The clinical pathway in ADMiRE, Ireland's first public specialist service for children and adolescents with attention deficit hyperactivity disorder.

Attention deficit hyperactivity disorder (ADHD) is a highly prevalent neurodevelopmental disorder occurring in approximately one in twenty young people in Ireland, and in one-third of those attending Irish Child and Adolescent Mental Health Services (CAMHS). It is important to treat ADHD, as un/poorly treated ADHD is associated with a raft of negative health and socio-economic outcomes. Effective interventions for ADHD are available, and the use of standardised, evidence-based pathways for assessment and management of ADHD optimises outcomes. Despite this, there is no national standardised clinical pathway for assessment and treatment of ADHD in Ireland. ADMiRE, the first public healthcare specialist service for children and adolescents in Ireland, has developed a strongly evidence-based, efficient, effective and safe clinical pathway for assessment and management of ADHD. This paper describes the ADMiRE Clinical Pathway and references ADMiRE resources that are available to other services.

Exploring the Trajectory of Catatonia in Neurodiverse and Neurotypical Pediatric Hospitalizations: A Multicenter Longitudinal Analysis.

Objective: Catatonia is a neuropsychiatric disorder that occurs in pediatric patients with a range of associated medical, psychiatric, and neurodevelopmental disorders (NDDs). This study describes hospital care of pediatric catatonia patients and compares treatments for neurotypical patients and those with NDDs. Methods: Retrospective cohort study from 1/1/2018 to 6/1/2023 of two academic medical centers of patients aged 18 and younger with catatonia. Patients were retrospectively assessed using the clinical global impressions-improvement (CGI-I) by two independent reviewers. Results: One hundred sixty-five patients were hospitalized for catatonia, of whom 50.3% had an NDD. Median age was 15. One hundred sixty-four patients were treated with a benzodiazepine, with a median maximum 24-hour dose of 6 mg lorazepam-equivalents, which did not differ for patients with and without NDDs. Electroconvulsive therapy (ECT) was utilized in 14.5% of patients. Median length of medical hospitalization was 5 days and hospitalizations were longer in neurotypical patients than in patients with NDDs. In an ordinal regression model, the probability of observing at least "much improvement" (CGI < 3) was 88.3% (95% CI: 82.4% to 92.3%), with NDD diagnosis associated with a lower odds of clinical response. Conclusions: The probability of patients achieving a CGI-I score indicating at least "much improvement" was 88.3%. Administered benzodiazepine dose and ECT treatment were similar for all patients, but neurotypical patients had longer hospitalizations than those with NDDs and had a higher odds of a more favorable clinical response. Research under controlled conditions is needed to optimize and endure equitable catatonia treatment in youth.

A Statewide Consultation Helpline for Rapid Linkage to Services for Youths With Opioid Use Disorder and Other Substance Use.

OBJECTIVE: The authors examined the initial implementation of the Indiana Adolescent Addiction Access (AAA) program, modeled on the widely disseminated Child Psychiatry Access Program framework. The AAA program developed a statewide consultation helpline to connect health care providers with adolescent addiction specialists. METHODS: The AAA line was staffed by a coordinator, who fielded initial questions, and on-call clinical specialists (social workers, nurse practitioners, psychiatrists, and psychologists), who were paged to complete telephone consultations and provide care recommendations. When necessary, AAA providers offered urgent clinical assessments and initiated treatment. Descriptive analyses were performed for key variables over the first 21 months of AAA operations. RESULTS: From July 2021 to March 2023, a total of 125 consultations were completed. Most callers were health care providers (71%) or parents (27%). Calls pertained to youths ages 10-18 years (mean±SD age=16.4±1.3; 62% of callers were male, 84% White, and 11% Black), with concerns around cannabis (63%), opioids (38%), and other substances. About 26% of calls related to an overdose, and 41% of cases were rated as severe. Recommendations included starting new medications (17%) or outpatient therapy (86%), and 17% of consultations resulted in urgent evaluations. CONCLUSIONS: The Indiana AAA program helps overcome key barriers to adolescent substance use treatment. Increasing the capacity to initiate medication for opioid use disorder and other treatment rapidly through consultation and direct care is a promising, scalable approach for preventing overdose deaths among youths.

A national research survey of childhood autism assessment services in the UK: empirical evidence of diagnostic practice, challenges and improvement opportunities.

BACKGROUND: The UK National Health Service (NHS) Long Term Plan aims to reduce waiting times for childhood autism diagnostic assessment and improve parent and child satisfaction. This empirical research investigated current childhood diagnostic practice provision, and changes made by teams to address challenges faced. METHODS: Data were collected using an online semi-structured research questionnaire. UK childhood autism diagnostic assessment services (for children aged 1-18 years) were invited to participate through multidisciplinary clinical networks, special interest groups and professionals mailing lists. The study was on the National Institute for Health Research Clinical Research Network portfolio. RESULTS: 128 clinicians from diverse NHS services responded including: 10 (8%) integrated services, 46 (36%) Child and Adolescent Mental Health Services (CAMHS) and 72 (56%) paediatric services. A minority of services (23, 17.9%) reported always meeting the National Institute for Health and Care Excellence guidance for assessment. Referrals rose 115% between 2015 and 2019. Clinicians described increased child and family complexity compared with previously; children had more co-occurring physical, mental health and neurodevelopmental conditions and there were more frequent family health problems and safeguarding concerns. Most services (97, 75.8%) reported recent funding stayed constant/decreased. Incomplete multidisciplinary teams (MDTs) were frequently reported; a minority of services reported increased availability of professionals, and some experienced reductions in key professionals. Many teams were unable to undertake assessments or make recommendations for associated neurodevelopmental and co-existing conditions. Teams described improvement strategies implemented (eg, adapting professionals' roles, supporting parents). CONCLUSIONS: Most UK autism paediatric and CAMHS diagnostic teams experience significant challenges affecting the assessment of children with possible autism, and recommendations regarding treatment/intervention. Where CAMHS or paediatric services work in isolation, there are often competency gaps in MDTs and ability to deliver full neurodevelopmental and mental health assessments. Teams identified service improvement strategies; however, investment in MDT expertise is required to enable services to implement changes to meet the needs of children and families.

Practice Pearls for Stimulant Treatment of Attention-Deficit/Hyperactivity Disorder in Youth.

Over half of youth with attention-deficit/hyperactivity disorder (ADHD) have co-occurring psychiatric or medical conditions that present treatment challenges. Stimulants are the most effective pharmacologic treatment of ADHD for preschoolers to adults but questions about safety with co-occurring conditions frequently arise. In addition, stigma surrounding diagnosis and treatment can negatively impact care. This manuscript presents evidence-based practice pearls to guide treatment decisions for youth with ADHD and common coexisting psychiatric and medical conditions. Recommendations address specific stimulant adverse effects (i.e., anxiety, cardiac, growth, mania, psychosis) along with management strategies. Pearls were developed for the most common clinical questions, controversial topics, or therapeutic issues that may not be widely known. The goals of this manuscript are to: 1) provide a detailed resource for interprofessional teams regarding stimulant use in youth with ADHD, 2) improve therapeutic outcomes for youth with ADHD and co-occurring psychiatric and/or medical conditions through evidence-based recommendations, and 3) decrease stigma associated with stimulant use through education.

The Development of Disinhibited Social Engagement Disorder: A Case Report on the Psychiatric Implications of Prenatal Fentanyl Use.

Exposure to drugs during pregnancy can result in neonatal abstinence syndrome (NAS), low birth weight, attention-deficit/hyperactivity disorder (ADHD), and behavioral issues, particularly during the school-age years. Recent research has expanded our understanding of the consequences of fentanyl exposure during pregnancy beyond the more commonly recognized effects, including respiratory complications, neurodevelopmental effects, increased risk of substance use disorders, gastrointestinal complications, cardiovascular effects, epigenetic changes, behavioral and emotional regulation disruptions, and long-term cognitive impairments. We present the case of a five-year-old female placed in foster care with a past medical history of asthma and a past psychiatric history of ADHD, oppositional defiant disorder (ODD), and disinhibited social engagement disorder. Her mother has a long history of substance use during pregnancy. From our interaction with the patient presented, we see that prenatal exposure to substances such as fentanyl and the disruption of attachment figures can have profound and lasting effects on a child's life, encompassing behavioral and cognitive aspects.

[The place and function of the gender of child psychiatric carers]. / Place et fonction du genre des soignants en pédopsychiatrie.

In a child psychiatry unit, where it is said that men are reassuring and women are mothering, the group experience of carers on the function of their gender in child care was explored. Gender is relevant to institutional care, but creates a divide. Representations focus on fear, sexuality, violence and fragility. Caregivers, ambivalent about neutralising gender, suffer from representations of what it does to children and to the institution.

[Questioning disruptive disorder with emotional dysregulation]. / Questionner le trouble disruptif avec dysrégulation émotionnelle.

Disruptive Emotional Dysregulation Disorder (DEDD) responds to an increase in diagnoses of clastic crises, reactive depression and bipolarity in children and adolescents. Emerging in the 1990s, EDD has become an issue for practitioners, parents and teachers alike, and has become an integral part of the landscape of paediatric and child psychiatric disorders. Its diagnostic complexity is accentuated by criteria that include persistent and disproportionate outbursts of anger, often confused with other pathologies, especially as diagnostic tools are few and far between. Professionals in the field know little about EDD, preferring to diagnose more familiar disorders.

Peer influence and its impact on behavior among South Indian adolescents: A descriptive cross-sectional study.

BACKGROUND: Peer influence, the development of attitudes, and behavioral changes are some of the phenomenal changes that happen in adolescence. MATERIALS AND METHODS: A descriptive cross-sectional study was undertaken to find out the association between peer influence and behavior among 355 adolescents within the age group of 16 to 18 years, randomly chosen from Pre-university schools of Udupi district, Karnataka using the Peer Influence Scale (PIS) and Strengths and Difficulties Questionnaire (SDQ). RESULT: The results indicate that their peers highly influenced 43.9% of the participants. Meanwhile, 23.1% and 7.9% of adolescents who participated in the survey showed borderline and abnormal behavior, respectively. The association between peer influence and behaviour was assessed using the Chi-square test; the results (χ2=14.545, P = 0.001) revealed that peers highly influence adolescent behavior and change adolescent conduct significantly. CONCLUSION: Adolescents should be aware of the accepted and non-accepted behaviors in society and be wise in choosing the right peers who later influence their behavior. Parents need to check the conduct of their children and guide them in developing their identity.

The visualization of autism: Filming children at the Maudsley Hospital, London, 1957-8.

This article examines three films made during the 1950s by Elwyn James Anthony at the psychotic clinic for children at the Maudsley Hospital that marked an important transition in the purpose and practice of visual documentation in a clinical setting: film as a research tool was transitioning from the recording of external signs as indicators of internal subjective states, to the capture of the visual flow of communication between subjects. It is a shift that had a particular impact on the emergent classification of autism, a modality not yet properly separated from the broader term of psychosis, as a non-relational condition whose visual capture demonstrated a void of inter-human communicational exchange. Film was significant not only as a recording apparatus, but as a method of cutting and crafting sequences of movements into brief repetitive motifs. The filmed behaviour of children remained opaque to interpretation, a 'finding' that facilitated the modelling of an emergent autism as subjects who were isolated, alienated and automaton-like, inhabiting a separate temporality. The article situates this 'second', affectless autism, within a broader context of post-war research into gestures as a language of the body, developed largely through an intellectual network of German émigré psychoanalysts who had fled to the US and UK in the 1930s.

Mother-blaming revisited: Gender, cinematography, and infant research in the heyday of psychoanalysis.

This article examines cinematographic observational studies of infants conducted by a loosely connected group of female psychologists and physicians in the USA from the 1930s to the 1960s. Largely forgotten today, these practitioners realized detailed and carefully planned research projects about infant behavior in a variety of settings-from the laboratory to the well-baby clinic. Although their studies were in conversation with better-known works, such as John Bowlby's research on attachment and René Spitz's films on institutionalized infants, they differed in a close examination of individual characteristics of babies and a critical attitude toward contemporary notions of 'pathological mothering'. In closely following the work of several researchers, including but not limited to pediatrician Margaret Fries (1898-1987), the clinical psychologist Sibylle Escalona (1915-96) and her team members-child psychiatrist Mary Leitch (1914-?) and avant-garde photographer Ellen Auerbach (1906-2004)-and psychologist Anneliese Korner (1918-2010), I argue that their cinematographic works shed a more nuanced light on the landscape of infant research and child psychiatry in the mid 20th century, and open a way for alternative readings of gender, psychoanalysis, and scientific observation at that time.

Antibullying Interventions in Schools: Assessing the Evidence Base.

OBJECTIVE: This systematic review used established rating criteria to describe the level of evidence for interventions aimed at preventing or reducing bullying perpetration and victimization in schools, synthesized the evidence for students from racially and ethnically diverse backgrounds, and reviewed the literature for available information to conduct an economic analysis of the interventions. METHODS: Major databases, gray literature, and evidence-base registries were searched to identify studies published from 2008 through 2022. The authors rated antibullying intervention models as having high, moderate, or low evidence depending on the number and rigor of studies with positive findings. RESULTS: Overall, 80 articles reporting on 71 original research studies describing a total of 48 antibullying interventions met the inclusion criteria for this review. Two schoolwide interventions received a high-evidence rating: the KiVa (Kiusaamista Vastaan) Antibullying Program and the Friendly Schools program. Multilevel interventions with components at the levels of school, classroom, and individual student most consistently showed strong evidence for reducing bullying behavior in elementary and middle school grades. Four interventions yielded positive effects in reducing bullying and victimization among diverse samples of students. CONCLUSIONS: Antibullying interventions can reduce bullying in schools. Some interventions show effectiveness with students from racially and ethnically diverse backgrounds. The gains relative to per-student costs were in the range that is considered cost-effective. Most implementation costs are spent on staff training and support. Research on successful implementation of whole-school interventions and additional synthesis of evidence pertaining to program structures would further advance the antibullying evidence base.

Assessing the Evidence Base for School-Based Promotion and Prevention Interventions: Introduction to the Series.

Schools are an important component in the mental health system of care for youths. Teachers and other school staff have unique opportunities to promote emotional wellness and prevent mental health conditions. Although numerous programs are available, identifying evidence-based and effective options is a significant challenge. This introduction lays out the rationale and methodology of the Assessing the Evidence Base (AEB) Series, a collection of systematic reviews of school-based mental health promotion and prevention approaches recommended by the National Academies of Sciences, Engineering, and Medicine for students in kindergarten through grade 12. Authors of the current AEB Series used the rating criteria derived from the 2014 AEB Series, which provided systematic reviews of a wide spectrum of interventions for mental and substance use disorders. Like its predecessor, the current series upholds a high standard of scientific rigor while ensuring that the information is easily accessible to various stakeholders in education, behavioral health, and communities. It describes the universal features included in each systematic review, such as a rating of the level of evidence for interventions, intervention program components, identification of interventions that have yielded positive outcomes for students from underserved populations, and a review of cost data. The AEB systematic reviews will serve as an important tool for decision makers involved in managing limited resources for various programs in school-based mental health services by synthesizing large bodies of research for use by leaders in education and behavioral health.

Síndrome de Rapunzel: atadura sicológica y simulación orgánica / Rapunzel syndrome: psychological bondage and organic simulation

Introducción. El síndrome de Rapunzel es una entidad infrecuente, que se presenta como un tricobezoar a causa de una aglomeración de cabello acumulado dentro del tracto gastrointestinal, por lo que simula otras patologías quirúrgicas. Caso clínico. Paciente femenina de 10 años de edad, con tricotilomanía y tricofagia, dolor abdominal y síntomas inespecíficos de obstrucción intestinal de ocho meses de evolución. Al examen físico se encontró abdomen con distensión y masa palpable en epigastrio y mesogastrio. La ecografía permitió hacer el diagnóstico de tricobezoar gástrico extendido hasta el intestino delgado, por lo que se llevó a cirugía para gastrotomía y se extrajo el tricobezoar, con evolución satisfactoria de la paciente. El abordaje integral permitió conocer la atadura sicológica por posible maltrato infantil. Resultado. La paciente tuvo una evolución satisfactoria y se dio egreso al quinto día de hospitalización. Actualmente se encuentra en seguimiento por sicología, siquiatría infantil y pediatría. Discusión. El caso clínico denota la importancia en reconocer situaciones de presentación infrecuente en pediatría, que puedan estar asociadas a alteraciones sicológicas o presunción de maltrato infantil y que se presenten como una condición orgánica recurrente que simule otras patologías abdominales frecuentes en la infancia. El retraso diagnóstico puede conducir a un desenlace no deseado con complicaciones. Conclusión. Se hace mandatorio el manejo integral del paciente pediátrico y aumentar la sensibilidad para reconocer situaciones de presunción de maltrato infantil, sobre todo en pacientes con una condición orgánica quirúrgica recurrente.

Introduction. Rapunzel syndrome is an uncommon condition that manifests as trichobezoars, which are hair bundles in the stomach or small intestine that can mimics other surgical illnesses. Multiple complications can arise from delayed diagnosis and treatment. Clinical case. A 10-year-old female patient with trichotillomania and trichophagia, with abdominal pain and nonspecific symptoms of intestinal obstruction of eight months of evolution. Physical examination revealed epigastric tenderness and a solid mass was palpable in the mesogastric and epigastric region. An abdominal ultrasound showed gastric trichobezoar that extended into the small intestine. A gastrotomy was performed and the trichobezoar was extracted with satisfactory evolution of the patient. The comprehensive approach allowed knowing the psychological bond due to possible child abuse. Results. The patient had a satisfactory evolution and was discharged on the fifth day of hospitalization. He is currently being monitored by psychology, child psychiatry and pediatrics. Discussion. This clinical case highlights the importance of recognizing situations that seldom present in pediatrics, which may have a psychological aspect due to the presumption of child abuse, and which present as a recurrent organic condition simulating other frequent abdominal pathologies in childhood; all of which may lead to an unwanted outcome due to diagnostic delay. Conclusion. The comprehensive management of the pediatric patient is mandatory to recognize situations of presumed child abuse, in the face of a recurrent surgical conditions.

Self-Pay Outpatient Mental Health Care for Children and Adolescents, by Socioeconomic Status.

OBJECTIVE: Many parents struggle to find mental health care for their children, and many mental health clinicians do not accept insurance payments. The authors aimed to estimate the frequency and cost of self-pay psychotherapy and psychotropic medication management visits for youths and to determine how service use varies by family income. METHODS: A descriptive cross-sectional analysis was performed among youths ages 5-17 years in the 2018-2020 Medical Expenditure Panel Survey. Specialist visits included those with psychiatrists, psychologists, social workers, and mental health counselors or family therapists. RESULTS: Approximately one in five of 13,639 outpatient mental health specialist visits were self-pay, with psychologists (23% of visits) and social workers (24% of visits) most likely to see youths on a self-pay basis. Use of self-pay care was strongly associated with higher income, but even families earning <$28,000 per year utilized some self-pay care, at a median cost of $95 per visit. Self-pay visits were associated with slightly lower clinical need than insurance-covered visits, although this measure varied by income. CONCLUSIONS: The self-pay market for child mental health care potentially exacerbates inequities in access to care by burdening low-income families with high costs. Incentivizing mental health providers to participate in insurance for larger portions of their patient panels, for example, by increasing reimbursement rates and reducing paperwork, may help improve equitable access to mental health care. To the extent that reimbursement rates drive insurance acceptance, the frequency of self-pay mental health visits suggests that mental health services are underreimbursed relative to their benefit to patients and families.

Exploring genetic testing requests, genetic alterations and clinical associations in a cohort of children with autism spectrum disorder.

Several studies show great heterogeneity in the type of genetic test requested and in the clinicopathological characteristics of patients with ASD. The following study aims, firstly, to explore the factors that might influence professionals' decisions about the appropriateness of requesting genetic testing for their patients with ASD and, secondly, to determine the prevalence of genetic alterations in a representative sample of children with a diagnosis of ASD. Methods: We studied the clinical factors associated with the request for genetic testing in a sample of 440 children with ASD and the clinical factors of present genetic alterations. Even though the main guidelines recommend genetic testing all children with an ASD diagnosis, only 56% of children with an ASD diagnosis were genetically tested. The prevalence of genetic alterations was 17.5%. These alterations were more often associated with intellectual disability and dysmorphic features. There are no objective data to explicitly justify the request for genetic testing, nor are there objective data to justify requesting one genetic study versus multiple studies. Remarkably, only 28% of males were genetically tested with the recommended tests (fragile X and CMA). Children with dysmorphic features and organic comorbidities were more likely to be genetic tested than those without. Previous diagnosis of ASD (family history of ASD) and attendance at specialist services were also associated with Genetically tested Autism Spectrum Disorder GTASD. Our findings emphasize the importance of establishing algorithms to facilitate targeted genetic consultation for individuals with ASD who are likely to benefit, considering clinical phenotypes, efficiency, ethics, and benefits.

Investing in School Mental Health: Strategies to Wisely Spend Federal and State Funding.

In the context of the current youth mental health crisis, it is prudent to reconsider how resources are allocated to facilitate the delivery of effective and comprehensive supports and services to children and adolescents. Schools are the main delivery sites for youth mental health services. Many districts have adopted comprehensive school mental health systems (CSMHS) to provide a multitiered approach comprising mental health promotion, prevention, and intervention to students via partnerships between school and community health and behavioral health providers. COVID-19 relief funding and other new federal and state investments in school mental health have led to expansions of school mental health programming in most states. An impending federal funding cliff necessitates an examination of how to wisely invest now to achieve the greatest positive future impact on youth mental health. To capitalize on opportunities to sustain effective school mental health and maximize return on investment, states may consider four strategies: leverage cross-sector partnerships to advance school mental health policies and funding, strengthen and expand Medicaid coverage of CSMHS, establish and enhance data systems, and create state technical assistance and professional development support for CSMHS implementation through local education agencies.

Understanding priorities and needs for child and adolescent mental health in Greece from multiple informants: an open resource dataset.

The Child and Adolescent Mental Health Initiative (CAMHI) aims to enhance mental health care capacity for children and adolescents across Greece. Considering the need for evidence-based policy, the program developed an open-resource dataset for researching the field within the country. A comprehensive, mixed-method, community-based research was conducted in 2022/2023 assessing the current state, needs, barriers, and opportunities according to multiple viewpoints. We surveyed geographically distributed samples of 1,756 caregivers, 1,201 children/adolescents, 404 schoolteachers, and 475 health professionals using validated instruments to assess mental health symptoms, mental health needs, literacy and stigma, service use and access, professional practices, training background, and training needs and preferences. Fourteen focus groups were conducted with informants from diverse populations (including underrepresented minorities) to reach an in-depth understanding of those topics. A dataset with quantitative and qualitative findings is now available for researchers, policymakers, and society [ https://osf.io/crz6h/ and https://rpubs.com/camhi/sdashboard ]. This resource offers valuable data for assessing the needs and priorities for child and adolescent mental health care in Greece. It is now freely available to consult, and is expected to inform upcoming research and evidence-based professional training. This initiative may inspire similar ones in other countries, informing methodological strategies for researching mental health needs.