Characteristics of a Pediatric Emergency Psychiatric Telephone Triage Service.

OBJECTIVES: Caregivers of youth in psychiatric crisis often seek treatment from hospital emergency departments (EDs) as their first point of entry into the mental health system. Emergency departments have struggled over the last decade with growing numbers and now, because of the pandemic, have experienced a deluge of mental health crises. As one approach to divert unnecessary ED admissions, pediatric emergency psychiatric telephone triage services have been created. This study aimed to define the characteristics and utilization of a pediatric triage service and to examine clinician documentation of calls to identify the assessment of risk and disposition. METHODS: This study included 517 youth (2-18 years; mean, 12.42 years; SD, 3.40 years) who received triage services in the winter of 2 consecutive years. Triage calls were received from caregivers (>75%), schools (17.0%), and providers (6.6%) regarding concerns, including suicidal ideation (28.6%), school issues (28.6%), and physical aggression (23.4%). RESULTS: Dispositions were for acute, same-day evaluation (9.7%), direct care service (28.8%), further evaluation (within 48-72 hours, 40.0%), and resource/service update information (21.5%). Findings revealed that most clinical concerns were referred for further evaluation. Both adolescent females and males were referred for emergency evaluations at high rates. CONCLUSIONS: A dearth of information on pediatric crisis telephone triage services exists; thus, developing an evidence base is an important area for future work. This information assists not only in our understanding of which, why, and how many youths are diverted from the ED but allows us to extrapolate significant costs that have been saved because of the utilization of the triage service.

Psychiatric Outcomes of Childhood Maltreatment: A Retrospective Chart Review from a Children's Psychiatric Inpatient Program.

Childhood maltreatment is linked to deleterious outcomes, whereby post-traumatic stress disorder (PTSD) has been identified as one of the most debilitating. This retrospective chart review examined whether self-reported affective measures (anxiety, depression, trauma), type of maltreatment (sexual, physical, emotional/verbal abuses), and demographics predicted a diagnosis of anxiety or PTSD among 169 children in a psychiatric inpatient hospital. Secondly, this study identified significant predictors of a PTSD diagnosis. Results indicated self-reported anxiety predicted a diagnosis of PTSD, while self-reported depression predicted PTSD only in maltreated children. Self-reported trauma predicted an anxiety diagnosis. PTSD risk variables including duration of stay, sex, self-reported anxiety, presence of sexual abuse, and presence of emotional/verbal abuse, showed sound sensitivity/specificity as predictors of risk for a PTSD diagnosis in an inpatient setting. Clinical implications are discussed.

Neurocognitive heterogeneity across the spectrum of psychopathology: need for improved approaches to deficit detection and intervention.

Neurocognition is one of the strongest predictors of clinical and functional outcomes across the spectrum of psychopathology, yet there remains a dearth of unified neurocognitive nosology and available neurocognition-targeted interventions. Neurocognitive deficits manifest in a transdiagnostic manner, with no psychiatric disorder uniquely affiliated with one specific deficit. In fact, recent research has identified that essentially all investigated disorders are comprised of 3-4 neurocognitive profiles. This within-disorder neurocognitive heterogeneity has hampered the development of novel, neurocognition-targeted interventions, as only a portion of patients with any given disorder possess neurocognitive deficits that would warrant neurocognitive intervention. The development of criteria and terminology to characterize these neurocognitive deficit syndromes would provide clinicians with the opportunity to more systematically identify and treat their patients and provide researchers the opportunity to develop neurocognition-targeted interventions for patients. This perspective will summarize recent work and discuss possible approaches for neurocognition-focused diagnosis and treatment in psychiatry.

Parent and Adolescent Motivational Enhancement Intervention for Substance-Using, Truant Adolescents: A Pilot Randomized Trial.

The purpose of this article is to present the results of a treatment development study designed to examine the feasibility, acceptability, and preliminary efficacy of motivational enhancement therapy (MET) for substance using, truant adolescents plus the Family Check-Up (FCU) for parents. A randomized controlled trial was used to test the hypothesis that MET plus the FCU (MET/FCU) would lead to greater reductions in alcohol and marijuana use as well as truant behavior compared to a psychoeducation (PE) condition delivered to both adolescents and parents. Participants (n = 69; M age = 15.8 years) were 39% female, 59% White, and 31% Hispanic/Latino. Adolescents were referred from family court, from school truancy courts, from school counselors, or after presentations in high school health classes. Eligible participants reported using marijuana at least 3 times in the prior 90 days and a history of school truancy in the prior school year. The MET/FCU condition was found to be feasible to implement and was acceptable to both adolescents and parents. The PE condition was also found to be an acceptable and credible comparison condition by participants. Results at the 6-month follow-up favored MET/FCU over PE on days of marijuana use and number of times marijuana was smoked per day (medium effect), high volume drinking days and other drug use (small to medium effects), truancy indicators (small effects), parental monitoring (medium to large effects), and parent-teen problem solving (medium to large effects). A larger study to test the efficacy of the MET/FCU appears warranted based on these promising findings.

Effects of Co-occurring marijuana use and anxiety on brain structure and functioning: A systematic review of adolescent studies.

The prevalence of marijuana use among adolescents with anxiety disorders in the USA is markedly high and well documented; however, the literature on this co-occurrence's effect on adolescent brain development and functioning is limited. This systematic review searched six databases to 1) explore the literature concerning marijuana use among adolescents with anxiety and 2) examine the effects of marijuana on brain structure and functioning. Overall, 27 studies from six countries were included in this review. Out of these studies, several disparate designs were utilized. The majority of studies revealed an association between marijuana use and anxiety, but the strength of the association and the variability among the studies' designs limited the comparison and warrants additional investigation. Only five studies met criteria that used brain-imaging techniques, and findings were non-conclusive. Future evaluations should further investigate the effects of co-occurring marijuana use and anxiety disorders on brain structure and functioning among adolescents.

Assessing Acute Secondary Treatment Outcomes in Early-Onset Obsessive-Compulsive Disorder.

Obsessive-compulsive disorder (OCD) in children under 8 years of age, referred to as early-onset OCD, has similar features to OCD in older children, including moderate to severe symptoms, impairment, and significant comorbidity. Family-based cognitive behavioral therapy (FB-CBT) has been found efficacious in reducing OCD symptoms and functional impairment in children ages 5-8 years with OCD; however, its effectiveness on reducing comorbid psychiatric symptoms in this same population has yet to be demonstrated. This study examined the acute effects of FB-CBT vs. family-based relaxation treatment over 14 weeks on measures of secondary treatment outcomes (non-OCD) in children with early-onset OCD. Children in the FB-CBT condition showed significant improvements from pre- to post-treatment on secondary outcomes, with a decrease in overall behavioral and emotional problems, internalizing symptoms, as well as overall anxiety symptom severity. Neither condition yielded significant change in externalizing symptoms. Clinical implications of these findings are considered.

Brief Alcohol Interventions for Youth in the Emergency Department: Exploring Proximal and Distal Outcomes.

Brief interventions (BI) for alcohol use in the emergency department (ED) have been shown efficacious among adolescents and young adults; however, whether these interventions extend to other outcomes - proximal and distal - are less explored. This study examined outcomes of ED BIs in four completed trials showing reductions in alcohol use. Limited and inconsistent effects were found on proximal outcomes including parental monitoring, and distal outcomes including tobacco use. Identifying the mechanisms that underlie alcohol-focused BIs as well the intervention processes that may lead to generalized, positive effects on other variables is an important area of future research.

Elevated Autism Spectrum Disorder Traits in Young Children with OCD.

Studies have shown a high prevalence of autistic spectrum traits in both children and adults with psychiatric disorders; however the prevalence rate has not yet been investigated in young children with OCD. The aim of the current study was to (1) determine whether ASD traits indicated by the Social Communication Questionnaire (SCQ) and the Social Responsiveness Scale (SRS) were elevated in young children with OCD who do not have a specific ASD diagnosis and (2) determine if ASD traits were associated with OCD severity. Participants (N = 127) were children ages 5-8 years enrolled in the pediatric obsessive-compulsive disorder treatment study for young children (POTS Jr.). Results indicated that the SRS showed elevated autistic traits in the sample and was associated with OCD severity whereas the SCQ did not indicate heightened ASD symptoms. Implications of these results are discussed.

Substance Use and Depressive Symptoms among Adolescents Treated in a Pediatric Emergency Department.

The current study examined associations between substance use and depressed mood by gender and type of substance used (no use, alcohol, marijuana or both alcohol and marijuana) in a sample of 713 adolescents (Mage = 15.3) recruited from a Pediatric Emergency Department (PED). Adolescents who reported any marijuana use had higher overall depressed mood scores compared to all other adolescents. When examined by gender, females with both alcohol and marijuana use reported the highest overall depressed mood symptoms. These results suggest the usefulness of screening and identification of depressive symptoms among adolescents presenting to a PED for substance use-related problems.

Development of an Emergency Department Family Navigator and Text Message Intervention for Caregivers to Reduce Youth Risk of Suicide and Self-injurious Behavior.

BACKGROUND: Suicide and self-injurious behavior (SSIB) in youth 10 to 14 years old has rapidly increased, with suicide rates for youth 10 to 18 years being the second leading cause of death. Youth with SSIB seen in the Emergency Department (ED) are often discharged to the community, yet less than 40% receive subsequent mental health (MH) care within 30 days. This open pilot study examined the feasibility, acceptability, and sample characteristics of a two-component Family Navigator with text messaging intervention, ED REaCH, for caregivers of youth with SSIB discharged from the ED. METHODS: Sixteen dyads of youth (M=12.67; SD=1.09) seeking emergency care for SSIB and their caregivers were enrolled from the ED of a pediatric hospital in the northeast US from November 2023 to March 2024. Dyads were enrolled in the ED REaCH intervention consisting of navigation procedures to promote linkage to care, engagement in community-based MH care for youth with SSIB, and a digital platform to extend purported mechanisms underlying the intervention's efficacy (MH literacy, MH communication, and MH engagement). Data was collected on measures of social identities, demographics, functioning, MH services, and intervention satisfaction. RESULTS: All (100%) caregivers accepted the text messages. Most (75%) utilized the Family Navigator and completed the intervention feedback interviews. Overall, caregivers endorsed positive experiences and satisfaction with the two-component intervention. All caregivers who utilized the Family Navigator reported that 100% of youth attended MH care. CONCLUSION: Preliminary findings suggest that the content and delivery methods of this intervention are perceived by caregivers as feasible and acceptable. As such, next steps include the evaluation of the ED REaCH intervention in a randomized clinical trial design. Future directions need to focus on intervention scalability, adaptability, personalization, and sustainability.

Identifying and Characterizing the Transgender and Nonbinary Population Presenting to Pediatric Psychiatry Emergency Services.

Transgender and nonbinary (TGNB) individuals have an increased risk of certain mental health outcomes, such as depression and suicide attempts. This population skews younger in the United States and prior studies have not included TGNB patients for the entire pediatric age range in an emergency department (ED) setting. The present study aimed to examine gender identity documentation in the electronic health record and then use that information to identify and further characterize the pediatric TGNB population presenting to a psychiatric emergency service. Preliminary findings include a greater percentage of TGNB patients compared to non-TGNB individuals who had repeat visits to the ED for high acuity psychiatric concerns. A larger portion of TGNB patients also had at least one evaluation that included suicidal ideation. These results call for increased attention on the quality of mental healthcare for TGNB youth both inside and outside of the ED.

Characterizing Autism Spectrum Disorder and Predicting Suicide Risk for Pediatric Psychiatric Emergency Services Encounters.

Individuals diagnosed with autism spectrum disorder (ASD) are at a higher risk for mental health concerns including suicidal thoughts and behaviors (STB). Limited studies have focused on suicidal risk factors that are more prevalent or unique to the population with ASD. This study sought to characterize and classify youth presenting to the psychiatric emergency department (ED) for a chief complaint of STB. The results of this study validated that a high number of patients with ASD present to the ED with STB. There were important differences in clinical characteristics to those with ASD versus those without. Clinical features that showed important impact in predicting high suicide risk in the ASD cases include elements of the mental status exam such as affect, trauma symptoms, abuse history, and auditory hallucinations. Focused attention is needed on these unique differences in ASD cases so that suicide risk level can be appropriately and promptly addressed.

A randomized trial of acceptance-based behavioral therapy to improve mental health outcomes for LGBTQ+ persons: Study protocol.

BACKGROUND: During the COVID-19 pandemic, public health measures limited social interactions as an effective and protective intervention for all. For many, however, this social isolation exacerbated mental health symptoms. People who identify as lesbian, gay, bisexual, transgender, and queer (LGBTQ+) were already at elevated risk of anxiety and depression, relative to cisgender and heterosexual populations, and pandemic-related social isolation likely heightened these disparities. In our prior work with sexual and gender minorities, we developed and established feasibility and acceptability of a novel acceptance-based behavioral therapy (ABBT) intervention for HIV treatment. ABBT showed promise in improving social support and reducing mental health symptoms. In the current study, we investigate the efficacy of ABBT, compared to a treatment-as-usual control condition, in a full-scale randomized controlled trial to improve social support for LGBTQ+ persons living with anxiety and depression. METHODS: Two hundred forty LGBTQ+ adults with anxiety and/or depressive symptoms will be recruited and equally randomized to receive: (a) the ABBT intervention, consisting of two 30-40 min sessions plus treatment-as-usual (TAU), or (b) TAU only. Primary outcomes are interviewer-assessed anxiety and depressive symptoms. Secondary outcomes are self-reported anxiety and depressive symptoms. Experiential avoidance and social support are hypothesized mediators and presence of an anxiety and/or depressive disorder is a hypothesized moderator. CONCLUSIONS: ABBT represents a novel, identify-affirming real-world approach to promoting social support as a means of improving mental health among individuals who identify as LGBTQ+. This study will contribute actionable data establishing the impact, mediational mechanisms, and effect modifiers of ABBT. CLINICALTRIALS: govregistration: NCT05540067.

A Comparison of Acute Mental Health Presentations to Emergency Services Before and During the COVID-19 Pandemic.

OBJECTIVE/BACKGROUND: This study aimed to understand how the COVID-19 pandemic affected youth presentations to the Emergency Department's psychiatric service and how many warranted an inpatient and acute residential admission. METHODS: This cross-sectional study examined the patients (youth ages 3 to 18 years) evaluated at Hasbro Children's Hospital's Emergency Department by Lifespan's Pediatric Behavioral Health Emergency Service (LPBHES) over four months, March through June, of years 2019, 2020, and 2021. The sample was categorized into two groups: Children ages 3 to 11 years and adolescents ages 12 to 18 years. RESULTS: Youth evaluated by LPBHES showed an increase in acuity, where 11% more children and 12% more adolescents met criteria for inpatient and acute residential admission from years 2019 to 2020. This increase was observed despite fewer overall LPBHES evaluations. CONCLUSION: Future directions include prospective studies that explore the barriers to youth receiving the appropriate level of outpatient mental health services to prevent acute mental health crises.

Reducing access to means for suicidal youth presenting to emergency services: A test of medication lock bag distribution.

OBJECTIVE: Emergency departments (ED) provide psychiatric assessments to approximately 4000 youth annually. While most are discharged home, they are not without risk. To improve safety, this study examined the distribution of medication lock bags (MLB) to caregivers of youth discharged following an emergency evaluation. METHOD: The objective was to evaluate caregiver attitudes and behaviors related to the bag and perceptions of whether the MLB enhanced their youth's safety. MLB distribution was limited to patients who had presented with recent or current non-suicidal self-injurious behavior, suicidal ideation, or a suicide attempt. RESULTS: Caregivers were contacted for a phone survey and asked components of their MLB experience. Of the 119 caregivers offered the MLB, 114 accepted and 5 declined. Results indicate that caregivers found the most positive aspects of the bag to include the "Bag is Secure" (39%) and "Safety of Child and Family" (31%). Parents found the most negative aspects of using the bag to be "Nothing" (30%) and "Size" (21%). CONCLUSION: These results suggest most caregivers will accept and use MLBs when it is provided during a psychiatric ED evaluation. Further, data suggests caregivers find the bag to be easy to use and that it provides them with a sense of safety/security.

The association between neurocognition and sexual abuse within a children's psychiatric inpatient program.

Objective: The aim of this study was to understand the detrimental effects of sexual abuse on neuropsychological variables including child's intelligence, executive functioning (EF), and learning/memory within a pediatric inpatient population.Method: This study examined the effect of sexual abuse on children's intelligence, EF, and learning/memory by conducting a retrospective chart review for 144 children (aged 7-12) who completed a neuropsychological assessment during a psychiatric inpatient hospitalization. Of the 144 children, participants were matched two to one by gender and age, with one group (n = 52) categorized by reported sexual abuse and the other group (n = 92) categorized by no reported sexual abuse. The neuropsychological measures included the Wechsler Abbreviated Scale of Intelligence (WASI-I/II) or Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV), Wide Range Assessment of Memory and Learning - Second Edition (WRAML-2): Story Memory Immediate/Delayed Recall and Delayed Recognition, Trail Making Test-B, Stroop Interference Test: Color-Word Condition, WRAML-2: Sentence Memory and Conners Continuous Performance Test-Second Edition.Results: Statistical analysis showed that participants with reported sexual abuse had significantly (p< .05) lower intelligence, EF, and learning/memory skills than those without reported sexual abuse. Only working memory and cognitive flexibility differences remained after controlling for clinical variables (e.g., PTSD, amount of total abuse types).Conclusions: These findings contributed to the limited research on the detrimental effects of sexual abuse in a pediatric inpatient population. They demonstrated a relationship between early sexual abuse and neuropsychological deficits, specifically executive function and IQ deficits.

Neurocognitive predictors of length of stay within a children's psychiatric inpatient program.

This study investigated the neurocognitive predictors of length of stay (LOS) within a children's psychiatric inpatient program. A medical chart review was conducted for 96 children aged 6-14 years who received a neuropsychological evaluation during hospitalization. Correlation and linear regression analyses examined the influence of neurocognition (memory, construction, executive functioning [EF], and intelligence [IQ]) on subsequent LOS. Impairment/performance was calculated by the standard mean composite score and global deficit score (GDS) approaches for each domain and for overall neurocognition. Rates of impairment were similar between the two approaches (ranging from 22.9% to 45.8% across domains). Overall neurocognition (r = .347 & -.270, respectively), EF (r = .333 & -.261, respectively), and construction (r = .287 & -.240), respectively, were significantly associated with LOS utilizing the GDS and composite approaches. After controlling for clinical/demographic predictors of LOS, GDS-Total, GDS-EF/Construction, and EF/Construction composite scores significantly predicted LOS. Further, receiver operating characteristic (ROC) curve detected the GDS was able to distinguish between those children that would and would not end up having a prolonged hospitalization. The GDS and composite score approaches to neurocognitive impairment detection were similarly able to capture neurocognitive impairment and the association of impairment to LOS within a children's psychiatric inpatient program.

Assessing performance validity with the TOMM and automatized sequences task in a pediatric psychiatric inpatient setting.

This study examined the performance of children consecutively admitted to an inpatient psychiatric unit on the Test of Memory Malingering (TOMM) (aged 5-12; n = 96) and Automatized Sequences Task (aged 8-12; n = 67). Eighty-three percent of children passed the TOMM Trial 2 (M raw score = 47.7, SD = 4.7) and 76% of children passed the Automatized Sequences Task total time (M = 23.1 seconds; SD = 8.2). The concordance rate between the TOMM and the total time on the Automatized Sequences Task was 73.1%. Receiver operating characteristic curves indicated that of the Automatized Sequences Task subtests, only Counting 1-20 significantly differentiated children who passed Trial 2 of the TOMM from those who did not pass Trial 2 of the TOMM (area under the curve = .756, p = .006). Performance on both PVTs was unrelated to demographic characteristics and measures of psychological and neuropsychological functioning on both the TOMM and Automatized Sequences Task. Further research is needed to determine whether the nearly 1 in 4 children (23.9%) who performed below recommended cutoffs on Automatized Sequences Task reflects genuine suboptimal effort, cognitive difficulties among these children, and/or other factors.

Measurement of executive functioning with the National Institute of Health Toolbox and the association to anxiety/depressive symptomatology in childhood/adolescence.

INTRODUCTION: Despite preliminary research, there remain inconsistent findings with regard to the role of executive functioning (EF) deficits in childhood anxiety and depression. This report examined the association of The National Institute of Health (NIH) Toolbox to clinical neuropsychological measures and to childhood, anxiety/depressive symptomatology. Methods: One-hundred eight children and adolescents completed the three EF measures from the NIH Toolbox (List Sorting Working Memory Test [LSWMT], Dimensional Change Card Sorting Test [DCCST], and Flanker Test of Attention and Inhibition [Flanker]) in an outpatient neuropsychology program. These tests were compared to established measures of EF in terms of linear correlations and detection of impairment. Heaton's Global Deficit Score (GDS) was utilized to calculate impairment. The Toolbox-EF measures were paired with parent-reported EF symptoms (Behavior Rating Inventory of Executive Function [BRIEF2]) to identify the role of EF in childhood anxiety/depressive symptomatology. RESULTS: Toolbox-EF measures displayed medium sized correlations with their clinically comparable counterparts, and generally did not differ in their detection of impairment. Toolbox-GDS was associated with depression diagnosis and clinically significant child-reported anxiety and depressive symptoms. Together, Toolbox/BRIEF2 accounted for 26.8-30.9% of elevated depressive symptom variance, but only 13.2-14% of elevated anxiety symptom variance. Further, EF impairment was associated with depression across self report, parent report, and clinical diagnosis. DISCUSSION: The NIH Toolbox-EF measures display comparable psychometric properties to clinically available EF measures in a pediatric (primarily psychiatric) neuropsychology setting. The Toolbox appears to display an appropriate ability to detect EF deficits secondary to self-reported depression in childhood.