Psychometric Properties and Validation of the General Anxiety Disorder 7-Item Scale Among Adolescents With Persistent Post-Concussive Symptoms.

The General Anxiety Disorder 7-Item (GAD-7) scale is commonly used in primary care as a self-report measure of general anxiety symptoms with adult populations. There is little psychometric research on this measure with adolescent populations, particularly those with persistent post-concussive symptoms (PPCS). This study examined the psychometrics properties of the GAD-7 among youth with PPCS. We used baseline data from a randomized controlled trial of collaborative care for treatment of PPCS among 200 sports-injured adolescents 11-18 years of age (Mage = 14.7 years, standard deviation = 1.7). Eligible adolescents had three or more PPCS that lasted for ≥1 month and spoke English. Adolescents reported on their anxious (GAD-7 and Revised Child Anxiety and Depression Scale-Short Version [anxiety subscale]; RCADS) and depressive (Patient Health Questionnaire-9; PHQ-9) symptoms. Parents used the RCADS to report on their adolescents' anxious symptoms. The GAD-7 had good internal validity (Cronbach's alpha = 0.87), and significant (p < 0.001) correlations were detected between the GAD-7 and youth and parent report of anxiety on RCADS (r = 0.73 and r = 0.29) and PHQ-9 (r = 0.77) scores. Confirmatory factor analysis suggested a one-factor solution. These results suggest that the GAD-7 is a valid measure of anxiety with good psychometric properties for youth experiencing PPCS. ClinicalTrials.gov identifier: NCT03034720.

Exploring Heterogeneity of Stepped Collaborative Care Treatment Response Trajectories after Adolescent Sports Injury Concussion.

Objective: Few clinical trials of posttraumatic interventions have utilized symptom trajectory modeling to explore heterogeneity of treatment responses. The goal of this investigation was to conduct a secondary analysis of a randomized clinical trial of stepped collaborative care for adolescents with sports and recreational related concussion and persistent symptoms of >1 month.Method: Trajectory modeling was used to examine the impact of randomization to the intervention as well as demographic, clinical, and injury characteristics on adolescent post-concussive symptom trajectories. Two hundred male and female adolescents were assessed >1 month after a concussion, and then 3-, 6- and 12-months later with a standardized measure of concussive symptoms, the Health and Behavior Inventory (HBI). Multinomial logistic regression was used to compare the association between intervention, demographic, clinical and injury characteristics with trajectory group membership.Results: Four post-concussive symptom trajectories emerged: recovery, remitting, low-persistent, and high-persistent. In adjusted analyses randomization to the intervention condition was associated with significantly greater odds of HBI recovery trajectory group membership (OR 3.29 95% CI 1.06-10.28). Female gender and prior concussion history were associated with significantly greater odds of high-persistent trajectory group membership relative to all other trajectories. Greater odds of high-persistent versus recovery group trajectory membership was observed for adolescents with a pre-injury history of anxiety and/or depressive disorders.Conclusions: Stepped collaborative care was associated with an increased odds of recovery versus high-persistent post-concussive symptom trajectories, while readily identifiable baseline characteristics were associated high-persistent symptoms. Future post-concussive clinical trials and practice improvement efforts could incorporate these observations.

Development of a Symptom-Focused Model to Guide the Prescribing of Antipsychotics in Children and Adolescents: Results of the First Phase of the Safer Use of Antipsychotics in Youth (SUAY) Clinical Trial.

OBJECTIVE: To develop a new approach to prescribing guidelines as part of a pragmatic trial, Safer Use of Antipsychotics in Youth (SUAY; ClinicalTrials.gov Identifier: NCT03448575), which supports prescribers in delivering high-quality mental health care to youths. METHOD: A nominal group technique was used to identify first- to nth-line treatments for target symptoms and potential diagnoses. The panel included US pediatricians, child and adolescent psychiatrists, and psychopharmacology experts. Meeting materials included information about Medicaid review programs, systematic reviews, prescribing guidelines, and a description of the pragmatic trial. Afterward, a series of 4 webinar discussions were held to achieve consensus on recommendations. RESULTS: The panel unanimously agreed that the guideline should focus on target symptoms rather than diagnoses. Guidance included recommendations for first- to nth-line treatment of target mental health symptoms, environmental factors to be addressed, possible underlying diagnoses that should first be considered and ruled out, and general considerations for pharmacological and therapeutic treatments. CONCLUSION: Prescribing guidelines are often ignored because they do not incorporate the real-world availability of first-line psychosocial treatments, comorbid conditions, and clinical complexity. Our approach addresses some of these concerns. If the approach proves successful in our ongoing pragmatic trial, Safer Use of Antipsychotics in Youth (SUAY), it may serve as a model to state Medicaid programs and health systems to support clinicians in delivering high-quality mental health care to youths. CLINICAL TRIAL REGISTRATION INFORMATION: Safer Use of Antipsychotics in Youth; http://clinicaltrials.gov/; NCT03448575.

Barriers to Increasing Access to Brief Pediatric Mental Health Treatment From Primary Care.

A quality improvement process targeted mental health care uptake and system capacity in an underserved region. The pediatric program created pathways for rapid referral from primary care and schools to four sessions of evidence-based treatments for disruptive behavior and depression with community clinicians. Of 250 referrals, 46 families enrolled in treatments for disruptive behavior and 21 for depression. Many families did not respond or required more intensive treatment. Acceptability of the program was high for participating families, referrers, and clinicians. Brief treatment met most participating families' needs. The process demonstrated barriers to mental health care access and delivery and the need for integrated and multitiered care delivery.

Effect of Collaborative Care for Persistent Postconcussive Symptoms on Academic Function: A Randomized Clinical Trial.

BACKGROUND: There is limited long-term data on the course of school-related problems and academic needs for youth with persistent post-concussive symptoms (PPCS). METHODS: This was a randomized trial comparing collaborative care to usual care for 200 youth 11-18 years of age with PPCS. In this report, the main outcomes were academic functioning, GPA, school absences, date of return to school, and school days missed. RESULTS: Youth were mean age of 14.7 (SD = 1.7), 62.0% female. New or worsening academic problems occurred in half of participants in both groups at 12 months after injury. Students were most concerned about grades and falling behind. There were no significant differences by study group on school problems or GPA, but number of days missed was lower in the collaborative care group compared at 3 months (12.5 [SD = 14.5] vs 16.1 days [20.4] adjusted relative risk [aRR] 0.67 [95% CI: 0.61, 0.74; p < .001]), 6 months (14.5 [22.1] vs 19.3 [26.6] aRR 0.77 [95% CI: 0.71, 0.84; p < .001]), and 12 months (16.9 [25.4] vs 19.6 [27.7], aRR 0.68 [95% CI: 0.62, 0.74; p < .001]). CONCLUSIONS: Youth with PPCS are at high risk of school problems in the year after injury.

Prevalence and risk factors for depression, anxiety and suicidal ideation in youth with persistent post-concussive symptoms (PPCS).

Objectives: To assess the prevalence and risk factors for emotional distress in youth with persistent post-concussive symptoms (PPCS) greater than one month.Methods: We used baseline data from an intervention study for youth with PPCS, utilizing Poisson regression to examine factors associated with exceeding clinical cut-points on measures of depression, anxiety, self-harm and suicidal ideation. Predictors included: age, sex, socioeconomic status, mental health history, duration of concussion symptoms, history of prior concussion, trauma history and sleep quality.Results: The sample included 200 youth with PPCS, (mean 14.7 SD 1.7 years, 82% white, 62% female). Forty percent reported clinically significant depressive symptoms, 25% anxiety, 14% thoughts of self-harm and 8% thoughts of suicide. History of depression was associated with 3-fold higher risk for thoughts of self-harm (95% CI:1.82-6.99) and 6-fold higher risk for suicidal ideation (95% CI:1.74-24.46). Better sleep quality was associated with lower risk for all outcomes. History of prior concussion and duration of PPCS were not significantly associated with any outcomes.Conclusions: Suicidal thoughts are common post-concussion, and history of depression is a strong risk factor. Tailored interventions may be needed to address mental health in this population.

Effect of Collaborative Care on Persistent Postconcussive Symptoms in Adolescents: A Randomized Clinical Trial.

Importance: Despite the high level of impairment for adolescents with persistent postconcussive symptoms, few studies have tested whether such problems can be remediated. Objective: To examine whether collaborative care treatment is associated with improvements in postconcussive, quality of life, anxiety, and depressive symptoms over 1 year, compared with usual care. Design, Setting, and Participants: The Collaborative Care Model for Treatment of Persistent Symptoms After Concussion Among Youth II Trial was a randomized clinical trial conducted from March 2017 to May 2020 with follow-up assessments at 3, 6, and 12 months. Participants were recruited from pediatric primary care, sports medicine, neurology, and rehabilitation clinics in western Washington. Adolescents aged 11 to 18 years with a diagnosed sports-related or recreational-related concussion within the past 9 months and with at least 3 symptoms persisting at least 1 month after injury were eligible. Data analysis was performed from June to September 2020. Interventions: The collaborative care intervention included cognitive behavioral therapy and care management, delivered mostly through telehealth, throughout the 6-month treatment period, with enhanced medication consultation when warranted. The comparator group was usual care provided in specialty clinics. Main Outcomes and Measures: Primary outcomes were adolescents' reports of postconcussive, quality of life, anxiety, and depressive symptoms. Secondary outcomes were parent-reported symptoms. Results: Of the 390 eligible adolescents, 201 (51.5%) agreed to participate, and 200 were enrolled (mean [SD] age, 14.7 [1.7] years; 124 girls [62.0%]), with 96% to 98% 3- to 12-month retention. Ninety-nine participants were randomized to usual care, and 101 were randomized to collaborative care. Adolescents who received collaborative care reported significant improvements in Health Behavior Inventory scores compared with usual care at 3 months (3.4 point decrease; 95% CI, -6.6 to -0.1 point decrease) and 12 months (4.1 point decrease; 95% CI, -7.7 to -0.4 point decrease). In addition, youth-reported Pediatric Quality of Life Inventory scores at 12 months improved by a mean of 4.7 points (95% CI, 0.05 to 9.3 points) in the intervention group compared with the control group. No differences emerged by group over time for adolescent depressive or anxiety symptoms or for parent-reported outcomes. Conclusions and Relevance: Although both groups improved over time, youth receiving the collaborative care intervention had fewer symptoms and better quality of life over 1 year. Intervention delivery through telehealth broadens the reach of this treatment. Trial Registration: ClinicalTrials.gov Identifier: NCT03034720.

Polypharmacy in the Management of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents: A Review and Update.

Objective: Prescription of multiple medications concurrently for children and adolescents has increased in recent years. Examination of this practice has been undervalued relative to its incidence. This article reviews studies investigating effectiveness of medication combinations for youth with attention-deficit/hyperactivity disorder (ADHD). Methods: A literature search identified studies that combined two or more prescribed medications for the treatment of ADHD. Included studies focused on youth; had study design of randomized controlled trial (RCT), nonrandomized trial, or case review (n > 10); and included an outcome measure of treatment effectiveness. Results: Thirty-nine pertinent studies were identified. All studies combined two medications, with the vast majority including a stimulant (n = 37). The largest group (n = 16) combined stimulant and alpha-agonist, finding greater efficacy than alpha-agonist alone but not stimulant alone in all cases. A few RCTs found benefit from the addition of risperidone or divalproex to stimulant for comorbid aggression. Four studies adding atomoxetine found mixed reports of benefit, including the only small RCT showing no benefit. RCTs with selective serotonin reuptake inhibitors found minimal evidence of benefit for mood or anxiety comorbidities. Conclusion: The best studied combination is stimulant and alpha-agonist; addition of alpha-agonist to stimulant seems effective for residual symptoms of ADHD. Stimulant plus risperidone has the most evidence of efficacy for comorbid aggression or disruptive behavior. Limited support exists for the effectiveness of other medication combinations, including no trials studying three or more medications concurrently. Combinations frequently yielded more side effects, leaving monotherapy preferable if a sufficient treatment response can be achieved.

A Second-Opinion Program for the Care of Youths Prescribed Five or More Psychotropics in Washington State.

This retrospective study describes a second-opinion review program for the care of children in Washington State who received Medicaid coverage and who were prescribed five or more psychotropic medications, primarily by mental health specialists. In total, 136 second-opinion reviews from 2013 and 169 from 2018 were included in this study. Attention-deficit hyperactivity disorder (ADHD), behavioral difficulties, anxiety, and trauma were prevalent among these children, and participants were commonly prescribed ADHD medications, selective serotonin reuptake inhibitors, and second-generation antipsychotics. The incidence of reviews remained stable over the two periods, but psychosocial treatment increased significantly over this time. This study sheds light on the initiation, maintenance, and identification of polypharmacy psychotropic regimens and highlights psychosocial treatment as an intervention that increases best practice care for at-risk patients.

Editorial: Best Practices in Child Antipsychotic Use Monitoring.

One major change in our field over the past 20 years has been the rapid increase and acceptance of antipsychotic use for children. Pediatric use of antipsychotics was quite rare as recently as the early 1990s, though this was followed by a roughly 6-fold increase in antipsychotic prescribing from 1996 to 2004 with continued higher use rates.1 There is, of course, nothing inherently wrong with rapidly increasing use of a drug class, particularly when it yields significant clinical results. However, alarm was raised for several reasons, such as use variations (eg, children in foster care having much higher rates of use), a majority of antipsychotic use for off-label indications, and significant cardio/metabolic medical complications from their use.2,3 Cost was another concern before generics were available; for instance, all-ages antipsychotic use at one time accounted for nearly one-third of my state's entire Medicaid pharmacy budget. These factors together drove health systems to devise and implement strategies to ensure that youth receiving antipsychotic medications were receiving them appropriately.

Safer use of antipsychotics in youth (SUAY) pragmatic trial protocol.

BACKGROUND: Programs such as the Pediatric Access Line in Washington state have shown decreases in antipsychotic medication use by youth with non-psychotic disorders. Program outcomes have been studied with observational designs. This manuscript describes the protocol for Targeted and Safer Use of Antipsychotics in Youth (SUAY), a randomized controlled trial of psychiatrist review of prescriptions and facilitated access to psychosocial care. The aim of the intervention is to reduce the number of person-days of antipsychotic use among participants. METHODS: Recruitment occurs at 4 health systems. Targeted enrollment is 800 youth aged 3-17 years. Clinicians are block randomized to intervention versus usual care prior to the study. Youth are nested within the arm of the prescribing clinician. Clinicians in the intervention group receive an EHR-based best practice alert with options to expedite access to psychosocial care and all medication orders are reviewed by a child and adolescent psychiatrist with feedback provided to the prescriber. The primary outcome is person-days of antipsychotic medication use in the 6 months following the initial order. All randomized individuals contribute data regardless of their level of participation (including declining all services). DISCUSSION: The trial has been approved by the institutional review boards at each of the 4 sites. The intervention has 4 novel design features including automated recruitment using a best practice alert, psychiatrist medication order review and consultation, telephone navigation to psychosocial care, and telemental health visits. Recruitment began in March of 2018 and will be completed in June 2020. Follow-up will be completed December 31, 2020. TRIAL REGISTRATION: Clinicaltrials.gov, NCT03448575.

Effectiveness of mandatory peer review to reduce antipsychotic prescriptions for Medicaid-insured children.

BACKGROUND: Prior authorization of prescription medications is a policy tool that can potentially impact care quality and patient safety. OBJECTIVE: To examine the effectiveness of a mandatory peer-review program in reducing antipsychotic prescriptions among Medicaid-insured children, accounting for secular trends that affected antipsychotic prescribing nationally. DATA SOURCE: Medicaid Analytical eXtracts (MAX) with administrative claims for health services provided between January 2006 and December 2011. STUDY DESIGN: This retrospective, observational study examined prescription claims records from Washington State (Washington) and compared them to a synthetic control drawing from 20 potential donor states that had not implemented any antipsychotic prior authorization program or mandatory peer review for Medicaid-insured children during the study period. This method provided a means to control for secular trends by simulating the antipsychotic use trajectory that the program state would have been expected to experience in the absence of the policy implementation. PRINCIPAL FINDINGS: Before the policy implementation, antipsychotic use prevalence closely tracked those of the synthetic control (6.17 per 1000 in Washington vs. 6.21 in the synthetic control group). Within two years after the policy was implemented, prevalence decreased to 4.04 in Washington and remained stable in the synthetic control group (6.47), corresponding to an approximately 38% decline. CONCLUSION: Prior authorization program designs and implementations vary widely. This mandatory peer-review program, with an authorization window and two-stage rollout, was effective in moving population level statistics toward safe and judicious use of antipsychotic medications in children.

Evaluation and Management of Psychiatric Emergencies in Children.

Mental illness among children and adolescents is an increasing burden, projected to become one of the world's leading disabilities in near future. A dearth of specialized services and personnel to provide optimal care affects the disease burden, prevalence, health care services, and health care costs. The increasing demand weighs down on generalized systems of care such as emergency department (ED) services, in which the lack of specific training, personnel, and specialized protocols tends to prolong length of stay, recidivism, and suboptimal care. This article reviews outcomes and trends of overburdened ED systems in the context of pediatric mental health care management, guidelines of care, and strategies to manage common pediatric mental health emergencies and expand services within the ED. [Pediatr Ann. 2018;47(8):e328-e333.].

Telemedicine for Child Collaborative or Integrated Care.

Telemedicine with child psychiatry specialists is a useful tool for collaborative and integrated care systems. This article reviews the workforce and care process rationale for using child psychiatric telemedicine for collaborative care, and discusses practical ways to address the technical challenges that arise when using telemedicine. Different systems of using telemedicine discussed include child psychiatry access programs, collaborative and integrated care use of telephone consultations, televideo consultations, and televideo care delivery. Telemedicine can also be used for collaboratively conducted but care review requested by third-party consultations with treatment providers or care teams.

Evaluating Integrated Mental Health Care Programs for Children and Youth.

Evaluations of integrated care programs share many characteristics of evaluations of other complex health system interventions. However, evaluating integrated care for child and adolescent mental health poses special challenges that stem from the broad range of social, emotional, and developmental problems that need to be addressed; the need to integrate care for other family members; and the lack of evidence-based interventions already adapted for primary care settings. Integrated care programs for children's mental health need to adapt and learn on the fly, so that evaluations may best be viewed through the lens of continuous quality improvement rather than evaluations of fixed programs.

Decrease in Statewide Antipsychotic Prescribing after Implementation of Child and Adolescent Psychiatry Consultation Services.

OBJECTIVE: To learn if a quality of care Medicaid child psychiatric consultation service implemented in three different steps was linked to changes in statewide child antipsychotic utilization. DATA SOURCES/STUDY SETTING: Washington State child psychiatry consultation program primary data and Medicaid pharmacy division antipsychotic utilization secondary data from July 1, 2006, through December 31, 2013. STUDY DESIGN: Observational study in which consult program data were analyzed with a time series analysis of statewide antipsychotic utilization. DATA COLLECTION/EXTRACTION METHODS: All consultation program database information involving antipsychotics was compared to Medicaid pharmacy division database information involving antipsychotic utilization. PRINCIPAL FINDINGS: Washington State's total child Medicaid antipsychotic utilization fell from 0.51 to 0.25 percent. The monthly prevalence of use fell by a mean of 0.022 per thousand per month following the initiation of elective consults (p = .004), by 0.065 following the initiation of age/dose triggered mandatory reviews (p < .001), then by another 0.022 following the initiation of two or more concurrent antipsychotic mandatory reviews (p = .001). High-dose antipsychotic use fell by 57.8 percent in children 6- to 12-year old and fell by 52.1 percent in teens. CONCLUSIONS: Statewide antipsychotic prescribing for Medicaid clients fell significantly at different rates following each implementation step of a multilevel consultation and best-practice education service.

Implementing Integrated Care in Pediatric Mental Health: Principles, Current Models, and Future Directions.

Traditional models of health care delivery are inadequate for addressing all the needs of the child and adolescent population that has mental illness. The integrated care model seeks to partner pediatric mental health specialists with primary providers to better meet these needs. The authors outline the core principles guiding integrated care for youths and describe key characteristics of the team members involved. Three models of integrated care have emerged and have proven effective. Several representative programs are described, and the advantages and disadvantages of each are reviewed. The review concludes by identifying the challenges that have prevented wider dissemination of the integrated care model and by exploring potential future directions for the field.

Integrated Care for Pediatric Substance Abuse.

Integrated care is a way to improve the prevention, identification, and treatment of mental health difficulties, including substance abuse, in pediatric care. The pediatrician's access, expertise in typical development, focus on prevention, and alignment with patients and families can allow successful screening, early intervention, and referral to treatment. Successful integrated substance abuse care for youth is challenged by current reimbursement systems, information exchange, and provider role adjustment issues, but these are being addressed as comfort with this care form and resources to support its development grow.

Collaborative Care for Adolescents With Persistent Postconcussive Symptoms: A Randomized Trial.

BACKGROUND AND OBJECTIVES: Postconcussive and co-occurring psychological symptoms are not uncommon after sports-related concussion and are associated with functional impairment and societal costs. There is no evidence-based treatment targeting postconcussive symptoms in children and adolescents. The goal of this study was to test a collaborative care intervention model with embedded cognitive-behavioral therapy, care management, and psychopharmacological consultation. We hypothesized that patients in collaborative care would demonstrate greater reductions in postconcussive, depressive, and anxiety symptoms and improvement in functioning over the course of 6 months, compared with usual care control. METHODS: Patients aged 11 to 17 years with persistent symptoms ≥1 month after sports-related concussion were randomly assigned to receive collaborative care (n = 25) or care as usual (n = 24). Patients were assessed before randomization and after 1, 3, and 6 months. Groups were compared over time via linear mixed effects regression models. RESULTS: Adolescents assigned to collaborative care experienced clinically and statistically significant improvements in postconcussive symptoms in addition to functional gains at 6 months compared with controls. Six months after the baseline assessment, 13.0% of intervention patients and 41.7% of control patients reported high levels of postconcussive symptoms (P = .03), and 78% of intervention patients and 45.8% of control patients reported ≥50% reduction in depression symptoms (P = .02). No changes between groups were demonstrated in anxiety symptoms. CONCLUSIONS: Orchestrated efforts to systematically implement collaborative care treatment approaches for slow-to-recover adolescents may be useful given the reductions in postconcussive and co-occurring psychological symptoms in addition to improved quality of life.