OpenNotes: Anticipatory Guidance and Ethical Considerations for Pediatric Psychologists in Interprofessional Settings.

OBJECTIVES: The 21st Century Cures Act included an "OpenNotes" mandate to foster transparent communication among patients, families, and clinicians by offering rapid electronic access to clinical notes. This article seeks to address concerns about increased documentation burden, vulnerability to patient complaints, and other unforeseen consequences of patients having near-real-time access to their records. METHODS: This topical review explores both extant literature, and case examples from the authors' direct experience, about potential responses/reactions to OpenNotes. RESULTS: The ethics of disclosing medical information calls for nuanced approaches: Although too little access can undermine a patient's autonomy and the capacity for truly egalitarian shared decision-making, unfettered access to all medical information has significant potential to harm them. Suggested strategies for mitigating risks in premature disclosure include patient and provider education and "modularizing" sensitive information in notes. CONCLUSION: The OpenNotes era has ushered in the possibilities of greater patient and family collaboration in shared decision-making and reduced barriers to documentation sharing. However, it has raised new ethical and clinician documentation considerations. In addition to clinician education, patients and families could benefit from education around the purpose of clinical documentation, how to utilize OpenNotes, and the benefits of engaging in dialogue regarding the content and tone of documentation.

Recalled Experiences of Bullying and Victimization in a Longitudinal, Population-Based Birth Cohort: The Influence of ADHD and Co-Occurring Psychiatric Disorder.

OBJECTIVE: To describe bullying experiences throughout childhood of people with and without childhood ADHD and co-occurring learning and psychiatric disorders from a population-based birth cohort. METHODS: In a secondary data analysis of 199 childhood ADHD cases and 287 non-ADHD referents (N = 486), reported experiences of peer interactions during elementary, middle, or high school were classified as "bully," "victim," "neither," or "both." Associations were assessed with multinomial logistic regression. RESULTS: Adjusted for male sex, the odds of classification as victim-only, victim/bully, or bully- only (vs. neither) were 3.70 (2.36-5.81), 17.71, and 8.17 times higher for childhood ADHD cases compared to non-ADHD referents. Victim-bullies (62.5%) and bullies (64.3%) had both childhood ADHD and other psychiatric disorders versus 38.4% of victims-only and 17.3% of those classified as "neither." CONCLUSION: The list of serious lifetime consequences of having ADHD also includes bullying. We offer future research directions for determining potential causal pathways.

Implementing Group Parent Training in Telepsychology: Lessons Learned During the COVID-19 Pandemic.

OBJECTIVE: We recently transitioned from in-person delivery of a brief behavioral parent intervention to telepsychology delivery to meet families' needs during the COVID-19 pandemic. In this topical review, we describe how we used treatment fidelity as a guiding principle to orient adaptations for telepsychology, as well as preliminary findings and early lessons learned in this implementation. Methods: Using rapid-cycle quality improvement methods, we adapted a brief parent training group (Bootcamp for Attention-Deficit/Hyperactivity Disorder; BC-ADHD) to three groups of caregivers (i.e., 5-7 families) of school-aged children with ADHD (n = 20; 85% males). Families were from the following ethnic backgrounds: 75% White non-Hispanic, 15% White Hispanic, and 10% Black. Clinicians completed measures on their implementation experience. Observers completed measures on content/process fidelity and attendance. Caregivers completed measures on demographics, treatment satisfaction, and telepsychology experience. RESULTS: Telepsychology BC-ADHD can be implemented with comparably high levels of content and process fidelity and treatment satisfaction to in-person groups; and it appears to be feasible and acceptable to caregivers. Caregiver and clinician qualitative feedback revealed themes of appreciating the convenience of telepsychology, while experiencing some challenges in relating to others and sharing over video. CONCLUSIONS: When treatment fidelity is used as a guiding tool, telepsychology parent training groups can be delivered with high fidelity and appear to be acceptable and feasible to caregivers and clinicians. Future research using larger and more diverse samples, multimethod and multi-informant measurement approaches, and controlled designs is needed to further assess the generalizability and efficacy of telepsychology parent training groups.

Quantitative Evaluation of Content and Age Concordance Across Developmental Milestone Checklists.

OBJECTIVE: Clinicians and caregivers rely on milestone checklists as tools for tracking a child's development. In addition, medical students and residents use milestone checklists to learn about normal child development. However, there are multiple published milestone checklists that vary qualitatively in structure and content, hindering their effective use in developmental surveillance and medical education. This project systematically evaluated the consistency and variability between commonly used milestone checklists. METHODS: A team of child psychologists and developmental pediatricians reviewed a total of 1094 milestones derived from 4 published checklists (2 developed for providers, 2 developed for caregivers) to create a comprehensive set of 728 discrete developmental observations, with each observation mapped to corresponding milestones. This observation-milestone relational database was then used to determine the degree of content overlap and milestone age range concordance across milestone checklists. RESULTS: Of the 728 discrete developmental observations, 40 (5.5%) were mapped to milestones in all 4 milestone checklists, and an additional 90 (12.4%) were mapped to 3 checklists. Among these 40 "universal" observations, most (42.5%) were in the motor domain. Of those 130 observations mapped to milestones in at least 3 of the 4 checklists, 26.9% (35/130) were mapped to milestones that were discordant in their associated age range. CONCLUSION: Four commonly used developmental milestone checklists were found to have limited overlap in content, and those that overlapped were inconsistent in their associated age ranges. The resulting observation-milestone relational database could be used to further validate age estimates of milestones and facilitate milestone surveillance through the electronic health record.

High-Functioning Autism, Severe Anxiety, and Bullying in a 26 Year Old.

CASE: Peter is a 26-year-old group home resident in Austria with a history of poor peer relationships, including being bullied, and previous diagnoses of attention-deficit hyperactivity disorder, Asperger syndrome, social anxiety, depression, and developmental coordination disorder. Consultation from our international neurodevelopmental team was requested for severe anxiety and avoidance of social interactions. He reported 4 or more spontaneous anxiety episodes per day. Anxiety triggers included returning to his group home from his vocational rehabilitation program each evening or returning to the group home after weekends at his parents' house. Each Sunday evening, in anticipation of returning to the group home, Peter engaged in tantrums, including screaming and throwing objects and suicidal threats without intent, but not direct aggression toward family members. He phoned his mother several times per day on weekdays.Peter's early history was significant for hyperactivity, impulsivity, aggression, and socially intrusive behavior; he repeated kindergarten and by first grade was characterized as motorically clumsy and "too much in [peers'] personal space." He played alone in kindergarten and had poor social boundaries; when older, he evidenced reduced social perception, and his family reported he did not notice when peers made fun of him. His language developed normally, but he had a "sophisticated style of speaking" and as an adult continued to have trouble understanding gestures, jokes, and social themes in movies.Between ages 7 and 11 years, Peter had been bullied and ostracized by male peers but did well academically, always got along well with adults, and preferred to play with girls. Exclusion by peers persisted through high school, at which time his independent functioning declined and he required his mother's assistance with organizing his materials. At age 15 years, Peter repeated a grade so that he could change classmates, and by the equivalent of his junior year, his grades deteriorated. He had several psychiatric admissions for depression and destructive outbursts (to avoid going to school) and was diagnosed with Asperger disorder. At age 18 years, Peter refused to return to school. He lived at home with his parents, only leaving the house to accompany them on errands, until placed in a group home for people with mental health disorders at age 20 years. At age 26 years, he is sharing a supported-living apartment with 2 young adults with chronic psychiatric disorders. He works in 3 highly structured sheltered workshops for a few hours each and becomes easily overwhelmed in unstructured situations and/or in situations in which he anticipates being reprimanded or letting someone down. Despite a strong interest in marine biology, anxiety prevents him from considering college.How would you proceed with diagnostic testing or intervention to help this young man?

Topical Review: Transitional Services for Teens and Young Adults With Attention-Deficit Hyperactivity Disorder: A Process Map and Proposed Model to Overcoming Barriers to Care.

Objective: To provide a topical review of the personal vulnerabilities and systemic barriers facing transitional age young adults with attention-deficit hyperactivity disorder (ADHD), followed by a proposed model for overcoming those barriers. Methods: Drawing from a growing, but limited, literature on the topic, we outline a process map for identifying and troubleshooting barriers to care in this at-risk population. Results: Young adults with ADHD frequently lack the organizational skills, time management, prioritization, and persistence to manage their health care at an expected level of adult independence. These difficulties are compounded by a health-care system that has less time or fewer resources for supporting young adult patients. Conclusions: Recommendations for easing the transition from pediatric to adult care for late adolescents with ADHD include heavily leveraging the doctor-patient relationship, and capturing the young adult's attention through technologies that already absorb them.

Treatment of Attention-Deficit/Hyperactivity Disorder in Adolescents: A Systematic Review.

IMPORTANCE: Although attention-deficit/hyperactivity disorder (ADHD) is highly prevalent in adolescents and often persists into adulthood, most studies about treatment were performed in children. Less is known about ADHD treatment in adolescents. OBJECTIVE: To review the evidence for pharmacological and psychosocial treatment of ADHD in adolescents. EVIDENCE REVIEW: The databases of CINAHL Plus, MEDLINE, PsycINFO, ERIC, and the Cochrane Database of Systematic Reviews were searched for articles published between January 1, 1999, and January 31, 2016, on ADHD treatment in adolescents. Additional studies were identified by hand-searching reference lists of retrieved articles. Study quality was rated using McMaster University Effective Public Health Practice Project criteria. The evidence level for treatment recommendations was based on Oxford Centre for Evidence-Based Medicine criteria. FINDINGS: Sixteen randomized clinical trials and 1 meta-analysis, involving 2668 participants, of pharmacological and psychosocial treatments for ADHD in adolescents aged 12 years to 18 years were included. Evidence of efficacy was stronger for the extended-release methylphenidate and amphetamine class stimulant medications (level 1B based on Oxford Centre for Evidence-Based Medicine criteria) and atomoxetine than for the extended-release α2-adrenergic agonists guanfacine or clonidine (no studies). For the primary efficacy measure of total symptom score on the ADHD Rating Scale (score range, 0 [least symptomatic] to 54 [most symptomatic]), both stimulant and nonstimulant medications led to clinically significant reductions of 14.93 to 24.60 absolute points. The psychosocial treatments combining behavioral, cognitive behavioral, and skills training techniques demonstrated small- to medium-sized improvements (range for mean SD difference in Cohen d, 0.30-0.69) for parent-rated ADHD symptoms, co-occurring emotional or behavioral symptoms, and interpersonal functioning. Psychosocial treatments were associated with more robust (Cohen d range, 0.51-5.15) improvements in academic and organizational skills, such as homework completion and planner use. CONCLUSIONS AND RELEVANCE: Evidence supports the use of extended-release methylphenidate and amphetamine formulations, atomoxetine, and extended-release guanfacine to improve symptoms of ADHD in adolescents. Psychosocial treatments incorporating behavior contingency management, motivational enhancement, and academic, organizational, and social skills training techniques were associated with inconsistent effects on ADHD symptoms and greater benefit for academic and organizational skills. Additional treatment studies in adolescents, including combined pharmacological and psychosocial treatments, are needed.

Overlapping 16p13.11 deletion and gain of copies variations associated with childhood onset psychosis include genes with mechanistic implications for autism associated pathways: Two case reports.

Copy number variability at 16p13.11 has been associated with intellectual disability, autism, schizophrenia, epilepsy, and attention-deficit hyperactivity disorder. Adolescent/adult- onset psychosis has been reported in a subset of these cases. Here, we report on two children with CNVs in 16p13.11 that developed psychosis before the age of 7. The genotype and neuropsychiatric abnormalities of these patients highlight several overlapping genes that have possible mechanistic relevance to pathways previously implicated in Autism Spectrum Disorders, including the mTOR signaling and the ubiquitin-proteasome cascades. A careful screening of the 16p13.11 region is warranted in patients with childhood onset psychosis.

A theoretical foundation for understanding clergy-perpetrated sexual abuse.

Incorporating elements from broadband theories of psychological adaptation to extreme adversity, including Summit's (1983) Child Sexual Abuse Accommodation Syndrome, Finkelhor and Browne's (1986) Traumagenic Dynamics Model of sexual abuse, and Pyszczynski and colleagues' (1997) Terror Management Theory, this paper proposes a unified theoretical model of clergy-perpetrated sexual abuse for future research. The model conceptualizes clergy-perpetrated sexual abuse as the convergence of interactive processes between the clergy-perpetrator, the parishioner-survivor, and the religious community.

The impact of clergy-perpetrated sexual abuse: the role of gender, development, and posttraumatic stress.

The literature on clergy-perpetrated sexual abuse suggests that there are two modal populations of survivors: boys and adult women. We review what is known about trauma and post-traumatic stress disorder following sexual abuse and explore the different treatment needs for these two survivor groups. For children, clergy-perpetrated sexual abuse can catastrophically alter the trajectory of psychosocial, sexual, and spiritual development. Depending on the age at which abuse occurred, adult clients may present with clinical issues that are more appropriate for a younger developmental stage. Additionally, the symptoms of traumatic stress may be misunderstood when clients conceptualize their abuse as an "affair" or "consensual" relationship. We discuss empirically supported treatments for post-traumatic stress disorder and potential adaptations for the needs of clergy-perpetrated sexual abuse survivors.

The internalizing and externalizing structure of psychiatric comorbidity in combat veterans.

This study examined the latent structure of psychiatric disorders in a sample with a high prevalence of PTSD. A series of confirmatory factor analyses tested competing models for the covariation between Structured Clinical Interview for DSM-III-R diagnoses among 1,325 Vietnam veterans. The best-fitting solution was a 3-factor model that included two correlated internalizing factors: anxious-misery, defined by PTSD and major depression, and fear, defined by panic disorder/agoraphobia and obsessive-compulsive disorder. The third factor, externalizing, was defined by antisocial personality disorder, alcohol abuse/dependence, and drug abuse/dependence. Both substance-related disorders also showed significant, albeit smaller, cross-loadings on the anxious-misery factor. These findings shed new light on the structure of psychiatric comorbidity in a treatment-seeking sample characterized by high rates of PTSD.

Family-focused treatment for childhood-onset depressive disorders: results of an open trial.

Study objectives were to develop a treatment manual for a family-focused intervention for depressed school-aged children, evaluate its feasibility and acceptability, and complete an initial open trial to examine treatment effects. Nine young people meeting criteria for depression (major depressive disorder, dysthymic disorder, or depression not otherwise specified), completed a 12-week family intervention, and were assessed immediately and at 9 months following treatment completion. The intervention presented an interpersonal model of how depressive symptoms are maintained, and emphasized developing family strategies for altering interpersonal processes, supporting recovery and enhancing resilience. At posttreatment 66% of the young people had recovered from their depressive episodes; by 9 months posttreatment 77% had recovered. Significant improvements in global functioning were noted. There were no relapses in the follow-up period and no instances of suicidal behavior during the intervention or follow-up. Mothers' and fathers' Child Behavior Checklist reports and children's self reports indicated significant symptom reductions. Exploratory analyses suggest particular benefit for young people with parents high in criticism. The family-focused intervention for childhood-onset depression demonstrated gains similar to those seen with empirically supported treatments for depressed adolescents and superior to those seen in naturalistic studies of depression outcomes. This favorable risk/benefit profile supports the value of a randomized controlled trial.

Influence of expressed emotion and perceived criticism on cognitive-behavioral therapy for social phobia.

This study examined significant others' expressed emotion (EE) and a closely related construct, perceived criticism, as predictors of cognitive-behavioral therapy outcome in a sample of 40 patients with social phobia (social anxiety disorder). Patients enrolled in group therapy for social phobia completed pre- and post-treatment questionnaire measures of perceived criticism and anxious and depressive symptoms. Designated significant others were assessed for the components of high EE (criticism, hostility and emotional overinvolvement) using the Camberwell Family Interview. It was hypothesized that these high-EE components and patients' perceived criticism would be associated with poorer treatment outcome, and results ran counter to these expectations. Controlling for initial social phobia severity, lower levels of perceived criticism predicted treatment dropout. There was also a nonsignificant trend for participants with a significant other rated as high in emotional overinvolvement to show less change on a composite symptom measure. Findings from this study suggest that close relationships impact the outcome of cognitive-behavioral interventions for social phobia.