Behavioral Management of Children With Autism in the Emergency Department.

ABSTRACT: Autism spectrum disorder (ASD) is characterized by impaired social communication in conjunction with patterned behaviors. Often associated with emotional dysregulation, irritability, aggression, depression, and suicidality, ASD youth frequently present to the emergency department for behavioral and mental health evaluation. Psychiatric comorbidities, agitation, and depression are commonly encountered. During these visits, practitioners must thoughtfully consider organic etiologies for presenting symptoms, formulate plans to address risk of agitation, and understand how to effectively formulate disposition options in this patient population.

Seventeen-Year-Old Female With History of Depression Presented With Mania and Enuresis.

A 17-year-old girl with a history of depression was referred by her psychologist to the emergency department (ED) because of concerning behavioral changes for the past 2 weeks. She was engaging in erratic behaviors, including excessive baking, handling broken glass, mixing chemicals, and swimming alone while clothed. She denied any intention to harm herself or others. She was feeling energized in the morning despite only sleeping a few hours at night. She also urinated on herself the day before her ED visit. Her examination and preliminary testing findings in the ED were largely normal. Her initial presentation was concerning for a psychiatric etiology, such as new-onset bipolar disorder given previous history of depression and recent impulsive symptoms suggestive of mania. As her clinical course evolved and urinary incontinence continued, her definitive diagnosis was made by an interdisciplinary team that included child psychiatry and pediatric neurology.

Functional Neurological Symptom Disorder in Children and Adolescents within Medical Settings.

Pediatric functional neurological symptom disorder (FNSD or conversion disorder) is an often misunderstood but treatable condition that frequently presents in medical settings with unexplained symptoms. Although research regarding treatment of pediatric FNSD is increasing, it is still in its infancy and studies in pediatrics do not provide clear guidelines about which patients are most likely to benefit from various treatments. The role of pediatric psychologists may include consultation, assessment, treatment, program development, and providing education to patients, families, and healthcare colleagues in various disciplines. The purpose of this article is to provide a review of FNSD, discuss the importance of timely and accurate diagnosis, suggest how to present information to patients and families, and present options for treatment that are either supported by preliminary research or clinical experiences of the authors.

Collaborative and Integrated Care for Adolescent Depression.

Creative collaborative approaches are required to meet the demands of managing depression in youth. Primary care providers are well positioned to engage depressed youth and their families, yet often lack the training, access to psychiatric providers, and the reimbursement structure to support their efforts. Child and adolescent psychiatrists are encouraged to support pediatricians in establishing more robust systems to provide screening and effective treatment interventions, particularly for youth at higher risk. Several models of collaborative care are described, in addition to their emerging evidence-base, in an effort to disseminate evolving treatment strategies that can drive implementation of effective collaborative approaches.

Behavioral Health Care for Children Who Are Medically Hospitalized.

Youth admitted to pediatric hospitals face a variety of emotional challenges throughout their stay. In addition to feeling compromised by their acute medical condition, managing the requirements imposed by hospital care can intensify the potential for behavioral dysregulation. Even meeting basic behavioral expectations often requires children to be highly vulnerable, uncomfortable, and in pain, having to trust a parade of people routinely delivering aversive interventions, all in the context of overwhelmed caregivers. Behavioral medicine approaches are thus essential for supporting adaptive coping to optimize emotional and pathophysiological recovery. Clinical implementation requires integration of emotional and behavioral health initiatives into medical services across the broadest of disciplines with hospital-wide vigilance to safety risks. Providers can support behavioral resiliency by nurturing youth who are hospitalized to become increasingly active agents in their care while bolstering the consistency of their behavioral expectations through effective communication and an empathic treatment approach tailored to their socioemotional needs. [Pediatr Ann. 2018;47(8):e323-e327.].

Novel in silico multivariate mapping of intrinsic and anticorrelated connectivity to neurocognitive functional maps supports the maturational hypothesis of ADHD.

From childhood to adolescence, strengthened coupling in frontal, striatal and parieto-temporal regions associated with cognitive control, and increased anticorrelation between task-positive and task-negative circuits, subserve the reshaping of behavior. ADHD is a common condition peaking in adolescence and regressing in adulthood, with a wide variety of cognitive control deficits. Alternate hypotheses of ADHD emphasize lagging circuitry refinement versus categorical differences in network function. However, quantifying the individual circuit contributions to behavioral findings, and relative roles of maturational versus categorical effects, is challenging in vivo or in meta-analyses using task-based paradigms within the same pipeline, given the multiplicity of neurobehavioral functions implicated. To address this, we analyzed 46 positively-correlated and anticorrelated circuits in a multivariate model in resting-state data from 504 age- and gender-matched youth, and created a novel in silico method to map individual quantified effects to reverse inference maps of 8 neurocognitive functions consistently implicated in ADHD, as well as dopamine and hyperactivity. We identified only age- and gender-related effects in intrinsic connectivity, and found that maturational refinement of circuits in youth with ADHD occupied 3-10x more brain locations than in typical development, with the footprint, effect size and contribution of individual circuits varying substantially. Our analysis supports the maturational hypothesis of ADHD, suggesting lagging connectivity reorganization within specific subnetworks of fronto-parietal control, ventral attention, cingulo-opercular, temporo-limbic and cerebellar sub-networks contribute across neurocognitive findings present in this complex condition. We present the first analysis of anti-correlated connectivity in ADHD and suggest new directions for exploring residual and non-responsive symptoms.

Functional Neurological Symptom Disorder in Youth.

Functional neurological symptom disorder (FNSD) is characterized by motor or sensory impairments inconsistent with recognized neurologic conditions. Usually emerging in adolescence, somatic symptoms remain challenging for the physician to assess and treat. Also termed "conversion disorder," FNSD has been recently reconceptualized with greater diagnostic emphasis on positive neurologic findings while eliminating the requirement for a precipitating stressor. This has broadened the initial treatment emphasis from mandating psychotherapeutic engagement to a more collaborative model that requires open communication of neurologic findings and strives to align with families' perspectives. Severe disorders necessitate a unified treatment approach from several clinical specialties, including behavioral approaches, and pediatricians may play a central role in the management of youth with FNSD as well as their families. Treatment engagement can be facilitated by validating the distress of the patient, providing resources to address diagnostic questions and parental concerns, and implementing shared goals toward rapid return to self-efficacy. [Pediatr Ann. 2016;45(10):e356-e361.].

Use of a Dedicated, Non-Physician-led Mental Health Team to Reduce Pediatric Emergency Department Lengths of Stay.

OBJECTIVES: Utilization of emergency departments (EDs) for pediatric mental health (MH) complaints is increasing. These patients require more resources and have higher admission rates than those with nonpsychiatric complaints. METHODS: A multistage, multidisciplinary process to reduce length of stay (LOS) and improve the quality of care for patients with psychiatric complaints was performed at a tertiary care children's hospital's ED using Lean methodology. This process resulted in the implementation of a dedicated MH team, led by either a social worker or a psychiatric nurse, to evaluate patients, facilitate admissions, and arrange discharge planning. We conducted a retrospective, before-and-after study analyzing data 1 year before through 1 year after new process implementation (March 28, 2011). Our primary outcome was mean ED LOS. RESULTS: After process implementation there was a statistically significant decrease in mean ED LOS (332 minutes vs. 244 minutes, p < 0.001). An x-bar chart of mean LOS shows special cause variation. Significant decreases were seen in median ED LOS (225 minutes vs. 204 minutes, p = 0.001), security physical interventions (2.0% vs. 0.4%, p = 0.004), and restraint use (1.7% vs. 0.1%, p < 0.001). No significant change was observed in admission rate, 72-hour return rate, or patient elopement/agitation events. Staff surveys showed improved perception of patient satisfaction, process efficacy, and patient safety. CONCLUSIONS: Use of quality improvement methodology led to a redesign that was associated with a significant reduction in mean LOS of patients with psychiatric complaints and improved ED staff perception of care.

ASD: Psychopharmacologic Treatments and Neurophysiologic Underpinnings.

Autism Spectrum Disorder encompasses a range of neurodevelopmental disorders characterized by early deficits in social communication in addition to restricted and repetitive behaviors. Symptoms are increasingly understood to be associated with abnormalities in the coordination of neuronal assemblies responsible for processing information essential for early adaptive behaviors. Pharmacologic treatments carry evidence for clinically significant benefit of multiple impairing symptoms of ASD, yet these benefits are limited and range across a broad spectrum of medication classes, making it difficult to characterize associated neurochemical impairments. Increasing prevalence of both ASD and its pharmacologic management calls for greater understanding of the neurophysiologic basis of the disorder. This paper reviews underlying alterations in local brain regions and coordination of brain activation patterns during both resting state and task-related processes. We propose that new pharmacologic treatments may focus on realigning trajectories of network specialization across development by working in combination with behavioral treatments to enhance social and emotional learning by bolstering the impact of experience-induced plasticity on neuronal network connectivity.

Pharmacotherapy for anxiety disorders in children and adolescents.

Anxiety disorders comprise the most prevalent mental health disorders among children and adults. Psychotherapy and pharmacotherapy are effective in improving clinical impairments from anxiety disorders and maintaining these improvements. This article discusses how to obtain a suitable diagnosis for anxiety disorders in youth for implementing appropriate treatments, focusing on the evidence base for pharmacologic treatment. Clinical guidelines are discussed, including Food and Drug Administration indications and off-label use of medications, and considerations for special populations and youth with comorbidities are highlighted. Findings suggest moderate effectiveness of medication, particularly selective serotonin reuptake inhibitors, in the treatment of anxiety disorders in youth.

Pharmacotherapy for anxiety disorders in children and adolescents.

Anxiety disorders are the most common mental health diagnoses in youth, and carry risks for ongoing impairments and subsequent development of other psychiatric comorbidities into adulthood. This article discusses considerations for assessment and treatment of anxiety disorders in youth, with a focus on the evidence base of pharmacologic treatment and important clinical considerations to optimize care. We then briefly describe the impact of anxiety on neuronal elements of fear circuitry to highlight how treatments may ameliorate impairments through enhanced plasticity Overall, pharmacotherapy for anxiety disorders is effective in improving clinical symptoms, particularly in combination with psychotherapy. Response is typically seen within several weeks, yet longitudinal studies are limited. Selective serotonin reuptake inhibitors are thought to be relatively safe and effective for acute treatment of several classes of anxiety disorders in youth, with increasing evidence supporting the role of neuronal plasticity in recovery.

Anxiety disorders in children and adolescents.

Anxiety disorders are among the most common and functionally impairing mental health disorders to occur in childhood and adolescence. Primary care providers can expect to treat youth who have anxiety disorders frequently, and this article aims to provide the tools necessary to evaluate and manage patients who present with anxiety symptoms during childhood or adolescence. This article discusses the epidemiology of anxiety disorders, including the increased risk of future anxiety disorders and other mental health problems that are associated with having an anxiety disorder in childhood and adolescence. Next, the etiology of anxiety disorders is delineated, including discussion of genetic, cognitive-behavioral, physiological, and ecological explanatory models, and a summary of neurophysiological findings related to childhood and adolescent anxiety. Next, methods and tools are presented for assessment and treatment of anxiety disorders, with a focus on assessment and treatment that can be initiated in a primary care setting. Evidence-based therapy and medication interventions are reviewed. The article includes a focus on developmental differences in symptom presentation, assessment techniques, and treatment strategies, such that a primary care provider will have tools for working with the wide age range in their practices: preschool children through adolescents. We conclude that many effective intervention strategies exist, and their improving availability and ease of use makes it both critical and achievable for children and adolescents with anxiety disorders to be accurately diagnosed and treated with evidence-based medication and therapy.

Pathology of layer V pyramidal neurons in the prefrontal cortex of patients with schizophrenia.

OBJECTIVE: Morphological indications of abnormal circuitry have been detected in the prefrontal neuropil of patients with schizophrenia. The authors tested the hypothesis that schizophrenia is associated with smaller dendritic field size in layer V pyramidal neurons in the prefrontal cortex. METHOD: Tissue from area 10 with a mean postmortem interval of 5.7 hours was obtained from 15 subjects with chronic schizophrenia and 18 normal comparison subjects. After Golgi impregnation, basilar dendritic field size was estimated for layer V pyramidal neurons by ring intersection analysis. RESULTS: The schizophrenia subjects had 40% fewer total ring intersections per neuron than comparison subjects. Smaller basilar dendritic field size was evident in proximal and distal branches. CONCLUSIONS: These results indicate that abnormal dendritic outgrowth or maintenance contributes to reduced neuropil and prefrontal connectivity in schizophrenia. Short postmortem intervals and resulting high tissue quality suggest that these dystrophic changes reflect schizophrenia pathology rather than postmortem artifact.

Experience effects on brain development: possible contributions to psychopathology.

Researchers and clinicians are increasingly recognizing that psychological and psychiatric disorders are often developmentally progressive, and that diagnosis often represents a point along that progression that is defined largely by our abilities to detect symptoms. As a result, strategies that guide our searches for the root causes and etiologies of these disorders are beginning to change. This review describes interactions between genetics and experience that influence the development of psychopathologies. Following a discussion of normal brain development that highlights how specific cellular processes may be targeted by genetic or environmental factors, we focus on four disorders whose origins range from genetic (fragile X syndrome) to environmental (fetal alcohol syndrome) or a mixture of both factors (depression and schizophrenia). C.H. Waddington's canalization model (slightly modified) is used as a tool to conceptualize the interactive influences of genetics and experience in the development of these psychopathologies. Although this model was originally proposed to describe the 'canalizing' role of genetics in promoting normative development, it serves here to help visualize, for example, the effects of adverse (stressful) experience in the kindling model of depression, and the multiple etiologies that may underlie the development of schizophrenia. Waddington's model is also useful in understanding the canalizing influence of experience-based therapeutic approaches, which also likely bring about 'organic' changes in the brain. Finally, in light of increased evidence for the role of experience in the development and treatment of psychopathologies, we suggest that future strategies for identifying the underlying causes of these disorders be based less on the mechanisms of action of effective pharmacological treatments, and more on increased knowledge of the brain's cellular mechanisms of plastic change.