Retrospective Examination of Peripubertal Return for Patients of Western Australia's Gender Diversity Service.

Purpose: Children far in advance of pubertal development may be deferred from further assessment for gender-affirming medical treatment until nearer puberty. It is vital that returning peripubertal patients are seen promptly to ensure time-sensitive assessment and provision of puberty suppression treatment where appropriate. This study investigates (1) how many referrals to the Child and Adolescent Health Service Gender Diversity Service at Perth Children's Hospital are deferred due to prepubertal status; and (2) how many deferred patients return peripubertally. Methods: A retrospective review of all closed referrals to the service was conducted to determine the frequency of prepubertal deferral and peripubertal re-referral. Results: Of 995 referrals received (2014 to 2020), 552 were closed. The reason for closure was determined for 548 referrals (99.3%). Prepubertal status was the second-most frequent reason for closure, and the most frequent for birth-registered males. Twenty-five percent of all deferred prepubertal patients returned peripubertally, before audit closure. A greater return frequency (55.6%) was estimated for those older than 13 years at audit closure. Conclusion: High rates of prepubertal referral indicate the importance of pediatric gender services in providing information, advice, and reassurance to concerned families. With increasing service demand, high rates of return peripubertally have implications for service planning to ensure that returning peripubertal patients are seen promptly for time-sensitive care. Frequency of peripubertal re-referral cannot, however, speak to the stability of trans identity or gender incongruence from childhood to adolescence. Clinics advising prepubertal deferral must proactively plan to ensure that sufficient clinical resources are reserved for this purpose.

Reidentification With Birth-Registered Sex in a Western Australian Pediatric Gender Clinic Cohort.

Importance: Some young people who identify as transgender and seek gender-affirming medical care subsequently reidentify with their sex registered at birth. Evidence regarding the frequency and characteristics of this experience is lacking. Objective: To determine the frequency of reidentification and explore associated characteristics in a pediatric gender clinic setting. Design, Setting, and Participants: This retrospective cohort study examined all referrals to the Child and Adolescent Health Service Gender Diversity Service at Perth Children's Hospital between January 1, 2014, and December 31, 2020. The Gender Diversity Service is the sole statewide specialist service in Western Australia that provides children and adolescents up to age 18 years with multidisciplinary assessment, information, support, and gender-affirming medical care. All closed referrals for this study were audited between May 1, 2021, and August 8, 2022. Exposure: Reidentification with birth-registered sex. Main Outcomes and Measures: The number of referrals closed due to reported reidentification with birth-registered sex was determined, as well as descriptives and frequencies of patient demographics (age, birth-registered sex), informant source, International Statistical Classification of Diseases, Tenth Revision gender-related diagnoses, pubertal status, any gender-affirming medical treatment received, and whether subsequent re-referrals were received. Results: Of 552 closed referrals during the study period, a reason for closure could be determined for 548 patients, including 211 birth-registered males (mean [SD] age, 13.88 [2.00] years) and 337 birth-registered females (mean [SD] age, 15.81 [2.22] years). Patients who reidentified with their birth-registered sex comprised 5.3% (29 of 548; 95% CI, 3.6%-7.5%) of all referral closures. Except for 2 patients, reidentification occurred before or during early stages of assessment (93.1%; 95% CI, 77.2%-99.2%). Two patients who reidentified with their birth-registered sex did so following initiation of puberty suppression or gender-affirming hormone treatment (1.0% of 196 patients who initiated any gender-affirming medical treatment; 95% CI, 0.1%-3.6%). Conclusions and Relevance: These findings from a pediatric gender clinic audit indicate that a small proportion of patients, and a very small proportion of those who initiated medical gender-affirming treatment, reidentified with their birth-registered sex during the study period. Longitudinal follow-up studies, including qualitative self-report, are required to understand different pathways of gender identity experience.

Pediatric Somatic Symptom and Related Disorders: Parent Acceptance Influences Recovery.

OBJECTIVES: To assess how clinicians discuss the diagnosis of somatic symptom and related disorders (SSRDs) in patients admitted to a children's hospital and explore the effect of parent and patient acceptance of the diagnosis on recovery. STUDY DESIGN: In this cross-sectional study, we reviewed the electronic medical records of pediatric admissions diagnosed with SSRD over 18 months. All diagnostic discussions with patients and families were analysed to identify concepts used by clinicians within these discussions and the extent of parent and patient acceptance of the diagnosis. Recovery status up to 12 months after diagnosis was also identified. Acceptance and recovery were categorized as "full," "partial," or "none." RESULTS: Ninety-five of 123 (77.2%) patients (median age 14.3 years, range 7.3-18.3) had at least 1 diagnostic discussion recorded. Clinical explanations within the diagnostic discussion spanned a variety of concepts, with the most common being a description of somatization (62%). Full parent acceptance of the diagnosis of SSRD was more likely when discussions involved two parents (P = .002). Full acceptance of the diagnosis by at least 1 parent was associated with complete functional recovery in their children (OR 8.94, 95% CI 2.24, 35.9, P = .002). In contrast, there was no significant association between full acceptance by patients and their recovery. CONCLUSION: The influence of parent acceptance of the diagnosis of SSRD reinforces the importance of therapeutic engagement with families, as well as with children and adolescents.

Somatic symptom and related disorders in a tertiary paediatric hospital: prevalence, reach and complexity.

Specialist paediatric services manage a variety of presentations of functional somatic symptoms. We aimed to describe the presentation and management of children and adolescents with somatic symptom and related disorders (SSRDs) requiring admission to a tertiary children's hospital with the objective of informing the development of a local clinical pathway. Patients admitted to any hospital department from May 2016 to November 2017 were identified through an electronic medical record (EMR)-linked diagnosis of SSRD. Each record was reviewed for demographic details and admission histories. The frequency of interspecialty consultations and multidisciplinary team (MDT) family meetings were recorded. One hundred twenty-three patients with SSRD were admitted on 203 occasions to 17 different departments. The median (range) age was 14.3 (7.3-18.3) years. Interspecialty consultations occurred in 84.6% of patients, and MDT family meetings occurred in 18.9% patients. SSRD was diagnosed as an inpatient in 79.9% patients, yet only 40.7% of patients, including those with multiple admissions, had SSRD recorded as a discharge diagnosis.Conclusion: Despite high rates of consultation with hospital teams, the frequency of MDT family meetings was low, and less than half the patients had SSRD documented at discharge. This affirms the value of developing a local clinical pathway. What is Known • Functional somatic symptoms are commonly seen in children and adolescents. • Few studies have explored the reach of functional somatic symptoms across a tertiary paediatric hospital; the majority of inpatient studies have focused on a limited set of disorders or cases referred to psychiatry departments. What is New • Symptoms that spanned multiple body systems were the most common presentation of SSRDs in admitted children and adolescents. • Somatic symptom disorders are less likely to be recorded as a discharge diagnosis compared with functional neurological symptom disorder.

Somatic Symptom Disorders in Adolescent Inpatients.

PURPOSE: There are only a few reports of adolescents with somatic disorders (SDs) whose symptoms are sufficiently severe to require hospital admission. The aim of this study was to describe the symptom profile, health service utilization, and outcome of adolescents with SDs admitted to a tertiary children's hospital. METHODS: A retrospective cohort study of all adolescents admitted to the Adolescent Medicine Unit of a tertiary children's hospital was undertaken from July 2013 to June 2014. In a two-stage process, medical records were examined to identify patients who met the diagnostic criteria for SD. Evidence of functional recovery was obtained for the period from 18 to 30 months after discharge and rated as completely recovered, partially recovered, or functionally disabled. RESULTS: A total of 60 admissions (53 patients, 79% female) were identified with SD, accounting for 12% of the unit's admissions and 2% of hospital admissions over 12 years old. Nearly half (45%) the presenting symptoms were neurological and 39% involved pain. In total, 20% of admissions were for complex symptoms involving multiple body systems. The majority (81%) of adolescents with follow-up documentation (n = 37) demonstrated complete or partial recovery. Patients whose families fully accepted the diagnosis were more likely to accept counseling following discharge (p < .001) and were almost 20 times more likely to have completely recovered compared to adolescents whose families partially accepted or rejected the diagnosis (odds ratio 17.36, p = .003). CONCLUSIONS: Hospitalized adolescents with SD utilize substantial resources due to the requirement for comprehensive assessment, including multidisciplinary communication. Recovery can be anticipated for the majority, especially if supported by parents.

Hyponatraemia and confusion in a 70-year-old female when bupropion was added to dothiepin and escitalopram.

OBJECTIVE: Hyponatraemia secondary to syndrome of inappropriate antidiuretic hormone secretion (SIADH) is a well-recorded adverse event observed in elderly patients on antidepressant treatment. Bupropion is an antidepressant agent usually reserved as an augmentation strategy for treatment-resistant depression. While hyponatraemia is not a documented side effect of bupropion, there are a few cases outside of Australia reported in the literature. We report on a case of hyponatraemia observed on bupropion initiation in a 70-year-old female patient with treatment-resistant depression. We present a discussion of the possible mechanism of action for the hyponatraemia observed in our case and prior reported cases. CONCLUSIONS: Our case and review of the available literature highlights the dangers of polypharmacy in the management of treatment-resistant depression. Our findings suggest that the association of hyponatraemia with bupropion in our and subsequent cases was likely the result of medication interaction and not a direct side effect of bupropion. Where bupropion is being used as an augmenting agent in the treatment of depression we would suggest checking of serum sodium prior to commencement of bupropion, and monitoring thereafter. This is especially important in elderly patients where other risk factors for hyponatraemia are likely to be present.

Depressive disorders among adolescents managed in a child and adolescent mental health service.

OBJECTIVE: The aims were to describe the prevalence and treatment of depressive disorders among case-managed adolescents attending a regional Child and Adolescent Mental Health Service (CAMHS). METHOD: An observational study was conducted in a regional CAMHS over a 3-month period. Clinicians recorded treatment of their case-managed adolescents aged 12-18 years at the end of each calendar month. The Health of the Nation Outcome Scale for Children and Adolescents (HoNOSCA) and Children's Global Assessment Scale (CGAS) were collected at the beginning of the study period or at entry into the service, and repeated at discharge from the service or at the conclusion of the study period. Adolescents also completed the Reynold's Adolescent Depression Scale, 2nd edition. RESULTS: Depressive disorders were the most common clinician diagnosis reported (22%). There was no statistically significant difference in treatment for depressed compared to non-depressed adolescents. There was a statistically significant improvement in both the HoNOSCA scores (p <0.001) and CGAS scores (p <0.001) for the whole sample. CONCLUSION: Treatment appeared to be the same in type for depressed compared to non-depressed adolescents case managed within CAMHS.