Narrative Matters: Who gets the credit for "discovering" ADHD and what is the question, really?

Recognition of hyperactivity, impulsivity, distractibility, and emotional lability as a clinical syndrome is at the heart of identifying whether there is a discoverer of the condition of attention deficit hyperactivity disorder (ADHD). Just as clinics of children diagnosed with ADHD do not capture a homogeneous group of boys and girls, however, history does not either. What different observers/clinicians have chosen to highlight reflects what is important to them and to the times in which they lived. The child/children described by Heinrich Hoffman (of Fidgety Phil fame) and George Still (who highlighted impulsive aggression as a moral defect), for instance, did not come with a list of criteria (with which even now we cannot always agree) to prove unequivocally that they had ADHD. Who cares! It is sufficient that they recognized the importance of certain co-occurring behaviors and shared their observations with us such that we can conclude our clinic's children were recognized by good past observers. ADHD-like children, like the poor, have probably always been with us.

Irritability: associations with real-time affect dynamics, social interactions, and daily substance use in older adolescents.

Irritability is a common and clinically significant symptom associated with a wide range of negative outcomes. Ecological Momentary Assessment (EMA) is a valuable tool for capturing experiences, such as emotions, social interactions, and substance use in real-time, and may be useful in understanding how irritability is related to everyday functioning. We investigated cross-sectional associations between a widely used self-report irritability rating scale and affect dynamics, social interactions, and substance use captured with EMA (5 surveys daily for 14 days) in 349 18-year-olds. We also examined the associations of self- and parent-reported irritability at ages 12 and 15 with the age 18 EMA variables to explore whether these relationships persist over time. Youth-reported irritability at age 18 was linked to greater intensity, variability, and inertia of irritability, sadness, and anxiety, less positive and more negative interpersonal experiences, and greater cigarette and drug use. Most effect sizes were in the medium-small range. Associations of youth- and parent-reported irritability at ages 12 and 15 with the age 18 EMA measures were generally similar, although smaller in magnitude. Findings contribute to understanding how irritability is manifested in real-time affect dynamics and interpersonal functioning, as well as daily substance use. Most effects were evident over the course of up to 6 years - that is, early adolescent irritability, reported by both youth and their parents, was associated with similar real-time affect dynamics and interpersonal experiences at age 18. This study contributes to the literature on the developmental psychopathology of irritability by extending findings to everyday functioning.

Long-Term Course of Remission and Recovery in Psychotic Disorders.

OBJECTIVE: Understanding prognosis is critical to anticipating public health needs and providing care to individuals with psychotic disorders. However, the long-term course of remission and recovery remains unclear. In this study, the most common trajectories of illness course are described for a cohort of individuals followed for 25 years since first admission for psychosis. METHODS: Participants are from the Suffolk County Mental Health Project, an epidemiological study of first-admission psychosis. Data for the present study was collected from six follow-ups, with 311 individuals assessed at the 25-year follow-up. Common patterns of remission and recovery were assessed in the baseline cohort of 591 individuals and the subsample from the 25-year follow up. RESULTS: In the baseline cohort and the 25-year subsample, the most common trajectory for individuals with schizophrenia spectrum disorders was no remission and no recovery. Among individuals with other psychotic disorders, in both the baseline and 25-year cohorts, the modal pattern was one of intermittent remission and recovery. Individuals with other psychotic disorders were more likely to experience stable remission (15.1%) and stable recovery (21.1%), outcomes that were rare among individuals with schizophrenia spectrum disorders (0% and 0.6%, respectively). CONCLUSIONS: The modal longitudinal pattern for individuals with other psychoses is one of multiple transitions into and out of symptomatic and functional recovery. Engagement in a long-term health care plan may help individuals detect and respond to these changes. Sustained remission and recovery are rare among people with schizophrenia spectrum disorders. Efforts should be directed toward developing more effective treatments for this population.

Future Directions: The Phenomenology of Irritable Mood and Outbursts: Hang Together or Hang Separately1.

Recognition of the importance of irritable mood and outbursts has been increasing over the past several decades. This "Future Directions" aims to develop a set of recommendations for future research emphasizing that irritable mood and outbursts "hang together," but have important distinctions and thus also need to "hang separately." Outbursts that are the outcome of irritable mood may be quite different from outbursts that are the trigger or driving force that make youth and his/her environment miserable. What, then, is the relation between irritable mood and outbursts? As the field currently stands, we not only cannot answer this question, but we may also lack the tools to effectively do so. Here, we will propose recommendations for understanding the phenomenology of irritable mood and outbursts so that more directed and clinically useful assessment tools can be designed. We discuss the transdiagnostic and treatment implications that relate to improvements in measurement. We describe the need to do more than repurpose our current assessment tools, specifically interviews and rating scales, which were designed for different purposes. The future directions of the study and treatment of irritable mood and outbursts will require, among others, using universally accepted nomenclature, supporting the development of tools to measure the characteristics of each irritable mood and outbursts, understanding the effects of question order, informant, development and longitudinal course, and studying the ways in which outbursts and irritable mood respond to treatment.

Irritability across adolescence: Examining longitudinal trajectory, stability, and associations with psychopathology and functioning at age 18.

BACKGROUND: Irritability, marked by diminished frustration tolerance, holds significant implications for youth mental health treatment. Despite prior research on irritability trajectories, understanding of individual differences during adolescence remains limited. This study examines the stability and trajectory of irritability across ages 12-18, investigating associations with psychopathology and functioning at age 18. METHODS: A community sample of families with 3-year-old children (N = 518) was recruited via commercial mailing lists. Irritability was assessed at ages 12, 15, and 18 using the Affective Reactivity Index. Psychopathology at age 18 was evaluated with the Kiddie Schedule for Affective Disorders and Schizophrenia, and functioning was assessed through the UCLA Life Stress Interview. Measurement invariance analyses and latent growth curve modeling were conducted within a structural equation modeling (SEM) framework. RESULTS: Configural, metric, and scalar invariance models were supported. Elevated irritability at age 12 predicted adverse outcomes at age 18, including increased psychotropic medication use, mental health treatment, suicidal ideation, self-injury, and psychiatric disorders. Importantly, these associations persisted even after accounting for corresponding variables at age 12. The trajectory of irritability during early adolescence significantly predicted heightened risks for various outcomes at age 18, including suicidal ideation, depression, anxiety, disruptive behavior disorders, and impaired interpersonal functioning. DISCUSSION: Limitations include using only youth-reported data at age 18, limited generalizability from a mostly White, middle-class sample, and insufficient exploration of the broader developmental trajectory of irritability. Nevertheless, the findings emphasize the crucial role of irritability's trajectory in influencing various psychopathological and functional outcomes in late adolescence.

Early Predictors and Concurrent Correlates of Tonic and Phasic Irritability in Adolescence.

Irritability is a common presenting problem in youth mental health settings that is thought to include two components: tonic (e.g., irritable, touchy mood) and phasic (e.g., temper outbursts), each with unique correlates and outcomes, including later internalizing and externalizing problems, respectively. However, we are unaware of any studies of early predictors of tonic and phasic irritability. We utilized data from a longitudinal study of a community sample of 3-year-old children followed to age 15 (n = 444). We conducted confirmatory factor analysis (CFA) of items from several self-report irritability measures at age 15, including the Affective Reactivity Index, the International Personality Item Pool, the Schedule for Non-Adaptive and Adaptive Personality Youth Version, and the Child Depression Inventory, and examined their early childhood predictors. The CFA identified dimensions consistent with tonic and phasic irritability. Tonic irritability at age 15 was uniquely associated with concurrent internalizing disorders and suicidal behavior while phasic irritability was uniquely associated with concurrent externalizing disorders. When adolescent tonic and phasic irritability were examined together, female sex and parental depressive and substance use disorders at age 3 uniquely predicted adolescent tonic irritability. Additionally, male sex, less parental education, greater laboratory-observed anger and impulsivity, ODD symptoms, higher irritability, and no parental substance use history at age 3 uniquely predicted adolescent phasic irritability. Youth-reported tonic and phasic irritability at age 15 appear to be distinguishable constructs with distinct concurrent correlates and early antecedents. Findings have important implications for research on the etiology of irritability and developing effective treatments.

Psychotropic medication use among adolescents participating in three randomized trials of DBT.

BACKGROUND: Frequently presenting with symptoms of mood or anxiety disorders, substance abuse or borderline personality disorder, suicidal and self-harming adolescents often are prescribed psychotropic medication. Though such treatment may be warranted, recurrent suicidal and self-harming behaviour is often linked to emotion dysregulation where pharmacological treatment has weak empirical support. There is a need for more clinical research into the frequency, type and rationale for pharmacological treatment in this group. In this secondary analysis of three randomized clinical trials of dialectical behaviour therapy for adolescents, we report on psychotropic medication use in the respective samples at the time of recruitment, compare use of psychotropic medication across trials and describe sample characteristics that may be associated with possible differences in psychotropic medication. FINDINGS: Trials were conducted in Norway, the US and Spain (labelled the Oslo, US and Barcelona samples). At baseline, 86% of the Barcelona sample, 67% of the US sample and 12% of the Oslo sample were taking at least one psychotropic medication with antidepressants as the most frequent, followed by antipsychotics (72%, 22% and 1.3% respectively) and mood stabilizers (14.2%, 16.2% and 0%). In the Oslo sample there was a significant association between receiving a diagnosis of major depression and the likelihood of receiving antidepressants, but no such association was found in the Barcelona and US samples. The overall 7-8 times higher proportion of participants in the US and Barcelona samples treated with psychotropic medication could only partially be explained by differences between the samples in diagnostic profiles, symptom severity or level of dysfunction. CONCLUSIONS: Highly prevalent in use among suicidal and self-harming adolescents with borderline features, psychotropic medication was still very unevenly prescribed across trials, differences not explained by differences in sample characteristics suggesting that current treatment practices are not fully empirically supported. We call for continued medical education and increased availability of evidence-based psychosocial interventions.

Irritability in Youths: A Critical Integrative Review.

Irritability, defined as proneness to anger that may impair an individual's functioning, is common in youths. There has been a recent upsurge in relevant research. The authors combine systematic and narrative review approaches to integrate the latest clinical and translational findings and provide suggestions for addressing research gaps. Clinicians and researchers should assess irritability routinely, and specific assessment tools are now available. Informant effects are prominent, are stable, and vary by age and gender. The prevalence of irritability is particularly high among individuals with attention deficit hyperactivity disorder, autism spectrum disorder, and mood and anxiety disorders. Irritability is associated with impairment and suicidality risk independent of co-occurring diagnoses. Developmental trajectories of irritability (which may begin early in life) have been identified and are differentially associated with clinical outcomes. Youth irritability is associated with increased risk of anxiety, depression, behavioral problems, and suicidality later in life. Irritability is moderately heritable, and genetic associations differ based on age and comorbid illnesses. Parent management training is effective for treating psychological problems related to irritability, but its efficacy in treating irritability should be tested rigorously, as should novel mechanism-informed interventions (e.g., those targeting exposure to frustration). Associations between irritability and suicidality and the impact of cultural context are important, underresearched topics. Analyses of large, diverse longitudinal samples that extend into adulthood are needed. Data from both animal and human research indicate that aberrant responses to frustration and threat are central to the pathophysiology of irritability, revealing important translational opportunities.

Parent and Teacher Ratings of Tonic and Phasic Irritability in a Clinical Sample.

Research on tonic (persistently angry or grumpy mood) and phasic (temper tantrums/outbursts) irritability in youth has utilized community samples and information from parents and youth. We examined whether tonic and phasic irritability are empirically distinguishable and have similar correlates using teacher, in addition to parent, reports in a clinical sample of children and adolescents. The sample included youth aged 5-18 evaluated at a university outpatient clinic, with complete information from 2481 parents and 2449 teachers. We conducted confirmatory factor analysis (CFA) using items from several parent- and teacher-report inventories and examined concurrent associations with psychopathology and functioning. The CFA supported a two-factor model consistent with tonic and phasic irritability in both parent- and teacher-reports. Parent-reported tonic irritability was associated with higher rates of depression and anxiety disorders, suicidality, and antidepressant medication use. Teacher-reported tonic irritability was associated with elevated rates of depression and antidepressant use. Both parent- and teacher-reported phasic irritability were linked to higher rates of ADHD combined type, oppositional defiant/conduct disorders, and referral for rages. Parent- and teacher-reported tonic and phasic irritability were all associated with impaired social functioning. Parents and teachers can distinguish tonic and phasic irritability, which are associated with internalizing and externalizing problems, respectively. Findings were generally consistent across informants, and with prior studies using community samples.

Irritability and Temperament: Concurrent and Prospective Relationships in Childhood and Adolescence.

OBJECTIVE: Irritability symptoms are closely associated with, and may reflect, temperament traits, particularly negative affectivity (NA). However, there are few empirical data on the relationships between child temperament and irritability symptoms. METHOD: We investigated cross-sectional and longitudinal relationships between irritability symptoms and temperament traits from age 3-15 in a community sample of 609 children and their parents. Irritability symptoms were assessed through structured interviews with parents at ages 3/6, and inventories completed by parents and youth at ages 12/15. Temperament traits were assessed using parent reports at ages 3/6, and parent and child reports at ages 12/15. Path analysis and structural equation modeling were used to explore longitudinal associations from ages 3-6 and 12-15, respectively. RESULTS: Higher levels of irritability symptoms at ages 3/6 were concurrently associated with higher levels of NA and lower levels of effortful control (EC). In adolescence, higher irritability symptoms were concurrently associated with higher negative temperament and disinhibition. In longitudinal analyses from age 3-6 and 12-15, irritability symptoms showed modest but significant stability after adjusting for the stability of temperament traits. However, there were significant differences in the stability paths at age 3-6, reflecting lower stability of irritability symptoms. Finally, EC at age 3 predicted increased irritability symptoms at age 6, while irritability symptoms at age 3 predicted increased NA at age 6. CONCLUSION: Irritability symptoms are robustly associated with both temperamental NA and difficulty regulating attention and behavior. These findings help situate irritability symptoms within widely accepted temperament/personality taxonomies.

Early childhood anxiety disorders: continuity and predictors in adolescence.

Anxiety disorders are among the most common disorders in early childhood. Although many older children and adolescents with anxiety disorders recover and remain well, little is known about the continuity of early childhood anxiety and the factors that predict persistence/recurrence in later childhood and adolescence. We followed 129 children who met anxiety disorder criteria at age 3 and/or 6 and determined how many continued to experience an anxiety disorder between age 7 and 15, as well as the continuity of specific anxiety disorders. We explored whether biological sex, number of anxiety disorders, early childhood persistence (i.e., anxiety diagnosis at both age 3 and 6), childhood comorbidities, temperamental behavioral inhibition, a maternal history of anxiety, and authoritarian and overprotective parenting predicted persistence/recurrence of an anxiety disorder from age 7 to 15. Sixty-five (50.4%) of the adolescents with an early childhood anxiety disorder met anxiety disorder criteria during the age 7-15 interval. Homotypic continuity from early childhood to school-age/mid-adolescence was observed for social anxiety disorder, separation anxiety disorder, and generalized anxiety disorder (GAD). Early childhood agoraphobia predicted school-age/mid-adolescent GAD and early childhood GAD predicted school-age/mid-adolescent specific phobia. In bivariate analyses, number of anxiety disorders, persistence of anxiety from age 3 to 6, and having a mother with a history of anxiety predicted the persistence/recurrence of anxiety disorders from age 7 to 15. Only early childhood persistence of anxiety uniquely predicted the persistence/recurrence of an anxiety disorder over and above the other predictors. Early intervention efforts should focus on identifying and intervening with young children who demonstrate a protracted course of anxiety.

Does the apple fall far from the tree? Commentary on Hafeman et al., early indicators of bipolar risk in preschool offspring of parents with bipolar disorder.

Comorbid externalizing and internalizing disorders are common in offspring of a parent with bipolar I or II disorder. In some cases, the symptoms are harbingers of future bipolar spectrum disorder. Even when they are not, they are likely to be impairing to the child. Clinicians need to be better informed about how the history leading up to mania/hypomania unfolds, and what comorbid disorders are impairing in and of themselves. More information is needed about the parents' psychopathology, course of illness and response to treatment. Until we have data on how to prevent bipolar disorder, the best course of action is to treat the child's current impairing symptoms and render the parent as asymptomatic as possible.

Strategies for Managing Impairing Emotional Outbursts.

This Viewpoint discusses the important role pediatricians play in assessment, prevention, and early intervention for children who display impairing emotional outbursts.

Psychiatric Characteristics of Students Who Make Threats Toward Others at School.

OBJECTIVE: While studies have focused on identifying potential school shooters, little is known about the mental health and other characteristics of students who make threats. This study aimed to describe these students and factors prompting psychiatric interventions and treatment recommendations. METHOD: Child and adolescent psychiatry threat assessment evaluations of 157 consecutive school-referred youths in grades K-12 between 1998 and 2019 were reviewed for demographics, reasons for referral, nature of threat, psychiatric diagnosis, and psychiatric and educational recommendations. Predictors of recommendations for psychiatric interventions were modeled using multivariable logistic regression as a function of above-mentioned covariates. RESULTS: Mean (SD) age of referred students was 13.37 (2.79) years; 88.5% were male; 79.7%, White; 11.6%, Hispanic; 10.1%, Black; 2.5%, Asian. Of students, 51.6% were receiving special education services. Verbal threat was made by 80%, and 29.3% brought a weapon to school. History included being bullied in 43.4%, traumatic family events in 52.2%, physical abuse in 5.1%, sexual abuse in 5.7%, and verbal abuse in 36.3%. Frequently encountered psychiatric diagnoses were attention-deficit/hyperactivity, learning, depressive, anxiety, and autism spectrum disorders, usually in combinations. History of medication treatment was reported in 79 (50.3%) and psychotherapeutic interventions in 57 (36.3%). Recommendations to return the student to their prior schools were made for 63.1%. Recommendations for psychotherapy were made for 79.9%, medication for 88.5%, and both for 70.1%. Therapeutic school setting or psychiatric hospitalization was more likely recommended (with statistical significance) with a prior threat history (odds ratio [OR] 5.47, 95% CI 1.91-15.70), paranoid symptoms (OR 5.72, 95% CI 1.55-21.14, p = .009), autism spectrum disorders (OR 3.45, 95% CI 1.32-9.00), mood disorder (OR 5.71, 95% CI 1.36-23.96), personality disorder (OR 9.47, 95% CI 1.78-50.55), or with psychotherapy recommendation (OR 4.84, 95% CI 1.08-21.75). CONCLUSION: Students who make threats have diverse psychiatric profiles and warrant treatments. A trauma and/or abuse history is common. Evaluations of youths who make threats need to go beyond simply assessing the threat itself and should include identifying underlying psychiatric problems. Psychiatric evaluation of students who issue threats of any type can lead to revelations about psychiatric diagnoses and crucial treatment and educational recommendations. DIVERSITY & INCLUSION STATEMENT: The author list of this paper includes contributors from the location and/or community where the research was conducted who participated in the data collection, design, analysis, and/or interpretation of the work.

Narrative Review: Impairing Emotional Outbursts: What They Are and What We Should Do About Them.

OBJECTIVE: Impairing emotional outbursts, defined by extreme anger or distress in response to relatively ordinary frustrations and disappointments, impact all mental health care systems, emergency departments, schools, and juvenile justice programs. However, the prevalence, outcome, and impact of outbursts are difficult to quantify because they are transdiagnostic and not explicitly defined by current diagnostic nosology. Research variably addresses outbursts under the rubrics of tantrums, anger, irritability, aggression, rage attacks, or emotional and behavioral dysregulation. Consistent methods for identifying and assessing impairing emotional outbursts across development or systems of care are lacking. METHOD: The American Academy of Child and Adolescent Psychiatry Presidential Task Force (2019-2021) conducted a narrative review addressing impairing emotional outbursts within the limitations of the existing literature and independent of diagnosis. RESULTS: Extrapolating from the existing literature, best estimates suggest that outbursts occur in 4%-10% of community children (preschoolers through adolescents). Impairing emotional outbursts may respond to successful treatment of the primary disorder, especially for some children with attention-deficit/hyperactivity disorder whose medications have been optimized. However, outbursts are generally multi-determined and often represent maladaptive or deficient coping strategies and responses. CONCLUSION: Evidence-based strategies are necessary to address factors that trigger, reinforce, or excuse the behaviors and to enhance problem-solving skills. Currently available interventions yield only modest effect sizes for treatment effect. More specific definitions and measures are needed to track and quantify outbursts and to design and assess the effectiveness of interventions. Better treatments are clearly needed.

Is the distinction between tonic and phasic irritability meaningful in 3-year-old children?

Irritability encompasses both normative misbehavior in early childhood and clinically significant problems across development. Recent studies have distinguished between tonic (i.e., persistently angry or grumpy mood) and phasic (i.e., temper tantrums or outbursts) forms of irritability and shown that they have different implications for psychopathology and functioning. However, data on this distinction in young (i.e., preschool aged) children are nonexistent. We utilized data from a longitudinal study of a community sample of 462 3-year-olds followed to age 15. We conducted confirmatory factor analysis (CFA) using items from a diagnostic interview and several parent-report inventories and examined concurrent and prospective associations with clinically relevant variables. The CFA identified dimensions consistent with tonic and phasic irritability. Tonic irritability was independently associated with concurrent parent-reported temperamental negative affectivity and surgency, and depressive and oppositional defiant (ODD) disorders, and predicted higher rates of disruptive behavior disorders (DBD) and suicidal behavior in later childhood and adolescence. Phasic irritability was independently associated with concurrent laboratory observations of child impulsivity, parent-reported temperamental negative affectivity, surgency, and low effortful control, maladaptive parenting, and generalized anxiety disorder (GAD), attention-deficit hyperactivity disorder (ADHD), and ODD, but it did not predict later psychopathology. Tonic and phasic irritability are separable in 3-year-old children, but their correlates and outcomes are not as distinct as in older youth. This may reflect the greater difficulty characterizing normative and pathological irritability in the preschool period.

Tonic and phasic irritability in 6-year-old children: differential correlates and outcomes.

OBJECTIVE: Irritability is a common and clinically important problem in children and adolescents and a risk factor for later psychopathology and impairment. Irritability can manifest in both tonic (e.g., irritable, touchy mood) and phasic (e.g., temper outburst) forms, and recent studies of adolescents suggest that they predict different outcomes. However, no studies have examined whether tonic and phasic irritability are empirically distinguishable in 6-year-old children and whether they have distinct correlates and outcomes. METHOD: We utilized data from a longitudinal study of an unselected community sample of four hundred fifty-two 6-year-olds followed at 3-year intervals to age 15. We conducted confirmatory factor analysis (CFA) using relevant items from a diagnostic interview and several parent-report inventories. RESULTS: The CFA identified dimensions that were consistent with tonic and phasic irritability. Tonic irritability was independently associated with concurrent parent-reported temperamental negative affectivity and internalizing and externalizing disorders at age 6 and predicted higher rates of internalizing psychopathology, and suicidal ideation, in adolescence. Phasic irritability was independently associated with concurrent parent-reported temperamental negative affectivity, surgency, and low effortful control, maladaptive parenting styles and practices, and externalizing disorders at age 6, and predicted higher rates of externalizing psychopathology in adolescence. CONCLUSIONS: Tonic and phasic irritability in 6-year-old children appear to be distinguishable constructs with different temperament and parenting correlates and psychopathological outcomes. Distinguishing these components has implications for research on the etiology and pathophysiology of irritability and developing effective treatments.

Factors Associated With Police Bringing Children to a Psychiatric Emergency Room.

OBJECTIVE: Sensational headlines describing police entanglements with young children have prompted questions about how often these incidents occur and why. The authors of this cross-sectional study examined the factors associated with police versus nonpolice arrivals to the psychiatric emergency room and those predicting subsequent police arrivals. METHODS: Electronic medical records of children ages 5.0-12.9 years brought to a comprehensive psychiatric emergency program (CPEP) at a university hospital were reviewed to determine whether a child was brought by police ("police arrival") in response to a 911 call by school personnel, a mental health or other medical professional, or a caregiver. Extracted data included the child's age, sex, race-ethnicity, family makeup, insurance status, arrival status, referral source, diagnosis, disposition, treatment, number of CPEP and police encounters, and occurrences of aggression and suicidality. Multilevel and ordinary logistic regression models were used to identify factors associated with a first and subsequent police arrival. RESULTS: Of 339 children with CPEP encounters from September 2017 to April 2018, 103 (30%) had had at least one police arrival. Children brought by police were more likely than peers brought by caregivers to be Black or Latinx, have Medicaid, come from families without two parents, and have aggressive outbursts or suicidal behavior. Results from multilevel logistic regression indicated that aggressive outbursts and suicidality were most significantly and consistently associated with experiencing both a first and subsequent police arrival. CONCLUSIONS: Clinical and sociodemographic differences in police arrivals highlight the need for a comprehensive systems approach for children, especially marginalized youths, who need psychiatric emergency care.