The Crisis in Children's Mental Health: What About the Babies?

The American Academy of Child and Adolescent Psychiatry (AACAP), the American Academy of Pediatrics (AAP), and the Children's Hospital Association (CHA) declared a national emergency in children's mental health.1 Much of the reporting has focused on children and teens, particularly with regard to increased emergency department visits and suicide attempts. Very little has been publicized about children between birth and 5 years of age, who may be among the most vulnerable to the psychosocial impacts of COVID-19. This commentary will outline some of the impacts of COVID-19 on very young children and their families and highlight activities of members of the Infant and Preschool Committee to address these impacts.

Addressing Pediatric Developmental and Mental Health in Primary Care Using Tele-Education.

This study evaluates the effectiveness of an early childhood tele-education program in preparing community pediatric clinicians to manage developmental and mental health disorders in young children. Community pediatric clinicians from rural, underserved, or school-based health center practices in the mid-Atlantic region participated in a weekly tele-education videoconference. There was a significant knowledge gain evidenced by the percentage of questions answered correctly from pre- to post- didactic exposure (P < .001). Participants reported an increase in knowledge from pre- (P < .001) and in confidence from pre- to post- participation (P < .001). Practice management changes demonstrated an encouraging trend toward managing patients in the Medical Home, as compared with immediately deferring to specialists following participation. This early childhood tele-education videoconferencing program is a promising response to the urgent need to confidently increase the role of pediatricians in the provision of care for childhood developmental and mental health disorders.

Adverse childhood experiences and developmental disabilities: risks, resiliency, and policy.

Thanks to the seminal work of Robert Anda and Vincent Felitti, it is now widely accepted that adverse childhood experiences (ACEs) can have lifelong effects on physical, behavioral, and mental health and that many adult diseases can be considered developmental disorders that began early in life. Genomics has advanced the neurobiological understanding that underpins ACEs, wellness, and disease, which are modulated through stress pathways and epigenetic modifications. While data are currently limited, children with developmental disabilities have an increased ACE risk compared to typically developing peers. This recognition has important ramifications for health and policy interventions that address the root causes of ACEs, especially in this vulnerable population. With increased societal recognition, advances in policy will lead to medical, financial, and public benefits in years to come, hopefully changing healthcare models from 'sick care' to 'well care'. What this paper adds Adverse childhood experience (ACE) research has refocused medicine from the question 'What is wrong with you?' to 'What happened to you?'. Adopting ACE research into public policy can redirect healthcare models from providing 'sick care' to promoting 'well care'. Not exploring the role of ACEs in children with developmental disabilities leads to further vulnerability and morbidity. ACEs can be mitigated by early identification and implementation of evidence-based interventions.

Gracias al trabajo fundamental de Robert Anda y Vincent Felitti, ahora se acepta ampliamente que las experiencias adversas de la infancia (ACE) pueden tener efectos de por vida en la salud física, conductual y mental y que muchas enfermedades de los adultos pueden considerarse trastornos del desarrollo que comenzaron temprano en la vida. La genómica ha avanzado la comprensión neurobiológica que sustenta las ACE, el bienestar y la enfermedad, que se modulan a través de las vías del estrés y las modificaciones epigenéticas. Si bien los datos son actualmente limitados, los niños con trastornos del desarrollo tienen un mayor riesgo de ACE en comparación con sus compañeros con desarrollo neurotípico. Este reconocimiento tiene ramificaciones importantes para las intervenciones de salud y políticas que abordan las causas fundamentales de las ACE, especialmente en esta población vulnerable. Con un mayor reconocimiento social, los avances en las políticas conducirán a beneficios médicos, financieros y públicos en los próximos años, con suerte cambiando los modelos de atención médica de "atención de enfermos" a "atención de bienestar".

Graças ao trabalho seminal de Robert Anda e Vincent Felitti, atualmente é amplamente aceito que experiências adversas na infância (EAIs) podem ter efeitos por toda a vida na saúde física, comportamental e mental, e muitas doenças adultas podem ser consideradas desordens desenvolvimentais que começaram cedo na vida. A genômica tem avançado a compreensão neurobiológica que embasa as EAIs, bem estar e doenças, que são moduladas por meio de vias do estresse e modificações epigenéticas. Embora os dados sejam atualmente limitados, crianças com incapacidades desenvolvimentais tem risco aumentado de EAIs comparadas com pares com desenvolvimento típico. Este reconhecimento tem ramificações importantes para as intervenções em saúde e políticas que abordam as causas originais das EAIs, especialmente nesta população vulnerável. Com o aumento do reconhecimento social, os avanços nas políticas levarão a benefícios médicos, financeiros e públicos nos próximos anos, com esperança de mudanças nos modelos de cuidado em saúde do 'cuidado ao doente' para o 'bem estar'.

Pre-school mental health disorders: a review.

Preschoolers are presenting in increasing numbers to primary care providers and mental health clinics with emotional and behavioural impairment. Preschoolers in the US have the highest rates of school expulsion of all age groups. Because young children are limited in their capacity to convey distress and internal states, impairment is most often expressed behaviourally. Disruptive behaviour, frequently in the form of aggression or dysregulation, is a final common pathway for many disorders in this age group. Tools and training to diagnose pre-school disorders are limited, and while some effective non-medication interventions exist, the evidence base for medication use in this age group is extremely limited. This article reviews approaches to assessing common pre-school disorders including attention deficit hyperactivity disorder (ADHD), disruptive behaviour disorders, anxiety and mood disorders, perceptual disturbances and psychosis, and trauma related disorders. The evidence base for both therapeutic and psychopharmacologic interventions for these disorders is discussed.

When Behavioral Health Concerns Present in Pediatric Primary Care: Factors Influencing Provider Decision-Making.

Primary care providers (PCPs) frequently encounter behavioral health (BH) needs among their pediatric patients. However, PCPs report variable training in and comfort with BH, and questions remain about how and when PCPs address pediatric BH needs. Existing literature on PCP decisions to address pediatric BH in-office versus referring to subspecialty BH is limited and findings are mixed. Accordingly, this study sought to examine parameters and contextual factors influencing PCP decisions and practices related to BH care. Qualitative interview results with 21 PCPs in Maryland indicated that decisions about how and when to address pediatric BH concerns are influenced by the type BH service needed, patient characteristics, the availability of BH services in the community, and possibly PCPs' perceptions of BH care as a distinct subspecialty. Findings suggest that efforts to support individual PCPs' capacity to address BH within primary care must be balanced by efforts to expand the subspecialty BH workforce.

The Five S's: A Communication Tool for Child Psychiatric Access Projects.

Given the gap in child psychiatric services available to meet existing pediatric behavioral health needs, children and families are increasingly seeking behavioral health services from their primary care clinicians (PCCs). However, many pediatricians report not feeling adequately trained to meet these needs. As a result, child psychiatric access projects (CPAPs) are being developed around the country to support the integration of care for children. Despite the promise and success of these programs, there are barriers, including the challenge of effective communication between PCCs and child psychiatrists. Consultants from the Maryland CPAP, the Behavioral Health Integration in Pediatric Primary Care (BHIPP) project, have developed a framework called the Five S's. The Five S's are Safety, Specific Behaviors, Setting, Scary Things, and Screening/Services. It is a tool that can be used to help PCCs and child psychiatrists communicate and collaborate to formulate pediatric behavioral health cases for consultation or referral requests. Each of these components and its importance to the case consultation are described. Two case studies are presented that illustrate how the Five S's tool can be used in clinical consultation between PCC and child psychiatrist. We also describe the utility of the tool beyond its use in behavioral health consultation.

Characteristics of temper tantrums in preschoolers with disruptive behavior in a clinical setting.

The purpose of this study was to describe clinician-observed, naturally occurring temper tantrums in preschoolers ages 2 to 5.5 diagnosed with severe behavior problems. Participants were 24 mother-child dyads enrolled in an intensive outpatient treatment program. Clinicians timed and observed 330 temper tantrums, rated their intensity, and recorded occurrence of 16 behaviors, tantrum precipitants, and interventions; parents completed the Achenbach Child Behavior Checklist pre- and posttreatment. Data were analyzed using descriptive statistics, Pearson chi square, paired t tests, and generalized linear modeling. Mean tantrum duration was 3.4 minutes (range = 0.2 to 26.5 minutes); most tantrums were low in intensity. Noncompliance precipitated 52% of tantrums. Aggressive behaviors were more likely to occur early in tantrums, with distress behaviors occurring later. Parent surveys indicated perceptions of behavioral improvement but no change in tantrum behavior. Study findings corroborate those of previous studies using retrospective parent reports.

Antipsychotic medication prescribing trends in children and adolescents.

The Food and Drug Administration has approved the use of antipsychotic medications in some children and adolescents with severe emotional and behavioral disorders. However, recent national data show a dramatic rise in off-label and Food and Drug Administration-approved uses of these medications. Of particular note is a twofold to fivefold increase in the use of antipsychotic medications in preschool children, despite little information on their long-term effects. This article describes the trend in pediatric antipsychotic medication use, possible explanations for the increase, implications for children's health, and recommendations for pediatric providers who work with parents of children and adolescents who seek or receive antipsychotic medication treatments.

Vertebral fracture assessment in patients presenting with incident nonvertebral fractures.

BACKGROUND: Patients with fractures should be prioritized for assessment for osteoporosis so that they can benefit from treatment for the secondary prevention of osteoporotic fractures. Assessment is seldom offered to patients with vertebral fractures because these fractures are typically not diagnosed. Vertebral fractures can be identified by vertebral fracture assessment (VFA) using current dual-energy X-ray absorptiometry (DXA) scanners. OBJECTIVE: The purpose of this study was to assess the prevalence of vertebral fractures, using VFA, in patients presenting with nonvertebral fractures and to assess whether this impacts on the management of these patients. DESIGN: A cohort study undertaken in 577 patients aged 50 years or over including 455 women, who presented with nonvertebral fractures and who underwent routine post-fracture assessment by a Fracture Liaison Service (FLS). MEASUREMENTS: The numbers and severity of vertebral fractures were assessed in evaluable vertebrae from TV4 to LV4 in addition to bone mineral density (BMD) assessment. RESULTS: Using DXA, 76% of vertebrae could be evaluated by VFA. Of the men and women with nonvertebral fractures, 19-20% had at least one vertebral fracture. The prevalence ranged from 6% in men with humeral fractures to 32% among women with hip fractures. The prevalence of vertebral fractures correlated most strongly with increasing age and with severity of reduction of BMD. Using local treatment protocols, VFA would result in only 3% more patients receiving treatment for fracture secondary prevention. CONCLUSIONS: In patients with nonvertebral fractures, VFA identifies a substantial burden of prevalent vertebral fractures that have not hitherto been recognized. Nevertheless, VFA seldom influences the need for treatment for fracture secondary prevention after a nonvertebral fracture.