Experiences with the Child and Adolescent Psychiatry Milestones: Results of Two Nationwide Surveys.

OBJECTIVES: Child and Adolescent Psychiatry began using milestones in 2015 as a way to document observable progress through training. The study is the first assessment of Child and Adolescent Psychiatry (CAP) faculty and fellows' experience with the milestones. METHODS: This study presents findings from two surveys conducted one year apart. The first electronic survey polled CAP fellows and faculty nationwide using five opinion questions; demographic data and comments were also gathered. The second, four-question survey polled CAP faculty at the American Association of Directors of Psychiatry Residency Training annual meeting. RESULTS: Seventy-nine fellows and 101 faculty members responded to the first survey. Averaged over the five questions, 53% of faculty and 49% of fellows responded positively, with 29 and 33% respectively giving neutral responses. Participants were a diverse group in terms of geographic distribution, program size, and experience level. Comments were predominantly negative or mixed. Fifty CAP faculty and fellows responded to the second survey. Of the three opinion questions, positive responses ranged from 62 to 90%. Forty percent of respondents reported having had no faculty development on the milestones. CONCLUSIONS: Implementing the milestones has been a mixed experience for faculty and fellows. Direct comparison between these two surveys is not possible given their different content and format. Future directions include standardization of faculty development sessions, and improved structures to create and share best practices for assessment of trainees.

General and Child and Adolescent Psychiatry Resident Training in Integrated Care: a Survey of Program Directors.

OBJECTIVE: Integrated care models are an evidence-based approach for integrating physical and behavioral health services. The American Association of Directors of Psychiatric Residency Training Integrated Care Task Force sought to describe current practices for providing training in integrated care to general and child and adolescent psychiatry residents. METHODS: Directors of US general and child and adolescent psychiatric residency training programs were anonymously surveyed to examine current practices in educating their residents in integrated care. Based on themes that emerged from the survey, the authors make recommendations for integrated care education of general and child and adolescent psychiatry residents. RESULTS: Fifty-two of 197 (26%) general and 36 of 111 (32%) child and adolescent program directors responded. Results demonstrate that a majority of responding general psychiatry (78%) and child and adolescent psychiatry (CAP) (72%) training programs offer integrated care rotations, many of which are electives for senior residents. The Veterans Health Administration (VA) and Federally Qualified Health Centers are common venues for such rotations. Sustainable funding of these rotations is a concern. Fewer than half of programs offer integrated care didactics. CONCLUSIONS: This report is intended to help program directors consider options for starting or optimizing their own integrated care curricula. Future research should examine the educational value, and the overall value to health care systems, of training in the integrated care model.

Social skills training for children with autism.

This article summarizes the current literature on social skills training for children and adolescents with autism spectrum disorders. The article describes several different methods of social skills training, along with a summary of research findings on effectiveness. Interventions described include social skills groups, peer mentoring/training, social stories, and video modeling. The article also describes information about accessing social skills training services, and concludes with future directions and recommendations for pediatricians.

Second opinions improve ADHD prescribing in a medicaid-insured community population.

OBJECTIVE: The appropriate use of psychotropic medications in youths is an important public health concern. In this article, we describe a review process developed to monitor the use of stimulants and atomoxetine for attention-deficit/hyperactivity syndrome (ADHD) in youths receiving fee-for-service Medicaid services. METHOD: Washington State Medicaid developed threshold safety parameters for ADHD medications through a process involving the community. A second opinion was mandated when safety thresholds based on dose, combination therapies, or age was exceeded. Use and cost were compared 2 years before and after the program began. RESULTS: From May 2006 to April 2008, 5.35% of ADHD prescriptions exceeded safety thresholds, resulting in 1,046 second-opinion reviews. Of those, 538 (51.4%) resulted in a prescription adjustment. Adjustments were made to primary care physician (52%), psychiatrist (50%), nurse practitioner (54%), and physician assistant-written (51%) prescriptions. When the preperiod and postperiod were compared, second opinions reduced ADHD medication at high doses (53%), in combinations (44%), and for patients 5 years of age and younger (23%). The review process resulted in a savings of $1.2 million, with 538 fewer patients exceeding safety thresholds. This was a 10:1 return over administrative costs; however, the overall Medicaid expenditures for ADHD medication still increased because of higher unit costs and the preferential use by clinicians of newer brands entering the market. CONCLUSIONS: A statewide second-opinion process reduced outlier ADHD medication prescription practices and was cost-effective. Suggestions for process and quality improvements in prescribing to children diagnosed with ADHD are discussed.

Treating depression in children and adolescents: what options now?

There have been significant developments in the understanding of depression in children and adolescents in the past few years, including an increased recognition that significant depressive illness occurs in this patient group. Pharmacological and psychotherapeutic treatments are used to manage depression in children and adolescents, and there is evidence from randomised, double-blind, placebo-controlled trials of benefit for both approaches. However, not all medication trials have been positive. In addition, there have been increasing concerns about specific safety issues related to the use of medications to treat depression, with an overall finding of mood-related adverse effects, including suicide attempts, in 4% of active drug versus 2% of placebo recipients in controlled trials involving children and adolescents. This has resulted in regulatory actions in a number of countries that have ranged from the declaration of contraindication for most antidepressants (in Great Britain), to relegation of antidepressants to a second-line intervention (in New Zealand) to a Black Box warning (in the US). It can be concluded that best practice combines treatment with both medication and psychotherapy, and that important safety issues must be monitored carefully when children and adolescents are treated for depression. On balance, there appears to be evidence of the benefit for antidepressant medications in children and adolescents, which outweigh safety concerns.

A survey of the interactions between psychiatry residency programs and the pharmaceutical industry.

OBJECTIVE: The authors report a survey of the American Association of Directors of Psychiatry Residency Training (AADPRT) on interactions between the pharmaceutical industry and psychiatry residency programs. METHODS: American Association of Directors of Psychiatry Residency Training membership was anonymously surveyed by e-mail and by paper distribution at the 2002 annual meeting. RESULTS: Twenty-seven percent of AADPRT members participated. Lunches for residents were the most common interaction, reported by 93% of programs, nearly all of which permitted literature and gifts to be distributed. Only 4% required faculty to be present. Retreats (27%) and travel funds (34%) were sponsored less frequently. One third of programs had written policies governing these interactions, but half of respondents did not know if their parent institutions had such policies. A minority of programs (40%) had formal didactic instruction for residents on this topic. Support for more information, direction, and teaching was widespread. CONCLUSIONS: The authors recommend more structured teaching and the establishment of formal program and institutional policies to govern these interactions.

Anxiety disorders in the child and teen.

Several disorders have been reviewed (Table 1). Based upon review of the literature, an algorithm has been developed, supporting the initial use of cognitive behavioral therapy, followed by a psychopharmacology algorithm if treatment is not successful. In this algorithm, severely anxious patients initially may require psychopharmacologic treatment to be able to participate in cognitive behavioral treatment. Nonspecific measures of parent education, general support, and illness education to parents and patients are overarching principles. In this algorithm, the SSRIs are perceived to be first-line interventions, with tricyclic antidepressants and venlafaxine as second-line agents. Buspirone is considered a second- or third-line agent, as are the benzodiazepines. Table 2 reviews psychopharmacologic agents shown to be useful in the management of anxiety disorders in youth. Although much research remains to be done, there is evidence of efficacy of several interventions for anxiety disorders in children and adolescents. There is a need for a holistic and comprehensive management plan. Particular attention must be given to specific psychopharmacologic and psychotherapy needs, family matters, abuse issues, freedom from substance abuse, the use of peer support groups, and the encouragement of healthier lifestyle choices such as exercise. A rising number of well-done, large, placebo-controlled studies are providing increased support for medication and psychotherapy to inform evidence-based treatment. There is a need for teamwork and effective communication among team members in addressing pediatric and adolescent anxiety disorders.