Pediatrics

Among school-aged children in the United States an estimated one in 50 has been diagnosed with autism spectrum disorder, according to a recent survey (.pdf) from the Centers for Disease Control and Prevention. In addition to raising concerns among researchers and parents about why the number of cases has increased, the findings underscored the need to do more autism research and to provide support and services for families caring for autistic children.

To help parents and others in the local community better understand the growing prevalence of autism and to learn about treatments and research advancements, the Stanford Autism Center at Packard Children’s Hospital will host its sixth annual Autism Spectrum Disorders Update on June 1. The event offers an opportunity for exchange between parents, caregivers and physicians and provides an overview of the center’s clinical services and ongoing autism research at the School of Medicine.

In anticipation of the day-long symposium, we’ve asked Carl Feinstein, MD, director of the center, to respond to your questions about issues related to autism spectrum disorder and to highlight how research is transforming therapies for the condition.

At the Stanford Autism Center, Feinstein works with a multidisciplinary team to develop treatments and strategies for autism spectrum disorders. In providing care and support for individuals with autism and their families, Feinstein and colleagues identify ways of targeting the primary autism symptoms, while also paying attention to associated behavior problems that may hold a child back from school or community involvement or seriously disrupt family life.

Questions can be submitted to Feinstein by either sending a tweet that includes the hashtag #AskSUMed or posting your question in the comments section below. We’ll collect questions until Wednesday (May 15) at 5 PM Pacific Time.

When submitting questions, please abide by the following ground rules:

• Stay on topic
• Be respectful to the person answering your questions
• Be respectful to one another in submitting questions
• Do not monopolize the conversation or post the same question repeatedly
• Kindly ignore disrespectful or off topic comments
• Know that Twitter handles and/or names may be used in the responses

Feinstein will respond to a selection of the questions submitted, but not all of them, in a future entry on Scope.

Finally – and you may have already guessed this – an answer to any question submitted as part of this feature is meant to offer medical information, not medical advice. These answers are not a basis for any action or inaction, and they’re also not meant to replace the evaluation and determination of your doctor, who will address your specific medical needs and can make a diagnosis and give you the appropriate care.

Previously: New public brain-scan database opens autism research frontiers, New autism treatment shows promising results in pilot study, Autism’s effect on family income, Study shows gene mutation in brain cell channel may cause autism-like syndrome, New imaging analysis reveals distinct features of the autistic brain and Research on autism is moving in the right direction
Photo by Wellcome Images

Does it make a difference if a gene – or group of genes – is inherited from your mother or your father?

That’s the question behind the study of genomic imprinting, a phenomenon in which a small percent of genes are thought to be expressed differently depending on which parent they came from. In particular, animal research suggests imprinting may affect aspects of brain development. Researchers wonder if genomic imprinting might explain differences in brain anatomy seen between men and women, such as men’s larger brain volumes.

A new Stanford study, published today in the Journal of Neuroscience, adds to evidence that genomic imprinting is, in fact, happening in humans’ brains. The finding comes from MRI brain scans performed on a group of young girls with Turner syndrome, a chromosomal disorder in which a girl or woman has one missing or malfunctioning X chromosome. Turner syndrome gives an unusual opportunity to study genetic imprinting, because it allows comparisons of individuals who received a single X from Mom to those who got a single X from Dad. (The typical two-X-chromosome female body expresses a mosaic of Mom’s X and Dad’s X, making it impossible to tease apart the effects of the two parents. Males invariably get their single X chromosome from their mothers, so their cells always express the maternal X.)

The Stanford team, led by Allan Reiss, MD, documented several distinctions between the brains of Turner syndrome girls who have only a maternal X, those with only a paternal X, and typical girls with two X chromosomes, such as differences in the thickness and volume of the cortex, and in the surface area of the brain. The work helps clarify murky results from earlier studies of adults with Turner syndrome, the researchers say, because many adult women with Turner syndrome take estrogen supplements, which may have their own effects on brain development. None of the girls in the new study had taken estrogen.

The most tantalizing part of the paper is the scientists’ comment on the implications of their work for our general understanding of genetic imprinting. In part, they say:

By far, the most consistent finding with regard to sex differences in brain anatomy is the larger brain volume found in males compared with females. Although our groups did not differ on most whole-brain measures, our analyses revealed the existence of significant trends on total brain volume, gray matter volume and surface area, where these variables increased linearly from the Xp [paternal X] group being smallest, to the Xm [maternal X] group being largest, with typically developing girls in between. Considering that typically developing males invariably inherit the maternal X chromosome, while typically developing females inherit both and randomly express one of them in each cell, a linear increase in brain volume as seen in the present study is in agreement with what would be expected if imprinted genes located on the X chromosome were involved in brain size determination.

In other words, men may have their mothers to thank for their larger brains.

Karyotype image from a Turner Syndrome patient by S Suttur M, R Mysore S, Krishnamurthy B, B Nallur R - Indian J Hum Genet (2009).

Daily text messages may be an effective option to help children with asthma manage their symptoms and reduce doctor visits, according to recent research from the Georgia Institute of Technology.

In the study (.pdf), pediatric patients with asthma were randomly assigned to three programs: one group received text messages on alternate days, another received text messages daily and a third served as the control and did not receive any text messages. Participants ranged in age from 10 to 17 years old, owned a mobile phone and could read at the fifth grade level. The text messages asked patients questions about their symptoms and provided health information about asthma. Futurity reports:

Over four months, the intervention groups received and responded to SMS messages 87 percent of the time, and the average response time was within 22 minutes. After the study, the research team analyzed patients who had follow-up visits with their physician and found that sending at least one text message a day, whether it was a question about symptoms or about asthma in general, improved clinical outcomes.

“The results indicate that both awareness and knowledge are crucial to individuals engaging in proactive behavior to improve their condition,” [said Rosa Arriaga, PhD, who led the study].

The findings are noteworthy in light of past data showing texting is teenagers’ preferred method of communication, they get an average of 3,339 texts a month, and previous research showing they are amenable to receiving health information via text message.

Previously: CDC explores potential of using smartphones to collect public health data, Promoting healthy decisions among teens via text and Craving a cigarette but trying to quit? A supportive text message might help
Photo by Summer Skyes 11

Past research suggests that poor sleep during adolescence can have “lasting consequences” on the brain. Now a new study offers additional insights into the negative health effects of sleep deprivation on teens’ health.

In the study, researchers analyzed data collected from more than 10,000 adolescents as part of the National Comorbidity Survey Adolescent Supplement. As MedPage Today reports, their findings show that prolonged fatigue is associated with mood and anxiety disorders among teens:

In a nationally representative sample of adolescents ages 13 to 18, 3% reported having extreme fatigue lasting at least 3 months and about half of those who did also had mood or anxiety disorders, according to Kathleen Merikangas, PhD, of the National Institute of Mental Health in Bethesda, Md., and colleagues.

Having both prolonged fatigue and a mood or anxiety disorder was associated with poorer physical and mental health and greater use of healthcare services compared with having only one of the disorders, the researchers reported online in the American Journal of Psychiatry.

“This suggests that the presence of fatigue may be used in clinical practice as an indicator of a more severe depressive or anxiety disorder,” Merikangas and colleagues wrote.

Stanford physician Michelle Primeau, MD, recently explored the topic of how teen sleep habits affect mood in a recent Stanford Center for Sleep Sciences and Medicine blog entry on the Huffington Post. In her post, she explains why teens in particular are at risk of chronic partial sleep deprivation:

Teenagers need to sleep about nine hours, and as they get older, they tend to sleep less. This is not because they need less, but because they are busier with school, jobs, extracurricular activities, and friends. Their biology also will often shift so that they tend to fall asleep later and want to sleep in later, an occurrence that may represent delayed sleep phase syndrome. This may explains why your teenager is so hard to wake up on Saturdays. But this shift to a later bedtime, both of social and biologic causes, in combination with fixed early school times, means that many teenagers are walking around sleep deprived.

Previously: Can sleep help prevent sports injuries in teens?, Study shows link between lack of sleep and obesity in teen boys, Study shows lack of sleep during adolescence may have “lasting consequences” on the brain, Teens and sleep: A Q&A, Sleep deprivation may increase young adults’ risk of mental distress, obesity, Districts pushing back bells for the sake of teens’ sleep and Lack of sleep may be harmful to a teen’s well-being
Photo by lunchtimemama

Third grade is a critical year for learning arithmetic facts, but while math comes easily to some children, others struggle to master the basics.

Now, researchers at Stanford have new insight into what separates adept young math students from those who have difficulty. The difference, described in a paper published today in the Proceedings of the National Academy of Sciences, can’t be detected with traditional intelligence measures such as IQ tests. But it shows up clearly on brain scans, as the new study’s senior author explained in our press release:

“What was really surprising was that intrinsic brain measures can predict change — we can actually predict how much a child is going to learn during eight weeks of math tutoring based on measures of brain structure and connectivity,” said Vinod Menon, PhD, the study’s senior author and a professor of psychiatry and behavioral sciences.

Menon’s research team conducted structural and functional MRI brain scans before third-grade students received 8 weeks of individualized math tutoring. The tutoring followed a well-validated format, combining instruction on math concepts with practice of math problems emphasizing speed. All the children who received math tutoring improved their math performance, but the performance improvements varied a lot — from 8 percent to 198 percent.

A few specific brain characteristics were particularly good at predicting which kids would benefit most from tutoring. In particular, a larger and better-wired hippocampus predicted performance improvements. The brain structures highlighted in the study are implicated in forming memories, and differ from the portions of the brain that adults use when they are learning about math. The fact that these systems are involved helps to explain why the combination of conceptual explanations and sped-up practice that the study’s tutors used is effective, Menon explained:

“Memory resources provided by the hippocampal system create a scaffold for learning math in the developing brain,” Menon said. “Our findings suggest that, while conceptual knowledge about numbers is necessary for math learning, repeated, speeded practice and testing of simple number combinations is also needed to encode facts and encourage children’s reliance on retrieval — the most efficient strategy for answering simple arithmetic problems.” Once kids are able to pull up answers to basic arithmetic problems automatically from memory, their brains can tackle more complex problems.

Next, the researchers plan to examine how brain wiring changes over the course of tutoring. The new findings could also help educators understand the basis for math learning disabilities, and may even provide a foundation for figuring out what kind of instruction could help children overcome these problems.

Previously: New research tracks “math anxiety” in the brain and We’ve got your number: Exact spot in brain where numeral recognition takes place revealed
Photo by Canadian Pacific

A luminescent lab mouse, genetically engineered to produce the same protein that makes fireflies’ tails light up, may accelerate progress in coming up with treatments for muscular dystrophy. This bioengineered mouse also has a genetic defect that, like its counterpart gene defect in people, causes the disease.

The luminescence happens only in damaged muscle tissue, and its intensity is in direct proportion to the amount of damage sustained in that tissue. So each glowing mouse muscle gives researchers an accurate real-time readout of just how much the disease has progressed and where.

It adds up to vastly expedited drug research. Tom Rando, MD, PhD, director of Stanford’s Glenn Laboratories for the Biology of Aging and founding director of Stanford’s Muscular Dystrophy Association Clinic, told me. As I wrote in my release about his new report in the Journal of Clinical Investigation about the Rando lab’s invention:

No truly effective treatments for muscular dystrophy exist. “Drug therapies now available for muscular dystrophy can reduce symptoms a bit, but do nothing to prevent or slow disease progression,” said Rando. Testing a drug’s ability to slow or arrest muscular dystrophy in one of the existing mouse models means sacrificing a few of them every couple of weeks and conducting labor-intensive, time-consuming microscopic and biochemical examinations of muscle-tissue samples taken from them, he said.

With an eye to vastly speeding up drug testing while simultaneously dropping its cost, Rando and his colleagues developed the new experimental strain whose glow (you see it through the skin) gives investigators an instantaneous, accurate reflection of what’s going on inside a mouse’s muscles, well before the degenerative changes could have been observed using standard detection techniques - without any need to kill the mouse in order to get the results.

Trivia point: The word “muscle” comes from the Latin musculus, meaning “little mouse.” More than mere coincidence?

Okay, probably not. But I thought it was worth mentioning.

Previously: Aging research comes of age, Can we reset the aging clock, one cell at a time? and Mouse model of muscular dystrophy points finger at stem cells
Photo by Goldring

Medicaid, the federal health-insurance program for low-income individuals, is set to undergo a big expansion in 2014 as part of the implementation of the Affordable Care Act. That expansion is good news for the children of low-income adults who will be newly eligible for health insurance, according to an opinion piece published online yesterday in JAMA Pediatrics.

Under the current system, Medicaid and SCHIP health insurance cover a much larger proportion of low-income children than adults, with the result that many insured children have uninsured parents. While insuring kids is important, it isn’t always enough, say the authors of the new piece, who are from Indiana University and Boston University.

“Children with uninsured parents are significantly less likely to receive recommended health services, even if they themselves are covered,” they write.

However, because of the U.S. Supreme Court’s 2012 decision on the Affordable Care Act, states get to choose whether or not to expand Medicaid. (The Supreme Court ruled that the ACA’s Medicaid-expansion mandate was coercive.) This is where the story gets really interesting. The piece describes states’ financial concerns about Medicaid expansion - essentially, that it will be expensive to add people to the Medicaid rolls - but then elaborates on some of the financial factors that states turning down Medicaid expansion may not be considering:

…[O]verall, the cost of the Medicaid expansion to states would be less than 1% of their local gross state product. Others have illustrated that, because uncompensated care reimbursements will decrease under the ACA and because some individuals will shift from Medicaid coverage to coverage through the private exchanges, many states might actuallywind up saving money by accepting the expansion. Medicaid can also have a stimulative effect on the economy, leading to increased employment and revenues, and, once again, can increase the potential for overall savings for many states.

Refusing the expansion will also come at a cost to clinicians, offices, and hospitals. Disproportionate hospital share payments will be trimmed by the ACA, reducing a source of income to hospitals. If many citizens are denied Medicaid, then it is likely that they will remain uninsured. Providers that continue to care for them will do so at a significant loss. Although many complain that Medicaid reimbursements are too low, they are still better than nothing. Such a complaint also ignores the fact that reimbursements for primary care services (even those provided by subspecialists) will go up significantly under the ACA, starting this year.

The authors hope that some or all of the states that have announced they will not expand Medicaid will eventually decide the expansion would be beneficial for their low-income citizens, including parents and children, and for their overall financial picture.

Previously: Stanford economist Victor Fuchs: Affordable Care Act “just a start”, Roundtable of doctors discuss Affordable Care Act and Analysis: The Supreme Court upholds the health reform act (really)

My daughters spent their first few days of life in the neonatal intensive care unit, and I won’t soon forget padding down the long hospital hallways, decked out in my flimsy gown and fluffy blue slippers, every two hours to go visit and feed them. As emotional as this time was for me and my husband, I recognize it would have been even more so if I wasn’t able to see my baby - which is why I think a new program at a Los Angeles hospital is so cool. Called BabyTime, the Cedars-Sinai program uses iPads to connect parents with their premature or ill newborns.

readwrite’s Brian S. Hall reported yesterday:

Mothers who are confined to recovery rooms following delivery, typically because of a cesarean section or other complications, often can’t see their newborns in the intensive care unit for 2-3 days. “With BabyTime, the new mother can now see their baby in about 2-3 hours,” Yvonne Kidder, a clinical nurse in the hospital’s Neonatal Intensive Care Unit (NICU), told me:

“BabyTime’s been wonderful. For mothers, to see their baby, this absolutely lessens their anxiety. For the fathers, who can become overwhelmed with all the information they are receiving, BabyTime bridges the gap and allows for a direct line between mother and caregivers.”

Previously: The emotional struggles of parents of preemies

Yesterday evening, Rebecca Rialon Berry, PhD, a child psychologist from Lucile Packard Children’s Hospital, participated in a San Jose Mercury News live chat covering topics such as how to recognize that a child has experienced a traumatic event and how to help teens manage their online presence.

A transcript of the chat is now available on the newspaper’s website. During the chat, Berry discussed the issue of empowering teens to be proactive in preventing, or notifying adults about, harmful online or in-person interactions. Below is her exchange with reporter Katy Murphy:

Murphy: Even if a child isn’t being bullied or bullying others, he or she might see it happening — online or in person. What effect do these harmful interactions have on bystanders, and what do you recommend that teens do if they see harmful images or messages shared?

Berry: Bystanders can have a very helpful role in preventing or stopping cyber bullying. Encourage youth who see online activity that might appear to be cyber bullying to print out the message, post, tweet, or email and share this with an adult … Adults can respond to receiving such messages by validating the teen’s openness to speak up and with encouragement to the teen to continue communicating about online activities that he/she does not feel is productive or healthy.

The full chat is worth taking a moment to read.

Previously: Packard Children’s Hospital psychologist to discuss helping children coping with trauma, Talking to children about school shootings and Talking to little ones about 9/11

As the ongoing investigation into the tragic death of California high-school student Audrie Pott has become national news, many parents are wondering how to help their children and teens cope in equally traumatic situations. In an effort to answer parents’ questions, Rebecca Rialon Berry, PhD, a child psychologist from Lucile Packard Children’s Hospital, will participate in a San Jose Mercury News live chat.

The chat begins today at 5:30 pm Pacific time and will cover topics ranging from how to recognize a child has experienced a traumatic event to how to help manage students’ social networking presence.

Previously: Talking to children about school shootings and Talking to little ones about 9/11
Photo by Troy Benson Photography