Outcomes for young people in out of home care accessing tiered mental health services in Sydney, Australia.

Young people in OOHC have complex mental health concerns, therefore the South Western Sydney Local Health District (SWSLHD) has trialled a tiered model of mental health care. Under this model the OOHC mental health team (OOHC-MHT) provides specialist tier four service delivery for those with the most severe, intense mental health needs. OOHC consumers with a reduced level of severity access services at a tier three centre-based iCAMHS. This study aims to understand the characteristics of young people in OOHC accessing different service provision options in Sydney, Australia. Sixty-six OOHC consumers 8-17 years accessing mental health services across SWSLHD from January 2020-December 2021 participated in the study. Group differences in OOHC-MHT and iCAMHS outcome measures were compared. HoNOSCA scores were significantly worse for OOHC-MHT than iCAMHS, indicating more severe psychopathology for OOHC-MHT at baseline. In OOHC-MHT, HoNOSCA decreased significantly from admission to discharge and scores on the CGAS increased significantly, indicating significant improvements in psychopathology and functioning. In the iCAMHS group scores on the HoNOSCA significantly decreased indicating improved psychopathology over this period. These findings support a tiered model of service delivery for OOHC consumers, with this tailored level of care resulting in significantly improved outcomes across a range of complexity.

A Study Protocol for Safeguards Child and Adolescent Mental Health Rapid Response Teams ('Safeguards Teams') Service.

Introduction: As the number of children and young people (CYP) presenting to Emergency Departments (ED) with acute mental health (MH) presentations has been steadily increasing over the years and further accelerated by the pandemic, there is an urgent need to develop and evaluate innovative solutions to respond to this growing challenge. Description: The evaluation of the Safeguards Teams Program (STP) aims to ascertain the impact, implementation and economic analysis of this acute rapid response recovery-focused, trauma-informed assessment and brief intervention for CYP (aged 0-17 years) presenting in acute MH crisis and their families/caregivers.The STP will support consumers (patients) and their families/caregivers to navigate the complex and often fragmented child and adolescent MH services (CAMHS) landscape, thereby avoiding unnecessary ED presentations or hospitalisations, and facilitating comprehensive assessment and appropriate care pathways for those who present in crisis. Discussion: The STP is expected to provide CYP in MH crisis and their support networks with early access to evidence-based specialist care at the right place and time. Conclusion: Implementation of the STP will assist with identifying and addressing gaps in acute care for CYP and provide the necessary evidence for service redesign in collaboration with consumers, service providers and other stakeholders.

Screening for Media Use in the Emergency Department Among Young Australians: Cross-sectional Study.

BACKGROUND: Research on problematic internet use has largely adhered to addiction paradigms, possibly impeding the identification of specific internet behaviors related to psychopathology. This study presents a novel approach to screening for specific problematic internet behaviors by using a new measure, the emergency department media use screener (EDMUS). OBJECTIVE: The purpose of this study was to identify patterns of internet use in young people presenting with mental health concerns to the emergency department (ED), ascertain associations with their mental health, and evaluate whether the EDMUS can be used to predict subsequent ED presentations within 3 months. METHODS: This cross-sectional retrospective study of Australian young people (N=149, aged 11-25 years; female: n=92, 61.7%) sought to use the EDMUS, a 24-item questionnaire, to identify problematic internet behaviors, including accessing or posting prosuicidal or proeating disorder content, cyberbullying, and inappropriate digital content. Data on each person's mental health were extracted from electronic medical records to look for associations with EDMUS responses and ED re-presentation over 3 months. EDMUS items were grouped into clusters for analysis using chi-square tests, binary logistic regression, and path analyses. RESULTS: Sharing suicidal digital content was the most common problematic internet use pattern identified by the EDMUS. However, this did not correlate with having a prior mental health diagnosis or predict readmission. Most participants had families with a concern for their internet use; however, this was less likely in participants with a diagnosis of personality disorder. Diagnoses of personality disorder or posttraumatic stress disorder were independent predictors of readmission (P=.003; P=.048). CONCLUSIONS: Although a history of complex psychopathology increases the likelihood of subsequent ED presentations, its links to internet use-related behaviors are still unclear. The EDMUS has potential for identifying young people who are most vulnerable to problematic internet behaviors and offers the opportunity for early intervention and potential prevention of more entrenched difficulties.

Helping Young People in Out-of-Home Care: Basic Elements.

Children and adolescents (young people) who experience maltreatment early in life and are subsequently placed in out-of-home care (OOHC) are specifically at risk for poor mental health outcomes.1 Although rates vary by survey and location, up to half of these young people have clinical-level mental health difficulties, and another 20% to 25% have difficulties approaching clinical significance.2 These difficulties are characterized by high symptom complexity and severity, and include maltreatment-related mental health symptoms.2 Many young people in OOHC are difficult to engage with and retain in treatment, compounded by a lack of specialized mental health services3 and a history of problematic social interactions with supports.4 They are often reluctant to seek help because of stigmatization and confidentiality concerns, limited opportunities for decision making, service inaccessibility, distrust of mental health services, and their perception that professionals do not understand their circumstances.5 We propose 6 clinical practice modifications for mental health services working with young people in OOHC to enhance therapeutic engagement and to maximize their therapeutic outcomes.

An intensive form of trauma focused cognitive behaviour therapy in an acute adolescent inpatient unit: An uncontrolled open trial.

PURPOSE: Post-traumatic stress disorder (PTSD) rates among hospitalised adolescents are between 21% and 32%, and there is a lack of evidence-based interventions for this population. Trauma-focused cognitive behaviour therapy (TF-CBT) is an evidence-based intervention for children and adolescents with PTSD; however, it has not been implemented in an acute adolescent inpatient unit. This study examines the implementation of an intensive form of TF-CBT in an adolescent inpatient unit. METHOD: An uncontrolled open trail study was conducted where 15 adolescents diagnosed with PTSD were treated with an intensive form of TF-CBT. Measures used were the University of California, Los Angeles' (UCLA) PTSD Reaction Index for Diagnostic and Statistical Manual of Mental Disorders (4th ed., Adolescent Version; DSM-IV-Adolescent Version), the National Stressful Events Survey PTSD Short Scale (NSESSS) and the Children's Global Assessment Scale (CGAS). RESULTS: Adolescents received an average of nine sessions of TF-CBT over a period of 28 days. The average NSESSS on admission was 23.73 and 8.27 at discharge; the CGAS average on admission was 19 and on discharge was 48.7; both were statistically significant changes. CONCLUSION: Preliminary findings support the use of an intensive form of TF-CBT to treat adolescents with PTSD admitted to acute adolescent inpatient units indicating the need for further research in this area.

Acute treatment of mania in children and adolescents.

PURPOSE OF REVIEW: To examine critically data concerning the efficacy and safety of acute treatments for mania in children and adolescents, in the light of considerable recent emergent evidence. RECENT FINDINGS: We found consistent evidence favouring the use of second-generation antipsychotics (SGAs), limited evidence favouring the use of combinations of SGA with a mood stabilizer, and no evidence supporting the use of mood stabilizer monotherapy in this context. Various SGA drugs are not clearly separated in terms of efficacy, but do differ in their side-effect profiles. There are insufficient data to comment on the benefit of alternative treatments, psychological treatments and electroconvulsive therapy. The presence of common comorbidities has an inconsistent influence on clinical effectiveness. SUMMARY: First-line treatment for mania in children and adolescents is a SGA, with combination therapies offering no clear advantage. Gaps in our knowledge remain about expected time to recovery, and when to augment or change treatment when there is lack of effect.

Do we really know how to treat a child with bipolar disorder or one with severe mood dysregulation? Is there a magic bullet?

Background. Despite controversy, bipolar disorder (BD) is being increasingly diagnosed in under 18s. There is scant information regarding its treatment and uncertainty regarding the status of "severe mood dysregulation (SMD)" and how it overlaps with BD. This article collates available research on treatment of BD in under 18s and explores the status of SMD. Methods. Literature on treatment of BD in under 18s and on SMD were identified using major search engines; these were then collated and reviewed. Results. Some markers have been proposed to differentiate BD from disruptive behaviour disorders (DBD) in children. Pharmacotherapy restricted to short-term trials of mood-stabilizers and atypical-antipsychotics show mixed results. Data on maintenance treatment and non-pharmacological interventions are scant. It is unclear whether SMD is an independent disorder or an early manifestation of another disorder. Conclusions. Valproate, lithium, risperidone, olanzapine, aripiprazole and quetiapine remain first line treatments for acute episodes in the under 18s with BD. Their efficacy in maintenance treatment remains unclear. There is no validated treatment for SMD. It is likely that some children who are currently diagnosed with BD and DBD and possibly most children currently diagnosed with SMD will be subsumed under the proposed category in the DSM V of disruptive mood dysregulation disorder with dysphoria.

Why do adolescents return to an acute psychiatric unit?

OBJECTIVE: The aim of this paper is to determine potentially modifiable factors associated with the high proportion of patients who are readmitted to adolescent psychiatric units. METHOD: The case notes of 112 adolescents admitted over 1 year to an acute adolescent psychiatry unit were reviewed. Socio-demographic and clinical variables were compared between those who were readmitted over a 12-month period post discharge and those who were not. RESULTS: The readmission rate over a 12-month period was 31%. Males were significantly more likely to be readmitted. No other statistically significant predictors of readmission were identified. There was a trend towards readmission for those with bipolar disorder and a trend away from readmission for those with adjustment disorders. A history of sexual abuse and cluster B personality traits were significantly related to a history of previous admission, but not with subsequent readmission. CONCLUSIONS: Readmission is influenced by a number of factors, which may not be easily identified by a chart review. Prospective studies which follow-up adolescents for several years after discharge are needed.

Integration of child mental health services to primary care: challenges and opportunities.

In the first decade of this new millennium, health professionals are faced with a rapidly increasing need for child mental health services and changing models of service provision. This gives us a unique opportunity to make provision for services where it has not been available before, or to improve upon the existing services. This paper examines the challenges and opportunities while attempting to integrate child mental health services to primary care.

Do cognitive deficits in juvenile bipolar disorder persist into adulthood?

This article reviews neuropsychological research in adults with bipolar disorder and compares the findings with emergent data on neuropsychological function in juvenile bipolar disorder. Despite a recent surge of interest in childhood onset bipolar disorder, there remains a scarcity of neuropsychological literature investigating this population. From the study of adult bipolar disorder a substantial body of literature points to the existence of trait deficits in verbal and executive function that are detectable even during euthymia. In the nascent literature on neuropsychology in early onset bipolar, there is growing evidence to suggest that some of the deficits apparent in adults are also discernible in adolescents. Precise knowledge about when, how, and why these deficits appear requires future research of prodromal changes in neurocognition in childhood and adolescent bipolar disorder.

Comparison of diagnostic guidelines for juvenile bipolar disorder.

The purpose of the present paper was to compare currently available diagnostic guidelines for juvenile bipolar disorder with respect to utility in research and clinical practice. A systematic search of psychiatric, medical and psychological databases was conducted using the terms 'juvenile bipolar disorder', 'paediatric bipolar disorder' and 'guidelines'. Three main sets of guidelines issued by the National Institute of Health and Clinical Excellence (UK), The National Institute of Mental Health (USA) and Child Psychiatric Workshop (USA) were found. There were key differences in the recommendations made by each regarding the diagnosis and symptomatic presentation of juvenile bipolar disorder. Although the diagnosis of juvenile bipolar disorder is gaining increased recognition, its definition remains controversial. It is recommended that clinicians and researchers need to develop diagnostic guidelines that have clinical salience and can be used for future research by incorporating key features of those that are currently available.

A prospective 4-5 year follow-up of juvenile onset bipolar disorder.

OBJECTIVE: Data on outcome of juvenile onset bipolar disorder is limited. This study examined the course and outcome of bipolar disorder and assessed the rate and predictors of recovery and relapse in a sample of children and adolescents over a 4-5 year period. METHOD: Twenty-five consecutively ascertained subjects (9-16 years) with a diagnosis of mania (mean duration at intake of 4.6 +/- 3.9 weeks), were comprehensively assessed at baseline and at 6-month intervals using the Diagnostic Interview for Children and Adolescents (revised) (DICA-R), the Missouri Assessment for Genetic Interview in Children (MAGIC), the Young's Mania Rating Scale (YMRS) and the Children's Global Assessment (CGAS). The study phenotype required DSM-IV criteria of mania with elation and/or grandiosity as a criterion to distinguish them from those with attention deficit hyperactivity disorder. Subjects received the standard treatment as prescribed by their primary treating team. RESULTS: During the course of the study period, all 25 subjects (100%) recovered from the index episode. The mean time to recovery was 44 +/- 46 days. The mean duration of follow-up was 51.6 +/- 4.1 months. Sixteen subjects (64%) relapsed after a mean period of 18 +/- 16.4 months. A majority of the relapses (72.4%) were while the subjects were on treatment. CONCLUSIONS: Acute juvenile onset mania has a high rate of recovery and low chronicity. The relapse rate was high and most of these occurred in the first 3 years despite aggressive prophylactic treatment. The effectiveness of currently used thymoleptics, in particular lithium, in the prophylaxis of juvenile bipolar disorder needs to be evaluated in controlled studies.