The parents of your 4-year-old patient with Autism level 2 with verbal impairment comes in to ask about leucovorin and whether it will help their child speak.

Leucovorin, also known as folinic acid, is the active form of folate (vitamin B9). It is used in cancers that require specific types of chemotherapies and in certain genetic disorders that cause folate deficiency in the brain. Interest in its use in autism began when researchers found that some children with autism have autoantibodies against the folate receptor alpha (FRAAs), which can block folate transport into the central nervous system. This can lead to low cerebrospinal fluid (CSF) folate despite normal serum levels- a condition known as cerebral folate deficiency (CFD). CFD has been linked to neurological symptoms including irritability, movement abnormalities, and language impairment, which overlaps with symptoms seen in some individuals with autism.

The most commonly cited study is a randomized, double-blind, placebo-controlled study by Frye et al. (2018), which involved 48 children with autism and language impairment. Children who were FRAA positive and received leucovorin calcium at 2 mg/kg/day (max 50 mg/day) showed improvements in verbal communication over 12 weeks compared to placebo.

However, there are important caveats:

·        Only children who were FRAA-positive showed significant improvement.

·        FRAA testing is not easily accessible in clinical practice.

·        The study was small, focused on males, and short-term. There has been no replication in large-scale trials and long-term safety remains unclear.

Leucovorin is not FDA-approved for the treatment of autism or language delay. There is ongoing discussion about its use in CFD, which can co-occur with autism but is not the same condition. There is currently no strong evidence that leucovorin can treat symptoms of autism. At this time, we do not recommend leucovorin as a universal treatment for autism. The AAP released an interim guidance: “At this time, the American Academy of Pediatrics (AAP) does not recommend the routine use of leucovorin (folinic acid) for autistic children.” The foundation of care remains behavioral and developmental therapies including ABA, speech therapy, and occupational therapy, which have demonstrated effectiveness and minimal risk.

We also do not recommend routine folate receptor autoantibody testing; this test is not validated, reliable, or covered by insurance. Additionally, we do not recommend testing for cerebral folate deficiency unless a child displays the symptoms typical for this disorder. Testing for cerebral folate deficiency is invasive, consisting of a lumbar puncture.

If your patients or their caregivers ask about leucovorin, a risk-benefit discussion may be helpful. One option could be enrolling in a research study. Otherwise, the cost of the medication would not be covered by insurance and would have to be paid out of pocket by families. Here are some points to consider in such discussions:

Potential Benefits: 

·        Some evidence of improved verbal communication only in FRAA-positive autism.

·        Generally tolerated in short-term use.

Potential Risks:

·        Long-term safety and effectiveness are not well studied.

·        May cause hyperactivity or irritability, which may require discontinuation.

·        No large trials to support use in the general autistic population.

·        No guidelines on starting doses or titration schedules.

If You Decide to Prescribe After Shared Decision-Making

·        Start low, go slow.

·        Some studies have used 0.5–2 mg/kg/day (max 50 mg/day).

·        Monitor closely for side effects and discontinue if symptoms worsen.

Back to our Case Presentation:

Prior to considering leucovorin, it will be important to review therapies and supports already in place, including autism intervention, speech therapy, and school-based services. It would also be important to review parents’ expectations about their child’s ability to communicate verbally and ensure their child has access to Augmentative and Alternative Communication devices.

Please call the SmartCare Behavioral Health Consultation Services at 858-880-6405 if you have a specific case you would like to discuss.

With Contributions by Dr. Hohui Eileen Wang (UCSF) and Dr. Will Connor (RCHSD)

References:

INSAR Public Statement – International Society for Autism Research

https://myemail.constantcontact.com/Cal-MAP-Clinical-Pearl–Leucovorin-and-Autism—Know-the-facts.html?soid=1136358974476&aid=fOmagiWxNiM

https://www.aap.org/en/patient-care/autism/use-of-leucovorin-in-autistic-pediatric-patients/?srsltid=AfmBOoqsvlDZJN1WxYZe7mrSlN-5YWGiD5-EcA_RKS27uTMZA3Sc3w-V

https://www.aap.org/en/pages/podcast/interim-guidance-on-leucovorin-25th-anniversary-of-pedialnk/?utm_source=MagnetMail&utm_medium=email&utm_term=MKG%5FPodcast%20Promotion&utm_campaign=POD%2DEpisodes%20269%2D270

AUTHOR:

Charmi Patel Rao MD, DFAACAP

Medical Director, Vista Hill Foundation

Voluntary Assistant Clinical Professor, UCSD Department of Psychia

You’re treating a 15-year-old girl with Major Depressive Disorder. She has moderate benefit from a combination of weekly therapy and sertraline. The sertraline dose has had to be titrated slowly because of nausea as a side effect. When the dose was recently increased to 200mg she complained of such severe nausea that she does not want to take it anymore. She is requesting to change medications. Because she had significant symptoms impacting school attendance and academic performance in the past and is now attending school and doing better academically, you are hesitant to taper off sertraline before starting another antidepressant medication.

Switching medications

Not infrequently, a patient does not tolerate or respond to an initial antidepressant trial, leading to a need to change to a different medication. Although the most conservative approach for changing from one antidepressant medication to another is to taper and stop one medication before starting another, most patients who are taking antidepressant medication can be safely cross titrated off the current medication and onto a different antidepressant concurrently, especially if both medications are in the same class. When switching from one selective serotonin reuptake inhibitor (SSRI) to another, it is important to consider the risk of serotonin syndrome. This risk increases when two serotonergic medications are used simultaneously. However, careful dose management during cross-titration can reduce the risk while also preventing withdrawal symptoms and relapse of depressive symptoms.

Withdrawal symptoms are rare in medications with long half-lives and more common in medications with short half-lives. If withdrawal symptoms occur, they typically occur within hours to days of a dosage decrease, abruptly stopping the medication or missing a dose of medication. The most common symptoms related to withdrawal from SSRI and serotonin norepinephrine reuptake inhibitor (SNRI) medications are flu-like symptoms, nausea, lethargy, dizziness, ataxia, “electric shock” sensations also called “brain zaps”, anxiety, irritability, insomnia and vivid dreams.

Certain factors increase the risk of discontinuation symptoms:

·        A history of withdrawal symptoms during past medication changes

·        Increased anxiety when starting or increasing medication doses

·        Taking the medication for longer than six weeks

·        Medications with short half-lives (e.g. paroxetine, venlafaxine). Fluoxetine carries a lower risk of discontinuation syndrome because of its long half-life.

The recommendation is to taper the first medication over 4 weeks and reduce the dose by 25% per week if the medication being tapered was taken for an extended time period. The medication can be reduced more slowly if discontinuation symptoms are encountered. The new medication can be titrated up at the same cadence, monitoring the overall dose of both medications. It is important to know the available dose formulations in order to prescribe doses that are achievable. When switching between medications, it is also important to know the pharmacokinetic and pharmacodynamic drug interactions between the two medications. For example, fluoxetine has a long half-life, therefore it can be decreased to 20mg then stopped and still remain in the system for a couple weeks, allowing for a natural taper. For cross-titration from medications that are strong CY2D6 inhibitors (for example fluoxetine and paroxetine) to medications that are primarily metabolized by CY2D6 (for example duloxetine and venlafaxine), a slower titration of the new medication might be needed.

A cross taper from one antidepressant to another can be achieved over the course of 2-4 weeks. From that point it will be important to give enough time to assess for response to the new medication.

Return to case example:

Your patient is at risk for relapse of depressive symptoms and is experiencing side effects from sertraline, therefore a cross-taper is recommended. The recommended cross titration schedule to change to escitalopram is:

Week 1: sertraline 150mg and escitalopram 2.5mg daily

Week 2: sertraline 100mg and escitalopram 5mg daily

Week 3: sertraline 50mg and escitalopram 10mg daily

Week 4: discontinue sertraline and increase escitalopram to 15mg daily. Consider increasing to 20mg over time if needed and tolerated.

References:

1.      Keks, N., Hope, J., & Keogh, S. Switching and stopping antidepressants. Aust Prescr. 2016 Jun 1;39(3):76–83.

https://pmc.ncbi.nlm.nih.gov/articles/PMC4919171/ Accessed March 4, 2026.

2.      Soreide, K., Ward, K., Bostwick, J. Strategies and Solutions for Switching Antidepressant Medications. Psychiatric Times.

https://www.psychiatrictimes.com/view/strategies-and-solutions-switching-antidepressant-medications. Accessed March 11, 2026

3.      Ogle NK, Akkerman SR. Guidance for the discontinuation or switching of antidepressant therapies in adults. J Pharm Pract. 2013;26:389-396.

AUTHOR:

Dr. Melissa Lorang, MD

Child, Adolescent and Adult Psychiatrist

Vista Hill Foundation

A 16-year-old comes in for a well child check. She has a history of anxiety and depression and is on 20mg of escitalopram daily. She goes to therapy weekly and finds it helpful. The medication has helped her depression but she is still pretty anxious at school most days. The anxiety distracts her from focusing on school work and she avoids going places on the weekend because of it. Her psychiatrist just retired and she has not been able to find a new one yet. She has already tried and didn’t respond to fluoxetine and had side effects sertraline. She wants to change her medication. What are your options?

FDA Approvals since 1997

SSRIs

Although selective serotonin reuptake inhibitors (SSRIs) are commonly used in children to treat mood, anxiety and other symptoms, there are limitations on what has been formally FDA approved in children. Sertraline is approved only for Obsessive Compulsive Disorder (OCD) in children as young as 6 years old, fluoxetine is approved for Obsessive OCD in children age 7 and up and Major Depressive Disorder (MDD) for age 8 and up. Fluvoxamine is approved for OCD in children as young as 8.  Escitalopram is approved for MDD in ages 12 and up and as of May 2023 for Generalized Anxiety Disorder (GAD) for children age 7 and up. These SSRIs and others are used in other diagnoses, age groups and beyond FDA approved dosages. There is some study data to support such use.

Anxiety disorders, especially OCD is known by psychiatrists to often require a high dose of medication beyond the usual dose that can treat depression. Although studies in children are limited there have been a number of trials showing benefit in adults when treating OCD with high doses of SSRI medications. Sertraline has been studied up to 400mg daily while the FDA approved maximum dose is 200mg. Escitalopram has been studied and found to have benefit in doses up to 50mg daily while the FDA approved maximum dose is 20mg. In patients who did not respond to a 20mg daily dose, 80% had treatment response at a higher dose. The average dose in higher dose trials was 33.8mg per day.

A meta review from 2020 of SSRIs in children and adolescents found fluoxetine was more efficacious in MDD compared to other antidepressant medications. Fluvoxamine and paroxetine were more effective in the treatment of anxiety disorders. Fluoxetine and sertraline were more efficacious in the treatment of OCD. Bupropion and desipramine showed improvement in ADHD symptoms. Because all antidepressants include a black box warning for increased risk of suicidal thoughts, this should always be discussed with children and their parents when prescribing these medications. The warning was based on a meta-analysis of many studies that suggested suicidal thoughts or behavior was present in 4% of young people prescribed antidepressants and 2% of those prescribed placebo. After the black box warning was fist instituted in 2004, antidepressant prescribing went down and adolescent suicide attempts by overdose increased. Further studies of suicide risk with antidepressants since 2004 have shown a potential increased risk for suicidality with paroxetine and venlafaxine. Sertraline actually reduced suicidality risk in youth with anxiety.

Other Medications

Duloxetine (Cymbalta), a selective serotonin and norepinephrine reuptake inhibitor, is approved for Generalized Anxiety Disorder (GAD) for age 7 and older. Lurasidone (Latuda) which is an atypical antipsychotic medication is approved for bipolar depression in children age 10 and older. There are a number of Tricyclic Antidepressants approved for use in children and teens but their use is limited by significant side effects as well as the risk of toxicity and overdose. Clomipramine is approved for OCD in children age 10 and up. Amitriptyline, desipramine, protriptyline, and trimipramine are all approved for MDD in age 12 and up. Imipramine is approved for enuresis in children age 6 and older.

Although not FDA approved in children or adolescents, there have been studies on mirtazapine which show benefit for depression and anxiety in children age 12 and up. It also can help with sleep and can increase appetite. Mirtazapine has been shown to be helpful for adolescents with ADHD and anxiety or depression who are also on stimulants for their ADHD. It can cause weight gain, so that is important to monitor, but if they have had appetite suppression from the stimulant, this could be helpful to counteract the effect.

Case Example Continued

Luckily you have a number of options that are likely to be safe and effective. Switching medications is an option and prescribing above the FDA approved maximum dosing is also reasonable. Increase this teenager’s dose above 20mg daily could prove useful to help her anxiety symptoms. Switching to or adding on duloxetine which is approved in GAD could also be an alternative. If she had ADHD symptoms instead of anxiety symptoms with her depression, bupropion could be a useful addition. Or if she had ADHD and were on a stimulant already, especially if she were struggling with appetite or low weight, mirtazapine could be helpful.

References

www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Pharmacy-Education-Materials/Downloads/ad-pediatric-factsheet11-14.pdf

Antidepressant Medications: Use in Pediatric Patients

pmc.ncbi.nlm.nih.gov/articles/PMC6738970/

Antidepressants for Pediatric Patients – PMC

Chris Paxos; Moving beyond first-line treatment options for OCD. Ment Health Clin. 2022 Nov 3;12(5):300–308. doi: 10.9740/mhc.2022.10.300

Moving beyond first-line treatment options for OCD – PMC

Katharine Boaden, Anneka Tomlinson, Samuele Cortese, Andrea Cipriani. Antidepressants in Children and Adolescents: Meta-Review of Efficacy, Tolerability and Suicidality in Acute Treatment. Front Psychiatry. 2020 Sep 2;11:717. doi: 10.3389/fpsyt.2020.00717

Antidepressants in Children and Adolescents: Meta-Review of Efficacy, Tolerability and Suicidality in Acute Treatment – PMC

Use of mirtazapine in children and adolescents

onlinelibrary.wiley.com/doi/pdfdirect/10.1002/pnp.493?msockid=2ee0e151ec6a6d521801f719edf86c0c

AUTHOR:

Dr. Melissa Lorang, MD

Child, Adolescent and Adult Psychiatrist

Vista Hill Foundation

The transition from high school to college can be daunting, especially for individuals with disabilities that impair academic performance. One in five postsecondary students has a disability, defined as a condition that substantially limits one or more major life activities. Psychiatric disabilities include, but are not limited to, depression, anxiety, attention deficit hyperactivity disorder, autism spectrum disorder, obsessive compulsive disorder, and learning differences. Compared with students without disabilities, college students with disabilities are more likely to drop out of school, take longer time to complete their degrees, and experience poorer academic outcomes overall. Academic accommodations have been linked to positive outcomes including higher GPAs and shorter time to graduation.

Although federally funded colleges and universities in the United States are legally required to provide reasonable modifications for students with disabilities under the Americans with Disabilities Act and Section 504 of the Rehabilitation Act, most postsecondary students with disabilities, especially males and non-white students, do not request accommodations. Barriers to requesting accommodations are numerous and may include a lack of awareness of available supports, concerns about stigma, and discomfort with self-advocacy. While K-12 schools are mandated to identify and evaluate students with disabilities, postsecondary schools are not. As a result, students who are accustomed to schools intervening on their behalf may not realize that obtaining support in college typically requires self-initiation.

Primary care providers can play an important role in advocating for their patients by equipping them with the knowledge and support needed to access accommodations in the college setting. Below are several ways to support college-bound patients with disabilities.

Educate patients about available accommodations. Colleges and universities offer a variety of academic modifications to help students with disabilities succeed. Common ones include extended time on exams, note-taking assistance, support with study skills, alternative exam formats, and access to adaptive technology. The specific accommodations granted to each student will depend on the nature of their disability. Discuss with patients and their families which supports were helpful in high school and whether similar accommodations may be beneficial in college.

Normalize requesting accommodations for disabilities. Patients may hesitate to request accommodations because of concerns about stigma. Listen to and validate their feelings while also emphasizing that disabilities affect approximately 19% of college students and that requesting support may help them achieve their academic goals. It can also be helpful to remind patients that federal laws protect students from disability-based discrimination.

Encourage early registration with the college’s disability services office. Once a patient decides to request accommodations, the first step is to register for the college’s disability services office. Contact information is typically easy to find through a quick online search. Recommend that patients register as soon as they receive an acceptance letter, as the accommodation process can take time. Encourage them to review their school’s specific requirements, as processes vary by institution. For example, at the University of San Diego, students are required to (1) schedule an intake appointment, (2) submit student forms, (3) submit forms from medical professionals, and (4) work with a disability specialist to determine reasonable accommodations.

Assist patients in gathering documentation. If a patient has or previously had a 504 Plan or an Individualized Education Plan (IEP) in high school, encourage them to maintain copies of these documents to share with the disability services office, as these may help support proof of disability. In many cases, students must also provide forms or letters from medical professionals, such as pediatricians or psychiatrists, to verify their condition.

Encourage patients to build a support team. If patients are comfortable, caregivers can help support them during the transition process. Patients can also ask high school staff to coordinate with college personnel to facilitate a smooth transition. Once in college, patients should plan to communicate proactively with their professors to ensure that their accommodations are implemented. For example, students can email professors their accommodation letters prior to the start of each semester. Providing patients with practical strategies like these can help them develop self-advocacy skills that will benefit them in college and beyond.

For the abovementioned high school senior, consider providing these tips to maximize his chance at academic success in college. This can help him build the confidence and skills needed to navigate this important life transition.

AUTHOR:

Charmi Patel Rao MD, DFAACAP

Medical Director, Vista Hill Foundation

Voluntary Assistant Clinical Professor, UCSD Department of Psychiatry

cpatelrao@vistahill.org

You are seeing a 9-year-old male with preexisting ADHD, predominantly Inattentive Presentation who was recently removed from his biological mother and placed in a foster home. He has been stable on Concerta 27mg every morning for the last year with improvement in his symptoms in the school setting. His foster mother reports he has been having some trouble initiating sleep since being placed in the home. They have unsuccessfully tried various sleep hygiene ideas and foster mother is wondering if she can give him melatonin, which she finds helpful for her other foster children.

Most primary care providers are aware of the informed consent process related to prescribing psychotropic medications to patients, which involves a careful discussion about risks, benefits, alternatives, and potential side effects with patients and caregivers. The informed consent process for prescribing psychotropic medications for patients who are in foster care involves a more complex process, and this BHCS newsletter aims to provide background information as well as some practical guidelines for completing the required forms and processes.

Psychotropic medications are defined as those medications prescribed to affect mood or behavior and may include, but are not limited to, anxiolytic agents, antidepressants, mood stabilizers, antipsychotic medications, anti-Parkinson agents, hypnotics, medications for dementia, and psychostimulants. By definition, this would include OTC medications and supplements like diphenhydramine and melatonin. Prescribing psychotropic medications to children and adolescents who are in foster care or in a court authorized group home or residential placement is and has been subject to governmental oversight and regulation in the State of California for many years. The oversight for prescribing medications intended for psychotropic use takes place through each county’s Juvenile Court. It involves prescribers submitting applications, known in the trade as “JVs” or “JV-220s”, in order to obtain the Court’s authorization for the prescriptions for psychotropic medications to treat a behavioral health condition.

The JV-220 application itself is a several page document providing patient data focused on the presenting symptoms, presumptive diagnosis, physical health status, planned medication plan, and other clinical considerations (i.e., labs, past history, prior meds, past and current psychotherapies, family status, trauma exposure and other support services, etc.). This form is sent to the child’s County social worker who forwards it to the Court for further processing. You can access and download the JV-220A form here: https://www.courts.ca.gov/documents/jv220a.pdf.

Given the multiple parties with interests when a foster child is prescribed a psychotropic medication (i.e., the child, biological parent(s), child protective worker, foster parents, public health nurses, the psychiatrist reviewer, a CASA Worker, lawyers for the child and family and, not the least, the Court itself), JV submissions to initiate a treatment can take up to several weeks to be processed. Because of this timeline, JV-220 applications can be submitted as emergent requests with review and authorization (or, rarely, denial of authorization) occurring after a psychotropic medication is actually prescribed. Emergent applications may be submitted when a delay in initiating treatment to protect the child or others from serious harm or significant suffering. Additionally, emergent applications may be submitted if a youth is already taking psychotropic medications when seeing a new prescriber, and stopping the medication could have negative effects in terms of the child’s emotional and behavioral well-being.

Locally, a team of board-certified child and adolescent psychiatrists (currently through the Vista Hill Foundation Center for Child and Youth Psychiatry clinic) reviews JV applications and informs the Court as to the appropriateness of provider requests. The psychiatric review focuses on assuring that the medication(s) proposed comport with the symptoms and diagnosis(es) reported, and that there are no major side effects or medical risk factors to consider. Reviewers consider the child’s age and developmental status and may want to see that ancillary psychotherapies and school supports (such as having an IEP or 504 Plan) are in place, where relevant. Most applications are approved on review but occasionally, a reviewer may ask for more information or justification for a specific regimen when there are concerns about the appropriateness of a treatment plan. These concerns might be related to number of medications being prescribed, maximum dose being proposed or type of medication being proposed for the target symptoms.

For most primary care providers providing care for a foster child with a commonplace behavioral health condition, such as ADHD or uncomplicated Anxiety or Depression, the JV-220 application is an uncomplicated, albeit somewhat time-intensive process. Appropriate medication regimens are typically approved and it is only with more complex clinical situations that the court will request either further information or other measures. Pragmatically, the JV-220 form can be completed by an ancillary clinical staff person (e.g., a nurse) but must be reviewed and signed by the prescribing physician. Nurse Practitioners or Physician Assistants submissions should be countersigned by their supervising physicians to ensure timely approval. JV-220 applications have to be renewed every 6 months or for any new medications, but if you are the same prescriber and the medications remain unchanged, a shorter application called the JV-220B can be completed: https://courts.ca.gov/sites/default/files/courts/default/2024-11/jv220b.pdf

A full description of the currently used guidelines for psychopharmacologic practice with children and adolescents under Juvenile Court jurisdiction in California is accessible at the website listed below (California Guidelines for the Use of Psychotropic Medication with Children and Youth in Foster Care 2024 Edition). The document is a good reference guide for dosing, indications, and clinical contraindications in general.

https://cdss.ca.gov/Portals/9/Additional-Resources/Letters-and-Notices/ACINs/2024/I-50_24.pdf?ver=2024-12-16-104600-837

Back to our Case Presentation:

After a thorough history and physical does not reveal anything remarkable, you decide to continue Concerta, which has been helpful for his ADHD symptoms particularly in the school setting. You refer for school accommodations as well as behavioral therapy as ancillary services. The youth also mentions that he has previously found melatonin 3mg helpful for insomnia so you also decide that it would be appropriate to recommend melatonin 3mg in addition to Concerta. Because these are both being used to alter mood or behavior, a JV-220A application is required for both so you submit one with both medications listed on it. You put the maximum dose for Concerta at 54mg in case the dose needs to be adjusted in the future. You decide to submit it on an emergency basis so that he does not have to miss taking Concerta, which has been helpful, while waiting for the JV-220 application to be approved.

Quick Tips:

1. Complete a JV-220A for any new patient who is a ward of court and needs psychotropic medications.
2. If you add a new psychotropic medication or it has been six months since the last JV-220, complete an updated JV-220A. If you are the same prescriber and medications have not changed, you can complete a JV-220B instead.

References/Resources:

https://www.optumsandiego.com/content/dam/san-diego/documents/organizationalproviders/opoh/opohresources/CA-Guidelines-for-Use-of-Psychotropic-Medication-with-Children-and-Youth-in-Foster-Care.pdf

https://cdss.ca.gov/Portals/9/Additional-Resources/Letters-and-Notices/ACINs/2024/I-50_24.pdf?ver=2024-12-16-104600-837

AUTHOR:

Charmi Patel Rao MD, DFAACAP

Medical Director, Vista Hill Foundation

Voluntary Assistant Clinical Professor, UCSD Department of Psychiatry

cpatelrao@vistahill.org

Some patients may choose to participate in a comprehensive, full-model DBT program, such as the one offered by the DBT Center of San Diego for adolescents and adults. These programs often last a minimum of six months and include individual therapy, group skills training, and coaching. However, not all patients can commit to such intensive programs. Many still benefit from learning and applying DBT skills within individual or group therapy settings. Primary care providers and caregivers can also learn some DBT skills to teach or reinforce during brief encounters with youth.

DBT is organized into four core skill areas: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness.

 Mindfulness. Mindfulness is the foundation of DBT. It involves becoming aware of one’s thoughts, emotions, and sensations in the present moment without judgment. For example, a simple mindfulness exercise is to sit comfortably for five minutes and observe a small object using all five senses. Notice your thoughts and feelings as they arise and let them pass without judgment. Over time, practicing mindfulness can help individuals become more aware of internal experiences they might otherwise overlook.

   Distress Tolerance. Distress tolerance skills help individuals manage intense or overwhelming emotions in healthy ways. These skills are especially valuable for people who rely on self-injurious behaviors to cope with distress. One useful technique is TIPP, which stands for Temperature, Intense exercise, Paced breathing, and Progressive muscle relaxation.

–         Temperature: Cool your body down, for instance by splashing cold water on your face.

–         Intense exercise: Engage in brief physical activity, such as running or doing jumping jacks.

–         Paced breathing: Try diaphragmatic breathing. Inhale through your nose for four counts and exhale through your mouth for six.

–         Progressive muscle relaxation: Tense and relax your muscles from your feet up to your head.

After practicing TIPP, many people feel calmer and more in control, reducing the urge to act impulsively.

Emotion Regulation. Emotion regulation skills teach individuals to identify, understand, and change unhelpful emotional patterns. A practical strategy involves breaking down an emotional experience into parts:

–         Describe the situation

–         Identify what triggered it

–         Name your primary and secondary emotions

–         Notice your urges and actions

–         Reflect on the outcomes

By examining emotions in this structured way, individuals can gain insight into their reactions and develop more adaptive coping responses.

Interpersonal Effectiveness. Interpersonal effectiveness skills help individuals build and maintain healthy relationships, set boundaries, and communicate assertively. A commonly used tool is DEAR MAN:

–         Describe the situation

–         Express your feelings and opinions

–         Assert your needs clearly

–         Reinforce the benefits of your request

–         Mindful: Stay focused on your goal

–         Appear confident: Maintain a calm, steady tone and body language

–         Negotiate: Be willing to compromise when appropriate

Using DEAR MAN can help individuals express themselves effectively while maintaining respect for both themselves and others.

There are many other DBT skills beyond these examples, all aimed at improving emotional and interpersonal functioning. As with any skill, consistent practice is essential. Individuals should rehearse DBT skills several times a week until they feel natural and easy to use. For primary care providers and caregivers, even learning a few of these tools can make a significant difference in supporting youth mental health.

AUTHOR:

Dr. Kristen Kim, MD

Child, Adolescent and Adult Psychiatrist

Vista Hill Foundation

The difference between a medical diagnosis of autism and the educational eligibility under “autism” in the IEP is actually pretty big-and it matters.

A medical diagnosis is given by licensed healthcare providers-typically a developmental pediatrician, psychologist, neurologist or psychiatrist-using the criteria from the DSM-5.  This diagnosis can be used to access therapies, insurance benefits and other medical related services such as OT, PT, ABA.  It is based on a comprehensive evaluation that includes clinical history, direct observation, review of the DSM criteria for autism and review of cognitive function and adaptive skills.

An educational eligibility under the “Autism” category in IDEA is determined by the school team (often a school psychologist) and is only about whether the characteristics of autism adversely affect the child’s educational performance. IDEA has defined 14 eligibility categories for IEPs. One of them is Autism. The school’s task is to evaluate the child and determine if they fit the eligibility criteria for any of the specific categories.  A child might have a medical diagnosis of autism, but not qualify under educational standards, or vice versa.

Can a school “diagnose” autism?

Schools cannot and should not diagnose.  In fact, the term “diagnose” should not be used in the educational domain. They do not have the authority to do so.  The DSM-5 is very specific about who can officially diagnose autism.  It is correct to say “child has an autism classification/eligibility” for school services.

When doing IEP evaluations, the school’s task is to evaluate the child and determine if they fit the eligibility criteria for any of the specific categories.  Determining eligibility is not the same as diagnosing.  The child must also be in need of specialized services. It is important to note that these services are not automatic with an eligibility determination.

Qualifying under the autism category in the school setting can come with more specialized services such as:

• Social Skills Training
• Behavioral Interventions
• Sensory Integration Supports
• Speech/language services
• Occupational Therapy

They are not interchangeable.

• A medical diagnosis doesn’t guarantee IEP eligibility
• An educational classification doesn’t mean the child has a medical diagnosis of ASD.

In the end, families often have to have multiple evaluations in order to determine their child’s eligibility for both medical and educational treatments and interventions unless they can find an evaluator who is both licensed and qualified to make a “medical diagnosis,” as well as certified to make an “educational classification.”

Call SmartCare BHCS or refer families who are seeking support in asking for an IEP and/or obtaining autism evaluations.

RESOURCES:

https://adayinourshoes.com/autism-whats-the-difference-between-medical-and-educational-diagnoses/

https://www.neuroassessconsult.com/what-is-educational-autism/

AUTHOR:

Shirley Fett, FNP, PMHS

Vista Hill SmartCare BHCS, Parent Care and Cal MAP

Many children and adolescents exhibit picky eating. While picky eating is not always problematic, it may signal a more serious issue when it becomes extreme or causes health consequences. Avoidant/Restrictive Food Intake Disorder (ARFID) is a feeding and eating disorder characterized by significant weight loss, nutritional deficiencies, dependence on enteral feeding or oral nutritional supplements, and/or marked interference with psychosocial functioning.

ARFID is a relatively new diagnosis that was introduced to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013. Unlike anorexia nervosa or bulimia nervosa, ARFID is not driven by concerns about body weight or shape. Instead, it is associated with one or more of the following subtypes:

1.   Lack of interest in eating

2.   Sensory sensitivities

3.   Concern about aversive consequences of eating

Symptoms may begin after an adverse food-related event, such as choking, vomiting, or foodborne illness. For example, a child who chokes on a ham sandwich may develop a long-term aversion to cold cuts. About half of individuals with ARFID meet criteria for more than one subtype.

ARFID can affect people of all ages. Prevalence estimates in youth vary widely, ranging from 0.3% to 15.5%. The average age of onset is around 12 years, earlier than the typical onset for anorexia nervosa or bulimia nervosa. The female-to-male ratio is approximately 60:40. Children with autism spectrum disorder, attention deficit hyperactivity disorder, anxiety, depression, or obsessive compulsive disorder are at increased risk, as are those with a family history of eating disorders.

Common physical symptoms include abdominal pain, reflux, nausea, diarrhea, and constipation. Medical complications may include weight loss, low bone mineral density, amenorrhea, electrolyte abnormalities, bradycardia, and cardiac issues.

Evaluation should include a thorough medical history, physical examination, and review of growth curves. Routine laboratory testing may include a complete blood count, comprehensive metabolic panel, and thyroid studies. In some cases, an electrocardiogram may be warranted.

As with other eating disorders, ARFID treatment requires a multidisciplinary approach, beginning with weight restoration when needed. Medical providers help manage nutritional deficiencies and medical complications. They can also consider prescribing medications, such as cyproheptadine to assist with appetite stimulation, and/or selective serotonin reuptake inhibitors for comorbid anxiety or depression. Therapists help patients address thoughts and behaviors around eating. Treatment may involve Family-Based Therapy (FBT), Cognitive Behavioral Therapy (CBT), or Supportive Parenting for Anxious Childhood Emotions (SPACE). Nutritionists or registered dieticians support with meal planning. Speech-language pathologists can be enlisted to conduct swallowing studies when choking is a concern.

Caregivers also play a crucial role in their child’s recovery. They can model eating a variety of foods, encourage trying new foods, reinforce positive eating behaviors, and help their child manage stress and anxiety around meals. FBT and SPACE are two therapy modalities that rely heavily on parental involvement.

In the case of the 12-year-old described above, his significant weight loss raises concern for ARFID, likely driven by a lack of interest in eating and sensory sensitivities. His physical symptoms further support the need for medical evaluation and intervention.

References

Fisher M, Zimmerman J, Bucher C, Yadlosky L. ARFID at 10 years: a review of medical, nutritional, and psychological evaluation and management. Curr Gastroenterol Rep. 2023;25(12):421-429.

Willmott E, Dickinson R, Hall C, et al. A scoping review of psychological interventions and outcomes for avoidant and restrictive food intake disorder (ARFID). Int J Eat Disord. 2024;57(1):27-61.

AUTHOR:

Dr. Kristen Kim, MD

Child, Adolescent and Adult Psychiatrist

Vista Hill Foundation

PCEs have been shown to counteract and balance the effects of Adverse Childhood Experiences (ACEs) when it comes to adult mental health. Research shows that children exposed to ACEs are at risk for changes in brain anatomy, gene expression via epigenetics, and delated social, emotional, physical and cognitive development. How can PCEs impact this? Studies have demonstrated that PCEs have a cumulative effect on life-long mental health outcomes. For those with some exposure to ACES, those with more PCEs showed better lifelong mental and relational health than those with fewer PCEs. PCEs potentially can protect against the possible effects of ACEs.

Positive Childhood Experiences questions asked how often the respondent:

1. Felt able to talk to their family about feelings
2. Felt their family stood by them during difficult times
3. Enjoyed participating in community traditions
4. Felt a sense of belonging in high school
5. Felt support by friends
6. Had at least two non-parent adults who took genuine interest in them
7. Felt safe and protected by an adult in their home

Primary care providers are poised to encourage boosting PCEs for their patients. Promoting PCEs and support building resiliency in children and families can be incorporated in well child appointments. PCPs can improve caregivers’ understanding of child development and how childhood positive experiences can mitigate childhood adversity. PCPs can work with community organizations and schools to encourage improving access to community integrated care and safe spaces for community traditions. PCPs can refer families to the Vista Hill SmartCare Behavioral Health Consultation Services Parent Line 858-956-5900 for specific referrals to build PCEs for patients.

References:

https://positiveexperience.org/wp-content/uploads/2020/03/BRFShandout2-18.pdf

https://www.apaf.org/our-programs/justice/free-resources/what-are-pce-s/

https://www.apaf.org/getmedia/9458d8f9-fcf9-4bb0-bcde-4d3f6472ad99/PCEs-Infographic.pdf

AUTHOR:

Dr. Charmi Patel Rao, MD

Medical Director, Vista Hill Foundation

Child, Adolescent and Adult Psychiatrist

Voluntary Assistant Clinical Professor, UCSD Department of Psychiatry

SPACE (Supportive Parenting for Anxious Childhood Emotions) offers an alternative, evidence-based pathway. Developed at Yale University by Eli Lebowitz, PhD, SPACE treats childhood anxiety indirectly by working primarily with parents rather than directly with the child. Research has shown that SPACE is as effective as CBT for childhood anxiety disorders including separation anxiety, social anxiety, generalized anxiety, selective mutism and school refusal. It is a tool for improving a child’s anxiety without direct child treatment. It can lead to improvements in family relationships as well.

The underlying principle focuses on parental accommodation. Parental behaviors play a central – and modifiable – role in maintaining anxiety in their child. When a child is anxious, parents naturally adjust the environment to prevent distress, because they believe they are protecting their child. Examples include providing constant reassurance, sleeping next to their child, speaking on their child’s behalf, and avoiding triggers (ex. school, social situations). Although these accommodations reduce distress in the moment, they unintentionally validate anxiety as dangerous, remove opportunities for coping, and prevent mastery and independence in their child. Anxiety thrives on avoidance, and while parents see one of their key jobs to protect their children from danger, discomfort is not dangerous, so parents don’t need to protect their children from discomfort.

SPACE works by improving parental support and then gradually reducing parental accommodations. Parental support focuses on communicating the message of “This is hard” and “We know you can handle hard things”. This blends empathy with confidence. The next step is to reduce one accommodation at a time. It is important to note that the change in behavior focuses on the parent(s) and the child is not asked to change any of their behavior but just understand that their parent is going to stop doing something in response to their anxiety. SPACE is accessible for families where children don’t want to cooperate with therapy.

Parents appreciate access to a therapeutic intervention like SPACE because they often feel helpless watching a child struggle. SPACE empowers caregivers when children decline or cannot participate in traditional therapy and gives them actionable steps, which can reduce parental guilt and improve family functioning. It can also be delivered by trained clinicians over 8–12 sessions (https://www.spacetreatment.net/space-providers ). Alternatively motivated parents can read about and implement the model on their own (https://www.spacetreatment.net/manual-and-books). There are some misconceptions parents might have about SPACE. They might worry that their child will feel abandoned but it is important to remind them that SPACE emphasizes empathy and connection first, before reducing accommodations.

In summary, SPACE (Supportive Parenting for Anxious Childhood Emotions) targets the parents’ accommodations and not the child’s behavior directly. SPACE gives provider a concrete, structured intervention to recommend. For providers faced with many anxiety visits, SPACE can offer a structured, parent-empowering tool that improves outcomes and restores family functioning. If you have a family that might be a good fit for this approach, consider referring them to the SmartCare Behavioral Health Consultation Services Parent Line (858-956-5900) for additional support finding a therapist.

Resources:

https://www.spacetreatment.net

https://iocdf.org/ocd-treatment-guide/space/

https://www.vistahillccyp.org/

AUTHOR:

Dr. Charmi Patel Rao, MD

Medical Director, Vista Hill Foundation

Child, Adolescent and Adult Psychiatrist

Voluntary Assistant Clinical Professor, UCSD Department of Psychiatry