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PURPOSE: The purpose of this study was to explore relationships between postoperative opioid administration and posttraumatic stress symptoms (PTSS) in preschool-aged children surviving cardiac surgery. DESIGN AND METHODS: This was a cross-sectional, descriptive study using survey administration and medical chart review. Primary caregivers of children aged three to six years who underwent cardiac surgery at our institution between 2018 and 2020 were invited to participate. Opioid administration was calculated according to morphine milligram equivalents and indexed to the child's body weight. Caregivers completed the Young Child Posttraumatic Stress Disorder Checklist to explore child PTSS. We used correlational methods to assess the strength and direction of relationships between postoperative opioid administration and child PTSS. RESULTS: We did not find a statistically significant relationship between total postoperative opioid administration and child PTSS. When analyzing individual opioid agents, morphine did show a significant inverse relationship to YCPC scores (rs = -.57, p = .017) in children with single ventricle physiology. CONCLUSIONS: Total postoperative opioid administration was not statistically significantly related to child PTSS in our sample. Differing patterns of association were noted among children with single- versus bi-ventricular physiology. Postoperative morphine administration was favorably associated with PTSS in children with single-ventricle physiology. PRACTICE IMPLICATIONS: Nurses caring for preschool children who undergo cardiac surgery should anticipate the potential development of PTSS in their patients. Studies using larger sample sizes and longitudinal design are needed to replicate the significant relationship between morphine administration and PTSS in preschoolers with single-ventricle physiology.
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Procedimentos Cirúrgicos Cardíacos , Transtornos de Estresse Pós-Traumáticos , Humanos , Pré-Escolar , Transtornos de Estresse Pós-Traumáticos/epidemiologia , Analgésicos Opioides/efeitos adversos , Estudos Transversais , Pais , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Derivados da MorfinaRESUMO
OBJECTIVE: Despite growing recognition of how curriculum modules can benefit child and adolescent psychiatry (CAP) training, there are few standardized teaching resources for pediatric consultation-liaison psychiatry (PCLP). A Special Interest Group (SIG) of the American Academy of Child and Adolescent Psychiatry Physically Ill Child Committee (PICC) conducted a needs assessment to establish interest in, and availability of, a library of online, self-paced learning modules specific to PCLP. METHOD: An email needs assessment survey was distributed to the PICC listserv in the fall of 2019 with four core areas of inquiry: (1) clinical service description, (2) teaching barriers, (3) interest in curriculum resources, and (4) interest in evaluation resources. RESULTS: Respondents were representative of typical academic PCLP programs. The response rate was 28% (n = 39). Programs endorsed barriers to teaching including high service obligations and limited protected teaching time. All respondents indicated that they would utilize high-quality, online learning modules. Psychiatric complications of medical illness, catatonia, and delirium were identified as priority topics in the care of pediatric patients with comorbid medical conditions. CONCLUSIONS: There are currently no published educational studies regarding the training needs for PCLP programs, even among tertiary care academic facilities. This training needs assessment is the first step in establishing a national PCLP training curriculum. New paradigms to develop standardized curriculum resources for PCLP are needed.
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Psiquiatria do Adolescente , Psiquiatria , Adolescente , Psiquiatria do Adolescente/educação , Criança , Currículo , Humanos , Avaliação das Necessidades , Psiquiatria/educação , Encaminhamento e Consulta , Inquéritos e Questionários , Estados UnidosRESUMO
OBJECTIVES: ICU delirium is a predictor of greater morbidity and higher mortality in the pediatric population. The diagnostic obstacles and validity of delirium monitoring among neonates and young infants have yet to be fully delineated. We sought to validate the Preschool Confusion Assessment Method for the ICU in neonates and young infants and determine delirium prevalence in this young population. DESIGN: Prospective cohort study to validate the Preschool Confusion Assessment Method for the ICU for the assessment of ICU delirium in neonates and young infants compared with the reference standard, Child and Adolescent Psychiatry. SETTING: Tertiary medical center PICU, including medical, surgical, and cardiac patients. PARTICIPANTS: Infants less than 6 months old admitted to the PICU regardless of admission diagnosis. MEASUREMENTS AND MAIN RESULTS: We enrolled 49 patients with a median age of 1.8 months (interquartile range, 0.7-4.1 mo), 82% requiring mechanical ventilation. Enrolled patients were assessed for delirium in blinded-fashion by the research team using the Preschool Confusion Assessment Method for the ICU and independently assessed by the psychiatry reference rater using Diagnostic and Statistical Manual of Mental Disorders-5 criteria. A total of 189 paired assessments were completed, and the Preschool Confusion Assessment Method for the ICU performed with a sensitivity of 95% (95% CI, 89-100%), specificity of 81% (68-90%), "negative and positive predictive values" of 97% (94-100%) and 69% (55-79%), respectively, compared with the reference rater. Delirium prevalence was 47%, with higher rates of 61% observed among neonates (< 1 mo old) and 39% among infants 1-6 months old. CONCLUSIONS: The Preschool Confusion Assessment Method for the ICU is a valid screening tool for delirium monitoring in infants less than 6 months old. Delirium screening was feasible in this population despite evolving neurocognition and arousal architecture. ICU delirium was prevalent among infants. The consequence of acute brain dysfunction during crucial neurocognitive development remains unclear. Future studies are necessary to determine the long-term impact of ICU delirium and strategies to reduce associated harm in critically ill infants.
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Confusão/classificação , Delírio/complicações , Programas de Rastreamento/normas , Estudos de Coortes , Confusão/etiologia , Delírio/psicologia , Feminino , Humanos , Lactente , Recém-Nascido , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Programas de Rastreamento/métodos , Programas de Rastreamento/estatística & dados numéricos , Prevalência , Estudos Prospectivos , Reprodutibilidade dos TestesRESUMO
OBJECTIVE: To assess the prevalence of psychiatric disorders and associated therapies in children during their heart transplantation admission. STUDY DESIGN: All pediatric heart transplant recipients (1999-2016) were included from a linked administrative and clinical registry database. Psychiatric disorders and associated therapies were identified using International Classification of Diseases or billing codes during the transplant admission. Data were analyzed using standard descriptive statistics. Multivariable logistic regression assessed factors independently associated with psychiatric disorders or therapies. RESULTS: A total of 3073 pediatric heart transplant recipients were included. Psychiatric disorders were present in 434 (14.1%) patients during the heart transplant admission, with adjustment disorders being the most common. Antidepressant therapy was prescribed to 212 patients (6.9%) and selective serotonin reuptake inhibitors were most commonly used. Psychiatric diagnoses (8.4% vs 18.1%; P < .001) and the use of antidepressants (4.5% vs 8.9%; P < .001) increased over time (era 1, 1999-2009 vs era 2, 2010-2016). Psychiatric disorders were present in 39.8% of patients ≥8 years of age requiring ventricular assist device support at heart transplantation. The need for ventricular assist device support was independently associated with psychiatric diagnoses (aOR, 1.57; 95% CI, 1.18-2.1; P = .002) and antidepressant therapy (aOR, 2.11; 95% CI. 1.43-3.12; P < .001). CONCLUSIONS: Psychiatric disorders are common in pediatric heart transplant recipients, especially among those bridged with ventricular assist device support. Psychiatric diagnoses and the use of antidepressants has increased over time, likely representing improved recognition of psychiatric comorbidities in this vulnerable population. Access to psychiatric services represents an important component of the multidisciplinary team caring for pediatric heart transplant recipients.
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Transtornos de Adaptação/complicações , Ansiedade/complicações , Transtorno Depressivo/complicações , Insuficiência Cardíaca/cirurgia , Transplante de Coração , Coração Auxiliar , Transtornos de Adaptação/epidemiologia , Adolescente , Antidepressivos/uso terapêutico , Ansiedade/epidemiologia , Criança , Pré-Escolar , Estudos Transversais , Bases de Dados Factuais , Transtorno Depressivo/tratamento farmacológico , Transtorno Depressivo/epidemiologia , Feminino , Insuficiência Cardíaca/psicologia , Humanos , Lactente , Recém-Nascido , Masculino , Análise Multivariada , Inibidores Seletivos de Recaptação de Serotonina/uso terapêutico , Adulto JovemRESUMO
BACKGROUND: Learners developing competency-based skills, attitudes, and knowledge through the achievement of defined milestones is a core feature of competency-based medical education. In 2017, a special interest study group of the American Academy of Child and Adolescent Psychiatry convened a panel of specialists to describe pediatric consultation-liaison psychiatry (CLP) best educational practices during child and adolescent psychiatry fellowship. OBJECTIVE: The objective of this project was to develop a national consensus on pediatric CLP competencies to help guide training in this specialty. METHODS: An expert working group developed a list of candidate competences based on previously established educational outcomes for CLP (formerly Psychosomatic Medicine), child and adolescent psychiatry, and general psychiatry. A survey was distributed to members of the American Academy of Child and Adolescent Psychiatry Physically Ill Child Committee to determine child and adolescent psychiatry fellowship educational needs on pediatric CLP services and generate consensus regarding pediatric CLP competencies. RESULTS: Most survey respondents were supportive of the need for a national consensus on core competencies for pediatric CLP. Consensus from a panel of experts in the field of pediatric CLP generated a list of proposed core competencies that track the Accreditation Council for Graduate Medical Education's six core competencies. CONCLUSIONS: Consistent learning outcomes provide the foundation for further development of tools to support training in pediatric CLP. There is a need to develop further tools including outcome assessment instruments and self-directed learning materials that can be used to support lifelong learning.
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Psiquiatria do Adolescente/educação , Psiquiatria Infantil/educação , Competência Clínica/estatística & dados numéricos , Educação de Pós-Graduação em Medicina/normas , Bolsas de Estudo/normas , Encaminhamento e Consulta/normas , Acreditação/normas , Psiquiatria do Adolescente/normas , Psiquiatria Infantil/normas , Competência Clínica/normas , Currículo/normas , Humanos , Estados UnidosRESUMO
OBJECTIVES: Delirium is prevalent among critically ill children, yet associated outcomes and modifiable risk factors are not well defined. The objective of this study was to determine associations between pediatric delirium and modifiable risk factors such as benzodiazepine exposure and short-term outcomes. DESIGN: Secondary analysis of collected data from the prospective validation study of the Preschool Confusion Assessment Method for the ICU. SETTING: Tertiary-level PICU. PATIENTS: Critically ill patients 6 months to 5 years old. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Daily delirium assessments were completed using the Preschool Confusion Assessment Method for the ICU. Associations between baseline and in-hospital risk factors were analyzed for likelihood of ICU discharge using Cox proportional hazards regression and delirium duration using negative binomial regression. Multinomial logistic regression was used to determine associations between daily risk factors and delirium presence the following day. Our 300-patient cohort had a median (interquartile range) age of 20 months (11-37 mo), and 44% had delirium for at least 1 day (1-2 d). Delirium was significantly associated with a decreased likelihood of ICU discharge in preschool-aged children (age-specific hazard ratios at 60, 36, and 12 mo old were 0.17 [95% CI, 0.05-0.61], 0.50 [0.32-0.80], and 0.98 [0.68-1.41], respectively). Greater benzodiazepine exposure (75-25th percentile) was significantly associated with a lower likelihood of ICU discharge (hazard ratio, 0.65 [0.42-1.00]; p = 0.01), longer delirium duration (incidence rate ratio, 2.47 [1.36-4.49]; p = 0.005), and increased risk for delirium the following day (odds ratio, 2.83 [1.27-6.59]; p = 0.02). CONCLUSIONS: Delirium is associated with a lower likelihood of ICU discharge in preschool-aged children. Benzodiazepine exposure is associated with the development and longer duration of delirium, and lower likelihood of ICU discharge. These findings advocate for future studies targeting modifiable risk factors, such as reduction in benzodiazepine exposure, to mitigate iatrogenic harm in pediatric patients.
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Benzodiazepinas/efeitos adversos , Estado Terminal/terapia , Delírio/induzido quimicamente , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Pré-Escolar , Feminino , Humanos , Lactente , Tempo de Internação , Masculino , Estudos Prospectivos , Fatores de Risco , Índice de Gravidade de Doença , Fatores de TempoRESUMO
OBJECTIVES: Delirium assessments in critically ill infants and young children pose unique challenges due to evolution of cognitive and language skills. The objectives of this study were to determine the validity and reliability of a fundamentally objective and developmentally appropriate delirium assessment tool for critically ill infants and preschool-aged children and to determine delirium prevalence. DESIGN AND SETTING: Prospective, observational cohort validation study of the PreSchool Confusion Assessment Method for the ICU in a tertiary medical center PICU. PATIENTS: Participants aged 6 months to 5 years and admitted to the PICU regardless of admission diagnosis were enrolled. MEASUREMENTS AND MAIN RESULTS: An interdisciplinary team created the PreSchool Confusion Assessment Method for the ICU for pediatric delirium monitoring. To assess validity, patients were independently assessed for delirium daily by the research team using the PreSchool Confusion Assessment Method for the ICU and by a child psychiatrist using the Diagnostic and Statistical Manual of Mental Disorders criteria. Reliability was assessed using blinded, concurrent PreSchool Confusion Assessment Method for the ICU evaluations by research staff. A total of 530-paired delirium assessments were completed among 300 patients, with a median age of 20 months (interquartile range, 11-37) and 43% requiring mechanical ventilation. The PreSchool Confusion Assessment Method for the ICU demonstrated a specificity of 91% (95% CI, 90-93), sensitivity of 75% (95% CI, 72-78), negative predictive value of 86% (95% CI, 84-88), positive predictive value of 84% (95% CI, 81-87), and a reliability κ-statistic of 0.79 (0.76-0.83). Delirium prevalence was 44% using the PreSchool Confusion Assessment Method for the ICU and 47% by the reference rater. The rates of delirium were 53% versus 56% in patients younger than 2 years old and 33% versus 35% in patients 2-5 years old using the PreSchool Confusion Assessment Method for the ICU and reference rater, respectively. The short-form PreSchool Confusion Assessment Method for the ICU maintained a high specificity (87%) and sensitivity (78%) in post hoc analysis. CONCLUSIONS: The PreSchool Confusion Assessment Method for the ICU is a highly valid and reliable delirium instrument for critically ill infants and preschool-aged children, in whom delirium is extremely prevalent.
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Confusão/diagnóstico , Estado Terminal , Delírio/diagnóstico , Unidades de Terapia Intensiva Pediátrica , Testes Neuropsicológicos , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Variações Dependentes do Observador , Estudos Prospectivos , Reprodutibilidade dos Testes , Respiração Artificial , Sensibilidade e Especificidade , Índice de Gravidade de DoençaAssuntos
Doenças Autoimunes/psicologia , Catatonia/psicologia , Transtorno Obsessivo-Compulsivo/psicologia , Anticorpos Antinucleares/imunologia , Anticorpos Antibacterianos/imunologia , Autoanticorpos/imunologia , Doenças Autoimunes/diagnóstico , Doenças Autoimunes/tratamento farmacológico , Doenças Autoimunes/imunologia , Doenças Autoimunes do Sistema Nervoso/diagnóstico , Doenças Autoimunes do Sistema Nervoso/imunologia , Proteínas de Bactérias/imunologia , Canais de Cálcio Tipo N/imunologia , Catatonia/tratamento farmacológico , Catatonia/fisiopatologia , Criança , Diagnóstico Diferencial , Encefalite/diagnóstico , Encefalite/imunologia , Feminino , Fluoxetina/uso terapêutico , Humanos , Hipnóticos e Sedativos/uso terapêutico , Lorazepam/uso terapêutico , Testes de Estado Mental e Demência , Transtorno Obsessivo-Compulsivo/diagnóstico , Transtorno Obsessivo-Compulsivo/tratamento farmacológico , Transtorno Obsessivo-Compulsivo/imunologia , Olanzapina/uso terapêutico , Inibidores Seletivos de Recaptação de Serotonina/uso terapêutico , Estreptolisinas/imunologiaRESUMO
Importance: Dose-related effects of antipsychotic medications may increase mortality in children and young adults. Objective: To compare mortality for patients aged 5 to 24 years beginning treatment with antipsychotic vs control psychiatric medications. Design, Setting, and Participants: This was a US national retrospective cohort study of Medicaid patients with no severe somatic illness or schizophrenia or related psychoses who initiated study medication treatment. Study data were analyzed from November 2022 to September 2023. Exposures: Current use of second-generation antipsychotic agents in daily doses of less than or equal to 100-mg chlorpromazine equivalents or greater than 100-mg chlorpromazine equivalents vs that for control medications (α agonists, atomoxetine, antidepressants, and mood stabilizers). Main Outcome and Measures: Total mortality, classified by underlying cause of death. Rate differences (RDs) and hazard ratios (HRs) adjusted for potential confounders with propensity score-based overlap weights. Results: The 2â¯067â¯507 patients (mean [SD] age, 13.1 [5.3] years; 1â¯060â¯194 male [51.3%]) beginning study medication treatment filled 21â¯749â¯825 prescriptions during follow-up with 5â¯415â¯054 for antipsychotic doses of 100 mg or less, 2â¯813â¯796 for doses greater than 100 mg, and 13â¯520â¯975 for control medications. Mortality was not associated with antipsychotic doses of 100 mg or less (RD, 3.3; 95% CI, -5.1 to 11.7 per 100â¯000 person-years; HR, 1.08; 95% CI, 0.89-1.32) but was associated with doses greater than 100 mg (RD, 22.4; 95% CI, 6.6-38.2; HR, 1.37; 95% CI, 1.11-1.70). For higher doses, antipsychotic treatment was significantly associated with overdose deaths (RD, 8.3; 95% CI, 0-16.6; HR, 1.57; 95% CI, 1.02-2.42) and other unintentional injury deaths (RD, 12.3; 95% CI, 2.4-22.2; HR, 1.57; 95% CI, 1.12-2.22) but was not associated with nonoverdose suicide deaths or cardiovascular/metabolic deaths. Mortality for children aged 5 to 17 years was not significantly associated with either antipsychotic dose, whereas young adults aged 18 to 24 years had increased risk for doses greater than 100 mg (RD, 127.5; 95% CI, 44.8-210.2; HR, 1.68; 95% CI, 1.23-2.29). Conclusions and Relevance: In this cohort study of more than 2 million children and young adults without severe somatic disease or diagnosed psychosis, antipsychotic treatment in doses of 100 mg or less of chlorpromazine equivalents or in children aged 5 to 17 years was not associated with increased risk of death. For doses greater than 100 mg, young adults aged 18 to 24 years had significantly increased risk of death, with 127.5 additional deaths per 100â¯000 person-years.
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Antipsicóticos , Esquizofrenia , Criança , Humanos , Masculino , Adulto Jovem , Adolescente , Antipsicóticos/efeitos adversos , Clorpromazina/uso terapêutico , Estudos Retrospectivos , Estudos de CoortesRESUMO
PROBLEM: Holistic review is a multifaceted concept that aims to increase diversity and applicant fit with program needs by complementing traditional academic requirements with appraisal of a wider range of personal characteristics and experiences. Behavioral interviewing has been practiced and studied in human resources, business, and organizational psychology for over 50 years. Its premise is that future performance can be anticipated from past actions. However, many of the interview approaches within the holistic framework are resource intensive and logistically challenging. APPROACH: The Vanderbilt University School of Medicine instituted a competency-based behavioral interview (CBBI) to augment the selection process in 2012. Behavioral interviews are based on key competencies needed for entering students and require applicants to reflect on their actual experiences and what they learned from them. The authors reviewed 5 years of experience (2015-2019) to evaluate how CBBI scores contributed to the overall assessment of applicants for admission. OUTCOMES: The final admission committee decision for each applicant was determined by reviewing multiple factors, with no single assessment determining the final score. The CBBI and summary interview scores showed a strong association (P < .005), suggesting that the summary interviewer, who had access to the full applicant file, and the CBBI interviewer, who did not, assessed similar strengths despite the 2 different approaches, or that the strengths assessed tracked in the same direction. Students whose 2 interview scores were not aligned were less likely to be accepted to the school. NEXT STEPS: The review raised awareness about the cultural aspects of interpreting the competencies and the need to expand our cultural framework throughout interviewer training. Findings indicate that CBBIs have the potential to reduce bias related to over-reliance on standardized metrics; however, additional innovation and research are needed.
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PURPOSE: To assess the safety of psychotropic medication use in children and adolescents, it is critical to be able to identify suicidal behaviors from medical claims data and distinguish them from other injuries. The purpose of this study was to develop an algorithm using administrative claims data to identify medically treated suicidal behavior in a cohort of children and adolescents. METHODS: The cohort included 80,183 youth (6-18 years) enrolled in Tennessee's Medicaid program from 1995-2006 who were prescribed antidepressants. Potential episodes of suicidal behavior were identified using external cause-of-injury codes (E-codes) and ICD-9-CM codes corresponding to the potential mechanisms of or injuries resulting from suicidal behavior. For each identified episode, medical records were reviewed to determine if the injury was self-inflicted and if intent to die was explicitly stated or could be inferred. RESULTS: Medical records were reviewed for 2676 episodes of potential self-harm identified through claims data. Among 1162 episodes that were classified as suicidal behavior, 1117 (96%) had a claim for suicide and self-inflicted injury, poisoning by drugs, or both. The positive predictive value of code groups to predict suicidal behavior ranged from 0-88% and improved when there was a concomitant hospitalization but with the limitation of excluding some episodes of confirmed suicidal behavior. CONCLUSIONS: Nearly all episodes of confirmed suicidal behavior in this cohort of youth included an ICD-9-CM code for suicide or poisoning by drugs. An algorithm combining these ICD-9-CM codes and hospital stay greatly improved the positive predictive value for identifying medically treated suicidal behavior.
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Comportamento do Adolescente/efeitos dos fármacos , Antidepressivos/efeitos adversos , Bases de Dados Factuais/estatística & dados numéricos , Prescrições de Medicamentos/estatística & dados numéricos , Ideação Suicida , Tentativa de Suicídio/psicologia , Adolescente , Fatores Etários , Algoritmos , Criança , Mineração de Dados , Revisão de Uso de Medicamentos/estatística & dados numéricos , Feminino , Hospitalização , Humanos , Tempo de Internação , Masculino , Medicaid/estatística & dados numéricos , Farmacoepidemiologia , Farmacovigilância , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Estados UnidosRESUMO
Critically ill children suffer from pain and anxiety additionally in the face of severe organ dysfunction. The critical care environment challenges pediatric patients' emotional and developmental capabilities. Disease-focused therapy is a priority and usually requires separation of patient from family and completion of invasive procedures. With the lack of familiar surroundings, inability to self-soothe, and deficiency of sleep, critically ill children may benefit from a multidisciplinary approach to care with a specific goal of pain management. Due to the challenges unique to critical care of children, sedatives and hypnotics are heavily relied upon to "protect" children from the intensive care experience. Delirium occurs in at least 30% of critically ill infants and children reported in small prospective studies, without a large-scale protocol for delirium monitoring. Adult studies demonstrate an overwhelming prevalence of delirium in the critically ill, associated with significant morbidity and mortality. Recently, the diagnosis of pediatric delirium has been enhanced by the validation of bedside tools that encourage monitoring within the critical care setting. Though there are likely many similarities in delirium among adults and children, there is much to learn in regard to unique risk factors and outcomes for children. Perhaps, considering the neurodevelopmental and psychosocial capacities of a child, a creative approach to assess and control pain and anxiety, while optimizing disease-related therapies, may ultimately minimize the risk for the development of delirium or other long-term complications of critical illness.
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Ansiedade/tratamento farmacológico , Delírio/terapia , Dor/tratamento farmacológico , Adulto , Fatores Etários , Analgésicos/uso terapêutico , Ansiedade/epidemiologia , Ansiedade/etiologia , Criança , Estado Terminal , Delírio/epidemiologia , Delírio/etiologia , Humanos , Hipnóticos e Sedativos/uso terapêutico , Lactente , Dor/epidemiologia , Dor/etiologia , Equipe de Assistência ao Paciente , Sistemas Automatizados de Assistência Junto ao Leito , Fatores de RiscoRESUMO
Introduction: Individuals with profound autism often present for inpatient care due to aggression. Diagnostic and treatment options are limited. Agitated catatonia is a treatable comorbidity in autism, which should be considered in cases of aggression. Preliminary data report high clinical response rates of catatonia in autism when treated with electroconvulsive therapy (ECT), with poor response to lorazepam. However, access to ECT is often limited, especially in pediatric populations. Methods: We conducted a retrospective chart review to identify cases of hyperactive catatonia with partial response to lorazepam in profoundly autistic children presenting to the pediatric medical hospital. Five cases were identified, all of whom were followed by the child and adolescent psychiatry consult-liaison service during admission and treated without the use of ECT. Data from the medical record were obtained after institutional review board (IRB) approval including the following: (1) treatment course, (2) Bush-Francis Catatonia Rating Scale (BFCRS) scores, and (3) Kanner Catatonia Rating Scale (KCRS) severity scores. The Clinical Global Impressions-Improvement (CGI-I) Scale was applied retrospectively to each case. Results: All five patients demonstrated clinically significant improvements. The average CGI-I score was 1.2. The average percentage reduction in the BFCRS and KCRS severity scores was 63% and 59%, respectively. Two of five patients were first stabilized with infusions midazolam and dexmedetomidine due to the symptom severity and then transitioned to long-acting oral benzodiazepines. Overall, four of five patients were stabilized with oral clonazepam and one of five with oral diazepam. Notably, four of five patients experienced an acute worsening of aggression, self-injury, and other catatonic symptoms with escalating dosages of antipsychotic treatment, which occurred before inpatient admission. All patients experienced resolution of physical aggression toward self and/or others, experienced improvement in their communicative abilities, and were able to return home or enter residential level of care upon discharge. Conclusions: Given the limited availability of ECT and the unclear utility of lorazepam for hyperactive catatonia in autism, the use of long-acting benzodiazepines and/or midazolam infusion may offer a safe and readily available treatment alternative.
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Transtorno Autístico , Catatonia , Eletroconvulsoterapia , Comportamento Autodestrutivo , Adolescente , Criança , Humanos , Benzodiazepinas/uso terapêutico , Catatonia/tratamento farmacológico , Catatonia/diagnóstico , Lorazepam/uso terapêutico , Transtorno Autístico/tratamento farmacológico , Estudos Retrospectivos , Midazolam/uso terapêutico , AgressãoRESUMO
Introduction: Delirium is a disturbance of attention and awareness that represents a change from baseline mental status. Accurate diagnosis of delirium is of paramount importance to improving the management of pediatric delirium in the intensive care unit. Despite ongoing education, inconsistencies in delirium assessments occur. Here, we aimed to determine the extent of the problem and increase compliance with delirium assessments. Methods: We collected preintervention data to assess baseline compliance of delirium assessments in the Pediatric Intensive Care Unit (PICU) and Pediatric Cardiac Intensive Care Unit (PCICU) at Monroe Carell Jr Children's Hospital at Vanderbilt in November 2020. We executed 2 Plan-Do-Study-Act cycles with different interventions and collected data after each and approximately 1 year after the interventions. The first intervention consisted of virtual lectures on delirium assessments for the nursing staff. The second intervention included an educational handout and a new electronic medical record documentation tool. Results: Five hundred five individual nurse-patient encounters were assessed and collected throughout the project. The mean compliance of delirium documentation before the interventions was 52.5%. Target compliance after interventions was 70%. Mean compliance was 70% after cycle 1, 78% after cycle 2, and 86% in March 2022. Conclusions: Using pre- and postintervention data from chart reviews and nurse interviews regarding delirium screenings, we found that interventions targeting nurse education and EMR flowsheet improved compliance with delirium assessment and documentation in the PICU and PCICU. Future work should focus on assessing the clinical implications of this project in diagnosing and treating delirium.
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OBJECTIVE: To validate a diagnostic instrument for pediatric delirium in critically ill children, both ventilated and nonventilated, that uses standardized, developmentally appropriate measurements. DESIGN AND SETTING: A prospective observational cohort study investigating the Pediatric Confusion Assessment Method for Intensive Care Unit (pCAM-ICU) patients in the pediatric medical, surgical, and cardiac intensive care unit of a university-based medical center. PATIENTS: A total of 68 pediatric critically ill patients, at least 5 years of age, were enrolled from July 1, 2008, to March 30, 2009. INTERVENTIONS: None. MEASUREMENTS: Criterion validity including sensitivity and specificity and interrater reliability were determined using daily delirium assessments with the pCAM-ICU by two critical care clinicians compared with delirium diagnosis by pediatric psychiatrists using Diagnostic and Statistical Manual, 4th Edition, Text Revision criteria. RESULTS: A total of 146 paired assessments were completed among 68 enrolled patients with a mean age of 12.2 yrs. Compared with the reference standard for diagnosing delirium, the pCAM-ICU demonstrated a sensitivity of 83% (95% confidence interval, 66-93%), a specificity of 99% (95% confidence interval, 95-100%), and a high interrater reliability (κ = 0.96; 95% confidence interval, 0.74-1.0). CONCLUSIONS: The pCAM-ICU is a highly valid reliable instrument for the diagnosis of pediatric delirium in critically ill children chronologically and developmentally at least 5 yrs of age. Use of the pCAM-ICU may expedite diagnosis and consultation with neuropsychiatry specialists for treatment of pediatric delirium. In addition, the pCAM-ICU may provide a means for delirium monitoring in future epidemiologic and interventional studies in critically ill children.
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Estado Terminal , Delírio/diagnóstico , Unidades de Terapia Intensiva Pediátrica , Criança , Pré-Escolar , Estudos de Coortes , Confusão/diagnóstico , Cuidados Críticos/métodos , Feminino , Humanos , Masculino , Neuropsiquiatria/normas , Variações Dependentes do Observador , Guias de Prática Clínica como Assunto , Estudos Prospectivos , Psicometria , Padrões de Referência , Reprodutibilidade dos Testes , Medição de Risco , Sensibilidade e Especificidade , Índice de Gravidade de DoençaRESUMO
Children with a diagnosis of Autoimmune Encephalitis (AE) frequently require multi-disciplinary care in order to mobilize the assessment and treatment necessary for recovery. Institutional and provider practice differences often influence the diagnostic workup and treatment pathways made available to patients. There are a variety of provider coalitions in pediatric rheumatology, internal medicine, and neurology that have been making meaningful progress toward the development of consensus in assessment and treatment approaches to patient care. However, child psychiatry is currently underrepresented in this work in spite of the high psychiatric symptom burden seen in some young patients. The need for consensus is often made visible only with inter-institutional dialogue regarding patient care trajectories. We aim to review key updates in the assessment and treatment of children and adolescents with autoimmune encephalitis during the acute phase, with or without catatonia, and to outline provider perspectives by comparing current treatment models in the United States, Canada, and Europe.
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OBJECTIVES: Pediatric behavioral health admissions to children's hospitals for disposition planning are steadily increasing. These children may exhibit violent behaviors, which can escalate to application of physical limb restraints for safety. Using quality improvement methodology, we sought to decrease physical restraint use on children admitted to our children's hospital for behavioral health conditions from a baseline mean of 2.6% of behavioral health patient days to <1%. METHODS: We included all children ≥3 years of age admitted to our hospital medicine service with a primary behavioral health diagnosis from July 1, 2016, to February 1, 2020. A multidisciplinary team, formed in July 2018, tested interventions based on key drivers targeted toward our aim. The primary outcome measure was the percent of behavioral health patient days on which physical restraints were ordered. The balancing measure was the percent of patient days with a staff injury event. Statistical process control charts were used to view and analyze data. RESULTS: Our cohort included 3962 consecutive behavioral health patient encounters, encompassing a total of 9758 patient days. A 2-year baseline revealed physical restraint orders placed on 2.6% of behavioral health patient days, which was decreased to 0.9% after interventions and has been sustained over 19 months without any change in staff injuries. CONCLUSIONS: Team-based quality improvement methodology was associated with a sustained reduction in physical restraint use on children admitted for behavioral health conditions to our children's hospital. These results indicate that physical restraint use can be safely reduced in children's hospitals.
Assuntos
Transtornos do Comportamento Infantil , Criança Hospitalizada/psicologia , Hospitalização , Hospitais Pediátricos/normas , Melhoria de Qualidade , Restrição Física/estatística & dados numéricos , Criança , Protocolos Clínicos , Hospitais Universitários/normas , Humanos , Avaliação de Resultados em Cuidados de Saúde , Equipe de Assistência ao Paciente , Utilização de Procedimentos e Técnicas , Tennessee , Centros de Atenção Terciária/normasAssuntos
Aconselhamento/organização & administração , Serviços de Saúde Mental/organização & administração , Serviços de Saúde para Estudantes/organização & administração , Universidades/organização & administração , Adolescente , Adulto , Aconselhamento/estatística & dados numéricos , Humanos , Serviços de Saúde Mental/estatística & dados numéricos , Serviços de Saúde para Estudantes/estatística & dados numéricos , Universidades/estatística & dados numéricos , Adulto JovemRESUMO
Transitional age youth with a history of mood disorders, such as major depressive disorder, are uniquely vulnerable to clinical destabilization and relapse in the context of life transition. Moving from a structured adolescence to a more independent and potentially more demanding young adult life can result in worsening symptoms and barriers to effective help-seeking. Transitional age youth newly diagnosed are exposed to their first course of treatment of a potentially chronic condition. This article describes the challenges inherent in navigating this life transition, and also offers strategies to promote a successful "launch" into adulthood.
Assuntos
Saúde do Adolescente , Saúde Mental , Estresse Psicológico/psicologia , Universidades , Adolescente , Adulto , Transtorno Depressivo Maior/psicologia , Humanos , Adulto JovemRESUMO
Importance: Children and youths who are prescribed antipsychotic medications have multiple, potentially fatal, dose-related cardiovascular, metabolic, and other adverse events, but whether or not these medications are associated with an increased risk of death is unknown. Objective: To compare the risk of unexpected death among children and youths who are beginning treatment with antipsychotic or control medications. Design, Setting, and Participants: This retrospective cohort study was conducted from 1999 through 2014 and included Medicaid enrollees aged 5 to 24 years in Tennessee who had no diagnosis of severe somatic illness, schizophrenia or related psychoses, or Tourette syndrome or chronic tic disorder. Data analysis was performed from January 1, 2017, to August 15, 2018. Exposures: Current, new antipsychotic medication use at doses higher than 50 mg (higher-dose group) or 50 mg or lower chlorpromazine equivalents (lower-dose group) as well as control medications (ie, attention-deficit/hyperactivity disorder medications, antidepressants, or mood stabilizers) (control group). Main Outcomes and Measures: Deaths during study follow-up while out of hospital or within 7 days after hospital admission, classified as either deaths due to injury or suicide or unexpected deaths. Secondary outcomes were unexpected deaths not due to overdose and death due to cardiovascular or metabolic causes. Results: This study included 189â¯361 children and youths in the control group (mean [SD] age, 12.0 [5.1] years; 43.4% female), 28â¯377 in the lower-dose group (mean [SD] age, 11.7 [4.4] years; 32.3% female), and 30â¯120 in the higher-dose group (mean [SD] age, 14.5 [4.8] years; 39.2% female). The unadjusted incidence of death in the higher-dose group was 146.2 per 100â¯000 person-years (40 deaths per 27â¯354 person-years), which was significantly greater than that in the control group (54.5 per 100â¯000 population; 67 deaths per 123â¯005 person-years) (P < .001). The difference was primarily attributable to the increased incidence of unexpected deaths in the higher-dose group (21 deaths; 76.8 per 100â¯000 population) compared with the control group (22 deaths; 17.9 per 100â¯000 population). The propensity score-adjusted hazard ratios were as follows: all deaths (1.80; 95% CI, 1.06-3.07), deaths due to unintentional injury or suicide (1.03; 95% CI, 0.53-2.01), and unexpected deaths (3.51; 95% CI, 1.54-7.96). The hazard ratio was 3.50 (95% CI, 1.35-9.11) for unexpected deaths not due to overdose and 4.29 (95% CI, 1.33-13.89) for deaths due to cardiovascular or metabolic causes. Neither the unadjusted nor adjusted incidence of death in the lower-dose group differed significantly from that in the control group. Conclusions and Relevance: The findings suggest that antipsychotic use is associated with increased risk of unexpected death and appear to reinforce recommendations for careful prescribing and monitoring of antipsychotic treatment for children and youths and to underscore the need for larger antipsychotic treatment safety studies in this population.