Social connectedness and adolescent suicide risk.

BACKGROUND: Despite evidence of the importance of interpersonal connectedness to our understanding of suicide risk, relatively little research has examined the protective and buffering effects of connectedness among adolescents. The aims of this study were to determine: (a) whether overall connectedness (composite of family, peer, and school) and specific domains of connectedness were related to a lower likelihood of suicide attempts, and (b) whether these factors buffer the prospective risk of suicide attempt for high-risk subgroups (i.e., recent suicidal ideation and/or lifetime history of suicide attempt, peer victimization, or sexual and gender minority status). METHODS: Participants were 2,897 adolescents (64.7% biological female), ages 12 to 17 (M = 14.6, SD = 1.6), recruited in collaboration with the Pediatric Emergency Care Applied Research Network (PECARN) from 14 emergency departments for the Emergency Department Screen for Teens at Risk for Suicide Study (ED-STARS). Suicide risk and protective factors were assessed at baseline; 3- and 6-month follow-ups were completed (79.5% retention). Multivariable logistic regressions were conducted, adjusting for established suicide risk factors. RESULTS: Higher overall connectedness and, specifically, school connectedness were associated with decreased likelihood of a suicide attempt across 6 months. Overall connectedness and connectedness domains did not function as buffers for future suicide attempts among certain high-risk subgroups. The protective effect of overall connectedness was lower for youth with recent suicidal ideation or a suicide attempt history than for those without this history. Similarly, overall connectedness was protective for youth without peer victimization but not those with this history. Regarding specific domains, family connectedness was protective for youth without recent suicidal ideation or a suicide attempt history and peer connectedness was protective for youth without peer victimization but not youth with these histories. CONCLUSIONS: In this large and geographically diverse sample, overall and school connectedness were related prospectively to lower likelihood of suicide attempts, and connectedness was more protective for youth not in certain high-risk subgroups. Results inform preventive efforts aimed at improving youth connectedness and reducing suicide risk.

Best Practices for Evaluation and Treatment of Agitated Children and Adolescents (BETA) in the Emergency Department: Consensus Statement of the American Association for Emergency Psychiatry.

Introduction: Agitation in children and adolescents in the emergency department (ED) can be dangerous and distressing for patients, family and staff. We present consensus guidelines for management of agitation among pediatric patients in the ED, including non-pharmacologic methods and the use of immediate and as-needed medications. Methods: Using the Delphi method of consensus, a workgroup comprised of 17 experts in emergency child and adolescent psychiatry and psychopharmacology from the the American Association for Emergency Psychiatry and the American Academy of Child and Adolescent Psychiatry Emergency Child Psychiatry Committee sought to create consensus guidelines for the management of acute agitation in children and adolescents in the ED. Results: Consensus found that there should be a multimodal approach to managing agitation in the ED, and that etiology of agitation should drive choice of treatment. We describe general and specific recommendations for medication use. Conclusion: These guidelines describing child and adolescent psychiatry expert consensus for the management of agitation in the ED may be of use to pediatricians and emergency physicians who are without immediate access to psychiatry consultation.Reprinted from West J Emerg Med 2019; 20:409-418, with permission from the authors. Copyright © 2019.

Approach to New-Onset Psychosis in Pediatrics: A Review of Current Practice and an Interdisciplinary Consensus-Driven Clinical Pathway at a Single-Center Institution.

New-onset psychosis in the pediatric population poses many diagnostic challenges. Given the diversity of underlying causes, which fall under the purview of multiple medical specialties, a timely, targeted, yet thorough workup requires a systematic and coordinated approach. A committee of expert pediatric physicians from the divisions of emergency medicine, psychiatry, neurology, hospitalist medicine, and radiology convened to create and implement a novel clinical pathway and approach to the pediatric patient presenting with new-onset psychosis. Here we provide background and review the evidence supporting the investigations recommended in our pathway to screen for a comprehensive range of etiologies of pediatric psychosis.

Treatment of Patients Presenting With Suicidal Behavior in North American Pediatric Emergency Departments.

OBJECTIVE: This study sought to identify current practices for the treatment of patients presenting with suicidal ideation or a recent suicide attempt in pediatric emergency departments (EDs) in North America. METHODS: From October 10, 2018, to January 19, 2020, the authors conducted a cross-sectional online survey on current practices of pediatric emergency medicine chiefs practicing in the United States and Canada. RESULTS: Forty-six (34%) of 136 chiefs of pediatric emergency medicine responded to the survey. The three most frequent improvements chiefs reported they would like to see in the care of young patients with suicidal ideation or suicide attempt were easier access to mental health personnel for evaluations, having mental health personnel take primary responsibility for patient evaluation and treatment, and better access to mental health personnel for dispositional planning. CONCLUSIONS: The findings highlight the need for better mental health care in pediatric EDs to serve patients at increased risk for suicide.

Assessing Violence Risk in Adolescents in the Pediatric Emergency Department: Systematic Review and Clinical Guidance.

INTRODUCTION: Violence risk assessment is one of the most frequent reasons for child and adolescent psychiatry consultation with adolescents in the pediatric emergency department (ED). Here we provide a systematic review of risk factors for violence in adolescents using the risk factor categories from the MacArthur Violence Risk Assessment study. Further, we provide clinical guidance for assessing adolescent violence risk in the pediatric ED. METHODS: For this systematic review, we used the preferred reporting items for systematic reviews and meta-analyses (PRISMA) 2009 checklist. We searched PubMed and PsycINFO databases (1966-July 1, 2020) for studies that reported risk factors for violence in adolescents. RESULTS: Risk factors for adolescent violence can be organized by MacArthur risk factor categories. Personal characteristics include male gender, younger age, no religious affiliation, lower IQ, and Black, Hispanic, or multiracial race. Historical characteristics include a younger age at first offense, higher number of previous criminal offenses, criminal history in one parent, physical abuse, experiencing poor child-rearing, and low parental education level. Among contextual characteristics, high peer delinquency or violent peer-group membership, low grade point average and poor academic performance, low connectedness to school, truancy, and school failure, along with victimization, are risk factors. Also, firearm access is a risk factor for violence in children and adolescents. Clinical characteristics include substance use, depressive mood, attention deficit hyperactivity disorder, antisocial traits, callous/unemotional traits, grandiosity, and justification of violence. CONCLUSION: Using MacArthur risk factor categories as organizing principles, this systematic review recommends the Structured Assessment of Violence Risk in Youth (SAVRY) risk- assessment tool for assessing adolescent violence risk in the pediatric ED.

Adaptations Made to Pediatric Consultation-Liaison Psychiatry Service Delivery During the Early Months of the COVID-19 Pandemic: A North American Multisite Survey.

BACKGROUND: The COVID-19 pandemic led to rapid changes in clinical service delivery across hospital systems nationally. Local realities and resources were key driving factors impacting workflow changes, including for pediatric consultation-liaison psychiatry service (PCLPS) providers. OBJECTIVE: This study aims to describe the early changes implemented by 22 PCLPSs from the United States and Canada during the COVID-19 pandemic. Understanding similarities and differences in adaptations made to PCLPS care delivery can inform best practices and future models of care. METHODS: A 20-point survey relating to PCLPS changes during the COVID-19 pandemic was sent to professional listservs. Baseline hospital demographics, hospital and PCLPS workflow changes, and PCLPS experience were collected from March 20 to April 28, 2020, and from August 18 to September 10, 2020. Qualitative data were collected from responding sites. An exploratory thematic analysis approach was used to analyze the qualitative data that were not dependent on predetermined coding themes. Descriptive statistics were calculated using Microsoft Excel. RESULTS: Twenty-two academic hospitals in the United States and Canada responded to the survey, with an average of 303 beds/hospital. Most respondents (18/22) were children's hospitals. Despite differences in regional impact of COVID-19 and resource availability, there was significant overlap in respondent experiences. Restricted visitation to one caregiver, use of virtual rounding, ongoing trainee involvement, and an overall low number of COVID-positive pediatric patients were common. While there was variability in PCLPS care delivery occurring virtually versus in person, all respondents maintained some level of on-site presence. Technological limitations and pediatric provider preference led to increased on-site presence. CONCLUSIONS: To our knowledge, this is the first multicenter study exploring pandemic-related PCLPS changes in North America. Findings of this study demonstrate that PCLPSs rapidly adapted to COVID-19 realities. Common themes emerged that may serve as a model for future practice. However, important gaps in understanding their effectiveness and acceptability need to be addressed. This multisite survey highlights the importance of establishing consensus through national professional organizations to inform provider and hospital practices.

Erratum: This Article Corrects: "Best Practices for Evaluation and Treatment of Agitated Children and Adolescents (BETA) in the Emergency Department: Consensus Statement of the American Association for Emergency Psychiatry".

[This corrects the article on p. 409 in vol. 20, PMID: 30881565.].

Erratum: This Article Corrects: "Best Practices for Evaluation and Treatment of Agitated Children and Adolescents (BETA) in the Emergency Department: Consensus Statement of the American Association for Emergency Psychiatry".

[This corrects the article on p. 409 in vol. 20, PMID: 30881565.].

Best Practices for Evaluation and Treatment of Agitated Children and Adolescents (BETA) in the Emergency Department: Consensus Statement of the American Association for Emergency Psychiatry.

INTRODUCTION: Agitation in children and adolescents in the emergency department (ED) can be dangerous and distressing for patients, family and staff. We present consensus guidelines for management of agitation among pediatric patients in the ED, including non-pharmacologic methods and the use of immediate and as-needed medications. METHODS: Using the Delphi method of consensus, a workgroup comprised of 17 experts in emergency child and adolescent psychiatry and psychopharmacology from the the American Association for Emergency Psychiatry and the American Academy of Child and Adolescent Psychiatry Emergency Child Psychiatry Committee sought to create consensus guidelines for the management of acute agitation in children and adolescents in the ED. RESULTS: Consensus found that there should be a multimodal approach to managing agitation in the ED, and that etiology of agitation should drive choice of treatment. We describe general and specific recommendations for medication use. CONCLUSION: These guidelines describing child and adolescent psychiatry expert consensus for the management of agitation in the ED may be of use to pediatricians and emergency physicians who are without immediate access to psychiatry consultation.

Disruptive Mood Dysregulation Disorder in Juvenile Justice.

Disruptive mood dysregulation disorder (DMDD) is a new diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). We compared juvenile justice involved youths with DMDD to those with disruptive behavior disorders (DBDs) and other mood disorders, to clarify the differences and to investigate differential correlates to DMDD relative to DBDs or mood disorders. Diagnostic and demographic data were available for 9,819 youths served by 57 juvenile justice sites. A subsample of 2,498 youths had data relevant to our study. The youths self-assessed mental health status on the Voice Diagnostic Interview Schedule for Children (V-DISC), and we retrofitted the V-DISC data to derive an approximate DMDD diagnosis. The retrofitted criteria for DMDD were met by 3.3 percent of justice-involved youths. Results from multinomial regression showed that, after adjustment for covariates, those with DMDD had fewer differences compared with those with other mood disorders than did those meeting criteria for DBDs. Consistent with the DSM-5 classification of DMDD as a depressive disorder, those with DMDD shared more characteristics with youths with mood disorders than with those reporting DBDs. Externalizing behaviors leading to justice involvement may overshadow internalizing symptoms of DMDD, but mood-related conditions should be identified and treated in this population.

The State of Emergency Child and Adolescent Psychiatry: Raising the Bar.

The current state of emergency child and adolescent psychiatry includes common historical challenges to safe and effective care as well as recent innovations in multiple settings that increase the quality of that care. These include (1) enhancements within pediatric emergency departments (EDs), (2) specialized and dedicated child psychiatry emergency programs that are hospital based, (3) telepsychiatry programs that spread access to child psychiatric evaluation and treatment planning, and (4) community-based mobile programs diverting youth from EDs. Together, these highlight the work in North America over the past 5 years to improve the care of youth in psychiatric crisis.

Crisis in the Emergency Department: The Evaluation and Management of Acute Agitation in Children and Adolescents.

Acute agitation in children and adolescents in the emergency department carries significant risks to patients and staff and requires skillful management, using both nonpharmacologic and pharmacologic strategies. Effective management of agitation requires understanding and addressing the multifactorial cause of the agitation. Careful observation and multidisciplinary collaboration is important. Medical work-up of agitated patients is also critical. Nonpharmacologic deescalation strategies should be first line for preventing and managing agitation and should continue during and after medication administration. Choice of medication should focus on addressing the cause of the agitation and any underlying psychiatric syndromes.

Training, Education, and Curriculum Development for the Pediatric Psychiatry Emergency Service.

Pediatric psychiatric emergency care is delivered in different settings with vastly different resources around the country. Training programs lack guidance on developing optimal curricula for this highly variable but crucial setting. A model curriculum for child and adolescent psychiatry trainees may be helpful to provide such guidance; its components include recommendations for assessing baseline knowledge, identifying and teaching core subject content, encouraging development of essential skills, and building in supervision for learners. Future directions include further study in current pediatric emergency psychiatry education and expanding the scope of curricula to include different learners and delivery models.

Separation anxiety disorder in OCD.

BACKGROUND: A history of separation anxiety disorder (SAD) is frequently reported by patients with obsessive-compulsive disorder (OCD). The purpose of this study was to determine if there are clinical differences between OCD-affected individuals with, versus without, a history of SAD. METHODS: Using data collected during the OCD Collaborative Genetic Study, we studied 470 adult OCD participants; 80 had a history of SAD, whereas 390 did not. These two groups were compared as to onset and severity of OCD, lifetime prevalence of Axis I disorders, and number of personality disorder traits. RESULTS: OCD participants with a history of SAD were significantly younger than the non-SAD group (mean, 34.2 versus 42.2 years; P<.001). They had an earlier age of onset of OCD symptoms (mean, 8.0 versus 10.5 years; P<.003) and more severe OCD, as measured by the Yale-Brown Obsessive Compulsive Scale (mean, 27.5 versus 25.0; P<.005). In addition, those with a history of SAD had a significantly greater lifetime prevalence of agoraphobia (odds ratio (OR) = 2.52, 95% confidence interval (CI) = 1.4-4.6, P<.003), panic disorder (OR = 1.84, CI = 1.03-3.3 P<.04), social phobia (OR = 1.69, CI 1.01-2.8, P<.048), after adjusting for age at interview, age at onset of OCD, and OCD severity in logistic regression models. There was a strong relationship between the number of dependent personality disorder traits and SAD (adjusted OR = 1.42, CI = 1.2-1.6, P<.001). CONCLUSIONS: A history of SAD is associated with anxiety disorders and dependent personality disorder traits in individuals with OCD.

Reversible vision loss secondary to malnutrition in a woman with severe anorexia nervosa, purging type, and alcohol abuse.

OBJECTIVE: To report a case of severe reversible vision loss in a woman with a 7-year history of anorexia nervosa, purging type, alcohol abuse and a severely restricted, vitamin-deficient diet. METHOD: Psychiatric, ophthalmologic, and medical records were reviewed, and a literature search was performed on visual complications associated with anorexia nervosa and malnutrition. DISCUSSION: Ophthalmologic complications of malnutrition are rare but include both oculomotor and visual sensory disturbances. Thiamine deficiency can cause both types of disorders. Vitamin B12 and folate deficiencies are typically associated with optic neuropathy. Clinicians treating eating disorders should be aware of the potential for vitamin deficiencies and associated visual loss in patients with anorexia nervosa. This case highlights the importance of a detailed dietary history to guide vitamin rehabilitation and to minimize or reverse nutritional visual loss.