LETTERS TO THE EDITOR

Disclosure: Dr. Bruns has served as a consultant to the Massachusetts Behavioral Health Partnership, the Institute on Disabilities, University of New Hampshire, Casey Family Services, the Los Angeles County Department of Mental Health, the Department of Child and Family Studies, University of South Florida, and the State of New York Office of Mental Health / New York University. Dr. Pullmann has served as a consultant to Johns Hopkins University, Portland State University, and the University of New Hampshire.

(also known as the “elephant in the room”), name it. Gordon Harper,

[email protected]

0890-8567/$36.00/ª2014 American Academy of Child and Adolescent Psychiatry

John Sargent,

Peshali Fernando,

W

MS

University of Otago Christchurch, New Zealand

REFERENCES

Dr. Harper et al. reply: e appreciate Dr. Bruns and Dr. Pullmann’s recognition of the split in children’s services to which we drew attention. We especially appreciate the cited initiatives from the Substance Abuse and Mental Health Services Administration and the states. However, the mutual scotomata that blind us to the need for true service integration and for truly integrated service research are not easily undone. Ask recent child psychiatry graduates what they know of systems of care; ask a care coordinator what has been learned recently about engaging difficult-toengage parents or what approaches are relevant for the treatment-resistant. The walls stand. To acknowledge them is not to admire them. We invoke a tested principle in our field: to address an unnamed obstacle whose power comes from being unacknowledged

MD

Tufts University School of Medicine Boston

http://dx.doi.org/10.1016/j.jaac.2014.05.021

1. Harper G, Sargent J, Fernando P. Helping Troubled Children: Divergent Discourses. J Am Acad Child Adolesc Psychiatry. 2014; 53:491-493. 2. Mann C, Hyde PS; Centers for Medicaid and Chip Services and Substance Abuse and Mental Health Services Administration. Joint CMCS and SAMHSA informational bulletin: coverage of behavioral health services for children, youth, and young adults with significant mental health conditions. http://medicaid.gov/FederalPolicy-Guidance/Downloads/CIB-05-07-2013.pdf. Published May 7, 2013. Accessed April 28, 2014. 3. Stroul B, Blau G, Friedman R. Updating the System of Care Concept and Philosophy. Washington, DC: Georgetown University Center for Child and Human Development, National Technical Assistance Center for Children’s Mental Health; 2010. 4. Daleiden EL, Chorpita BF, Donkervoet C, Arensdorf AM, Brogan M, Hamilton JD. Getting better at getting them better: Health outcomes and evidence-based practice within a system of care. J Am Acad Child Adolesc Psychiatry. 2006; 45:749-756. 5. Bruns E, Walker J, Bernstein A, Daleiden E, Pullmann M, Chorpita B. Family voice with informed choice: coordinating wraparound with research-based treatment for children and adolescents. J Clin Child Adolesc Psychology. 2014;43:256-269. 6. Hoagwood K, Jensen P, Acri M, Olin S, Lewandowski R, Herman R. Outcome domains in child mental health research since 1996: have they changed and why does it matter? J Am Acad Child Adolesc Psychiatry. 2012;51:1241-1260.

MD

Harvard Medical School Boston

Disclosure: Please see the disclosure statement in the original article published in May 2014. 0890-8567/$36.00/ª2014 American Academy of Child and Adolescent Psychiatry http://dx.doi.org/10.1016/j.jaac.2014.05.020

Rethinking the “Complex Problem of Obesity” To the Editor: r. Kristopher Kaliebe’s article in the April 2014 issue of the Journal, “Rules of Thumb: Three Simple Ideas for Overcoming the Complex Problem of Childhood Obesity,”1 reminds child and adolescent psychiatrists that nutrition, activity, and thoughtful use of technology are important when promoting the health and wellness of children. As practitioners, we should help children and their families have healthy relationships with physical activity and food, and we should have an ongoing dialog about the use of media and technology by our patients and families. We should not be setting out to combat obesity as the problem, however, because doing so places children and families at risk for behaviors that are shared risk factors for mental illness, eating disorders (ED), addictions, and obesity. When it comes to the child and adolescent psychiatrist’s role in addressing nutrition and eating, we must be aware of the current epidemiology of disordered eating. One third of all high school athletes have some form of disordered eating, which includes food restriction and skipping of meals.2 The prevalence of partialsyndrome EDs in nonclinical populations is at least twice that of full-syndrome EDs, and there is a progression in some individuals from less to more severe disturbances in eating behavior. If

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