Improving Emergency Department Care for Suicidality in Autism: Perspectives from Autistic Youth, Caregivers, and Clinicians.

ABSTRACT: Purpose: Emergency department (ED) visits for suicidal ideation and self-harm are more prevalent in autistic than non-autistic youth. However, providers are typically offered insufficient guidance for addressing suicide risk in autistic youth, likely impacting confidence and care. METHODS: In this pilot study, we conducted semi-structured interviews with 17 key members of the autism community (i.e., autistic youth with a history of suicidality, caregivers of autistic youth with a history of suicidality, autism specialist clinicians, ED clinicians) to inform the development of recommendations for modifying ED care for autistic patients, with a focus on suicide risk screening and management. RESULTS: Participants reported on challenges they encountered receiving or providing care and/or recommendations for improving care. Participant perspectives were aligned, and four main categories emerged: accounting for autism features, connection and youth engagement in care, caregiver and family involvement, and service system issues. CONCLUSION: As research continues in the development of autism-specific suicide risk assessment tools and management strategies, it is essential we better equip providers to address suicide risk in autistic patients, particularly in ED settings.

Implementation Feasibility and Hidden Costs of Statewide Scaling of Evidence-Based Therapies for Children and Adolescents.

OBJECTIVE: State mental health systems are retraining their workforces to deliver services supported by research. Knowledge about evidence-based therapies (EBTs) for child and adolescent disorders is robust, but the feasibility of their statewide scaling has not been examined. The authors reviewed implementation feasibility for 12 commonly used EBTs, defining feasibility for statewide scaling as an EBT having at least one study documenting acceptability, facilitators and barriers, or fidelity; at least one study with a racially and ethnically diverse sample; an entity for training, certification, or licensing; and fiscal data reflecting the costs of implementation. METHODS: The authors reviewed materials for 12 EBTs being scaled in New York State and conducted a literature review with search terms relevant to their implementation. Costs and certification information were supplemented by discussions with treatment developers and implementers. RESULTS: All 12 EBTs had been examined for implementation feasibility, but only three had been examined for statewide scaling. Eleven had been studied in populations reflecting racial-ethnic diversity, but few had sufficient power for subgroup analyses to demonstrate effectiveness with these samples. All had certifying or licensing entities. The per-clinician costs of implementation ranged from $500 to $3,500, with overall ongoing costs ranging from $100 to $6,000. A fiscal analysis of three EBTs revealed hidden costs ranging from $5,000 to $24,000 per clinician, potentially limiting sustainability. CONCLUSIONS: The evidence necessary for embedding EBTs in state systems has notable gaps that may hinder sustainability. Research-funding agencies should prioritize studies that focus on the practical aspects of scaling to assist states as they retrain their workforces.

The Association of Pediatric Emergency Medicine Physicians' Self-Identified Skills in Suicide Risk Assessment and Management With Training in Mental Health.

OBJECTIVE: Because changes to pediatric emergency medicine (PEM) education may help address barriers to youth suicide risk screening programs, this study aimed to understand the impact of formal training in areas that likely include suicide-related practices, developmental-behavioral pediatrics (DBP) and adolescent medicine (AM), on PEM physician-perceived level of training, attitudes, and confidence assessing and managing youth suicide risk. METHODS: Twenty-seven PEM attendings and trainees completed an online survey and were divided into 2 groups: those who had completed DBP and AM rotations (DBP/AM+; n = 20) and those who had not completed either rotation (DBP/AM-; n = 7). We compared perceived level of training, attitudes, and confidence in assessing and managing suicide risk across groups. We also examined the relationship between perceived level of training and confidence. Finally, we conducted exploratory analyses to evaluate the effect of an additional formal rotation in child psychiatry. RESULTS: The DBP/AM+ and DBP/AM- groups did not differ on perceived level of training or on attitudes and confidence in suicide risk assessment or management. Perceived level of training in assessment and management predicted confidence in both assessing and managing suicide risk. Additional training in child psychiatry was not associated with increased perceived level of training or confidence. CONCLUSIONS: The DBP and AM rotations were not associated with higher perceived levels of suicide risk training or greater confidence; however, perceived level of training predicted physician confidence, suggesting continued efforts to enhance formal PEM education in mental health would be beneficial.