Clinical Outcomes Following Acute Residential Psychiatric Treatment in Transgender and Gender Diverse Adolescents.

Importance: Transgender and gender diverse (TGD) individuals, who have a gender identity that differs from their sex assigned at birth, are at increased risk of mental health problems, including depression, anxiety, self-injurious behavior, and suicidality, relative to cisgender peers. Objective: To examine mental health outcomes among TGD vs cisgender adolescents in residential treatment. Design, Setting, and Participants: This cohort study's longitudinal design was used to compare groups at treatment entry and discharge, and 1-month postdischarge follow-up. The setting was an adolescent acute residential treatment program for psychiatric disorders. Participants were TGD or cisgender adolescents enrolled in the treatment program. Statistical analysis was performed October 2019 to March 2021. Exposure: Adolescents participated in a 2-week acute residential treatment program for psychiatric disorders. Main Outcomes and Measures: Primary outcomes were depressive (the Center for Epidemiologic Studies Depression Scale [CES-D]) and anxiety (the Multidimensional Anxiety Scale for Children [MASC]) symptoms, and emotional dysregulation (the Difficulties in Emotion Regulation Scale [DERS]), measured at treatment entry and discharge, and postdischarge follow-up. Age of depression onset, suicidality, self-injury, and childhood trauma also were assessed at treatment entry. Results: Of 200 adolescent participants who completed treatment entry and discharge assessments, the mean (SD) age was 16.2 (1.5) years; 109 reported being assigned female at birth (54.5%), 35 were TGD (17.5%), and 66 (49.3%) completed 1-month follow-up. TGD participants had an earlier mean (SD) age of depression onset (TGD: 10.8 [2.4] years vs cisgender: 11.9 [2.3] years; difference: 1.07 years; 95% CI, 0.14-2.01 years; P = .02), higher mean (SD) suicidality scores (TGD: 44.4 [23.1] vs cisgender: 28.5 [25.4]; difference: 16.0; 95% CI, 6.4-25.5; P = .001), more self-injurious behavior (mean [SD] RBQ-A score for TGD: 3.1 [2.5] vs cisgender: 1.7 [1.9]; difference: 1.42; 95% CI, 0.69-2.21; P = .001) and more childhood trauma (eg, mean [SD] CTQ-SF score for emotional abuse in TGD: 12.7 [5.4] vs cisgender: 9.8 [4.7]; difference: 2.85; 95% CI, 1.06-4.64; P = .002). The TGD group also had higher symptom scores (CES-D mean difference: 7.69; 95% CI, 3.30 to 12.08; P < .001; MASC mean difference: 7.56; 95% CI, 0.46 to 14.66; P = .04; and DERS mean difference: 18.43; 95% CI, 8.39 to 28.47; P < .001). Symptom scores were significantly higher at entry vs discharge (CES-D mean difference, -12.16; 95% CI, -14.50 to -9.80; P < .001; MASC mean difference: -3.79; 95% CI, -6.16 to -1.42; P = .02; and DERS mean difference: -6.37; 95% CI, -10.80 to -1.94; P = .05) and follow-up (CES-D mean difference: -9.69; 95% CI, -13.0 to -6.42; P < .001; MASC mean difference: -6.92; 95% CI, -10.25 to -3.59; P < .001; and DERS mean difference: -12.47; 95% CI, -18.68 to -6.26; P < .001). Conclusions and Relevance: This cohort study found mental health disparities in TGD youth relative to cisgender youth, with worse scores observed across assessment time points. For all participants, primary clinical outcome measures were significantly lower at treatment discharge than at entry, with no significant differences between discharge and 1-month follow-up. Given the substantial degree of mental health disparities reported in TGD individuals, these findings warrant focused clinical attention to optimize treatment outcomes in gender minority populations.

Associations between parental distress and pediatric anxiety and obsessive-compulsive disorder treatment outcomes.

This study investigated whether an intensive group-based cognitive-behavioral therapy program with family involvement for children with anxiety disorders and obsessive-compulsive disorder could help reduce parental distress by addressing the larger family system. This study also examined associations between parental distress and parent-reported child outcomes of treatment. Two hundred ninety-nine children and adolescents, ages 6-19, who were patients in the intensive treatment program and their caregivers participated in this intervention-based study. Parents reported significant reductions in their own distress from admission to discharge, and greater reductions in parent-reported distress predicted greater reductions in parents' reports of their children's anxiety symptoms and the degree of child functional impairment. Higher levels of parent-reported parent mental health symptoms at children's admission and at discharge were associated with poorer levels of functioning in children at discharge. Parents' mental health symptoms may play a critical role in children and adolescents' treatment outcomes and therefore may need to be a separate treatment target.

The impact of intensive treatment for pediatric anxiety and obsessive-compulsive disorder on daily functioning.

This study investigated whether intensive group-based cognitive-behavioral therapy (CBT) with family involvement for children with anxiety disorders and obsessive-compulsive disorder (OCD) would facilitate children's return to their daily routines. The focus shifted from the usual emphasis on remission to an improvement in functioning. The aim was to capture potentially missed gains when children pursue their fears and engage in more adaptive behaviors as these efforts may result in ongoing symptoms. Two hundred twelve children and adolescents aged 8-19 years old, who were patients in an intensive outpatient group-based treatment program at an academic hospital, participated in this study. Results indicated that both children and their parents endorsed significant improvement in children's functioning from admission to discharge. Symptom reduction was assessed for reference, and both children and parents reported significant decreases in child anxiety symptoms from admission to discharge, and children endorsed decreases in their comorbid depression symptoms. Short-term group-based intensive treatment in a clinical setting may help children return to their daily activities quickly.

Promoting Mental Health and Wellness in Youth Through Physical Activity, Nutrition, and Sleep.

The medical benefits to youth conferred by physical activity, balanced nutrition, and quality sleep have been increasingly encouraged by medical and mental health providers. Emerging evidence continues to reveal benefits for youth mental health and well-being, including for youth with psychiatric disorders. This evidence seems multifactorial through both neurobiological and psychosocial systems, with common mechanisms present between physical activity, nutrition, and sleep. This article reviews the benefits of optimizing physical activity, nutrition, and sleep; how to assess these lifestyle domains with patients and their parents; and appropriate interventions to optimize well-being in youth.

Being present at school: implementing mindfulness in schools.

Developmentally sensitive efforts to help students learn, practice, and regularly use mindfulness tactics easily and readily in and beyond the classroom are important to help them manage future stresses. Mindfulness emphasizes consciously focusing the mind in the present moment, purposefully, without judgment or attachment. Meditation extends this to setting aside time and places to practice mindfulness, and additionally, yoga includes physical postures and breathing techniques that enhance mindfulness and meditation. Several mindfulness programs and techniques have been applied in schools, with positive benefits reported. Some elements of these programs require modifications to be sensitive to the developmental state of the children receiving mindfulness training.

Educational impacts of the social and emotional brain.

Advances in neuroscience related to social and emotional development have significant implications for educational practice. The human brain cannot fully dissociate cognitive from emotional events, and therefore educational programming that recognizes the importance of social-emotional development also facilitates academic achievement. The ideal learning environment encourages the development of social-emotional and academic neuronal pathways. Taking advantage of the emerging understanding of the developing brain offers opportunities to facilitate greater academic gains.

Pharmacologic treatments for pediatric bipolar disorder: a review and meta-analysis.

OBJECTIVE: A growing body of literature has documented pediatric bipolar disorder to be a severely impairing form of psychopathology. However, concerns remain as to the inadequacy of the extant literature on its pharmacotherapy. Furthermore, treatment studies have not been systematically reviewed for treatment effects on core and associated symptoms. Thus, a systematic evaluation and synthesis of the available literature on the efficacy of antimanic pharmacotherapy for pediatric bipolar disorder on symptoms of mania, depression, and attention-deficit/hyperactivity disorder was undertaken. METHOD: A systematic search was conducted through PubMed from 1989 through 2010 for open-label and randomized controlled trials published in English on the pharmacotherapy of pediatric mania. RESULTS: There have been 46 open-label (n = 29) and randomized (n = 17) clinical trials of antimanic agents in pediatric bipolar disorder encompassing 2,666 subjects that evaluated a range of therapeutic agents, including traditional mood stabilizers, other anticonvulsants, second-generation antipsychotics, and naturopathic compounds. This literature has documented that the available armamentarium has different levels of efficacy in the treatment of pediatric mania. Because all psychotropic classes are associated with important adverse effects, a careful risk-benefit analysis is warranted when initiating pharmacologic treatment with any of these compounds. In the limited data available, the effects of antimanic agents on depression and symptoms of attention-deficit/hyperactivity disorder have been, in general, modest. Few studies have evaluated the effects of antimanic agents in children younger than 10 years. CONCLUSIONS: A substantial body of scientific literature has evaluated the safety and efficacy of various medicines and drug classes in the treatment of mania in pediatric bipolar disorder. More work is needed to assess the safety and efficacy of psychotropic drugs in children younger than 10 years, to further evaluate the efficacy of naturopathic compounds, and to further evaluate the effects of antimanic treatments for the management of depression and attention-deficit/hyperactivity disorder.

Prescribing patterns for treatment of pediatric bipolar disorder in a specialty clinic.

OBJECTIVE: The aim of this study was to describe prescribing practices in the treatment of pediatric bipolar disorder in a university practice setting. METHOD: A retrospective chart review was performed on 53 youths diagnosed using Diagnostic and Statistical Manual of Mental Disorders, 4(th) edition (DSM-IV), criteria with bipolar spectrum disorder under the active care of child psychiatrists practicing in a pediatric psychopharmacology specialty clinic. Current medications, doses, and related adverse events were recorded. Clinicians were asked to provide a target disorder (bipolar mania/mixed state, depression, attention deficit hyperactivity disorder [ADHD], or anxiety) for each medication to the best of their ability. The Clinical Global Impressions-Severity (CGI-S) scale was used to measure severity of each disorder before treatment and the Clinical Global Impressions-Improvement (CGI-I) was used to quantify the magnitude of improvement with treatment. Meaningful improvement of the disorder was defined by CGI-I score of 1 or 2. RESULTS: The mean number of psychotropic medications per patient was 3.0 +/- 1.6. A total of 68% of patients were treated for co-morbid disorders; 23% of patients were treated with monotherapy, primarily with second-generation antipsychotics. Mania improved in 80% of cases, mixed state improved in 57% of cases, ADHD improved in 56% of cases, anxiety improved in 61% of cases, and depression improved in 90% of cases. CONCLUSION: The management of pediatric bipolar disorder often requires multiple medications. For the treatment of mania/mixed states, clinicians prescribed second-generation antipsychotics more frequently than mood stabilizers, especially in the context of monotherapy. Co-morbidity was a frequent problem with moderate success obtained with combined pharmacotherapy approaches. Further psychosocial strategies to augment pharmacotherapy may improve outcome while reducing the medication burden in pediatric bipolar disorder.

Alternative treatments in pediatric bipolar disorder.

There has been growing interest in the use of complementary and alternative treatments in pediatric bipolar disorder (BPD). There are limited data, however, regarding the safety and efficacy of these treatments. This article discusses select complementary and alternative treatments that have been considered for use in pediatric BPD and/or depression, including omega-3-fatty acids, inositol, St. John's wort, SAMe, melatonin, lecithin, and acupuncture. Background information, reference to available adult and pediatric data, proposed mechanisms of action, dosing, side effects, and precautions of these treatments are included. Across the board, more research is necessary and warranted regarding the long-term safety and efficacy of available complementary and alternative treatments for the management of pediatric BPD.