Implementation of a Suicide Risk Screening Clinical Pathway in a Children's Hospital: A Feasibility Study.

OBJECTIVES: Youth suicide is a pressing global concern. Prior research has developed evidence-driven clinical pathways to screen and identify suicide risk among pediatric patients in outpatient clinics, emergency departments (ED) and inpatient hospital units. However, the feasibility of implementing these pathways remains to be established. Here, we share the results of a hospital-wide "youth suicide risk screening pathway" implementation trial at an urban academic pediatric hospital to address this gap. METHODS: A 3-tier "youth suicide risk screening pathway" using The Ask Suicide-Screening Questions (ASQ) was implemented for patients aged 10 to 26 years who received care at an urban academic pediatric hospital's emergency department or inpatient units. We retrospectively reviewed implementation outcomes of this pathway from January 1 to August 31, 2019. The feasibility of this implementation was measured by assessing the pathway's degree of execution, fidelity, resource utilization, and acceptability. RESULTS: Of 4108 eligible patient encounters, 3424 (83%) completed the screen. Forty-eight (1%) screened acute positive, 263 (8%) screened nonacute positive and 3113 (91%) screened negative. Patients reporting positive suicide risk were more likely to be older and female, although more males required specialty mental health evaluations. Pathway fidelity was 83% among all positive screens and 94% among acute positive screens. The clinical pathway implementation required 16 hours of provider training time and was associated with slightly longer length of stay for inpatients that screened positive (4 vs 3 days). Sixty-five percent of nurses and 78% of social work providers surveyed supported participation in this effort. CONCLUSIONS: It is feasible to implement a youth suicide risk screening pathway without overburdening the system at an urban academic pediatric hospital.

Consultation-Liaison Case Conference: Systemic Challenges in Management of Aggression in a Pediatric Patient With Seronegative Autoimmune Encephalitis.

We present the case of a 9-year-old girl who presented to a tertiary-care academic children's hospital with acute onset of severe obsessive-compulsive symptoms, perseveration, grimacing, and personality changes with resultant agitation. Extensive multidisciplinary workup led to a diagnosis of seronegative autoimmune encephalitis. The clinical course included multiple general pediatric and inpatient psychiatric unit admissions that were complicated by severe affective dysregulation with physical aggression towards staff and family. Top experts in the consultation-liaison field provide guidance for this commonly encountered clinical case based on their experience and a review of available literature. Key teaching points include assessment and management of seronegative autoimmune encephalitis and catatonia. We discuss the system-level challenges of management of aggression in health care settings and ways to improve care for patients presenting with behavioral manifestations (aggression) of physical illness.

Implementing Suicide Risk Screening in a Pediatric Primary Care Setting: From Research to Practice.

OBJECTIVE: To describe the methodological development and feasibility of real-world implementation of suicide risk screening into a pediatric primary care setting. METHODS: A suicide risk screening quality improvement project (QIP) was implemented by medical leadership from a suburban-based pediatric (ages 12-25 years) primary care practice in collaboration with a National Institute of Mental Health (NIMH) suicide prevention research team. A pilot phase to acclimate office staff to screening procedures preceded data collection. A convenience sample of 271 pediatric medical outpatients was screened for suicide risk. Patients, their parents, and medical staff reported their experiences and opinions of the screening procedures. RESULTS: Thirty-one (11.4%) patients screened positive for suicide risk, with 1 patient endorsing imminent suicide risk (3% of positive screens; 0.4% of total sample). Over half of the patients who screened positive reported a past suicide attempt. Most patients, parents, and medical staff supported the implementation of suicide risk screening procedures into standard care. A mental health clinical pathway for suicide risk screening in outpatient settings was developed to provide outpatient medical settings with guidance for screening. CONCLUSIONS: Screening for suicide risk in pediatric primary care is feasible and acceptable to patients, their families, and medical staff. A clinical pathway used as guidance for pediatric health care providers to implement screening programs can aid with efficiently detecting and managing patients who are at risk for suicide.

Training Needs Assessment Survey in Pediatric Consultation-Liaison Psychiatry.

OBJECTIVE: Despite growing recognition of how curriculum modules can benefit child and adolescent psychiatry (CAP) training, there are few standardized teaching resources for pediatric consultation-liaison psychiatry (PCLP). A Special Interest Group (SIG) of the American Academy of Child and Adolescent Psychiatry Physically Ill Child Committee (PICC) conducted a needs assessment to establish interest in, and availability of, a library of online, self-paced learning modules specific to PCLP. METHOD: An email needs assessment survey was distributed to the PICC listserv in the fall of 2019 with four core areas of inquiry: (1) clinical service description, (2) teaching barriers, (3) interest in curriculum resources, and (4) interest in evaluation resources. RESULTS: Respondents were representative of typical academic PCLP programs. The response rate was 28% (n = 39). Programs endorsed barriers to teaching including high service obligations and limited protected teaching time. All respondents indicated that they would utilize high-quality, online learning modules. Psychiatric complications of medical illness, catatonia, and delirium were identified as priority topics in the care of pediatric patients with comorbid medical conditions. CONCLUSIONS: There are currently no published educational studies regarding the training needs for PCLP programs, even among tertiary care academic facilities. This training needs assessment is the first step in establishing a national PCLP training curriculum. New paradigms to develop standardized curriculum resources for PCLP are needed.

Report of the Academy of Consultation-Liaison Psychiatry Task Force on Lessons Learned From the COVID-19 Pandemic: Executive Summary.

BACKGROUND: The COVID-19 pandemic forced consultation-liaison psychiatrists to adapt to unprecedented circumstances. The Academy of Consultation-Liaison Psychiatry (ACLP) recognized the need and opportunity to assess its response and convened a task force in mid-2020 to review the lessons learned from the initial experience of the COVID-19 pandemic. OBJECTIVE: The aim of the study was to summarize experience and make recommendations to the ACLP Board of Directors about potential ACLP directions related to current and future pandemic response. METHODS: In August-November 2020, the task force reviewed local experiences, ACLP list-serv contributions, and the published literature and generated recommendations for ACLP actions. RESULTS: Recommendations addressed telepsychiatry, hospital staff wellness, support for consultation-liaison psychiatrists, the need for additional research on psychiatric and neuropsychiatric aspects of COVID-19, and the ACLP's role in advocacy and dissemination of information. The task force report was submitted to the ACLP Board of Directors in November 2020. CONCLUSIONS: As the preeminent organization of consultation-liaison psychiatrists, the ACLP can implement actions related to pandemic awareness and preparedness for the benefit of consultation-liaison psychiatrists, other health care workers, patients, and the general population.

Adaptations Made to Pediatric Consultation-Liaison Psychiatry Service Delivery During the Early Months of the COVID-19 Pandemic: A North American Multisite Survey.

BACKGROUND: The COVID-19 pandemic led to rapid changes in clinical service delivery across hospital systems nationally. Local realities and resources were key driving factors impacting workflow changes, including for pediatric consultation-liaison psychiatry service (PCLPS) providers. OBJECTIVE: This study aims to describe the early changes implemented by 22 PCLPSs from the United States and Canada during the COVID-19 pandemic. Understanding similarities and differences in adaptations made to PCLPS care delivery can inform best practices and future models of care. METHODS: A 20-point survey relating to PCLPS changes during the COVID-19 pandemic was sent to professional listservs. Baseline hospital demographics, hospital and PCLPS workflow changes, and PCLPS experience were collected from March 20 to April 28, 2020, and from August 18 to September 10, 2020. Qualitative data were collected from responding sites. An exploratory thematic analysis approach was used to analyze the qualitative data that were not dependent on predetermined coding themes. Descriptive statistics were calculated using Microsoft Excel. RESULTS: Twenty-two academic hospitals in the United States and Canada responded to the survey, with an average of 303 beds/hospital. Most respondents (18/22) were children's hospitals. Despite differences in regional impact of COVID-19 and resource availability, there was significant overlap in respondent experiences. Restricted visitation to one caregiver, use of virtual rounding, ongoing trainee involvement, and an overall low number of COVID-positive pediatric patients were common. While there was variability in PCLPS care delivery occurring virtually versus in person, all respondents maintained some level of on-site presence. Technological limitations and pediatric provider preference led to increased on-site presence. CONCLUSIONS: To our knowledge, this is the first multicenter study exploring pandemic-related PCLPS changes in North America. Findings of this study demonstrate that PCLPSs rapidly adapted to COVID-19 realities. Common themes emerged that may serve as a model for future practice. However, important gaps in understanding their effectiveness and acceptability need to be addressed. This multisite survey highlights the importance of establishing consensus through national professional organizations to inform provider and hospital practices.

A Clinical Pathway to Standardize Care of Children With Delirium in Pediatric Inpatient Settings.

Pediatric delirium is an important comorbidity of medical illness in inpatient pediatric care that has lacked a consistent approach for detection and management. A clinical pathway (CP) was developed to address this need. Pediatric delirium contributes significantly to morbidity, mortality, and costs of inpatient care of medically ill children and adolescents. Screening for delirium in hospital settings with validated tools is feasible and effective in reducing delirium and improving outcomes; however, multidisciplinary coordination is required for implementation. The workgroup, composed of international experts in child and adolescent consultation psychiatry, reviewed the literature and developed a flowchart for feasible screening and management of pediatric delirium. When evidence was lacking, expert consensus was reached; stakeholder feedback was included to create the final pathway. A CP expert collaborated with the workgroup. Two sequential CPs were created: (1) "Prevention and Identification of Pediatric Delirium" emphasizes the need for systematic preventive measures and screening, and (2) "Diagnosis and Management of Pediatric Delirium" recommends an urgent and ongoing search for the underlying causes to reverse the syndrome while providing symptomatic management focused on comfort and safety. Detailed accompanying documents explain the supporting literature and the rationale for recommendations and provide resources such as screening tools and implementation guides. Additionally, the role of the child and adolescent consultation-liaison psychiatrist as a resource for collaborative care of patients with delirium is discussed.

Developing a Clinical Pathway for Somatic Symptom and Related Disorders in Pediatric Hospital Settings.

Somatic symptom and related disorders (SSRDs) are commonly encountered in pediatric hospital settings. There is, however, a lack of standardization of care across institutions for youth with these disorders. These patients are diagnostically and psychosocially complex, posing significant challenges for medical and behavioral health care providers. SSRDs are associated with significant health care use, cost to families and hospitals, and risk for iatrogenic interventions and missed diagnoses. With sponsorship from the American Academy of Child and Adolescent Psychiatry and input from multidisciplinary stakeholders, we describe the first attempt to develop a clinical pathway and standardize the care of patients with SSRDs in pediatric hospital settings by a working group of pediatric consultation-liaison psychiatrists from multiple institutions across North America. The authors of the SSRD clinical pathway outline 5 key steps from admission to discharge and include practical, evidence-informed approaches to the assessment and management of children and adolescents who are medically hospitalized with SSRDs.

Suicide Risk Screening in Pediatric Hospitals: Clinical Pathways to Address a Global Health Crisis.

BACKGROUND: Youth suicide is on the rise worldwide. Most suicide decedents received healthcare services in the year before killing themselves. Standardized workflows for suicide risk screening in pediatric hospitals using validated tools can help with timely and appropriate intervention, while attending to The Joint Commission Sentinel Event Alert 56. OBJECTIVE: Here we describe the first attempt to generate clinical pathways for patients presenting to pediatric emergency departments (EDs) and inpatient medical settings. METHODS: The workgroup reviewed available evidence and generated a series of steps to be taken to feasibly screen medical patients presenting to hospitals. When evidence was limited, expert consensus was used. A standardized, iterative approach was utilized to create clinical pathways. Stakeholders reviewed initial drafts. Feedback was incorporated into the final pathway. RESULTS: Clinical pathways were created for suicide risk screening in pediatric EDs and inpatient medical/surgical units. The pathway outlines a 3-tiered screening process utilizing the Ask Suicide-Screening Questions for initial screening, followed by a brief suicide safety assessment to determine if a full suicide risk assessment is warranted. This essential step helps conserve resources and decide upon appropriate interventions for each patient who screens positive. Detailed implementation guidelines along with scripts for provider training are included. CONCLUSION: Youth suicide is a significant public health problem. Clinical pathways can empower hospital systems by providing a guide for feasible and effective suicide risk-screening implementation by using validated tools to identify patients at risk and apply appropriate interventions for those who screen positive. Outcomes assessment is essential to inform future iterations.

Pediatric Delirium: Evaluation, Management, and Special Considerations.

Delirium describes a syndrome of acute brain dysfunction with severe consequences on patient outcomes, medical cost, morbidity, and mortality. It represents a final common pathway of numerous pathophysiologic disturbances disrupting cerebral homeostasis. The diagnosis is predicated on recognition of the clinical features of the syndrome through ongoing clinical assessment. Early identification can be aided by routine screening, particularly in high-risk populations. Evaluation and management are continuous and simultaneous processes involving a multidisciplinary care team including child psychiatry consultation. Prevention, early identification and management are critical in alleviating symptoms, improving outcomes, and reducing distress for patients, families, and care teams. This review highlights our current understanding regarding pediatric delirium, its mechanisms, clinical manifestations, detection and management.

Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder During Adolescence in the Primary Care Setting: A Concise Review.

Attention deficit hyperactivity disorder (ADHD) is a chronic neurodevelopmental disorder with a worldwide prevalence of about 5% in school-age children. This review is intended to assist primary care providers (PCPs) in diagnosing and treating ADHD in adolescents. PubMed, PsychInfo, and Science Citation Index databases were searched from March 1990 to 2015 with the keywords: ADHD, primary care/pediatrics, and children/adolescents. Abstracts addressing diagnosis and/or treatment with 105 citations were identified including supplementary treatment guidelines/books. Adolescent ADHD presents with significant disturbances in attention, academic performance, and family relationships with unique issues associated with this developmental period. Diagnostic challenges include the variable symptom presentation during adolescence, complex differential diagnosis, and limited training and time for PCPs to conduct thorough evaluations. The evidence base for treatments in adolescence in comparison to those in children or adults with ADHD is relatively weak. Providers should be cognizant of prevention, early identification, and treatment of conditions associated with ADHD that emerge during adolescence such as substance use disorders. Adolescent ADHD management for the PCP is complex, requires further research, and perhaps new primary care psychiatric models, to assist in determining the optimal care for patients at this critical period.

Diagnosis and Management of Delirium in Critically Ill Infants: Case Report and Review.

Delirium in children is common but not widely understood by pediatric practitioners, often leading to underdiagnosis and lack of treatment. This presents a significant challenge in the young patients in the PICU who are most at risk for delirium and in whom the core features of delirium are difficult to assess and treat. However, because of the potential increased morbidity and mortality associated with untreated delirium in adults and children, it remains important to address it promptly. The literature for delirium in this age group is limited. Here we present the case of an infant with multiple underlying medical risk factors who exhibited waxing and waning motor restlessness with disrupted sleep-wake cycles contributing significantly to destabilization of vital parameters. Making a diagnosis of delirium was key to guiding further treatment. After appropriate environmental interventions are implemented and underlying medical causes are addressed, antipsychotic medications, although not Food and Drug Administration-approved in infants, are the mainstay of pharmacotherapy for delirium in older age groups. They may lengthen corrected QT interval (QTc) intervals, presenting a challenge in infants who frequently have other coexisting risks for QTc prolongation, as in our case. The risk from QTc prolongation needs to be balanced against that from untreated delirium. Low doses of risperidone were successfully used in this patient and without side effects or worsening of QTc interval. This case illustrates the importance of increased recognition of delirium in children, including infants, and the role for cautious consideration of atypical antipsychotics in the very young.

Social impairments in chromosome 22q11.2 deletion syndrome (22q11.2DS): autism spectrum disorder or a different endophenotype?

High prevalence of autism spectrum disorders (ASD) has been reported in 22q11.2DS, although this has been based solely on parent report measures. This study describes the presence of ASD using a procedure more similar to that used in clinical practice by incorporating history (Social Communication Questionnaire) AND a standardized observation measure (Autism Diagnostic Observation Schedule) and suggests that ASD is not as common as previously reported in 22q11.2DS. Differences in methodology, along with comorbid conditions such as anxiety, likely contribute to false elevations in ASD prevalence and information from multiple sources should be included in the evaluation of ASD.

Caregiver Burden in Fragile X Families.

Complex caregiving issues occur in multigenerational families carrying the fragile X mutation and premutation. The same family members may care for children or siblings with fragile X syndrome (FXS) and for elderly parents with fragile X-associated tremor/ataxia syndrome (FXTAS). Family caregivers experience anxiety, depression, neglect of personal health care needs, employment difficulties, and loss of social support, leading to isolation and further psychiatric consequences. There is growing awareness of caregiver burden with regard to parents of children with FXS, but much less is known about the needs of informal caregivers of patients with FXTAS. In this paper, we review the available literature to date and provide suggestions for further exploration of caregivers' needs. Evidence-based strategies to address these needs are included. Many more research studies exploring caregiver burden in multigenerational fragile X families are needed, as well as studies aimed at investigating interventions and their impact on reduction.