Bright Light Therapy for Major Depressive Disorder in Adolescent Outpatients: A Preliminary Study.

BACKGROUND: Bright light therapy (BLT) has not been well-studied in adolescents with major depressive disorder, particularly in outpatient settings. METHODS: We conducted an 8-week clinical trial of BLT in adolescents recruited from a primary care practice with moderate to severe major depression. Acceptability and feasibility were defined by daily use of the light box and integration into daily routines. To assess treatment effects, we utilized the Short Mood and Feelings Questionnaire (SMFQ) and actigraphic sleep variables. RESULTS: Of the nine enrolled adolescents, the rate of daily use of the light therapy box was 100% at week 2, 78% at week 4 (n = 7), and 67% at weeks 6 and 8 (n = 6). Participants were better able to integrate midday BLT compared to morning BLT into their day-to-day routines. Mean depression scores improved during the 2-week placebo lead-in (dim red light-DRL) and continued to show significant improvement through 6 weeks of BLT. Sleep efficiency increased significantly (p = 0.046), and sleep onset latency showed a trend toward a significant decrease (p = 0.075) in the BLT phase compared to the DRL phase. CONCLUSION: Bright light treatment that was self-administered at home was feasible, acceptable, and effective for adolescent outpatients with depression. Findings support the development of larger, well-powered, controlled clinical trials of BLT in coordination with primary care.

A Precision Mental Health Model for Predicting Stability of 4-year-olds' Attention Deficit/Hyperactivity Disorder Symptoms to Age 6 Diagnostic Status.

OBJECTIVE: Estimates of the stability of a preschooler's diagnosis of Attention Deficit/Hyperactivity Disorder (ADHD) into early elementary school vary greatly. Identified factors associated with diagnostic instability provide little guidance about the likelihood a particular child will have ADHD in elementary school. This study examined an approach to predicting age 6 ADHD-any subtype (ADHD-any) from preschoolers' demographics and ADHD symptoms. METHOD: Participants were 796 preschool children (Mage = 4.44; 51% boys; 54% White, non-Hispanic) recruited from primary pediatric care and school settings. Parents completed ADHD Rating Scales at child ages 4 and 5 years, and a structured diagnostic interview (DISC-YC) at ages 4 and 6. Classification tree analyses (CTAs) examined the predictive utility of demographic and symptom variables at ages 4 and 5 years for age 6 ADHD. RESULTS: Over half (52.05%) of preschoolers meeting diagnostic criteria for ADHD-any at age 4 did not meet those criteria at age 6; more than half (52.05%) meeting criteria for ADHD-any at age 6 had not met those criteria at age 4. A CTA conducted at age 4 predicted age 6 ADHD-any diagnosis 65.82% better than chance; an age 5 CTA predicted age 6 ADHD-any 70.60% better than chance. At age 4, likelihood of age 6 ADHD-any diagnosis varied from <5% to >40% across CTA tree branches and from <5% to >78% at age 5. CONCLUSIONS: Parent-reported patterns of preschool-age symptoms may differentially predict ADHD-any at age 6. Psychoeducation regarding these patterns may aid in decision about pursuing multidisciplinary evaluations or initiating treatment.

Pediatric collaborative care outcomes in a regional model.

Background: Despite the movement toward hospital-based medical centers acquiring pediatric primary care offices, many primary care pediatricians still work in small, independent practices. To expand mental healthcare access, service delivery models must consider primary care practice needs and regionally available resources. Objective: This report describes the implementation and evaluation of the Mood, Anxiety, ADHD Collaborative Care (MAACC) program over a 4 years period. MAACC. MAACC engaged 97 pediatric primary care clinicians across 39 practices in mental health training and supported the treatment of referred patients through a collaborative care model. To support psychosocial treatment needs, we built a child community therapy referral network of 213 licensed psychotherapy providers. Methods: Data were collected on service delivery patterns (e.g., referrals, treatment use, and attrition) and patient outcomes. Measures included parent and children and adolescents PROMIS anxiety and depression short forms and the Parent NICHQ Vanderbilt. Results: Six hundred ninety-six children and adolescents aged 6-18 were evaluated and provided treatment recommendations. Anxiety disorders were the most common diagnosis (45.4%), followed by ADHD (30.7%) and mood disorder (17%). For children and adolescents with an anxiety or mood disorder, significant improvement was observed from baseline to any initial follow-up and from baseline to 6, 12-, and 18 weeks on children and adolescents and parent measures of anxiety and depression. For children and adolescents with ADHD, significant improvement was observed from baseline to any initial follow-up measure and at 6 and 18 weeks on parent-reported inattentive symptoms. Significant differences in treatment outcomes were identified for children and adolescents with anxiety receiving psychotherapy alone and medication management and psychotherapy. Conclusion: MAACC utilization and patient outcomes suggest that real-world collaborative care can effectively provide high-quality care while cultivating increased primary care treatment capacity and building on existing community resources.

Time Management Strategies for Addressing Mental Health Concerns in the Pediatric Visit.

Addressing mental health concerns within the time constraints of a busy pediatric practice can be challenging. Increasingly, pediatricians are tasked to cover even more during a routine checkup, including any sleep and dietary concerns as well as screening for mental health problems, social influencers of health, and hand-on-door queries. Since the start of the COVID-19 (coronavirus disease 2019) pandemic, primary care physicians have reported an increase in anxiety and depression in their pediatric patients. We present time management strategies that facilitate the clinician's ability to confront these problems together with the family. These include setting an agenda, acknowledging the limited time, using shared decision-making to prioritize topics, and offering an opportunity for further discussion at a follow-up visit. Using the mnemonic HEL2P3 can provide guidance to balance a visit with competing issues. [Pediatr Ann. 2023;52(11):e426-e429.].

Electronic health records identify timely trends in childhood mental health conditions.

BACKGROUND: Electronic health records (EHRs) data provide an opportunity to collect patient information rapidly, efficiently and at scale. National collaborative research networks, such as PEDSnet, aggregate EHRs data across institutions, enabling rapid identification of pediatric disease cohorts and generating new knowledge for medical conditions. To date, aggregation of EHR data has had limited applications in advancing our understanding of mental health (MH) conditions, in part due to the limited research in clinical informatics, necessary for the translation of EHR data to child mental health research. METHODS: In this cohort study, a comprehensive EHR-based typology was developed by an interdisciplinary team, with expertise in informatics and child and adolescent psychiatry, to query aggregated, standardized EHR data for the full spectrum of MH conditions (disorders/symptoms and exposure to adverse childhood experiences (ACEs), across 13 years (2010-2023), from 9 PEDSnet centers. Patients with and without MH disorders/symptoms (without ACEs), were compared by age, gender, race/ethnicity, insurance, and chronic physical conditions. Patients with ACEs alone were compared with those that also had MH disorders/symptoms. Prevalence estimates for patients with 1+ disorder/symptoms and for specific disorders/symptoms and exposure to ACEs were calculated, as well as risk for developing MH disorder/symptoms. RESULTS: The EHR study data set included 7,852,081 patients < 21 years of age, of which 52.1% were male. Of this group, 1,552,726 (19.8%), without exposure to ACEs, had a lifetime MH disorders/symptoms, 56.5% being male. Annual prevalence estimates of MH disorders/symptoms (without exposure to ACEs) rose from 10.6% to 2010 to 15.1% in 2023, a 44% relative increase, peaking to 15.4% in 2019, prior to the Covid-19 pandemic. MH categories with the largest increases between 2010 and 2023 were exposure to ACEs (1.7, 95% CI 1.6-1.8), anxiety disorders (2.8, 95% CI 2.8-2.9), eating/feeding disorders (2.1, 95% CI 2.1-2.2), gender dysphoria/sexual dysfunction (43.6, 95% CI 35.8-53.0), and intentional self-harm/suicidality (3.3, 95% CI 3.2-3.5). White youths had the highest rates in most categories, except for disruptive behavior disorders, elimination disorders, psychotic disorders, and standalone symptoms which Black youths had higher rates. Median age of detection was 8.1 years (IQR 3.5-13.5) with all standalone symptoms recorded earlier than the corresponding MH disorder categories. CONCLUSIONS: These results support EHRs' capability in capturing the full spectrum of MH disorders/symptoms and exposure to ACEs, identifying the proportion of patients and groups at risk, and detecting trends throughout a 13-year period that included the Covid-19 pandemic. Standardized EHR data, which capture MH conditions is critical for health systems to examine past and current trends for future surveillance. Our publicly available EHR-mental health typology codes can be used in other studies to further advance research in this area.

State of the Evidence for Use of Psychotropic Medications in School-Age Youth.

Psychotropic medications are commonly prescribed to school-aged youth for the management of mental health concerns. This paper describes the current state of evidence for psychotropic medications in school-aged youth. More specifically, the following sections summarize relevant medication research trials and practice parameters pertaining to psychotropic medication prescribing as well as the specific medications indicated for a range of commonly presenting disorders and symptom clusters in school-aged youth. For each of these disorders and symptom clusters, key findings pertaining to the current state of science and practice are highlighted for the purpose of offering patients, clinicians, researchers, and policymakers with nuanced considerations for the role of psychopharmacology within the context of a larger "whole-child" approach to care that relies on the collaboration of providers and services across systems of care to promote optimal child and family health and wellness. The paper concludes with a discussion about supporting the use of medication treatments in schools, including considerations for ensuring effective family-school-health system collaboration to best meet youth mental health needs.

Light Therapy for Adolescent Depression: A Scoping Review.

PURPOSE: Depressive disorders in adolescents are a major health concern associated with developmental, social, and educational impairment. Bright Light Therapy (BLT) is a feasible and effective treatment for depressive disorders in adults, but few controlled trials have been conducted with children or adolescents. This scoping review focuses on the current state of knowledge for BLT in the treatment of adolescent depression. We reviewed the literature for novel data and methodologic approaches using BLT and pediatric and young adult populations. RECENT FINDINGS: BLT is a tolerable treatment with few side effects. However, there is a marked lack of well-powered studies to support BLT as a treatment for depressive disorders in adolescent populations. Given evidence of tolerability and positive treatment effect on depression in the adult literature, research is needed to establish the efficacy, feasibility, and acceptability of BLT in adolescents.

Improving diagnostic accuracy: Comparison of nomograms and classification tree analyses for predicting the diagnosis of oppositional defiant disorder.

Unstructured clinical interviews are inaccurate tools for diagnostic decision-making. While structured diagnostic evaluations improve reliability, they are infrequently used in clinical practice. Empirical approaches are a hallmark of evidenced-based assessment and may reduce burdens of structured interviews. We explore two approaches to empirical prediction of diagnosis, the naïve nomogram, and classification tree analysis (CTA). To illustrate the clinical utility of each approach, we compared their use in a sample of 6-year-olds (N = 619) to predict structured-interview diagnoses of oppositional defiant disorder (ODD). Findings indicate the accuracy of both approaches in predicting the absence of a disorder and improved detection of ODD using CTA for subgroups of children. Both empirical prediction techniques have applicability to diagnostic decision-making in psychiatry and pediatrics. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Systematic review on quantifying pedestrian injury when evaluating changes to the built environment.

Modifying the built environment to make communities more walkable remains one strategy to promote physical activity. These modifications may have the added benefit of reducing the risk of pedestrian injury; however, there is a gap in the physical activity literature regarding how best to measure pedestrian injury. Examining the measures that have been used and related data sources can help inform the use of pedestrian injury data to evaluate whether safety is optimized as walking increases. We conducted a systematic review of the literature to identify studies that evaluated changes to the built environment that support walking and measures impacts on pedestrian injury as a measure of safety. We searched PubMed, PsycInfo, and Web of Science to identify peer-review studies and websites of fifteen organizations to document studies from the grey literature published in English between January 1, 2010 and December 31, 2018. Our search identified twelve studies that met the inclusion criteria. The few studies that measured changes in pedestrian injury used crash data from police reports. Injury frequency was often reported, but not injury severity, and no studies reported injury risk based on walking exposure. We conclude that few studies have measured pedestrian injury in the context of creating more walkable communities. Future research would benefit from using well-characterized measures from existing studies to support consistency in measurement, and from more longitudinal and evaluation research to strengthen the evidence on additional benefits of walkability. Increased collaborations with injury prevention professionals could bolster use of valid and reliable measures.

Self-reported symptoms of arm lymphedema and health-related quality of life among female breast cancer survivors.

We examined cross-sectional associations between arm lymphedema symptoms and health-related quality of life (HRQoL) in the Health, Eating, Activity and Lifestyle (HEAL) Study. 499 women diagnosed with localized or regional breast cancer at ages 35-64 years completed a survey, on average 40 months after diagnosis, querying presence of lymphedema, nine lymphedema-related symptoms, e.g., tension, burning pain, mobility loss, and warmth/redness, and HRQoL. Analysis of covariance models were used to assess HRQoL scores in relation to presence of lymphedema and lymphedema-related symptoms. Lymphedema was self-reported by 137 women, of whom 98 were experiencing lymphedema at the time of the assessment. The most common symptoms were heaviness (52%), numbness (47%), and tightness (45%). Perceived physical health was worse for women reporting past or current lymphedema than those reporting no lymphedema (P-value < 0.0001). No difference was observed for perceived mental health (P-value = 0.31). Perceived physical health, stress, and lymphedema-specific HRQoL scores worsened as number of symptoms increased (P-values ≤ 0.01). Women reporting tension in the arm had lower physical health (P-value = 0.01), and those experiencing burning pain, tension, heaviness, or warmth/redness in the arm had lower lymphedema-specific HRQoL (P-values < 0.05). Treatment targeting specific lymphedema-related symptoms in addition to size/volume reduction may improve some aspects of HRQoL among affected women.

Models of Mental Health Consultation and Collaboration in Primary Care Pediatrics.

Pediatricians are increasingly asked to address the mental health care needs of their patients, despite lack of formal mental health training. Pediatricians who wish to expand their scope of practice to include mental health care may benefit from didactic training as well as ongoing consultative or collaborative relationships with mental health specialists. Consultative and collaborative relationships between mental health and primary care have evolved in various models across the country. We outline models of mental health consultation and collaboration, address some considerations for pediatricians prior to adopting a model, and list key collaborative care resources. [Pediatr Ann. 2020;49(10):e416-e420.].

Developmental Aspects of Pediatric Mental Health.

Mental health disorders emerge in predictable patterns across pediatric development. Understanding these patterns can help clinicians anticipate emerging mental health problems. In this article, we review child development, merging concepts from developmental psychology with motor, language, cognitive, and social development. We point out developmental red flags for mental health disorders in each developmental period. [Pediatr Ann. 2020;49(10):e426-e430.].

Diagnosis and Management of Comorbid Anxiety and ADHD in Pediatric Primary Care.

Attention-deficit/hyperactivity disorder (ADHD) and anxiety disorders, which are the most common pediatric mental health problems, frequently co-occur. The overlap of symptoms and the varied presentations of both disorders can make diagnosis and treatment planning challenging. Picking an initial treatment target with reassessment of the diagnoses based on response may help clinicians successfully treat children with comorbid ADHD/anxiety. Treating ADHD with stimulants can lead to improvement in ADHD-related anxiety symptoms. Treating anxiety can reduce anxiety-related attentional problems and executive functioning. Atomoxetine and alpha agonists treat ADHD and may have some benefit for anxiety symptoms. Behavioral treatment should be part of the plan for ADHD co-occurring with anxiety disorders. [Pediatr Ann. 2020;49(10):e436-e439.].

Identification of Effective Programs to Improve Access to and Use of Trails among Youth from Under-Resourced Communities: A Review.

The primary purpose of this paper is to identify and review studies evaluating the effectiveness of programs to increase access to trails and trails use (physical activity) among youth from under-resourced communities. Three additional goals include identifying: (1) Correlates of physical activity/trail use and features of transportation systems and/or built environment and land use destinations, that may inform and support the planning and implementation of programs to promote trail use among youth, (2) benefits associated with trail use, and (3) barriers to trail use. Under-resourced communities are defined as those lacking sufficient resources (i.e., under-funded). METHODS: A review of the literature was conducted to identify, abstract, and evaluate studies related to programs to promote trail use among youth and youth from under-resourced communities. In anticipation of very few studies being published about this topic, studies were also reviewed to identify correlates of transportation systems and built environment and land use destinations related to increases in physical activity, and benefits of, and barriers to trail use. PUBMED, MEDLINE, PsycINFO, Sportdiscus, Annual Reviews, American Trails, and Google Scholar databases were searched using terms including trails, built environment, physical activity, exercise, walking, children, adolescents, and youth to identify studies that potentially related to the purposes for conducting this review. Review methods identified, 5278 studies based on our search terms. A review of study titles, abstracts, and select full article screens determined that 5049 studies did not meet the study inclusion criteria, leaving 221 studies included in this review. RESULTS: No studies were located that evaluated programs designed to promote and increase trail use among youth, including youth from under-resourced communities. Eight studies used longitudinal or quasi-experimental designs to evaluate physical activity and neighborhood characteristics prospectively among adolescent girls (n = 1), the effects of the path or trail development on physical activity behaviors of children, youth, and adults (n = 4), marketing or media campaigns (n = 2), and wayfinding and incremental distance signage (n = 1) to promote increased trail use. Correlates of transportation systems (e.g., trail access, road traffic congestion related to safe active travel, lack of sidewalks, closer proximity to trails, access to transportation), destinations (e.g., park availability and access, park improvements, greenspaces), or both routes and destinations (e.g., perceptions of safety, lighting), were identified. These correlates may support the planning and implementation of programs to increase trail use among youth, or may facilitate the connection of trails or routes to destinations in communities. Barriers to trail use included costs, crime, lack of transportation, lack of role models using trails, and institutional discrimination. CONCLUSIONS: Scientific evidence in support of addressing the underrepresentation of trail use by youth from under-resourced communities is lacking. However, there is a related body of evidence that may inform how to develop programs that support trail use by youth from under-resourced areas. Dedicated, deliberate, and systematic efforts will be required to address research and knowledge gaps, and to evaluate programs and practice related to trail use among youth from low income, often racially or ethnically diverse under-resourced neighborhoods or communities.

A systematic review of physical activity and quality of life and well-being.

Maintaining or improving quality of life (QoL) and well-being is a universal goal across the lifespan. Being physically active has been suggested as one way to enhance QoL and well-being. In this systematic review, conducted in part for the 2018 U.S. Health and Human Services Physical Activity Guidelines for Americans Scientific Advisory Committee Report, we examined the relationship between physical activity (PA) and QoL and well-being experienced by the general population across the lifespan and by persons with psychiatric and neurologic conditions. Systematic reviews, meta-analyses, and pooled analyses from 2006 to 2018 were used for the evidence base. Strong evidence (predominantly from randomized controlled trials [RCTs]) demonstrated that, for adults aged 18-65 years and older adults (primarily 65 years and older), PA improves QoL and well-being when compared with minimal or no-treatment controls. Moderate evidence indicated that PA improves QoL and well-being in individuals with schizophrenia and Parkinson's disease, and limited evidence indicated that PA improves QoL and well-being for youth and for adults with major clinical depression or bipolar disorder. Insufficient evidence existed for individuals with dementia because of a small number of studies with mixed results. Future high-quality research designs should include RCTs involving longer interventions testing different modes and intensities of PA in diverse populations of healthy people and individuals with cognitive (e.g., dementia) and mental health conditions (e.g., schizophrenia) to precisely characterize the effects of different forms of PA on aspects of QoL and well-being.

Measurement-Based Care in the Treatment of Anxiety.

Treatment of pediatric anxiety disorders is complicated by their number, comorbidity, and the differential impact of a child's anxiety on the child and parents. Measurement-based care, using patient-level rating scales, can guide clinical decisions, track symptom improvement, and monitor treatment response. We review instruments for measurement-based care in pediatric anxiety. Measures used to track pediatric anxiety should be brief, accessible, sensitive to change, and reliable. Because parent-child agreement about a child's anxiety tends to be low, measures from both should be obtained. Measurements can also track functional improvement, expectancy related to treatment, and readiness to change.

Evidence-based assessment in clinical settings: Reducing assessment burden for a structured measure of child and adolescent anxiety.

Clinically useful and evidence-based mental health assessment requires the identification of strategies that maximize diagnostic accuracy, inform treatment planning, and make efficient use of clinician and patient time and resources. This study uses classification tree analyses to determine whether parent- and child-report instruments, alone or in combination, can accurately predict diagnoses as measured by the Anxiety Disorders Interview Schedule (ADIS). The ADIS, which is the gold-standard semistructured interview for anxiety disorders in children and adolescents, requires formal training and lengthy administration. Data were collected as part of the standard diagnostic assessment process for 201 patients (ages 5 to 17 years) in an urban outpatient psychiatry specialty clinic. Analyses examined 2 models to determine which predictors reached an acceptable level of diagnostic accuracy for generalized anxiety, social anxiety, and separation anxiety disorders. The first model used scores on a parent- and child-report anxiety measure combined with demographic factors, and the second model incorporated a broad-band measure of child psychopathology and a depression measure into the analysis. Although demographic factors did not emerge as accurate predictors in either model, particular measures, either alone or in combination, were able to predict specific ADIS diagnoses in some cases, allowing for the potential streamlining of ADIS administration. These results suggest that a classification-tree analysis lends itself to the construction of simple algorithms that have high clinical utility and may advance the feasibility and utility of evidence-based assessment strategies in real-world practice settings by balancing cost effectiveness, administration demands, and accuracy. (PsycInfo Database Record (c) 2020 APA, all rights reserved).