Conducting a Pilot Randomized Controlled Trial on a Medical Inpatient Unit Utilizing Cognitive Remediation Therapy for Adolescents with Restrictive Eating Disorders: Protocol Updates and Reflections on Feasibility.

We conducted a pilot randomized control trial (RCT) to simultaneously examine the feasibility of effectively implementing Cognitive Remediation Therapy (CRT) for adolescents with anorexia nervosa (AN) during medical hospitalization at a single-site hospital center. Employment of this protocol occurred on a general medical unit with diverse medical admitting diagnoses, not an eating disorder floor of a hospital and not part of a structured inpatient anorexia nervosa treatment program. This was the first time an RCT for a psychosocial intervention was implemented on this unit with patients with eating disorders. Here, we describe the process of piloting the study, including modifications that needed to be made to the original protocol. We also describe the feedback from major stakeholders regarding the process of conducting the pilot study. We summarize lessons learned and steps to take for smooth integration of an RCT of a therapeutic intervention on medical unit.Trial registration: ClinicalTrials.gov Identifier NCT02883413.

Mental Health Conditions and Symptoms in Pediatric Hospitalizations: A Single-Center Point Prevalence Study.

BACKGROUND: Children and adolescents necessitating hospitalization for physical health conditions are at high risk for mental health conditions; however, the prevalence of mental health conditions and symptoms among hospitalized children and adolescents is uncertain. The objective of this study was to determine the proportion of hospitalized children and adolescents who have diagnosed mental health disorders or undiagnosed mental health problems. METHODS: In this single-center point prevalence study of hospitalized children between the ages of 4 and 21 years, patients or their parents reported known mental health diagnoses and use of services using the Services Assessment for Children and Adolescent, and they reported patient mental health symptoms using the Pediatric Symptom Checklist, 17-item form (PSC-17). RESULTS: Of 229 eligible patients, 119 agreed to participate. Demographic characteristics of patients who enrolled were not statistically significantly different from those of patients who declined to participate. Among participants, 26% (95% confidence interval [CI], 18%-35%) reported a known mental health diagnosis. On the PSC-17, 29% (95% CI, 21%-38%) of participants had a positive screen for mental health symptoms. Of those with a positive screen, 38% (95% CI, 21%-55%) had no known mental health diagnosis, and 26% (95% CI, 12%-43%) had not received ambulatory mental health services in the 12 months before hospitalization. CONCLUSIONS: Mental health conditions and symptoms are common among patients hospitalized in a tertiary children's hospital, and many affected patients are not receiving ambulatory mental health services.

Training Pediatric Psychologists for Perinatal Behavioral Health Services in a Pediatric Hospital.

Although pediatric hospitals specialize in providing care to children and adolescents, at The Children's Hospital of Philadelphia (CHOP), our team has been providing behavioral health services for two unique parent populations-parents with a child in the Newborn Infant Intensive Care Unit and pregnant women carrying fetuses with specific birth defects and receiving prenatal care in the Center for Fetal Diagnosis and Treatment. A new training program was developed to expand the scope of pediatric psychologists' practice to include perinatal behavioral health services, specifically for these two unique parent populations served at CHOP. The program includes direct service provision for adult mental health concerns, as well as education and support to help families cope with the existing medical conditions. This article describes the training program and its implementation as a model of training for other pediatric hospitals. The roles of psychologists embedded in these units and hospital privileges are discussed.

A description of 200 consecutive admissions to an adolescent male treatment unit.

OBJECTIVES: The objective of this study is to characterize patients admitted to a mental health Adolescent Male Treatment Unit (AMTU) over an 18-month interval. METHODS: The study is a cross-sectional retrospective chart review. Data concerning medication management was abstracted along with age, psychiatric diagnoses, degree of impairment, length-of-stay (LOS), and episodes of locked seclusion/restraint. RESULTS: Two hundred consecutive admissions were analyzed. It was common for a patient to be receiving multiple psychiatric medications. Multiple psychiatric diagnoses were the rule, and externalizing disorders were very frequent. Based on LOS, 4 distinct categories emerged. Patients in Categories I and II accounted for two-thirds of admissions to AMTU and had an LOS of 2 weeks or less. Patients in Category III and IV were one-third of admissions, were more ill, needed locked seclusion/restraint, and required a longer LOS to stabilize and treat them. Treatment tended to include a reduction in the number of psychiatric medications previously prescribed. CONCLUSIONS: The majority of patients could be stabilized and discharged in 2 weeks or less. A minority required more intensive intervention including a long LOS. Receiving multiple psychiatric medications may not be of benefit for some patients. Psychiatric medications may induce behavioral adverse effects in at least a subset of patients.

Comorbidity moderates response to methylphenidate in the Preschoolers with Attention-Deficit/Hyperactivity Disorder Treatment Study (PATS).

OBJECTIVE: The aim of this study was to examine whether demographic or pretreatment clinical and social characteristics influenced the response to methylphenidate (MPH) in the Preschoolers with ADHD Treatment Study (PATS). METHODS: Exploratory moderator analyses were conducted on the efficacy data from the PATS 5-week, double-blind, placebo-controlled six-site titration trial. Children (N = 165, age 3-5.5 years) were randomized to 1 week each of four MPH doses (1.25, 2.5, 5, and 7.5 mg) and placebo administered three times per day (t.i.d.). We assessed the fixed effects on the average slope in the regression outcome on moderators, weight-adjusted dose, and the moderator-by-dose interaction using SAS PROC GENMOD. RESULTS: A significant interaction effect was found for a number of co-morbid disorders diagnosed in the preschoolers at baseline (p = 0.005). Preschoolers with three or more co-morbid disorders did not respond to MPH (Cohen's d at 7.5 mg dose relative to placebo = -0.37) compared to a significant response in the preschoolers with 0, 1, or 2 co-morbid disorders (Cohen's d = 0.89, 1.00, and 0.56, respectively). Preschoolers with more co-morbidity were found to have more family adversity. No significant interaction effect was found with the other variables. CONCLUSIONS: In preschoolers with ADHD, the presence of no or one co-morbid disorder (primarily oppositional defiant disorder) predicted a large treatment response at the same level as has been found in school-aged children, and two co-morbid disorders predicted moderate treatment response; whereas the presence of three or more co-morbid disorders predicted no treatment response to MPH.

Case study: delirium in an adolescent girl with human immunodeficiency virus-associated dementia.

Delirium and human immunodeficiency virus (HIV)-associated dementia are well recognized neuropsychiatric consequences of HIV infection in adults. Almost nothing is known regarding the management of delirium in HIV-infected children and adolescents. HIV-related progressive encephalopathy is thought to represent the pediatric form of HIV-associated dementia; however, this condition occurs in HIV-infected infants and preschool children and is rapidly followed by death. This report describes the identification and treatment of apparent HIV-associated dementia complicated by delirium in an adolescent girl.

Selective serotonin reuptake inhibitor-induced sexual dysfunction in adolescents: a review.

OBJECTIVE: To review the existing literature on selective serotonin reuptake inhibitor (SSRI)-induced sexual dysfunction in adolescents. METHOD: A literature review of SSRI-induced adverse effects in adolescents focusing on sexual dysfunction was done. Nonsexual SSRI-induced adverse effects were compared in adult and pediatric populations. Information regarding SSRI-induced sexual dysfunction was extracted from pediatric SSRI clinical trials, clinical reviews, treatment guidelines, case reports, and MedWatch reports. RESULTS: Although the incidences of nonsexual SSRI-induced adverse effects seemed to be similar for both adult and pediatric populations, only one male of 1,346 pediatric subjects receiving an SSRI reported sexual dysfunction. Approximately one third of the clinical reviews and treatment guidelines reviewed raised some concern about SSRI-induced sexual dysfunction. In 11 years, only eight MedWatch reports regarding SSRI-induced sexual dysfunction in adolescents have been filed. Only one letter to the editor describing impaired sexual functioning in three of five adolescents on SSRIs could be found. CONCLUSIONS: Information on SSRI-induced sexual dysfunction in adolescents is lacking. Researchers and clinicians may be failing to ask adolescents about sex and sexual functioning in the context of SSRI treatment.

Whole-body positron emission tomography in patients with HIV-1 infection.

Positron emission tomography with fluorine-18-deoxyglucose (FDG-PET) detects active lymphoid tissues during HIV-1 infection in man. We used FDG-PET to study anatomical correlates of HIV-1 infection in man. Whole-body FDG-PET images from 15 patients with HIV-1 showed distinct lymphoid tissue activation in the head and neck during acute disease, a generalised pattern of peripheral lymph-node activation at mid-stages, and involvement of abdominal lymph nodes during late disease. Unexpectedly, HIV-1 progression was evident by distinct anatomical correlates, suggesting that lymphoid tissues are engaged in a predictable sequence. Understanding the anatomy of HIV-1 infection could encourage use of surgical or radiological interventions to supplement chemotherapy.