Search This Blog

Tuesday, March 28, 2017

How Do Acute and Chronic Stress Impact the Development of Self-Regulation?

From the Frank Porter Graham Child Development Institute

By D. W. Murray and A. Hamoudi
January, 2017


Stress has been linked to long term physical health and numerous indicators of well-being, and there is increasing evidence that stress experienced in childhood and adolescence may lead to physiological changes in the brain and to disruptions in development.

However, much of the data suggesting these connections are based on associations rather than on causal evidence from experiments.

There are also many unanswered questions related to the relationship between stress and self-regulation, particularly with regard to the impact of social adversity during sensitive developmental periods, the variability in stress responsiveness across individuals, and the possibility for reversing negative effects.

Read the full paper here: Office of Planning, Research and Evaluation (PDF; 4 pages).

Citation
  • Murray, D. W., & Hamoudi, A. (2017). How do acute and chronic stress impact the development of self-regulation? (OPRE Report 2016-83). Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services.

Supreme Court Rejects Education Minimum Applied by Gorsuch

From The New York Times

By Richard Perez-Pena
March 22, 2017

Schools may not settle for minimal educational progress by disabled students, the Supreme Court ruled on Wednesday, rejecting a standard that some lower courts have applied, and that the nominee to join the high court, Neil M. Gorsuch, has been criticized for using.

The justices said Wednesday that schools should not be satisfied with
minimal educational progress for students with disabilities.

The federal Individuals With Disabilities Education Act requires “free appropriate public education” for all children. In multiple cases, the federal Court of Appeals for the 10th Circuit, in Denver, has held that the law demands little “more than de minimis” — merely a program intended for a student to show some annual gains.

“It cannot be the case that the Act typically aims for grade-level advancement for children with disabilities who can be educated in the regular classroom, but is satisfied with barely more than de minimis progress for those who cannot,” Chief Justice John G. Roberts Jr. wrote for a unanimous court.

“When all is said and done, a student offered an educational program providing ‘merely more than de minimis’ progress from year to year can hardly be said to have been offered an education at all,” he wrote. “The IDEA demands more. It requires an educational program reasonably calculated to enable a child to make progress appropriate in light of the child’s circumstances.”


In a 2008 ruling, Judge Gorsuch, who sits on the Court of Appeals for the 10th Circuit, applied the “de minimis” standard in rejecting a parents’ claim that a school’s provisions for their autistic child were inadequate.

Since Judge Gorsuch’s nomination to the Supreme Court by President Trump, some Democrats have cited that and other opinions as evidence that the judge hews to an extreme conservative philosophy.

At about the same time that Chief Justice Roberts was announcing the decision on Wednesday, Judge Gorsuch was questioned about the issue in a confirmation hearing before the Senate Judiciary Committee.

In the hearing, the judge noted, as he did in the 2008 ruling, that he had simply adhered to precedent, following a standard the appeals court had set in a 1996 ruling — which, in turn, cited rulings in other courts — and its understanding of a 1982 Supreme Court decision.

The Supreme Court ruling on Wednesday acknowledged that both the federal law, enacted in 1975 and amended a few times since then, and the 1982 ruling interpreting it, are vague about what schools must do. That is by design, the court said, because what is appropriate differs widely from one child to another.

“The de minimis standard was outrageous and really meant that schools could do nothing and get away with it, so of course we’re pleased that the court soundly rejected that,” said Curtis L. Decker, executive director of the National Disability Rights Network. “But we would have preferred a clearer standard. The vagueness puts a burden on the family to try to show that their particular child needs a certain program to succeed.”

Nicole Jorwic, director of rights policy for the Arc, an advocacy organization for people with intellectual disabilities, said a review of Judge Gorsuch’s opinions related to people with disabilities “reveals an exceptionally narrow view of the protections offered by federal disability rights laws.”

She said the Arc supported Wednesday’s Supreme Court ruling, but had not taken an official stance on whether Mr. Gorsuch should be confirmed.

“We would hope that in his future rulings, Judge Gorsuch would see that the purpose of IDEA is to help students with disabilities achieve more meaningful progress that can ultimately lead to their success and full life in their communities,” she said.

The case decided on Wednesday, Endrew F. v. Douglas County School District, concerns an autistic boy in Colorado, whose progress in school had stalled, in part because of his severe behavioral problems.

“Endrew would scream in class, climb over furniture and other students, and occasionally run away from school,” Chief Justice Roberts wrote. “He was afflicted by severe fears of commonplace things like flies, spills, and public restrooms.”

According to the parents, he needed a drastically different approach in school, but the district offered more of what was not working. So they put him in a private school specializing in educating autistic children, where his behavior and academic performance improved markedly.

The parents demanded reimbursement from the district for the cost of private school, arguing that the public schools had failed to meet the federal mandate. The Supreme Court did not directly address the question of reimbursement, but sent the case back to the lower courts for consideration.

Monday, March 27, 2017

Excess Brain Fluid May Forecast Autism in Babies

From Spectrum News

BY Nicholette Zeliadt
March 6, 2017

Some infants who are later diagnosed with autism have too much fluid between the brain and skull, according to a study published today in Biological Psychiatry (1). The extent of the fluid accumulation at 6 months of age can predict whether a child will be diagnosed with autism at age 2.

Blank space: An infant with autism (right) has more fluid between the brain
and the skull than does a typically developing baby at the same age (left).

The findings point to a possible biomarker that could help doctors detect autism early.

The study “identifies a potential subgroup of autistic individuals with a common biological marker,” says lead investigator Joseph Piven, Thomas E. Castelloe Distinguished Professor of Psychiatry at the University of North Carolina at Chapel Hill.

Clinicians typically diagnose children with autism around age 4, after observing difficulties in social interactions, along with restricted interests and repetitive behaviors. But signs of autism are likely to be present in the brain much earlier.


In support of this idea, a 2013 study of 55 children in California suggested that 6-month-old infants later diagnosed with autism tend to have excess fluid surrounding the brain. This cerebrospinal fluid (CSF) transports compounds involved in brain growth and, as it circulates, removes waste that could otherwise alter brain development.

The study focused on ‘baby sibs’ — infant siblings of children with autism. Baby sibs are roughly 20 times more likely to have autism than are children in the general population.

In the new study, Piven’s team confirmed the 2013 result using brain scans from more than 300 children at four sites.

“There are virtually no early markers of autism that have been independently validated or replicated in two different studies like this,” says David Amaral, director of research at the University of California, Davis MIND Institute, who led the 2013 study.

Clinicians will need more evidence before they use fluid accumulation to diagnose or screen for autism, however. For one thing, it is unclear whether the excess fluid appears in children with autism who have no family history of the condition. What’s more, only some children with autism show this tendency.

Still, the fluid might be one part of an arsenal of biomarkers for the condition. “A study like this is a critical step in moving the field forward and to ultimately be able to come up with reliable biological methods for diagnosing autism,” says Geraldine Dawson, director of the Duke Center for Autism and Brain Development at Duke University in Durham, North Carolina, who was not involved in the work.


Fluid Finding

Following the 2013 study, Amaral looked for a large group of children with a family history of autism. He collaborated with Piven and other researchers conducting the Infant Brain Imaging Study (IBIS), which has magnetic resonance imaging (MRI) brain scans and other data from hundreds of children, starting in infancy.

Piven’s team looked at 221 baby sibs and 122 children who have no family history of autism or related conditions. The children all had brain scans at 6 months of age; more than half in each group also had scans at 1 and 2 years old. At all three time points, the researchers assessed the children’s motor, language and visual skills.

The IBIS study had tested all the children for autism at age 2 and diagnosed 47 baby sibs with the condition. Clinicians also diagnosed three children from the control group with autism, but then excluded them from the analyses.

The researchers developed an automated method to quantify CSF. They trained a computer to recognize the space between the brain and the skull, and tested the program on scans from the 2013 study. This method yielded results highly similar to those from the 2013 study.

Babies later diagnosed with autism had about 18 percent more fluid outside the brain at 6 months than those without autism, after controlling for brain size, age, sex and clinical site. The excess fluid remained evident at 1 and 2 years of age.

“It’s not easy to do a longitudinal study in children and collect hundreds of images,” says Andrew Michael, director of the Neuroimaging Analytics Laboratory at the Autism & Developmental Medicine Institute in Lewisburg, Pennsylvania. Michael was not involved in the new work, but led a study last year that found excess CSF in people with autism ranging in age from 7 to 64 years (2).

Predictive Program

Piven’s team entered the 6-month fluid measures from the baby sibs into a machine-learning algorithm to predict which infants would later be diagnosed with autism.

The algorithm honed its own predictive abilities by analyzing data from all but nine of the baby sibs to predict the diagnosis of the remaining infants, and repeating the process 25 times. Ultimately, the computer forecast autism with 69 percent accuracy.

The researchers then applied the algorithm to the 33 baby sibs from the 2013 study. They correctly identified autism for 80 percent of the baby sibs with autism, but incorrectly flagged 33 percent.

The team then looked for features that set apart the subset of children with autism who have excess CSF. They split the group in half based on the severity of autism features. The half with more severe features have significantly more fluid at all ages than the other children in the study. The researchers also found that too much fluid at 6 months tracks with poor motor skills.

Problems with fluid circulation could underlie the fluid accumulation and, with it, a buildup of molecules that alter brain development, Amaral says. But his findings don’t reveal whether the fluid contributes to autism or is a consequence of the condition.

Either way, he says, doctors should not view excess fluid around the brain as benign. “It really may be an indication of increased risk for a neurodevelopmental disorder,” he says.

Amaral says he would like to determine whether excess CSF is specific to autism, or might also signal increased risk for other conditions.

References
  1. Shen M.D. et al. Biol. Psychiatry Epub ahead of print (2017) Abstract
  2. Katuwal G.J. et al. Front. Neurosci. 10, 439 (2016) PubMed

Do Healthy Lunches Improve Student Test Scores?

From The Atlantic

By Melinda D. Anderson
March 22, 2017

A new study identifies a link between food quality and achievement.


For more than a decade, standardized-test scores have been the dominant metric for measuring what public-school students know and are able to do. No Child Left Behind, the sweeping federal education law enacted in 2002, ushered in a new era of student testing and school compliance.

And, in the years that followed—to meet targets and avoid sanctions—education leaders at the local and state levels have sought a variety of ways to boost students’ performance on tests, including extending the school day and giving bonus pay to teachers based on students’ test scores.

Even less conventional methods, such as banning cell phones and offering yoga-like exercises, emerged as school administrators pursued the holy grail of high standardized-test scores.

But according to a new study, there’s one option that may have been overlooked: the ubiquitous school lunch. As detailed in a recent paper, economists set out to determine whether healthier school lunches affect student achievement as measured by test scores.

The intense policy interest in improving the nutritional content of public-school meals—in addition to vendors’ efforts to market their school meals as good for the body and the mind—sparked the researchers’ curiosity and led to an unexpected discovery: Students at schools that contract with a healthier school-lunch vendor perform somewhat better on state tests—and this option appears highly cost-effective compared to policy interventions that typically are more expensive, like class-size reduction.

“When school boards are going out and contracting with these vendors, what they're thinking is that they're going to improve the health of the students, that they'll get them to eat healthier. I don't think they're thinking of it as a tool to actually improve academic performance [but] we found that it is,” said Michael L. Anderson, an associate professor of economics at the University of California, Berkeley, and one of the study's co-authors.

“Something that is basically cheap, that is going to improve student health, and that has test-score gains seems like it would be very attractive [to] policymakers.”

According to Anderson, who spoke as school meals received renewed attention due to President Trump’s proposed budget, this is the first large-scale study to examine how the overall nutritional quality of school meals affects student test-score achievement. In 2010, as part of a push to combat childhood obesity, theHealthy, Hunger-Free Kids Act was passed, resulting in more rigorous nutrition standards for school cafeterias. There is a body of recent literature that suggested a link between school meals and student test scores, but that research focused on improving access rather than the meals’ nutritional value.


To determine the link between food quality and student achievement, Anderson and his colleagues collected data from the California Department of Education on school districts’ meal vendors for the academic years from 2008-09 to 2012-13. Over that five-year period, 1,192 schools—about 12 percent of California public schools, including public charter schools—contracted for at least one school year with an outside company to provide lunch.

The team then hired the Nutrition Policy Institute, a research unit housed at the University of California, to score the nutritional content of vendors’ school lunches. Armed with sample school-lunch menus, NPI calculated the Healthy Eating Index (HEI), a U.S. Department of Agriculture measure of dietary quality for food items, for all of those companies’ meals. The average HEI score among all vendors with menu information was tabulated, and vendors with above-median scores were classified as healthy school-lunch providers.

But there was still one crucial piece of information missing: how students at schools with healthy vendors stacked up against their peers at non-vendor schools on state tests.

In pursuit of that answer, the study’s authors compiled a database covering the same five-year timespan with school-by-grade-level test results on California’s Standardized Testing and Reporting exam, a statewide test given at the time to all public-school students in grades 2 through 11.

Test score data from some 9,700 elementary, middle, and high schools found that contracting with a healthy meal vendor correlated with increased student performance by between .03 and .04 standard deviations—a statistically significant improvement for economically disadvantaged and non-disadvantaged students, Anderson said, adding that the size of the effect “is not huge … but it is notable.”

What’s more, he said, districts are almost getting these improvements free of charge. After tabulating the average price per meal in the vendor contracts—and estimating the cost of in-house school meals based on National School Lunch Program reimbursements—the study found that it cost about $222 per student per year to switch from in-house school-lunch preparation to a healthier lunch vendor that correlated with a rise of 0.1 standard deviations in the student’s test score.

To put that statistic into perspective, healthier meals could raise student achievement by about 4 percentile points on average.

In comparison, it cost $1,368 per year to raise a student’s test score by 0.1 standard deviations in the Tennessee STAR experiment, a project that studied the effects of class-size on student achievement in elementary school. The paper notes that established research in the field supports the need for “lower-cost policies with modest effects on student test scores [that] may generate a better return than costly policies with larger absolute effects.”

Sean Patrick Corcoran, an associate professor of economics and education policy at New York University’s Steinhardt School of Culture, Education, and Human Development, said the study underscores the positive impact of schools serving healthier meals, and he seconded the authors’ conclusions regarding cost-effectiveness. “I've seen a number of other rigorous studies that also find a connection between healthy eating and academic performance,” he said.

“Students who eat regular, healthy meals are less likely to be tired, are more attentive in class, and retain more information.” And he said some effects are almost immediate: “Even when schools serve calorie-rich food on test day, students perform better on tests.”

In Oakland, California, Kweko Power, 15, a sophomore at Oakland High School, agreed that there’s an academic benefit to healthier meals—citing classmates who skip school lunch because it’s unhealthy and unappealing—but she believes the benefits extend beyond test scores.

“When students eat healthier and better food, they get more stamina because their body doesn't have to work as hard to process what they’re eating,” she said. “When you eat and feel good, you [are] happier … and feel less cranky. While I am usually upbeat around people, I can't be myself without good food.”

“Without good food, students are just stressed at school, and then still stress about being expected to perform well.”

For children living in areas of concentrated poverty like Oakland, good food like fruits, vegetables, and whole grains can be hard to come by. A secondary finding in the study was that contracting with a healthy lunch provider showed no evidence of reducing student obesity. And Power’s personal experience helps explain why.

“In my neighborhood, we have a Lucky's [grocery store] nearby but it's expensive … it's cheaper to go to the three liquor stores that are within five blocks of that Lucky's,” she said. “When there are liquor stores that sell cheaper and unhealthier food, families tend to opt for cheaper food; they have no other choice. In areas where youth don't have access to healthier food options, you'll tend to see more obesity.”

Power, a student leader with Californians for Justice, emphasized that test scores aside, access to healthier food is fundamentally an issue of equity and civil rights. “It's also important to look at stress levels and what contributes to stress for students,” Power explained. She said hunger and lack of proper nutrition are everyday worries for low-income students.

“Without good food, students are just stressed at school, and then still stress about being expected to perform well. Having healthy school meals is really related to how the school system is serving students that don't have [much access and availability] to resources.”

Sunday, March 26, 2017

The ADHD Controversy

From Science-Based Medicine

By Steven Novella
March 1, 2017

ADHD was already a controversial diagnosis; are Jerome Kagan’s recent criticisms of it warranted?


Is attention deficit hyperactivity disorder (ADHD) a legitimate diagnosis or is it mostly a fraud?

The answer has important implications for many individuals and for society. The diagnosis is accepted as legitimate by the psychiatric profession, but continues to have its vehement critics. Recently, noted psychologist Jerome Kagan has been giving tremendous weight to these criticisms by calling ADHD mostly a fraud. There are significant problems with his criticism, however.

What is ADHD?

ADHD was first described in children in 1902, and was understood as an impulse control disorder. It was not formally recognized as a diagnosis, however, until the second edition of the DSM in 1968. The first approved drug used to treat ADHD was benzedrine in 1936. Ritalin, still used to treat the disorder, was approved in 1955.

Here is the official DSM diagnosis:
  • A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development
  • Six or more of the symptoms have persisted for at least six months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities. Please note: The symptoms are not solely a manifestation of oppositional behaviour, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), five or more symptoms are required
  • Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years
  • Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g. at home, school, or work; with friends or relatives; in other activities)
  • There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic or occupational functioning
  • The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g. mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal)


There are a few aspects of this diagnosis worth pointing out.

First, this is what we call a clinical diagnosis, it is based entirely on signs and symptoms without any objective diagnostic tests. You cannot see ADHD on an MRI scan of the brain, an EEG, or a blood test. This is not unusual in medicine, especially for brain disorders. The same is true, for example, of migraine headaches. It is entirely a clinical diagnosis.

This, by itself, should not call the diagnosis into question. Brain function relies not only on the health of the cells and the absence of identifiable anatomical or gross pathology. It also depends on the pattern of connections among brain cells, the density of their connections, and the details of their biochemistry. We are just starting to be able to image the brain at this level.

As an example, raise someone in a closet for 20 years and I guarantee you they will have a psychological disorder, but you would not be able to tell that from looking at their brain with any tool we currently have.

Because mood, thought, and behavior largely rely on brain function that cannot be imaged, psychiatrists have relied on elaborate schemes of clinical diagnoses to at least have a common language for thinking and talking about mental illness. It is imperfect, and extremely fuzzy around the edges, but it has its utility.

That fuzziness is partly based in the limits of our current technology and understanding. But it is also based in the fact that humans are neurologically heterogeneous and the fact that the brain is an extremely complex system. This means that the same end result (behavior, for example) might result from almost endless permutations of interactions among various systems in the brain and their interaction with the environment.

You can see this in the formal description of ADHD above. There is a sincere attempt to capture a real neurological phenomenon, and to filter out other factors that might contribute to or cause similar symptoms. Signs used to establish the diagnosis cannot be temporary, or isolated to only one environment, or related to other conditions or situations that might provoke them. You need to have many symptoms persistent over a long time without other identifiable causes and to a sufficient degree that they cause demonstrable harm.

There is also an attempt to separate out those who have a real disorder from the typical spectrum of human behavior. This is also a common problem in medicine. Many disorders, like high blood pressure, do not have a sharp demarcation line.

The curves for normal blood pressure and hypertension overlap. Experts have to decide where to draw the line, either capturing more people with the disorder but also more people just at the upper range of normal, vs excluding those who are just at the upper range of normal but also then missing more people with the disorder.

Eventually such clinical questions evolve from, “Who has the disorder” to “Who benefits from treatment for the disorder.” That is the real question.

Neuroanatomical Correlates

Despite the fact that ADHD is a fuzzy clinical entity, we have made progress in understanding what is happening in the brain of most people with ADHD. The current consensus is that ADHD is a deficit of executive functions. The frontal lobes carry out many critical functions, some considered executive functions: they include being able to focus your attention, maintain focus, switch among tasks, filter out distractions, and impulse control.

Executive function includes the ability to weigh the probable outcomes of your behavior and then make high-level decisions about how you will behave.

As an adult neurologist I see patients with executive function disorder frequently, usually from head trauma. Car accidents in particular result in frontal lobe damage as it is common to hit your head against the windshield during many types of accidents.

Patients frequently develop the symptoms of ADHD after frontal head trauma. They have poor focus, and poor impulse control. In one dramatic case a patient’s entire personality changed. She lost all ability to control or moderate her behavior (as have others). Often these patients respond favorably to the same stimulants we use to treat ADHD.

When we look at the brains of those who meet the clinical diagnosis of ADHD with our modern imaging techniques, such as fMRI and EEG, we find a similar pattern of brain dysfunction:

"Convergent data from neuroimaging, neuropsychology, genetics and neurochemical studies consistently point to the involvement of the frontostriatal network as a likely contributor to the pathophysiology of ADHD. This network involves the lateral prefrontal cortex, the dorsal anterior cingulate cortex, the caudate nucleus and putamen. Moreover, a growing literature demonstrates abnormalities affecting other cortical regions and the cerebellum."

At this point there is no reasonable disagreement about the fact that ADHD is a disorder of brain function. Children who meet the strict diagnostic criteria are demonstrably different, in consistent and predictable ways, than children who do not (controlling for other possible factors). They have impaired executive functions, and we can see this in changes to the relevant parts of the brain.

We still have a lot to learn (again, the brain is complex) but a consistent picture is emerging.

Jerome Kagan’s Criticism

Jerome Kagan is a preeminent psychologist. This gives his opinions about a psychological topic a great deal of weight. The press loves him because he has a sensational story to tell and he has impeccable credential. Articles about Kagan often spend an entire paragraph or two touting those credentials.

Unfortunately this is a common mistake that mainstream journalists make when discussing scientific topics. They confuse the expertise of an individual with scientific authority. No individual ever represents the consensus of scientific opinion, they can only represent their own quirky opinions (which may or may not be in line with the consensus).

This is a classic example of this error. Kagan’s opinions do not conform to the current consensus of scientific opinion, but he is presented as an unimpeachable authority. Further, all reporting that I have seen on Kagan’s opinions regarding ADHD fail to put his expertise into a reasonable context. Kagan is a psychologist. He is not a psychiatrist, nor a neuroscientist.

Often related fields covering the same question have different opinions. Geologists and paleontologists disagree about the relative contribution of a meteor impact to the extinction of the dinosaurs at the K-Pg boundary. If a reporter talked only to a geologist they would not capture the true state of the broader scientific opinion.

Many psychologists have opinions about psychiatry that do not reflect the consensus of psychiatric opinion. In essence, even though Kagan has relevant expertise, he is not a clinician, and therefore is an outsider when it comes to the practice of psychiatry. He also does not seem to be up to date on the neuroscience of ADHD.

Yet his recent interview with Spiegel is being widely reports as definitive criticism of the diagnosis and treatment of ADHD. Here are some of the highlights. He says:

"Let’s go back 50 years. We have a 7-year-old child who is bored in school and disrupts classes. Back then, he was called lazy. Today, he is said to suffer from ADHD (Attention Deficit Hyperactivity Disorder). That’s why the numbers have soared."

We are familiar with a similar criticism of autism diagnoses. Yes, diagnostic practices have changed. Awareness of the diagnosis has changed. The implication here is that the 1950s diagnosis (a bored child) was better than the current diagnosis of ADHD.

But, if you recall the diagnostic criteria from above, displaying ADHD behavior in school alone is not sufficient to establish the diagnosis. So, Kagan’s example is simply wrong. The child in his example should not be diagnosed with ADHD.

Being generous, he may be implying only that doctors are overdiagnosing ADHD and not following their own diagnostic criteria. This is a real issue, but here is a far more nuanced discussion from an actual clinician:

"ADHD is real—it’s not made up. But it exists on a continuum. There’s no marker or white line that says you’re in the “definite” or “highly likely” group. There’s almost unanimous agreement that five or six percent clearly have enough of these symptoms for an ADHD diagnosis. Then there’s the next group, where the diagnosis is more of a judgment call, and for these kids, behavioral therapy might work. And then there’s a third group, on the borderline. These are the ones we’re worried about being pushed into an inaccurate diagnosis."

The real issue is – are schools pushing for more kids in the gray zone to be diagnosed because of funding and regulation issues? Also, there is a real “demarcation problem” with the diagnosis, and we have to carefully consider the risks and benefits of using looser or tighter criteria. These discussions are happening within the profession, and are very evidence-based and nuanced.

Kagan’s criticism, by comparison, is shooting from the hip and simplistic. (I will add the caveat that the interview may not reflect the full depth of his opinion, but he is responsible for how he communicates to the public, especially given how widely his opinions have been spread.)

He continues:

SPIEGEL: Experts speak of 5.4 million American children who display the symptoms typical of ADHD. Are you saying that this mental disorder is just an invention?

Kagan: That’s correct; it is an invention. Every child who’s not doing well in school is sent to see a pediatrician, and the pediatrician says: “It’s ADHD; here’s Ritalin.” In fact, 90 percent of these 5.4 million kids don’t have an abnormal dopamine metabolism. The problem is, if a drug is available to doctors, they’ll make the corresponding diagnosis.

That characterization, while you might dismiss it as hyperbole, is irresponsible. “Every” child? Again, this does not meet the official diagnostic criteria for ADHD which requires more than just not doing well in school. His reference to “dopamine metabolism” is just weird.

It is true that some studies show some children with ADHD have impaired reward system function. This may be playing a role in some subtypes of ADHD. It is not a core feature of ADHD, however, and the evidence is still very preliminary.

Invoking what is essentially a preliminary side point about the neuroanatomical correlates of ADHD as reason to doubt the diagnosis is, to be kind, highly problematic.

Kagan then broadens his criticism to encompass psychiatry in general:

"We could get philosophical and ask ourselves: “What does mental illness mean?” If you do interviews with children and adolescents aged 12 to 19, then 40 percent can be categorized as anxious or depressed. But if you take a closer look and ask how many of them are seriously impaired by this, the number shrinks to 8 percent.

Describing every child who is depressed or anxious as being mentally ill is ridiculous. Adolescents are anxious, that’s normal. They don’t know what college to go to. Their boyfriend or girlfriend just stood them up. Being sad or anxious is just as much a part of life as anger or sexual frustration."

This is a typical anti-mental illness statement. This is simply a straw man of what psychiatry does.

He is saying that we should not confuse the normal range of behavior with a disorder, as if this is a huge insight. This understanding has already been incorporated into clinical thinking. As I pointed out above – there are great pains taken when defining mental disorders to separate true disorders from the healthy range of human behavior.

Further, being “seriously impaired” is already part of the diagnosis, so what is he talking about?

He goes on to argue that some people are depressed in response to a life event. Right – psychiatrists call this a “reactive depression” because it is already recognized, and not confused with a chronic depression. That is why the diagnosis of clinical depression excludes depression that follows a major trigger, and must continue for greater than six months to be considered a disorder.

From reading the entire interview I am left wondering, exactly what Kagan is criticizing? He is certainly not criticizing the standard of care within psychiatry. He seems to be tilting at a straw man of the worst possible malpractice that deviates from that standard. He is raising issues as if these are not already part of a vigorous evidence-based discussion within psychiatry itself.

A Kernel of Truth

We often take a sharply critical approach to medical science here at SBM. Self-criticism is critical to improvement. That is the essence of science itself, it is designed for error correction through self-criticism.

Our nuanced position is that science basically works, but there is a lot of room for improvement. Enemies of science, however, or those with a specific ideological axe to grind, use the same evidence to argue that the institution of science is fatally flawed and can be comfortably dismissed or ignored.

I find the same is true of much of the public criticism of psychiatry. There is a lot to criticize in the profession (as in medicine in general), and a lot of room for improvement. Some of that is just the current status of the science. We don’t know everything, and yet medicine (including psychiatry) is an applied science. We have to make important decisions with limited information.

There are also many issues of quality control. Medicine is hard, and keeping quality standards high is challenging.

So there are many legitimate criticisms of ADHD and psychiatry, but that does not mean ADHD is a fraud. The scientific evidence, both clinical and neuroscience, is robust. Kagan’s criticisms are mostly greatly exaggerated, or they are straw men because they are already incorporated into the standard of care.

Unfortunately, you will not be exposed to any of that from reading any of the popular press breathlessly reporting that ADHD is a fraud.

...................................................................

Founder and currently Executive Editor of Science-Based Medicine, Steven Novella, M.D. is an academic clinical neurologist at the Yale University School of Medicine. He is also the president and co-founder of the New England Skeptical Society, the host and producer of the popular weekly science podcast, The Skeptics’ Guide to the Universe, and the author of the NeuroLogicaBlog, a daily blog that covers news and issues in neuroscience, but also general science, scientific skepticism, philosophy of science, critical thinking, and the intersection of science with the media and society. Dr. Novella also contributes every Sunday to The Rogues Gallery, the official blog of the SGU.

Autism May Be Detectable in Blood

From DisabilityScoop

By Shaun Heasley
March 16, 2017

Scientists say they can predict with near perfect accuracy whether or not a child has autism from a blood sample.

New research suggests that blood samples could one day be
used to identify whether or not a child has autism.

Using an algorithm to assess metabolites in blood, researchers were able to identify samples that came from kids with autism in 97.6 percent of cases.

The findings published Thursday in the journal PLOS Computational Biology open the door to a possible biomarker for autism.


“The method presented in this work is the only one of its kind that can classify an individual as being on the autism spectrum or as being neurotypical,” said Juergen Hahn of the Rensselaer Polytechnic Institute in Troy, N.Y., lead author of the study.

“We are not aware of any other method, using any type of biomarker that can do this, much less with the degree of accuracy that we see in our work.”

The study involved blood samples collected from 83 children with autism and 76 neurotypical children ages 3 to 10 at Arkansas Children’s Hospital. Rather than examining one particular gene or a single biomarker, researchers used big data techniques to take a broader look in order to find statistically significant patterns.

In kids with autism, substances produced by what are known as folate-dependent one-carbon metabolism and transulfuration pathways were altered, according to the findings.

“Instead of looking at individual metabolites, we investigated patterns of several metabolites and found significant differences between metabolites of children with ASD and those that are neurotypical. These differences allow us to categorize whether an individual is on the autism spectrum,” Hahn said.


“By measuring 24 metabolites from a blood sample, this algorithm can tell whether or not an individual is on the autism spectrum, and even to some degree where on the spectrum they land.”

Hahn said that he’s looking to replicate the results, but indicated the findings could point to new ways to diagnose autism or potential treatments for the developmental disorder.

Saturday, March 25, 2017

Unanimous Supreme Court Expands Scope of Special Education Rights

From the Education Week Blog
"School Law"


By Mark Walsh
March 22, 2017

The U.S. Supreme Court on Wednesday issued a major decision expanding the scope of students' special education rights, ruling unanimously that schools must do more than provide a "merely more than de minimis" education program to a student with a disability.

In Endrew F. v. Douglas County School District, the high court rejected the "merely more than de minimis" standard set by the U.S. Court of Appeals for the 10th Circuit, in Denver. That language was also used in an opinion in another special education case by Judge Neil M. Gorsuch, President Donald Trump's nominee for the Supreme Court.

Gorsuch has already faced criticism for his own ruling reflecting the "merely more than de minimis" standard, and he was questioned by the Senate Judiciary Committee about the Supreme Court's ruling before the morning ended.

Chief Justice John G. Roberts Jr. wrote the opinion for the eight-member court, and he delivered much of it from the bench Wednesday morning.

"When all is said and done, a student offered an educational program providing 'merely more than de minimis' progress from year to year can hardly be said to have been offered an education at all," Roberts said.

"For children with disabilities, receiving instruction that aims so low would be tantamount to 'sitting idly ... awaiting the time when they were old enough to drop out,'" he added, quoting from key 1982 Supreme Court precedent on special education, Board of Education of the Hendrick Hudson Central School District v. Rowley, that also dealt with the Individuals with Disabilities Education Act.

"The IDEA demands more," the chief justice said. "It requires an educational program reasonably calculated to enable a child to make progress appropriate in light of the child's circumstances."

Higher Standard

That standard was the one suggested by President Barack Obama's administration, in one of its final arguments before the justices in January.

The decision comes in the case of a Colorado student named Endrew F. whose autism led to behavioral issues in school. After four years in the Douglas County schools, near Denver, the boy's parents believed his academic and functional progress had stalled.


Endrew F.'s individualized education programs largely carried over the same educational goals and objectives from one year to the next, Roberts observed, "indicating he was failing to make meaningful progress toward his aims."

The parents pulled the boy from public school amid a dispute over his 5th grade IEP and enrolled him a private school specializing in autism, the Firefly Autism House.

"Firefly ... added heft to Endrew's academic goals," the chief justice said. "Within months, Endrew's behavior improved significantly, permitting him to make a degree of academic progress that had eluded him in public school."

Under established precedents, the family sought reimbursement from the Douglas County district for the private school tuition. They lost before a state administrative law judge, a federal district court, and the 10th Circuit.

The appeals court said that the Supreme Court's Rowley decision merely requires an IEP to provide "some educational benefit."

The appellate court said it was relying on 10th Circuit precedent that interpreted that passage ofRowley to mean that a child's IEP is adequate as long as it is calculated to confer an "educational benefit that is merely more than de minimis."

The appeals court then cited to the opinion by Gorsuch in a 2008 decision, Thompson R2-J School District v. Luke P. In his opinion in that case, Gorsuch had cited to an even earlier 10th Circuit case for the "more than de minimis" language, but he added the word "merely," and that formulation was debated by the justices during oral arguments in Endrew F.

'A General Formula'

The chief justice discussed the Rowley decision and said its reference to IEPs conferring "some educational benefit" and other language "in isolation do support the school district's argument."

"But the district makes too much of them," Roberts said. "We cannot accept the school district's reading of Rowley."

Roberts said the "reasonably calculated" standard will not require an "ideal" IEP, but one that "must aim to enable the child to make progress."

And "that the progress contemplated by the IEP must be appropriate in light of the child's circumstances should come as no surprise," he said. "A focus on the particular child is at the core of the IDEA."

He said for children in special education who are in a regular classroom, an IEP should be reasonably calculated "to enable the child to achieve passing marks and advance from grade to grade."

For a child for whom a regular classroom is not "a reasonable prospect," the chief justice said, the educational program must be "appropriately ambitious in light of his circumstances."

"Of course this describes a general standard, not a formula," Roberts said. "But whatever else can be said about it, this standard is markedly more demanding than the 'merely more than de minimis' test applied by the 10th Circuit."

Grilling Gorsuch

It didn't take long for Democrats on the Judiciary Committee to raise the Endrew F. decision with Gorsuch. Sen. Richard Durbin of Illinois quoted from the chief justice's opinion and called it "a powerful decision."

He asked Gorsuch why, in his opinion in Thompson, he wanted to "lower the bar" to the "merely more than de minimis standard."

Gorsuch said he had been handed the Endrew F. ruling "as I went to the bathroom a moment ago."

He said his ruling in Thompson, which also had involved a student with autism, was based on 10th Circuit precedent, particularly a 1996 decision, Urban v. Jefferson County School District.

"If anyone suggests I like an outcome where an autistic child happens to lose, that is a heartbraking outcome to me," Gorsuch said. "But the fact remains that I was bound by circuit precedent."

Durbin pressed him on his addition of the word "merely," in his Thompson opinion, to the "more than de minimis language" from that earlier 10th Circuit ruling, in Urban.

"Most people reading that would say you pushed the 'de minimis' [standard] further down, and so it was that word that was overruled by the Supreme Court," Durbin said.

Gorsuch replied that the three-judge panel ruling in Thompson was unanimous, and that one member of the panel was appointed by a Democratic president. And again, Gorsuch said, the panel was following circuit precedent.


Later, Sen. Ted Cruz, R-Texas, addressed the issue with friendly questions to Gorsuch about whether he felt bound by 10th Circuit precedent in the Thompson case.

"My colleagues have repeatedly demanded that Judge Gorsuch follow precedent," Cruz said. "This is another example of Judge Gorsuch doing exactly that—following precedent."

He asked the nominee whether he would be bound to follow a Supreme Court decision that upset an appeals court precedent.

"Yes, Senator." Gorsuch said. "That's how it works."