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.

Medical Student Interest in Straight-from-Medical-School Child and Adolescent Psychiatry Specialization.

OBJECTIVE: The authors investigated fourth-year medical students' interest in straight-from-medical-school residency training resulting in specialization in child and adolescent psychiatry (CAP) and why students are interested in these options. They also examined factors influencing medical student choice of specialty. METHODS: The authors distributed an online survey to two consecutive classes of fourth-year students at an urban, public, allopathic medical school. Students were asked about interest in 3-, 4-, and 5-year tracks resulting in board certification in CAP only or CAP and general psychiatry,  factors impacting their interest and CAP-related experiences. RESULTS: Of 397 students surveyed, 168 (42.3%) responded. Twenty-two students (14.3%) reported psychiatry as a first-choice specialty and 18 (13.1%) reported Pediatrics. Fifty of the students (30%) indicated interest in at least one of the CAP tracks, with those interested in Psychiatry more likely to be interested in all track options. Students interested in Pediatrics were more likely to indicate interest in the 3-year CAP-only track (p < 0.05). Students interested in family medicine were more likely to indicate interest in the 4-year adult and CAP residency track (p < 0.05). Among all students, the 4-year combined CAP and adult track was the most popular. CONCLUSION: In this pilot survey, medical students in their 4th year of training, especially those interested in applying to psychiatry, were interested in residencies allowing for specialization in CAP in fewer years. Medical students whose first choice specialty was Pediatrics or Family Medicine also expressed interest. Given the CAP workforce shortage, creation of this type warrants further investigation.

The DSM-5 Clinical and Public Health Committee (CPHC): operations, mechanics, controversies and recommendations.

BACKGROUND: For DSM - 5, the American Psychiatric Association Board of Trustees established a robust vetting and review process that included two review committees that did not exist in the development of prior DSMs, the Scientific Review Committee (SRC) and the Clinical and Public Health Committee (CPHC). The CPHC was created as a body that could independently review the clinical and public health merits of various proposals that would fall outside of the strictly defined scientific process. METHODS: This article describes the principles and issues which led to the creation of the CPHC, the composition and vetting of the committee, and the processes developed by the committee - including the use of external reviewers. RESULTS: Outcomes of some of the more involved CPHC deliberations, specifically, decisions concerning elements of diagnoses for major depressive disorder, autism spectrum disorder, catatonia, and substance use disorders, are described. The Committee's extensive reviews and its recommendations regarding Personality Disorders are also discussed. CONCLUSIONS: On the basis of our experiences, the CPHC membership unanimously believes that external review processes to evaluate and respond to Work Group proposals is essential for future DSM efforts. The Committee also recommends that separate SRC and CPHC committees be appointed to assess proposals for scientific merit and for clinical and public health utility and impact.

Sexual Health in Child and Adolescent Psychiatry: Multi-Site Implementation Through Synchronized Videoconferencing of an Educational Resource Using Standardized Patients.

Objective: Matters of sexuality and sexual health are common in the practice of child and adolescent psychiatry (CAP), yet clinicians can feel ill-equipped to address them with confidence. To address this gap in training and practice, we developed, implemented, and evaluated an educational module enhanced by videotaped depictions of expert clinicians interacting with professional actors performing as standardized patients (SPs). Methods: We developed an educational resource highlighting common issues of sexual health relevant to CAP practice, including sexual development, psychotropic-related side effects, and sexuality in children with autism. We wrote original scripts, based on which two clinicians interacted with three SPs. Digital recordings were edited to yield 5 clips with a cumulative running time of 20 min. The clips were interspersed during a 90-min session comprising didactic and interactive components. Due to the COVID-19 pandemic, we used synchronous videoconferencing, which allowed content dissemination to several training programs across the country. Results: We recruited 125 learners from 16 CAP training programs through the American Academy of CAP's Alliance for Learning and Innovation (AALI). Routine inquiry into adolescent patients' sexual function was uncommon, reported by only 28% of participants, with "awkward" and "uncomfortable" the most common terms mentioned in reference to the clinical task. The didactic intervention led to measurable improvements after 2 weeks in skills and knowledge (p = 0.004) and in attitudes (p < 0.001). The three items with the greatest improvement were: (a) availability of developmentally tailored resources; (b) comfort in addressing sexual development with underage patients; and (c) with parents or guardians of neuroatypical or developmentally disabled patients (p < 0.001 for each). Conclusions: A sexual health curriculum enriched by video-based examples can lead to measurable improvement in outcomes pertinent to the clinical practice of CAP. These educational materials are available for distribution, use and adaptation by local instructors. Our study also provides proof-of-principle for the use of multisite educational initiatives in CAP through synchronized videoconferencing.

Direct Supervision in Outpatient Psychiatric Graduate Medical Education.

OBJECTIVE: The authors describe a stimulus case that led training staff to examine and revise the supervision policy of the adult and child and adolescent psychiatry clinics. To inform the revisions, the authors reviewed the literature and national policies. METHODS: The authors conducted a literature review in PubMed using the following criteria: Supervision, Residents, Training, Direct, and Indirect and a supplemental review in Academic Psychiatry. The authors reviewed institutional and Accreditation Council for Graduate Medical Education resident and fellow supervision policies to develop an outpatient and fellow supervision policy. RESULTS: Research is limited in psychiatry with three experimental articles demonstrating positive impact of direct supervision and several suggesting different techniques for direct supervision. In other areas of medicine, direct supervision is associated with improved educational and patient outcomes. The authors present details of our new supervision policy including triggers for direct supervision. CONCLUSIONS: The term direct supervision is relatively new in psychiatry and medical education. There is little published on the extent of implementation of direct supervision and on its impact on the educational experience of psychiatry trainees and other medical specialties. Direct supervision has been associated with improved educational and patient outcomes in nonpsychiatric fields of medicine. More research is needed on the implementation of, indications for, and effects of direct supervision on trainee education and on patient outcomes.

Risk for emerging bipolar disorder, variants, and symptoms in children with attention deficit hyperactivity disorder, now grown up.

AIM: To determine the prevalence of bipolar disorder (BD) and sub-threshold symptoms in children with attention deficit hyperactivity disorder (ADHD) through 14 years' follow-up, when participants were between 21-24 years old. METHODS: First, we examined rates of BD type I and II diagnoses in youth participating in the NIMH-funded Multimodal Treatment Study of ADHD (MTA). We used the diagnostic interview schedule for children (DISC), administered to both parents (DISC-P) and youth (DISCY). We compared the MTA study subjects with ADHD (n = 579) to a local normative comparison group (LNCG, n = 289) at 4 different assessment points: 6, 8, 12, and 14 years of follow-ups. To evaluate the bipolar variants, we compared total symptom counts (TSC) of DSM manic and hypomanic symptoms that were generated by DISC in ADHD and LNCG subjects. Then we sub-divided the TSC into pathognomonic manic (PM) and non-specific manic (NSM) symptoms. We compared the PM and NSM in ADHD and LNCG at each assessment point and over time. We also evaluated the irritability as category A2 manic symptom in both groups and over time. Finally, we studied the irritability symptom in correlation with PM and NSM in ADHD and LNCG subjects. RESULTS: DISC-generated BD diagnosis did not differ significantly in rates between ADHD (1.89%) and LNCG 1.38%). Interestingly, no participant met BD diagnosis more than once in the 4 assessment points in 14 years. However, on the symptom level, ADHD subjects reported significantly higher mean TSC scores: ADHD 3.0; LNCG 1.7; P < 0.001. ADHD status was associated with higher mean NSM: ADHD 2.0 vs LNCG 1.1; P < 0.0001. Also, ADHD subjects had higher PM symptoms than LNCG, with PM means over all time points of 1.3 ADHD; 0.9 LNCG; P = 0.0001. Examining both NSM and PM, ADHD status associated with greater NSM than PM. However, Over 14 years, the NSM symptoms declined and changed to PM over time (df 3, 2523; F = 20.1; P < 0.0001). Finally, Irritability (BD DSM criterion-A2) rates were significantly higher in ADHD than LNCG (χ(2) = 122.2, P < 0.0001), but irritability was associated more strongly with NSM than PM (df 3, 2538; F = 43.2; P < 0.0001). CONCLUSION: Individuals with ADHD do not appear to be at significantly greater risk for developing BD, but do show higher rates of BD symptoms, especially NSM. The greater linkage of irritability to NSM than to PM suggests caution when making BD diagnoses based on irritability alone as one of 2 (A-level) symptoms for BD diagnosis, particularly in view of its frequent presentation with other psychopathologies.

Variability among research diagnostic interview instruments in the application of DSM-IV-TR criteria for pediatric bipolar disorder.

OBJECTIVE: The DSM-IV-TR criteria for a manic episode and bipolar disorder (BD) were developed for adults but are used for children. The manner in which clinicians and researchers interpret these criteria may have contributed to the increase in BD diagnoses given to youth. Research interviews are designed to improve diagnostic reliability and validity, but vary in how they incorporate DSM-IV-TR criteria for pediatric BD. METHOD: We examined DSM-IV-TR criteria and the descriptive text for a manic episode and the mania sections of six commonly used pediatric diagnostic research interviews focusing on the following: interpretation of DSM-IV-TR, recommendations for administration, and scoring methods. RESULTS: There are differences between the DSM-IV-TR manic episode criteria and descriptive text. Instruments vary in several ways including in their conceptualization of the mood criterion, whether symptoms must represent a change from the child's usual state, and whether B-criteria are required to co-occur with the A-criterion. Instruments also differ on recommendations for administration and scoring methods. CONCLUSIONS: Given the differences between DSM-IV-TR manic episode criteria and explanatory text, it is not surprising that there is considerable variation between diagnostic instruments based on DSM-IV-TR. These differences likely lead to dissimilarities in subjects included in BD research studies and inconsistent findings across studies. The field of child psychiatry would benefit from more uniform methods of assessing symptoms and determining pediatric BD diagnoses. We discuss recommendations for changes to future instruments, interviews, assessment, and the DSM-5.

Symptoms leading to a bipolar diagnosis: a phone survey of child and adolescent psychiatrists.

OBJECTIVE: We surveyed child and adolescent psychiatrists (CAPs) to characterize how they diagnose bipolar disorder (BPD) in children. METHODS: We approached by mail and then telephone 100 CAPs randomly sampled from five regions of the main professional organization of American CAPs; 53 CAPs were reached and agreed to participate. We asked about their training and practice setting, and asked them to name 10 symptoms indicative of BPD. We conducted descriptive analyses to determine how CAPs ranked symptoms, whether reports were consistent with Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR) criteria, and whether alternative symptom models might guide their decision making. RESULTS: CAPs considered lability, grandiosity, family history of BPD, aggression, and expansive or euphoric mood as the most important factors in diagnosing BPD. Only 21 (39.6%) CAPs reported sufficient symptoms to meet DSM criteria for BPD (DSM-Yes status). DSM-Yes status was associated with participants' region, less expertise (< or =10 years practicing child and adolescent psychiatry), and lower levels of self-reported confidence in their ability to diagnose BPD. CONCLUSIONS: CAPs vary in the symptoms they use to diagnose BPD, with most using a mixture of DSM and non-DSM symptoms. Expertise and confidence may lessen one's reliance on DSM criteria. Further studies are needed to understand CAPs' diagnostic decisions about BD and to develop interventions to support accurate diagnostic decision making and improve patient care.

Frontiers between attention deficit hyperactivity disorder and bipolar disorder.

The co-occurrence of attention deficit hyperactivity disorder (ADHD) and bipolar disorder has received much recent attention in the literature. The authors review the literature examining associations between ADHD and bipolar disorder in children, and data concerning severe irritability in youth with ADHD. This article focuses on (1) population-based studies examining ADHD and bipolar disorder or ADHD and co-occurring irritability, (2) the co-occurrence and prospective relationships of ADHD and bipolar disorder in clinical samples, (3) phenomenology and assessment of bipolar disorder and ADHD, (4) treatment of comorbid ADHD and bipolar disorder, (5) family and genetic studies of ADHD and bipolar disorder, and (6) pathophysiologic comparisons between children with ADHD and irritability and bipolar disorder. We draw on the research to make clinical recommendations and highlight important directions for future research.

Medical decision making: a selective review for child psychiatrists and psychologists.

Physicians, including child and adolescent psychiatrists, show variability and inaccuracies in diagnosis and treatment of their patients and do not routinely implement evidenced-based medical and psychiatric treatments in the community. We believe that it is necessary to characterize the decision-making processes of child and adolescent psychiatrists using theories and methods from cognitive and social sciences in order to design effective interventions to improve practice and education. This paper selectively reviews the decision-making literature, including recent studies on naturalistic decision making, novice-expert differences, and the role of technology on decision making and cognition. We also provide examples from other areas of medicine and discuss their implications for child psychiatry.

Response to methylphenidate in children with attention deficit hyperactivity disorder and manic symptoms in the multimodal treatment study of children with attention deficit hyperactivity disorder titration trial.

OBJECTIVE: Recent reports raise concern that children with attention deficit hyperactivity disorder (ADHD) and some manic symptoms may worsen with stimulant treatment. This study examines the response to methylphenidate in such children. METHODS: Data from children participating in the 1-month methylphenidate titration trial of the Multimodal Treatment Study of Children with ADHD were reanalyzed by dividing the sample into children with and without some manic symptoms. Two "mania proxies" were constructed using items from the Diagnostic Interview Schedule for Children (DISC) or the Child Behavior Checklist (CBCL). Treatment response and side effects are compared between participants with and without proxies. RESULTS: Thirty-two (11%) and 29 (10%) participants fulfilled criteria for the CBCL mania proxy and DISC mania proxy, respectively. Presence or absence of either proxy did not predict a greater or lesser response or side effects. CONCLUSION: Findings suggest that children with ADHD and manic symptoms respond robustly to methylphenidate during the first month of treatment and that these children are not more likely to have an adverse response to methylphenidate. Further research is needed to explore how such children will respond during long-term treatment. Clinicians should not a priori avoid stimulants in children with ADHD and some manic symptoms.

Side effects of desipramine and age.

INTRODUCTION: The treatment response of children and adolescents to tricyclic antidepressants differs from that of adults. Few data exist on the impact of age on side effects. This study compares desipramine-associated side effects in children, adolescents, and adults. METHODS: Data from three trials of desipramine were combined to produce a sample of 148 subjects, aged 7 to 66 years. Pulse and blood pressure were measured at baseline and while participants were receiving desipramine. Side effects were rated by a clinician. For data analysis, subjects were divided into two groups, younger patients (18 and younger) and older patients (19 and older). Group means of side effect ratings and vital signs were compared. Results were also analyzed covarying for plasma levels of desipramine. RESULTS: There were significant differences between younger and older patients in pulse and blood pressure at baseline, on desipramine, and in changes in vital signs between baseline and medicated states. Younger patients had significantly lower mean ratings for constipation and dry mouth. DISCUSSION: Treatment with desipramine results in differing degrees of subjective side effects and changes in vital signs across the life cycle. Physicians should not assume that side effects experienced by children and adolescents are identical to those experienced by adults.