Child and Adolescent Mental Health Boarding Without Transfer.

This letter reports a study initiated after concern about the large number of children boarding in the hospital during the COVID-19 pandemic. Children with behavioral or emotional complaints presented to the emergency department (ED). There the decision was made when indicated to either admit them to an inpatient medical unit for stabilization or board them in the ED while waiting for a bed to become available. The Joint Commission defines boarding as "the practice of holding patients in the emergency department or another temporary location after the decision to admit or transfer has been made" and recommends boarding duration of less than 4 hours.1 Mental health boarding reduces the number of ED and inpatient beds available for medical and surgical care while delaying psychiatric care.2.

Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents With Major and Persistent Depressive Disorders.

OBJECTIVE: To enhance the quality of care and clinical outcomes for children and adolescents with major depressive disorder (MDD) and persistent depressive disorder (PDD). The aims are as follows: (1) to summarize empirically based guidance about the psychosocial and psychopharmacologic treatment of MDD and PDD in children and adolescents; and (2) to summarize expert-based guidance about the assessment of these disorders as an integral part of treatment, and the implementation of empirically based treatments for these disorders in clinical practice. METHOD: Statements about the treatment of MDD and PDD are based upon empirical evidence derived from a critical systematic review of the scientific literature conducted by the Research Triangle Institute International-University of North Carolina at Chapel Hill (RTI-UNC) Evidence-based Practice Center under contract with the Agency for Healthcare Research and Quality (AHRQ). Evidence from meta-analyses published since the AHRQ/RTI-UNC review is also presented to support or refute the AHRQ findings. Guidance about the assessment and clinical implementation of treatments for MDD and PDD is informed by expert opinion and consensus as presented in previously published clinical practice guidelines, chapters in leading textbooks of child and adolescent psychiatry, the DSM-5-TR, and government-affiliated prescription drug information websites. RESULTS: Psychotherapy (specifically, cognitive-behavioral and interpersonal therapies) and selective serotonin reuptake inhibitor (SSRI) medication have some rigorous (randomized controlled trials, meta-analyses) empirical support as treatment options. Because effective treatment outcomes are predicated in part upon accuracy of the diagnosis, depth of the clinical formulation, and breadth of the treatment plan, comprehensive, evidence-based assessment may enhance evidence-based treatment outcomes. CONCLUSION: Disproportionate to the magnitude of the problem, there are significant limitations in the quality and quantity of rigorous empirical support for the etiology, assessment, and treatment of depression in children and adolescents. In the context of a protracted severe shortage of child and adolescent-trained behavioral health specialists, the demonstration of convenient, efficient, cost-effective, and user-friendly delivery mechanisms for safe and effective treatment of MDD and PDD is a key research need. Other research priorities include the sequencing and comparative effectiveness of depression treatments, delineation of treatment mediators and moderators, effective approaches to treatment nonresponders and disorder relapse/recurrence, long-term effects and degree of suicide risk with SSRI use, and the discovery of novel pharmacologic or interventional treatments.

Disruptive Behavior Disorders and ADHD: A Problem-Based Learning Activity for Psychiatry Clerkship Students.

INTRODUCTION: Clinicians are challenged when differentiating the symptoms of attention deficit hyperactivity disorder from those of disruptive behavior disorders such as oppositional defiant disorder and conduct disorder, as many of the core symptoms overlap. Without a correct diagnosis, it is difficult to create an effective treatment plan. This progressive disclosure case was developed with the intention of helping medical students learn the process of clinical evaluation. The purpose of this resource is to provide a lesson plan to teach intermediate/advanced learners how to systematically approach a case with symptoms of disruptive behavior and attention and focus problems in order to improve their ability to establish the correct diagnosis. METHODS: Students were assigned readings, including relevant sections of the Diagnostic and Statistical Manual of Mental Disorders (fifth edition) and a textbook chapter. During a 1-hour class, a child psychiatrist facilitated students in the progressive disclosure case. The learning process included a pre- and posttest. RESULTS: Students positively perceived the emphasis of important points and showed increased motivation to learn more. Participant evaluations overall were positive, although some students still preferred learning from straight lectures. DISCUSSION: Feedback led to modifications of the pre- and posttests to reflect a greater emphasis on factual material. Progressive disclosure cases can be used to facilitate structured exposure to clinical topics in child and adolescent psychiatry.

A+KIDS, a web-based antipsychotic registry for North Carolina youths: an alternative to prior authorization.

OBJECTIVE: The rise in use of antipsychotics among U.S. children is well documented. Compliance rates with current safety-monitoring guidelines are low. In response, the North Carolina Division of Medical Assistance established the Antipsychotics-Keeping It Documented for Safety (A+KIDS) registry. The initial objectives of the project were to successfully establish a Web-based safety registry and to obtain and evaluate clinical information derived from the registry. METHODS: In April 2011, A+KIDS began asking prescribers of antipsychotics for children age 12 and under to respond to a set of questions regarding dose, indication, and usage history. Antipsychotic registrations were examined by linking North Carolina Medicaid prescription claims to registry entries. Prescribers were classified into different types, and the number of patients and registrations per prescriber were examined. RESULTS: In the initial six months, 730 prescribers registered 5,532 patients, 19% below age seven. By month 6 of the registry, 72% of all fills were registered with the program. Top diagnosis groups for registry patients were unspecified mood disorders, autism spectrum disorders, and disruptive behavior disorders. Top target symptoms were aggression (48%), irritability (19%), and impulsivity (11%). Psychosis accounted for 5% of the target symptoms. Twenty-eight percent of children were receiving no form of psychotherapy. Twenty-five percent of all A+KIDS prescribers were responsible for 81% of the registrations. CONCLUSIONS: The A+KIDS registry initiative has been successful, as measured by rapid uptake, and is providing clinical information not available from claims data alone. Future efforts will allow for detailed examinations of antipsychotic utilization and further safety improvement.

Use of telepsychiatry to improve care for people with mental illness in rural North Carolina.

Telehealth improves access to medical services, especially for people living in rural areas. In North Carolina, the advantages of telepsychiatry also go beyond improving access. This article describes a diverse program of telehealth and telepsychiatric service delivery and discusses its advantages and disadvantages.

Xenotropic murine leukemia virus-related virus-associated chronic fatigue syndrome reveals a distinct inflammatory signature.

BACKGROUND: The recent identification of xenotropic murine leukemia virus-related virus (XMRV) in the blood of patients with chronic fatigue syndrome (CFS) establishes that a retrovirus may play a role in the pathology in this disease. Knowledge of the immune response might lead to a better understanding of the role XMRV plays in this syndrome. Our objective was to investigate the cytokine and chemokine response in XMRV-associated CFS. MATERIALS AND METHODS: Using Luminex multi-analyte profiling technology, we measured cytokine and chemokine values in the plasma of XMRV-infected CFS patients and compared these data to those of healthy controls. Analysis was performed using the Gene Expression Pattern Analysis Suite and the Random Forest tree classification algorithm. RESULTS: This study identifies a signature of 10 cytokines and chemokines which correctly identifies XMRV/CFS patients with 93% specificity and 96% sensitivity. CONCLUSION: These data show, for the first time, an immunological pattern associated with XMRV/CFS.

Telepsychiatry assessments of child or adolescent behavior disorders: a review of evidence and issues.

BACKGROUND: The limited number of mental health specialists for children has led to an increased need for child and adolescent psychiatrists to provide primary care consultations and treatment recommendations. Psychiatric assessments and treatments provided via two-way videoconferencing (telepsychiatry) have been used to increase the availability of child psychiatrists. This article reviews the literature on telepsychiatry assessment of children and adolescents. METHODS: Research on telepsychiatry has focused on the comparability of telepsychiatric treatments to in-person treatment for adult patients. Relatively little research has addressed the ability of telepsychiatric assessments to facilitate favorable treatment outcomes, particularly for child or adolescent patients. This was a literature search using Medline via Ovid. It focused on English-language material published between 1996 and 2009. A range of search terms relating to assessment, mental health, telemedicine, and children was used. Any studies focusing on child and adolescent psychiatric assessment were included. RESULTS: The limited literature on children is usually related to project descriptions or case reports. The studies tend to find acceptance and the diagnoses and recommendations are not seen as different from in-person assessments. Practical considerations that arise in giving telepsychiatric assessments are discussed. CONCLUSION: Although there are significant weaknesses in the research justifying telepsychiatric assessments in children and adolescents, there are no data that suggest that this process contributes to negative outcomes. Details on the setting for telepsychiatry assessments and camera view have not been studied.

A comparison of preferred treatment outcomes between children with ADHD and their parents.

OBJECTIVE: The newest guidelines for the treatment of ADHD call for the formation of an individualized treatment plan based on collaboration. Because the process of collaboration requires the communication of desired outcomes, the authors' goal is to examine the preferred outcomes of treatment for ADHD for children and parents. METHOD: A preferred outcomes questionnaire is used to gather data. A listing of the outcomes in ranked order is generated for each group. Spearman's rho is used to generate comparative data. RESULTS: Our results indicate a significant correlation between the preferred outcomes of the children and the parents. There is one outlier regarding the use of medication. CONCLUSION: The existence of the single outlier concerning the use of medication may infer that an assessment of the child's feelings regarding a medication regimen is therapeutically indicated.

Former Latchkey Children: Personality and Academic Correlates.

The purpose of this study was to examine the prevalence and correlates (demographic, personality, and academic) of former latchkey status (children unsupervised by an adult after school during their elementary or middle school years) in a college student sample (N = 188). A clear operational definition of latchkey status was provided. Students were surveyed and administered a personality questionnaire, and their academic aptitude test scores were verified through university records. Twenty-five percent of the male and 14% of the female participants were identified as former latchkey children, resulting in an 18% latchkey prevalence rate. The mean age of onset of latchkey status was 8.7 years for the male and 10.0 years for the female subjects. Having been a latchkey child was positively associated with being male and Caucasian, coming from a one-parent family, and having had a mother who worked outside the home. Multivariate analyses of the personality and academic measures revealed no significant between-group differences.