Protocol for mapping psychosocial screening to resources in pediatric oncology: a pilot randomized controlled trial.

BACKGROUND: A pediatric cancer diagnosis and its treatment can have a detrimental effect on the mental health of children and their families. Screening to identify psychosocial risk in families has been recognized as a standard of care in pediatric oncology, but there has been limited clinical application of this standard thus far. A significant impediment to the implementation of psychosocial screening is the dearth of information on how to translate psychosocial screening to clinical practice, and specifically, how to follow-up from screening results. This manuscript aims to describe a protocol of a new intervention examining the feasibility and acceptability of mapping via a Psychosocial Navigator (PSN) psychosocial screening results to specific recommendations of resources for families based on measured risk for psychosocial distress and mental health symptoms. METHODS: The pilot randomized control trial (RCT) consists of dyads of youth (10-17 years) newly diagnosed with cancer and their primary caregiver. This RCT includes two arms (intervention and control group), with each group completing measurements near diagnosis and 1 year later. After the initial assessment, dyads in the intervention group receive monthly screening results and recommendations from the study PSN that are tailored to these results. The patient's primary healthcare team (nurse, social worker, oncologist) also receive the risk, distress, and mental health results as well as the recommendations from the PSN. DISCUSSION: This study addresses a significant barrier to the implementation of psychosocial screening in pediatric oncology: specifically, the limited knowledge of how to follow-up from screening results. Findings from this pilot will inform a future definitive RCT to test the effectiveness of the intervention on patient and family mental health outcomes. This project has implications for enhancing clinical care in pediatric oncology, as well as other pediatric populations. STRENGTHS AND LIMITATIONS OF THIS STUDY: This is the first study of screening and follow-up using a psychosocial navigator. This study involves both patient and caregiver report. The small sample size necessitates a future larger study to investigate the effects of intervention. TRIAL REGISTRATION: NCT04132856 , Registered 10 October 2019-retrospectively registered.

Association Between Comorbid Psychiatric Disorders and Hospital Resource Use in Physically Ill Pediatric Inpatients: A Case-Matched Analysis.

OBJECTIVE: To understand differences in hospital length of stay and costs associated with the presence of a comorbid psychiatric disorder among physically ill inpatients within a publicly funded pediatric hospital. METHOD: This was a retrospective observational design using administrative data on physically ill inpatients 2 to 18 years old who were admitted over a 5-year period (n = 54,316 admissions). Records with (n = 4,953) and without (n = 49,363) documented comorbid psychiatric disorder were compared for differences in baseline characteristics. To optimize the balance of measured covariates, individuals with comorbid psychiatric disorders were matched on propensity score, case mix group, and Elixhauser comorbidities, resulting in 4,371 pairs of inpatients with and without a comorbid psychiatric disorder. Differences in length of stay and total hospital costs were assessed using generalized estimating equation models on matched patients. RESULTS: Unmatched analyses demonstrated that inpatient admissions with comorbid psychiatric disorders were associated with higher occurrence of previous hospitalizations (69.2% versus 55.0%), unscheduled admissions (66.9% versus 60.9%), medical admissions (75.6% versus 52.7%), urgent admissions (62.5% versus 56.2%), and Elixhauser comorbidities (69.0% versus 39.0%), with standardized differences > |0.1|. Matched analyses demonstrated a 9.6% longer length of stay (95% CI = 5.7-13.7; p < .001) and 9.6% higher costs per admission (95% CI = 5.9-13.4; p < .001) in inpatients with comorbid psychiatric disorders compared to those without. CONCLUSION: The complexity of inpatients with a comorbid psychiatric disorder, in conjunction with the approximate 10% increase in hospital resource use, highlights the need for innovative models of clinical care and research directed at improving patient outcomes and reducing hospital costs.

Few guidelines offer recommendations on how to assess and manage anxiety and distress in children with cancer: a content analysis.

PURPOSE: To (1) describe and compare, across all eligible guidelines, recommendations that address any aspect of clinical assessment or management of anxiety and distress experienced by children and adolescents undergoing cancer treatment or hematopoietic stem cell transplantation (HSCT), and (2) assess guideline characteristics that influence identified recommendations. METHODS: We searched five databases for relevant guidelines and conducted a grey literature search. Guidelines had to refer to children 0-18 years old who were undergoing cancer treatment or HSCT, describe any aspect of clinical assessment or management of symptoms of anxiety and distress, and be publicly accessible and published in English on or after 2000. RESULTS: We identified 118 guidelines on pediatric cancer of which 13 mentioned clinical assessment or management of anxiety and distress. Six contained ≥ 1 recommendation addressing assessments of symptoms of which only two recommended specific screening instruments. Ten contained ≥ 1 recommendation addressing interventions for symptoms, of which six described specific interventions such as distraction and medication. Psychologists and nurses were the most common panel members and three guideline panels included a patient advocate. Only two guidelines received overall quality ratings > 80.0%. CONCLUSION: We identified no guidelines that were specific to clinical assessment or management of anxiety and distress among children and adolescents undergoing cancer treatment or HSCT, and thus, clinicians lack evidence-informed guidance on how to manage these specific symptoms. Future research should establish high-quality guidelines that offer recommendations specific to clinical assessment and management of anxiety and distress in pediatric oncology and HSCT.

Health Care Use and Costs of Children, Adolescents, and Young Adults With Somatic Symptom and Related Disorders.

Importance: Somatic symptom and related disorders are highly prevalent mental health disorders among young people. Presentation can be varied, and patients often face long delays and see multiple practitioners to receive a diagnosis. Objective: To evaluate the health care use and costs in a population-based sample of children and young people with somatic symptom and related disorders in Ontario, Canada. Design, Setting, and Participants: This population-based cohort study used linked health and administrative databases in Ontario, Canada, where health services are funded through a universal single-payer health insurance plan. Participants included children aged 4 to 12 years, adolescents aged 13 to 17 years, and young adults aged 18 to 24 years residing in Ontario, Canada, during the period of April 1, 2008, to March 31, 2015. Included participants had a first health record diagnosis of somatic symptom and related disorders and were grouped based on the setting of their index somatic symptom and related disorders contact: outpatient, emergency department, or inpatient. Data were analyzed from August 1, 2017, to February 1, 2018. Exposures: One year before and 1 year after diagnosis of somatic symptom and related disorders. Main Outcomes and Measures: Outcome measures included overall and mental health-specific ambulatory and acute care visits and overall health system costs and sector-specific costs. Results: A total of 33 272 patients (median [interquartile range {IQR}] age, 20 [16-22] years; 17 387 female [52.3%]) were included in the analysis. Among these patients, 3875 (11.6%) were aged 4 to 12 years, 7273 (21.9%) were aged 13 to 17 years, and 22 124 (66.5%) were aged 18 to 24 years. A total of 17 893 (53.8%) had their index visit as outpatients, whereas 13 310 (40.0%) and 2069 (6.2%) were diagnosed in the emergency department and inpatient settings, respectively. Ambulatory physician visits were frequent and persisted 1 year after diagnosis within each setting (before vs after 1 year, median [IQR] visits, inpatient setting: 7 [3-13] vs 7 [3-13]; emergency department setting: 4 [2-8] vs 4 [2-9]; outpatient setting: 3 [1-7] vs 4 [2-7]; P < .001). After diagnosis, many did not receive physician-delivered mental health care (35.3% [730 of 2069] in an inpatient setting, 59.1% [7866 of 13 310] in an emergency department setting, 58.5% [10 467 of 17 893] in an outpatient setting; P < .001). Acute care use was frequent and remained so after diagnosis across settings. Of those hospitalized as inpatients at diagnosis, 37.7% (779 of 2069) were readmitted within 1 year. Mean (SD) 2-year patient costs were CAD$9845 ($39 725) (median [IQR], $2401 [$960-$7019]). Hospitalized patients had a 2-year mean (SD) cost of $51 424 ($100 416) (median [IQR], $21 997 [$12 510-$45 841]) per-patient expenditure. Conclusion and Relevance: This study found that children and young people with somatic symptom and related disorders frequently used the health system with substantial health system costs before and after diagnosis. Many of these patients did not receive physician-delivered mental health care. These findings suggest that this population may be under-recognized, and initiatives for early recognition and engagement with mental health support may be warranted.

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.

Severity, change over time, and risk factors of anxiety in children with cancer depend on anxiety instrument used.

OBJECTIVE: The primary objective was to describe severity of anxiety among children and adolescents receiving chemotherapy for cancer or undergoing hematopoietic stem cell transplantation (HSCT). Secondary objectives were to describe how anxiety changes over time and determine factors associated with anxiety. METHODS: Participants were aged 8 to 18 and either receiving chemotherapy for cancer or undergoing HSCT for any indication. Respondents self-reported three anxiety measurement instruments at chemotherapy cycle or HSCT conditioning start and 3 weeks later. RESULTS: The proportion of participants with severe anxiety ranged from 10/77 (13.0%) to 22/77 (28.6%) depending on instrument used. Change over time also varied across instruments, with significant improvement observed with PedsQL (procedural) (P = 0.037) and PROMIS (P = 0.013). Factors associated with anxiety similarly varied by instrument. Older age was associated with more anxiety on the PedsQL (worry) (P = 0.036), and higher household income was associated with less anxiety on the MASC-10 (P = 0.028). CONCLUSIONS: While we found that a small proportion of patients met or exceeded thresholds for severe anxiety, we also noted that severity, change over time, and predictors of anxiety varied depending on instrument used. Future research should ensure that selected instruments measure the construct of interest and describe how anxiety is conceptualized in the study.

Instruments to measure anxiety in children, adolescents, and young adults with cancer: a systematic review.

PURPOSE: The primary objective was to describe anxiety measurement instruments used in children and adolescents with cancer or undergoing hematopoietic stem cell transplantation (HSCT) and summarize their content and psychometric properties. METHODS: We conducted searches of MEDLINE, Embase, PsycINFO, HAPI, and CINAHL. We included studies that used at least one instrument to measure anxiety quantitatively in children or adolescents with cancer or undergoing HSCT. Two authors independently identified studies and abstracted study demographics and instrument characteristics. RESULTS: Twenty-seven instruments, 14 multi-item and 13 single-item, were used between 78 studies. The most commonly used instrument was the State-Trait Anxiety Inventory in 46 studies. Three multi-item instruments (Children's Manifest Anxiety Scale-Mandarin version, PROMIS Pediatric Anxiety Short Form, and the State-Trait Anxiety Inventory) and two single-item instruments (Faces Pain Scale-Revised and 10-cm Visual Analogue Scale, both adapted for anxiety) were found to be reliable and valid in children with cancer. CONCLUSIONS: We identified 14 different multi-item and 13 different single-item anxiety measurement instruments that have been used in pediatric cancer or HSCT. Only three multi-item and two single-item instruments were identified as being reliable and valid among pediatric cancer or HSCT patients and would therefore be appropriate to measure anxiety in this population.

Development of the Vanderbilt Assessment for Delirium in Infants and Children to Standardize Pediatric Delirium Assessment By Psychiatrists.

BACKGROUND: Pediatric delirium assessment is complicated by variations in baseline language and cognitive skills, impairment during illness, and absence of pediatric-specific modifiers within the Diagnostic and Statistical Manual of Mental Disorders delirium criterion. OBJECTIVE: To develop a standardized approach to pediatric delirium assessment by psychiatrists. METHODS: A multidisciplinary group of clinicians used Diagnostic and Statistical Manual criterion as the foundation for the Vanderbilt Assessment for Delirium in Infants and Children (VADIC). Pediatric-specific modifiers were integrated into the delirium criterion, including key developmental and assessment variations for children. The VADIC was used in clinical practice to prospectively assess critically ill infants and children. The VADIC was assessed for content validity by the American Academy of Child and Adolescent Psychiatry Delirium Special Interest Group. RESULTS: The American Academy of Child and Adolescent Psychiatry-Delirium Special Interest Group determined that the VADIC demonstrated high content validity. The VADIC (1) preserved the core Diagnostic and Statistical Manual delirium criterion, (2) appropriately paired interactive assessments with key criterion based on development, and (3) addressed confounders for delirium. A cohort of 300 patients with a median age of 20 months was assessed for delirium using the VADIC. Delirium prevalence was 47%. CONCLUSION: The VADIC provides a comprehensive framework to standardize pediatric delirium assessment by psychiatrists. The need for consistency in both delirium education and diagnosis is highlighted given the high prevalence of pediatric delirium.

Anti-NMDA receptor encephalitis. The disorder, the diagnosis and the immunobiology.

Anti-NMDAR encephalitis is a newly characterized syndrome with a progressive, predictable clinical course and the possibility of effective treatment. Accurate and timely diagnosis is critical to selection and implementation of treatments, and optimal patient outcomes. Outcomes are improved with early diagnosis via indirect immunofluorescence or cell-based assays, and the rapid and appropriate administration of immunosuppressant and anti-psychotic therapies. Three possible scenarios accounting for the immunopathogenesis of anti-NMDAR encephalitis are presented, with the most probable one being that of paraneoplastic autoimmunity. Future efforts in this disorder should focus on elucidating the mechanisms that contribute to initiation of this antibody response, as well as exploring the role of tumors, infectious triggers and immune-reactivation. Finally, accessible tools need to be developed that allow for reliable identification of specific antibody markers against synaptic proteins.

Anxiety Disorders and Perceptual Disturbances in Adolescents with 22q11.2 Deletion Syndrome Treated with SSRI: A Case Series.

INTRODUCTION: Psychotic symptoms are highly prevalent in adolescents with 22q11.2 Deletion Syndrome (22qDS), with as many as half reporting transient psychotic symptoms. Anxiety is also commonly seen in this population, and patients frequently report both psychotic symptoms and anxiety. OBJECTIVE: To describe the psychiatric presentation, course and management of primary anxiety disorders in patients with 22qDS who also presented with isolated perceptual disturbances. METHOD: This report describes a 24-month clinical follow-up of three patients with 22qDS who were seen in the Medical Psychiatry clinic at the Hospital for Sick Children (Toronto, Canada). RESULTS: Patients presented with primary anxiety disorders and perceptual disturbances. Patients were placed on selective serotonin reuptake inhibitor only, with improvement of both anxiety and perceptual disturbances being noted. CONCLUSIONS: Some patients with 22qDS who present with psychotic symptoms do not develop a psychotic disorder; therefore, the use of antipsychotics for every child or adolescent with 22qDS who experience psychotic symptoms is debatable. Long-term follow-up, phenomenological and treatment efficacy studies in larger samples are needed to determine optimal treatment of psychotic symptoms in children and adolescents with 22qDS.