Autism Spectrum Disorder and Sleep.

Children and adolescents with autism spectrum disorder (ASD) experience sleep disturbances, particularly insomnia, at rates much higher than the general population. Daytime behavioral problems and parental stress are associated with the resultant sleep deprivation. Behavioral interventions, parental education, and melatonin are effective treatments. The epidemiology of sleep disturbances in youth with ASD is reviewed in this article as well as the latest in treatments.

Sources of Medications Used by Children and Adolescents for Intentional Ingestion: A Retrospective Chart Review.

INTRODUCTION: Suicide is a leading cause of death among adolescents. Oregon ranks 17th nationally for youth suicide rates, and ingestion of medications as a means of suicide is common. Despite the high prevalence of intentional poisoning among youth in Oregon, information about medications used by children and adolescents for attempted suicide, in particular the sources of medications, is not readily available. METHODS: The objective of this study is to describe types and sources of medications used for intentional ingestion among patients seen by the Doernbecher Children's Hospital Child and Adolescent Psychiatry Consultation-Liaison Service. This was a retrospective analysis of patients seen by the Child and Adolescent Psychiatry Consultation-Liaison Service for intentional ingestion from 2015 to 2017. Data on 434 total intentional ingestions were collected, including demographic information, types of medications ingested, and sources of both over-the-counter (OTC) and prescription (Rx) medications. Ingestions without intent of suicide were excluded. Descriptive analysis of ingestion data was performed. RESULTS: Intentional ingestions included Rx and OTC medications in similar frequencies. For Rx medications, 68% of ingestions included patients' own Rxs. Eighty-eight percent of ingestions that were not the patients' own Rx belonged to someone else living in their home. For OTC medications, 66% of medications were available at home. CONCLUSIONS: Intentional ingestions among adolescents most frequently involve medications that are readily available in their homes, and these include both OTC and Rx medications. This study highlights the importance of securing medications at home as a preventative measure and the importance of anticipatory guidance for primary care providers.

Mental Health Diagnoses and Seasonal Trends at a Pediatric Emergency Department and Hospital, 2015-2019.

BACKGROUND: Increasingly, youth with mental health disorders and suicidality are presenting to emergency departments (EDs) and requiring hospitalization. For youth with suicidality, studies reveal seasonal variations in frequency of presentations but do not identify associated diagnoses or whether other primary mental health complaints also reveal seasonal variations. METHODS: Data were collected between January 2015 and December 2019 by a child and adolescent psychiatry consultation-liaison service in a pediatric ED and hospital. Descriptive analysis and multiple linear regression were performed to assess volume over time, seasonal trends, and associated diagnoses. RESULTS: A total of 2367 patients were included, with an average age of 13.9 years and female predominance (62.3%). During the study period, annual ED consultations increased 87.5% and hospital consultations increased 27.5%. Consultations revealed seasonal trends, with highest volumes during January, April, May, October, and November (P < .001; adjusted R 2 = 0.59). The most frequent diagnostic categories were depressive disorders and trauma- or stressor-related disorders. Thirty-six percent of patients presented after a suicide attempt, with the highest rates in spring (P = .03; adjusted R 2 = 0.19). Boarding rates revealed significant seasonality, with higher instances in February, March, April, May, and October (P = .009; adjusted R 2 = 0.32). CONCLUSIONS: Mental health presentations to a pediatric ED and hospital reveal seasonal trends, with the highest volumes in fall and spring and the most common diagnoses being depressive and trauma-related disorders. Suicide attempts are highest in late spring. Knowledge of these trends should inform hospitals, mental health services, and school systems regarding staffing, safety, surveillance, and prevention.

Autism Spectrum Disorder and Sleep.

Children and adolescents with autism spectrum disorder (ASD) experience sleep disturbances, particularly insomnia, at rates much higher than the general population. Daytime behavioral problems and parental stress are associated with the resultant sleep deprivation. Behavioral interventions, parental education, and melatonin are effective treatments. The epidemiology of sleep disturbances in youth with ASD is reviewed in this article as well as the latest in treatments.

Wall teichoic acids govern cationic gold nanoparticle interaction with Gram-positive bacterial cell walls.

Molecular-level understanding of nanomaterial interactions with bacterial cell surfaces can facilitate design of antimicrobial and antifouling surfaces and inform assessment of potential consequences of nanomaterial release into the environment. Here, we investigate the interaction of cationic nanoparticles with the main surface components of Gram-positive bacteria: peptidoglycan and teichoic acids. We employed intact cells and isolated cell walls from wild type Bacillus subtilis and two mutant strains differing in wall teichoic acid composition to investigate interaction with gold nanoparticles functionalized with cationic, branched polyethylenimine. We quantified nanoparticle association with intact cells by flow cytometry and determined sites of interaction by solid-state 31P- and 13C-NMR spectroscopy. We find that wall teichoic acid structure and composition were important determinants for the extent of interaction with cationic gold nanoparticles. The nanoparticles interacted more with wall teichoic acids from the wild type and mutant lacking glucose in its wall teichoic acids than those from the mutant having wall teichoic acids lacking alanine and exhibiting more restricted molecular motion. Our experimental evidence supports the interpretation that electrostatic forces contributed to nanoparticle-cell interactions and that the accessibility of negatively charged moieties in teichoic acid chains influences the degree of interaction. The approaches employed in this study can be applied to engineered nanomaterials differing in core composition, shape, or surface functional groups as well as to other types of bacteria to elucidate the influence of nanoparticle and cell surface properties on interactions with Gram-positive bacteria.

Suicide Risk Screening in Pediatric Hospitals: Clinical Pathways to Address a Global Health Crisis.

BACKGROUND: Youth suicide is on the rise worldwide. Most suicide decedents received healthcare services in the year before killing themselves. Standardized workflows for suicide risk screening in pediatric hospitals using validated tools can help with timely and appropriate intervention, while attending to The Joint Commission Sentinel Event Alert 56. OBJECTIVE: Here we describe the first attempt to generate clinical pathways for patients presenting to pediatric emergency departments (EDs) and inpatient medical settings. METHODS: The workgroup reviewed available evidence and generated a series of steps to be taken to feasibly screen medical patients presenting to hospitals. When evidence was limited, expert consensus was used. A standardized, iterative approach was utilized to create clinical pathways. Stakeholders reviewed initial drafts. Feedback was incorporated into the final pathway. RESULTS: Clinical pathways were created for suicide risk screening in pediatric EDs and inpatient medical/surgical units. The pathway outlines a 3-tiered screening process utilizing the Ask Suicide-Screening Questions for initial screening, followed by a brief suicide safety assessment to determine if a full suicide risk assessment is warranted. This essential step helps conserve resources and decide upon appropriate interventions for each patient who screens positive. Detailed implementation guidelines along with scripts for provider training are included. CONCLUSION: Youth suicide is a significant public health problem. Clinical pathways can empower hospital systems by providing a guide for feasible and effective suicide risk-screening implementation by using validated tools to identify patients at risk and apply appropriate interventions for those who screen positive. Outcomes assessment is essential to inform future iterations.

Impact of an Inpatient Psychiatric Unit on Pediatric Emergency Mental Health Care.

OBJECTIVES: Mental health complaints are a frequent presentation to the pediatric emergency department (PED). It is unclear if having an on-site inpatient pediatric psychiatric unit impacts pediatric mental health care in the acute setting. The objective of this study was to compare PED mental health care between a pediatric tertiary care center with an associated inpatient child psychiatric unit (PAPED) and one that does not (NOPED) with the hypothesis that children have longer lengths of stay (LOS) at the PED without an inpatient unit. METHODS: This was a retrospective, observational study of all mental health presentations aged 1 to 18 years to 2 tertiary care PEDs from March 2012 to June 2013 with a final mental health diagnosis International Classification of Diseases, Ninth Revision code. RESULTS: A total of 1409 patient encounters comprised the study group. The PAPED had a significantly higher rate of admission 41.3% versus 18.8% (P < 0.0001). The LOS was significantly longer at the NOPED compared with the PAPED with a visit of 15.6 versus 6.3, respectively (P < 0.0001). When LOS was stratified for disposition, patients requiring admission from the NOPED had a significantly longer LOS of 33.4 compared with an emergency department LOS of 8.1 at the PAPED (P < 0.0001). CONCLUSIONS: Mental health care in the PED seems to be affected by having an associated inpatient child psychiatric unit. Further research needs to address this growing problem and ways to utilize community resources to develop safe outpatient plans and divert admission if possible.

The Effect of a Dedicated Psychiatric Team to Pediatric Emergency Mental Health Care.

BACKGROUND: Pediatric emergency department (PED) visits among children and adolescents with acute mental health needs have increased over the past decade with long wait times in the PED awaiting disposition. OBJECTIVE: The objective of this study was to evaluate the effect of a new pediatric mental health liaison program with the hypothesis that this model reduces length of stay (LOS) and hospitalization rates among pediatric mental health patients. METHODS: This was a pre- and postintervention retrospective study of the year prior to (June 2012-June 2013) and the year after (October 2013-October 2014) implementation of a new PED psychiatric team. All patients aged 1-18 years with a mental health International Classification of Diseases-9(th) Revision code were included. Patients who did not receive a Psychiatry consult in the PED were excluded. RESULTS: There were 83 encounters in the year prior to and 129 encounters in the year after the implementation of the liaison program. There was an increase in the suicidality of mental health patients during this time. There was a significant decrease in mean PED LOS of 27% (95% confidence interval [CI] 0-46%; p = 0.05) from pre- to postintervention period. The decrease in the proportion of patients admitted/transferred to an inpatient psychiatric facility in the postintervention year was statistically significant (odds ratio 0.35; 95% CI 0.17-0.71; p < 0.01). CONCLUSIONS: The use of a dedicated child psychiatrist and mental health social worker to the PED results in significantly decreased LOS and need for admission without any change in return visit rate. Larger, multicenter studies are needed to confirm these findings.

Mental Health Utilization in a Pediatric Emergency Department.

OBJECTIVE: Mental health complaints are frequent in the pediatric emergency department (PED). The objective of this study was to describe trends over time in PED utilization for mental health care at in a single pediatric tertiary care hospital. It is our hypothesis that the resources used by this patient population are high and that mental health-related visits have increased over the most recent decade. METHODS: This was a retrospective study of all pediatric mental health presentations to the PED from January 2009 to July 2013 at a single pediatric hospital. All patients aged 1 to 19 years with an International Classification of Diseases, Ninth Revision code of 291, 292, 295 to 309, and 311 to 314 were included. Data collected included demographic data, medications received, restraint use, suicidality, length of stay (LOS), charges incurred, final disposition, and daily PED operation variables. Trends over time in presentation, charges, and LOS were analyzed using multiple mixed effects regression models after adjusting for potential patient and PED level confounding variables and clustering of multiple visits within patients. RESULTS: A total of 732 PED visits from 2009 to 2013 were identified representing 646 unique patients. The average age was 13.8 years, and 53% were male. Approximately 25% of the patients expressed suicidal ideation, and 44% of those had attempted suicide before arrival. Behavioral or chemical restraints were used in 33% of patients during their PED visit. There were statistically significant increases in annual visits, LOS, and charges over this period (P < 0.05). Increased charges were significantly associated with longer LOS (P = 0.0062). Charges (P = 0.46) and LOS (P = 0.62) were not significantly different between suicidal and nonsuicidal patients. Approximately 21% of patients were admitted or transferred to another facility. CONCLUSIONS: In this single-center study, we found evidence that the resources required to care for pediatric patients with mental health complaints have increased significantly over time both by increased number of annual visits and an increasing LOS. Further research is necessary to determine if our data are consistent with national trends to further our understanding of the problem and improve resource allocation.

Impacts of gold nanoparticle charge and ligand type on surface binding and toxicity to Gram-negative and Gram-positive bacteria.

Although nanomaterials facilitate significant technological advancement in our society, their potential impacts on the environment are yet to be fully understood. In this study, two environmentally relevant bacteria, Shewanella oneidensis and Bacillus subtilis, have been used as model organisms to elucidate the molecular interactions between these bacterial classes and Au nanoparticles (AuNPs) with well-controlled and well-characterized surface chemistries: anionic 3-mercaptopropionic acid (MPA), cationic 3-mercaptopropylamine (MPNH2), and the cationic polyelectrolyte poly(allylamine hydrochloride) (PAH). The data demonstrate that cationic, especially polyelectrolyte-wrapped AuNPs, were more toxic to both the Gram-negative and Gram-positive bacteria. The levels of toxicity observed were closely related to the percentage of cells with AuNPs associated with the cell surface as measured in situ using flow cytometry. The NP concentration-dependent binding profiles were drastically different for the two bacteria strains, suggesting the critical role of bacterial cell surface chemistry in determining nanoparticle association, and thereby, biological impact.

Nocturnal sleep-wake parameters of adolescents at home following cancer chemotherapy.

PURPOSE: The purpose of this descriptive, longitudinal study was to describe objective nocturnal sleep-wake parameters of adolescents at home after receiving chemotherapy in the hospital or outpatient clinic and explore differences in sleep variables by age, gender, and corticosteroid use. METHODS: We collected 7 days of wrist actigraphy and sleep diary data from 48 adolescents (10-19 years) who were receiving cancer chemotherapy for a primary or secondary cancer or a relapse. The actigraphic sleep variables included rest interval (i.e., time in bed), sleep onset, sleep offset, sleep duration, total sleep time (TST), wake after sleep onset (WASO), and %WASO. RESULTS: Of the 48 adolescents, 38 had at least five nights of scored actigraphy and were included in analyses. Older (13-18 years) adolescents went to bed later and had fewer minutes of TST than younger adolescents (10-12 years). Exploratory analyses revealed no differences between adolescents who were taking oral corticosteroids (i.e., prednisone, dexamethasone) and those who were not or between males and females. CONCLUSION: These adolescents had sleep durations that met or exceeded the recommended sleep duration for their age groups but experienced significant WASO. Further research is needed to estimate sleep needs of adolescents during chemotherapy and determine factors that contribute to nocturnal wake-time so that targeted interventions can be designed to improve sleep quality.

Sleep quality and sleep hygiene behaviors of adolescents during chemotherapy.

STUDY OBJECTIVES: Describe the self-reported sleep quality and sleep hygiene behaviors of adolescents before diagnosis and during chemotherapy (CTX), compare their sleep quality and sleep hygiene behaviors with published normative data for healthy adolescents and adolescents with chronic pain, and explore factors that predict sleep quality. METHODS: Subjects were 51 adolescents (10 to 19 years) receiving CTX for cancer. A questionnaire was used to assess sleep patterns prior to the adolescent's cancer diagnosis, and a 7-day sleep diary was used to assess subjective sleep-wake activity during CTX. Sleep quality was assessed using the Adolescent Sleep Wake Scale, and sleep-facilitating and sleep-inhibiting behaviors using the Adolescent Sleep Hygiene Scale. RESULTS: Adolescents receiving CTX reported significantly worse sleep quality and sleep hygiene behaviors than healthy adolescents, and better sleep quality but similar sleep hygiene behaviors to adolescents with chronic pain. Significant interactions were found between bedtimes and wake-times on weekdays and weekends before diagnosis and during CTX. Sleep hygiene and demographic variables accounted for 24% of the variance in sleep quality. The cognitive and emotional subscales of the sleep hygiene scale and demographic variables accounted for 36% of the variance in sleep quality. CONCLUSIONS: Both the weekday and weekend sleep-wake patterns of adolescents receiving CTX resembled their weekend sleep patterns prior to diagnosis.

Sleep patterns in autism spectrum disorders.

Like children with other developmental disabilities, children with autism spectrum disorders suffer from sleep problems at a greater rate than typically developing children. It is increasingly recognized that addressing these sleep problems may improve daytime functioning and decrease family stress. The sleep problems experienced by children with autism spectrum disorders are presented in this article.

Review of disrupted sleep patterns in Smith-Magenis syndrome and normal melatonin secretion in a patient with an atypical interstitial 17p11.2 deletion.

Smith-Magenis syndrome (SMS) is a disorder characterized by multiple congenital anomalies and behavior problems, including abnormal sleep patterns. It is most commonly due to a 3.5 Mb interstitial deletion of chromosome 17 band p11.2. Secretion of melatonin, a hormone produced by the pineal gland, is the body's signal for nighttime darkness. Published reports of 24-hr melatonin secretion patterns in two independent SMS cohorts (US and France) document an inverted endogenous melatonin pattern in virtually all cases (96%), suggesting that this finding is pathognomic for the syndrome. We report on a woman with SMS due to an atypical large proximal deletion ( approximately 6Mb; cen<->TNFRSFproteinB) of chromosome band (17)(p11.2p11.2) who presents with typical sleep disturbances but a normal pattern of melatonin secretion. We further describe a melatonin light suppression test in this patient. This is the second reported patient with a normal endogenous melatonin rhythm in SMS associated with an atypical large deletion. These two patients are significant because they suggest that the sleep disturbances in SMS cannot be solely attributed to the abnormal diurnal melatonin secretion versus the normal nocturnal pattern.

Sleep hygiene for children with neurodevelopmental disabilities.

Sleep disturbances in children with neurodevelopmental disabilities are common and have a profound effect on the quality of life of the child, as well as the entire family. Although interventions for sleep problems in these children often involve a combination of behavioral and pharmacologic strategies, the first line of treatment is the promotion of improved sleep habits or "hygiene." Despite the importance of sleep-hygiene principles, defined as basic optimal environmental, scheduling, sleep-practice, and physiologic sleep-promoting factors, clinicians often lack appropriate knowledge and skills to implement them. In addition, sleep-hygiene practices may need to be modified and adapted for this population of children and are often more challenging to implement compared with their healthy counterparts. This first comprehensive, multidisciplinary review of sleep hygiene for children with disabilities presents the rationale for incorporating these measures in their treatment, outlines both general and specific sleep-promotion practices, and discusses problem-solving strategies for implementing them in a variety of clinical practice settings.

Sleep in children with autism spectrum disorders.

Children with autism spectrum disorders frequently have significant sleep problems, most commonly insomnia. Fortunately, a variety of treatments are available, including behavioral interventions and pharmacotherapy. When establishing a treatment plan, it is imperative to understand the underlying etiology of the sleep problem, which in many cases is multifactorial. Some sleep problems, such as suspected obstructive sleep apnea, should be referred to a sleep specialist. Identifying and treating sleep disorders may not only result in improved sleep but also may favorably affect daytime behavior and family functioning. In general, when treating insomnia, behavioral interventions should be instituted initially, followed by pharmacotherapy if needed.

Assessment and pharmacologic treatment of sleep disturbance in autism.

Like children with other developmental disabilities, children with autism spectrum disorders suffer with sleep problems at a higher rate than do typically developing children. There is a growing recognition that addressing these sleep problems may improve daytime functioning and decrease family stress. Presented here is a discussion of the sleep problems experienced by children with autism spectrum disorders, focusing on appropriate assessment and pharmacologic treatment.

Sleep in children with autism spectrum disorders.

The amount of research conducted on sleep in children and adolescents has increased dramatically over the past decade due to the recognition that many children have significant sleep problems leading to daytime dysfunction. Approximately one third of typically developing children have sleep difficulties at some point, and a similar percentage of adolescents have impaired or insufficient sleep leading to daytime impairments. Sleep problems are known to occur at even greater rates in children with special needs, such as those with developmental disabilities, psychiatric conditions, and medical illnesses. The recognition that interventions can improve sleep and may result in better daytime functioning has fueled a growing interest in more fully characterizing the sleep problems in children with special needs. This article presents a discussion of the sleep problems experienced by children with one particular group of developmental disorders--the autism spectrum disorders.

Pain, sleep disturbance, and fatigue in children with leukemia and their parents: a pilot study.

PURPOSE/OBJECTIVES: To determine the feasibility of collecting symptom data at home from school-age children with acute lymphoblastic leukemia (ALL) and from their fathers and mothers and to obtain initial descriptions of pain, sleep disturbance, and fatigue experienced by the family members at home. DESIGN: Prospective and descriptive. SETTING: Children's homes in Oregon and southwestern Washington. SAMPLE: 9 children with ALL (aged 8-16 years), 6 fathers, and 7 mothers. The children received vincristine during the maintenance phase of their outpatient chemotherapy treatments. METHODS: With age-appropriate, paper-and-pencil diaries and wrist actigraphy, data were collected for three days in the families' homes. Families were reminded by telephone to complete their sleep and activity diaries. MAIN RESEARCH VARIABLES: Pain, sleep disturbance, and fatigue in school-age children and their fathers and mothers. FINDINGS: Most of the families who were approached indicated willingness to participate in the study. After receiving outpatient chemotherapy, the children reported pain, sleep disturbance, and fatigue data over three days. Fathers and mothers also reported symptoms. Actigraphy showed children waking more often during the night than mothers or fathers. CONCLUSIONS: Children's pain, sleep disturbance, and fatigue suggest that the symptoms are influencing families' quality of life. Larger studies are needed to examine the symptom patterns and health outcomes of children, fathers, and mothers over the course of chemotherapy. IMPLICATIONS FOR NURSING: Improving sleep and managing pain and fatigue after chemotherapy treatment for children with ALL may improve health outcomes for children and parents.