Understanding the uptake of virtual care for first and return outpatient appointments in child and adolescent mental health services: a mixed-methods study.

OBJECTIVE: To describe patterns of virtual and in-person outpatient mental health service use and factors that may influence the choice of modality in a child and adolescent service. DESIGN: A pragmatic mixed-methods approach using routinely collected administrative data between 1 April 2020 and 31 March 2022 and semi-structured interviews with clients, caregivers, clinicians and staff. Interview data were coded according to the Consolidated Framework for Implementation Research (CFIR) and examined for patterns of similarity or divergence across data sources, respondents or other relevant characteristics. SETTING: Child and adolescent outpatient mental health service, Nova Scotia, Canada. PARTICIPANTS: IWK Health clinicians and staff who had participated in virtual mental healthcare following its implementation in March 2020 and clients (aged 12-18 years) and caregivers of clients (aged 3-18 years) who had received treatment from an IWK outpatient clinic between 1 April 2020 and 31 March 2022 (n=1300). Participants (n=48) in semi-structured interviews included nine clients aged 13-18 years (mean 15.7 years), 10 caregivers of clients aged 5-17 years (mean 12.7 years), eight Community Mental Health and Addictions booking and registration or administrative staff and 21 clinicians. RESULTS: During peak pandemic activity, upwards of 90% of visits (first or return) were conducted virtually. Between waves, return appointments were more likely to be virtual than first appointments. Interview participants (n=48) reported facilitators and barriers to virtual care within the CFIR domains of 'outer setting' (eg, external policies, client needs and resources), 'inner setting' (eg, communications within the service), 'individual characteristics' (eg, personal attributes, knowledge and beliefs about virtual care) and 'intervention characteristics' (eg, relative advantage of virtual or in-person care). CONCLUSIONS: Shared decision-making regarding treatment modality (virtual vs in-person) requires consideration of client, caregiver, clinician, appointment, health system and public health factors across episodes of care to ensure accessible, safe and high-quality mental healthcare.

Pharmacological treatment of psychiatric disorders in children and adolescents: focus on guidelines for the primary care practitioner.

This article is a practical review of the current psychopharmacological agents used in the treatment of child and adolescent psychiatric disorders. Psychostimulants such as methylphenidate, dexamphetamine and pemoline are effective in the control of symptoms associated with attention deficit hyperactivity disorder. The controlled release preparations and the adjunctive use of clonidine are helpful to extend stimulant effects and control adverse effects. Tricyclic antidepressants are helpful in individual cases of child and adolescent depression, but adverse effects may limit their use. Clomipramine has been found to be effective for childhood obsessive-compulsive disorder. Selective serotonin (5-HT) reuptake inhibitors (SSRIs) appear to be safer for depression and are also useful in obsessive-compulsive disorder. Buspirone is effective for the treatment of anxiety disorders in children. Newer atypical antipsychotics such as risperidone may have less limiting adverse effects than older antipsychotics in the treatment of psychosis and severe behaviour disorders, but the physician must be vigilant for the emergence of tardive dyskinesia. Drug treatment in children and adolescents must take into account the child's environmental influences and be part of an overall treatment plan where individual, familial and cultural issues are addressed.

Itard's 1828 mémoire on "Mutism caused by a lesion of the intellectual functions": a historical analysis.

OBJECTIVE: To demonstrate that Itard was one of the first clinicians to describe autism (which Itard named "intellectual mutism") and effectively separate these cases from mental retardation. Known for his attempts at rehabilitation of the Wild Boy of Aveyron, Itard wrote a largely unacknowledged paper in 1828 on the different causes of "intellectual mutism," the result of 28 years of observations at the Institut des Sourd-Muets in Paris. METHOD: Itard emphasized a complete examination of the child's faculties including attention, memory, and imitative capacity. He also described the behavior of these children as unsocialized, with poor peer relationships, superficial contact with adults in order to satisfy their own needs, and difficulties in language, especially with pronouns. RESULTS: He then described his various diagnostic and treatment approaches to determine whether the child can regain language and is educable. His description of the key features of intellectual mutism is compared to Kanner's classic description of autism. CONCLUSION: Itard rejected the overly inclusive diagnosis of "idiocy" and offered a way to distinguish children with mental retardation from those with pervasive developmental disorders, described key clinical features, and offered an assessment and treatment of these cases, all before 1830. His contribution should be recognized in textbooks of child psychiatry and developmental disorders.

Physiological and cognitive correlates of child abuse.

OBJECTIVE: To compare the physiological responses of abused children to different stimuli with responses of children in a reference group and to correlate the physiological responses with intellectual and personality functioning. METHOD: Abused children were compared with a reference group on two batteries of tests that were administered on separate days. In one session, children were shown slides with emotional or cognitive content while heart rate, pulse height, skin conductance, electromyography, and skin temperature were measured. In the other session, intellectual and personality functioning was measured using the WISC-R, Quick Neurological Screening Test, and the Junior Eysenck personality inventory. RESULTS: Abused children had smaller changes in pulse height in the first two stimulus conditions presented ("No Signal" and "Math"), but their electrodermal responses were lower throughout all stimulus conditions. Abused children also had higher introversion and lower Verbal and Full Scale IQ scores. Verbal and Full Scale IQ scores were inversely related to the severity of abuse that had been experienced. When these variables were used in a discriminant function analysis, children were assigned to the correct group 86% of the time. CONCLUSION: These findings support a model that describes the effects of abuse as delaying cognitive development and inhibiting physiological responsiveness to the environment.

Update and recommendations for the use of antipsychotics in early-onset psychoses.

A review was undertaken of studies evaluating the efficacy and tolerability of antipsychotic medications for the management of psychosis in children and adolescents. All identified published and unpublished studies from 1996 onward were included for review. The search located one randomized control trial, seven open-label trials, six retrospective chart reviews, and nine case reports. The studies assessed the use of haloperidol, clozapine, risperidone, olanzapine, and quetiapine in the management of psychosis in children and adolescents. Most studies reported reasonable treatment response; however, extrapyramidal side effects, sedation, and weight gain are concerning. This points to the need for appropriate baseline assessments prior to initiating treatment with these agents. Particular attention should be given to assessment of the extrapyramidal system as well as to baseline weight, lipid profile, and blood glucose. Further study is needed to refine the use of antipsychotic medications in children and adolescents in order to minimize adverse effects while conferring an optimum therapeutic response. The importance of instituting effective early treatment in youth with psychoses is an important goal that may serve to lessen the long-term morbidity of the illness.

Suicidal ideation and child abusers. Three case studies.

1. Although the topic of the treatment of child abusers does not evoke much sympathy in the public or the mental health profession, the solution to this problem does not lie in hoping that all abusers should commit suicide--or that suicide is a deserved outcome for the abuser. 2. Our first priority is and should remain the child's safety; however, in too many cases the abuser-perpetrator is inextricably linked to the child, and whatever happens to the abuser may have consequences for the child. 3. It is hoped that the skewed punitive view of the abuser will change as we better understand the dynamics among violence, depression, and child abuse in our society. We could then offer the victim and perpetrator better treatment and improve our preventive strategies.

How to deal with sexual acting-out on the child psychiatric inpatient ward.

1. Although the management of sexually abused children is not new, a comprehensive approach is often lacking, especially as it pertains to dealing with sexually acting-out children. 2. In addition to the usual social work measures of child protection, a program of developmentally and psychoeducationally based interventions supplemented by behavioral techniques were found to be most effective. 3. Acting-out children often provoke reactions of rage, betrayal, and impotence among the staff. Discussions of interventions must take into account the staff's own philosophy about how sexuality should be taught to these children. 4. The treatment team leader must decide whether the sexual acting-out among children is due to active solicitation from sexually abused children, delinquent acting-out, or age-appropriate exploration.