros and cons of this medication, used to treat children with severe behavior problems.

Risperdal is a medication that’s widely used to treat children who are aggressive or excessively irritable. Though it was originally approved to treat psychosis, its use in children, including those with autism or ADHD diagnoses, has grown dramatically over the last two decades.

That’s because Risperdal can successfully calm down kids with severe behavior problems, enabling them to function in school and within their families. Without it, some would require residential treatment.

But Risperdal (generic name risperdone) can have serious side effects, and it’s important to make sure a child taking it is monitored carefully. Parents should know what the medical community agrees are the “best practices” to be followed by a doctor who prescribes Risperdal, to insure good treatment.

Here are the basics about Risperdal: what it’s used for, potential side effects, and how a child on Risperdal should be monitored.

What is Risperdal for?

Risperdal is what is called an atypical, or second-generation antipsychotic (SGA). It was a new kind of antipsychotic approved by the Federal Drug Administration in the 1990s to treat the symptoms of psychosis in schizophrenia and bipolar disorder.

Now it is more widely used to treat aggression and irritability in both dementia patients, often in inpatient facilities, and in children.

Many kids on the autism spectrum take Risperdal to reduce behavior problems like aggression or self-injury, and the FDA has approved it for that use. But it’s also prescribed to many kids who have conduct disorders like ADHD (attention-deficit hyperactivity disorder), ODD (oppositional defiant disorder) or DMDD (disruptive mood dysregulation disorder).

When kids act out dangerously or are at risk of getting kicked out of school or removed from the home, they may be given Risperdal or another SGA to calm them down. For kids who do not have an autism diagnosis, these prescriptions are off-label — that is, they are not an FDA-approved use for the drug. But a substantial body of evidence suggests they are effective in reducing persistent behavioral problems.

Why is Risperdal controversial?

Risperdal is controversial because side effects that include substantial weight gain and metabolic, neurological and hormonal changes that can be harmful. Some experts are concerned that children are being treated with the drug in lieu of other treatment — including behavioral treatment — that could be effective without the risk of these side effects.

Risperdal has been in the news over the last several years because of thousands of lawsuits from families who say they were not informed about side effects that might adversely affect their kids, and the kids were not taken off the medication when problems developed.

Many of the suits are on behalf of boys who, in a rare side effect, developed breasts because of an increase in a hormone called prolactin.

Problems in School and at Home

Wendy Moyal, M.D., a child and adolescent psychiatrist at the Child Mind Institute, describes a common scenario in which Risperdal is prescribed because a child’s aggressiveness or irritability has become acutely problematic. This behavior often presents in early adolescence, says Dr. Moyal. “These are kids who are very aggressive, meaning they might push, shove, punch, break furniture.”

When these kids can’t control their tempers, they may be a danger to other children, their parents and themselves. “Sometimes their parents are so desperate they have considered calling 911,” Dr. Moyal notes. Or the child might already have been sent to the emergency room after an outburst at school.

For kids in crisis, Risperdal is often clinicians’ first choice for stabilizing the situation. If it’s not a crisis, they recommend that other treatments be tried first.

Behavioral Therapy

Most experts, including Dr. Moyal, stress the importance of thoroughly investigating the causes of aggressive behavior as part of the evaluation for medication.

Behavior problems can have many different sources, including undiagnosed anxiety, ADHD, learning disorders, trauma and medical problems. Treating those problems may alieviate the behavior issues in a more effective (and lasting) way than giving the child antipsychotic medication.

For children with disruptive behavior problems that haven’t reached a crisis stage, experts’ first choice for treatment is behavioral therapy, including parent training, to rein things in. Depending on the level of risk, Dr. Moyal says she might recommend a first trial of behavioral therapy, or medication together with behavioral therapy.


Alternative Medications

In a more stable situation, Dr. Moyal also favors first trying more targeted medications with fewer side effects. For instance, in a child with ADHD, stimulants (Ritalin or Aderall) or non-stimulant ADHD medications like clonidine (Catapres, Kapvay, Nexiclon) or guanfacine (Estulic, Tenex, Intuniv) could reduce impulsive aggression.

For a child with ODD, she says, antidepressants (SSRIs) can help with underlying depression or anxiety that could trigger outbursts.

If these attempts are not effective, Dr. Moyal may try an SGA. Abilify (aripiprazole), which is also approved for irritability in kids on the spectrum and commonly used for aggression, is usually her first choice, because it has fewer side effects than Risperdal, including lower weight gain and endocrine disruption. But medication treatment should always be in combination with behavioral therapy, she stresses, which could include parent training.

The medical community agrees. A survey of treatment recommendations from top experts emphasizes that medication should not replace behavioral therapy.

Analysis: Why Are All the Stories About Boys Falling Behind Girls at School Ignoring the Forces Keeping Them There?

From The 74 Million

By Richard Whitmire
December 3, 2017

A recent flurry of articles on boys falling behind in school do a great job laying out the facts — but fall short when it comes to asking the right questions.

Take the recent Atlantic piece as an example. Great facts, all accurate: As of 2015, 72.5 percent of females who recently graduated from high school were enrolled in college, versus 65.8 percent of men (compared to 1967, when 57 percent of the males and 47.2 percent of the females were in college).

This is important stuff. Today, at a time when college has become the new high school as many employers demand college degrees for jobs that don’t truly need those skills, there are 2.2 million more women than men in college.

Startling, right? But here’s the thing. All these articles, with roughly the same statistics, could have been written a decade ago, at the time I published Why Boys Fail. You see, nothing much has changed about the plight of boys. No improvements.

So, the relevant, but unasked, question in all these articles about boys: Why has nothing changed?

To someone new to this issue, that probably sounds like a really difficult question to answer. Surely, a multitude of intricate social maladies make this dilemma insolvable.

Not really.

Nothing changes for a very simple reason. None of the relevant players want to take any action, the very reason I pretty much gave up hope on this issue and rarely write about it anymore.

Weird, right? Half our children are boys. Who’s against doing something to make them more successful in K-12 schools, more likely to earn college degrees that today are needed for scores of jobs that a couple of decades ago didn’t require them?

Lots of people, actually, all of them involved with our schools.

Let’s start with the elementary school teachers, nearly all them female and annoyed as hell by all the boys in their classrooms who aggressively wave their arms in the air when a question is asked. They continually ask: Shouldn’t we be doing more to encourage the shyer girls who seem intimidated?

Actually, their focus would be better placed on the fact that too many of those boys have no clue what the right answer is. They’re just fidgety and want to wave their arms around.

What about the principals? Aren’t they held accountable for student performance? Roughly, yes, but only along racial and socioeconomic guidelines. Gender gaps were never part of any accountability regime.

Then we move on to the major players in how schools are staffed and run, the teachers unions: the American Federation of Teachers and the National Education Association. These are groups dedicated to repelling all efforts to hold them responsible for the ills of society.

Boys, they insist, lag behind only because boys are more affected by poverty than their sisters. Solve poverty, and you’ll solve this problem, they insist. This has nothing to do with how boys are taught!

On the surface, their argument seems to have merit. The gender gaps truly are greater for poor, minority boys. But you can find these gaps at all levels, even among boys at pricey private schools where girls have to achieve at far higher levels to land spots in selective colleges. And boys from white, blue-collar families suffer from serious gender gaps, as I discovered in Maine during the book research.

Surely, parents demand explanations for why their sons lag behind their daughters, right? Surprisingly not. Parents are told by educators that boys are just slow starters. Be patient, they counsel, he’ll catch up. So dads keep tossing footballs with their sons and reading to their daughters, clueless about the brutal reality that a lot of sons never catch up.

When it comes to college, middle-class and upper-middle-class parents with underperforming sons get a break that helps disguise these gaps. Many colleges, desperate to recruit more men, are more than willing to admit less-qualified males. The takeaway for parents: If you’ve got the tuition money, you’ll find a spot for your son somewhere.

Now we move on to the American Association of University Women, which is closely allied to the teachers unions. The AAUW demands that schools hew tightly to the long-running campaigns to boost the number of girls taking math and science courses and going into STEM careers (a problem that’s been pretty much resolved at the high school level and seeing progress at the college level).

The AAUW sees this as a zero-sum game: shifting the focus to boys means less attention for girls.

There’s nothing wrong with focusing on girls and STEM; those campaigns worked. But why can’t K-12 schools simultaneously focus on what’s holding back boys, their lagging literacy skills in the early grades?

My conclusion from researching Why Boys Fail: Boys got caught up in the riptide created by the well-intended reforms to boost college readiness, which led to ramped-up literacy skills in the early grades, a time when they are less developmentally equipped to absorb those skills.

Boys see girls ace school, especially reading and writing, and conclude that school is for girls. It’s not an illogical conclusion, but all too often it means game over for boys, as the literacy skills demanded, even in math and science classes, only accelerate in the later grades.

What should happen — an all-out push to remedy those deficits, as continues to happen with girls in science and math — doesn’t seem likely to occur, for all the reasons listed above. Teachers, administrators, the teachers unions, the AAUW … they all prefer the status quo.

And that’s why nothing has improved with boys. Nobody really wants it to happen.

Education writer Richard Whitmire is the author of five books about education, including Why Boys Fail.