Using Hospital Incident Command Systems to Respond to the Pediatric Mental and Behavioral Health Crisis of the COVID-19 Pandemic.

ABSTRACT: Hospital incident command systems (HICS) were implemented to expand mental and behavioral healthcare (MBHC) services during the COVID-19 pandemic. Data on patient census, nurse vacancies, staff injuries, and staff perceptions were analyzed to quantify issues and track progress toward HICS goals. Data, environment of care, staffing, staff support, staff education, and communication resources were developed. After HICS implementation, 84% of nurses reported confidence in providing care to youth with acute MBHC needs. Nurse leaders should consider HICS for addressing other crises.

A Clinical Program for Transgender and Gender-Diverse Neurodiverse/Autistic Adolescents Developed through Community-Based Participatory Design.

Objective: A series of studies report elevated rates of autism and autistic characteristics among gender-diverse youth seeking gender services. Although youth with the co-occurrence present with complex care needs, existing studies have focused on co-occurrence rates. Further, clinical commentaries have emphasized provider-centered interpretations of clinical needs rather than key stakeholder-driven clinical approaches. This study aimed to employ community-based participatory research methodologies to develop a key stakeholder-driven clinical group program.Method: Autistic/neurodiverse gender-diverse (A/ND-GD) youth (N = 31), parents of A/ND-GD youth (N = 46), A/ND-GD self-advocates (N = 10), and expert clinical providers (N = 10) participated in a multi-stage community-based participatory procedure. Needs assessment data were collected repeatedly over time from A/ND-GD youth and their parents as the youth interacted with one another through ongoing clinical groups, the curriculum of which was developed progressively through the iterative needs assessments.Results: Separate adolescent and parent needs assessments revealed key priorities for youth (e.g., the importance of connecting with other A/ND-GD youth and the benefit of experiencing a range of gender-diverse role models to make gender exploration and/or gender affirmation more concrete) and parents (e.g., the need for A/ND-related supports for their children as well as provision of an A/ND-friendly environment that fosters exploration of a range of gender expressions/options). Integration and translation of youth and parent priorities resulted in 11 novel clinical techniques for this population.Conclusions: With generally high acceptability ratings for each component of the group program, this study presents a community-driven clinical model to support broad care needs and preferences of A/ND-GD adolescents.

The Complexities of Treatment Planning for Transgender Youth with Co-Occurring Severe Mental Illness: A Literature Review and Case Study.

Gender variance and dysphoria are present across all classes, ethnicities, and experiences, including among those with severe and chronic mental illness. In these, our most vulnerable populations, adequate assessment and treatment of gender dysphoria often is overlooked despite evidence that appropriate treatment of gender dysphoria leads to improvement in psychological functioning (Smith, van Goozen, Kuiper, & Cohen-Kettenis, 2005). The World Professional Association for Transgender Health recommend in their Standards of Care that somatic and surgical treatments for gender dysphoria should be made available to those with medical or mental illness with the caveat that "[the illness] must be reasonably well-controlled (2011)." In this article, we will utilize case-based material to elucidate the challenges of treating gender dysphoria in the context of complex mental illness such as bipolar disorder, schizophrenia, and sexual trauma, and the pitfalls of defining "well-controlled" for the sake of treatment.

Initial Clinical Guidelines for Co-Occurring Autism Spectrum Disorder and Gender Dysphoria or Incongruence in Adolescents.

Evidence indicates an overrepresentation of youth with co-occurring autism spectrum disorders (ASD) and gender dysphoria (GD). The clinical assessment and treatment of adolescents with this co-occurrence is often complex, related to the developmental aspects of ASD. There are no guidelines for clinical care when ASD and GD co-occur; however, there are clinicians and researchers experienced in this co-occurrence. This study develops initial clinical consensus guidelines for the assessment and care of adolescents with co-occurring ASD and GD, from the best clinical practices of current experts in the field. Expert participants were identified through a comprehensive international search process and invited to participate in a two-stage Delphi procedure to form clinical consensus statements. The Delphi Method is a well-studied research methodology for obtaining consensus among experts to define appropriate clinical care. Of 30 potential experts identified, 22 met criteria as expert in co-occurring ASD and GD youth and participated. Textual data divided into the following data nodes: guidelines for assessment; guidelines for treatment; six primary clinical/psychosocial challenges: social functioning, medical treatments and medical safety, risk of victimization/safety, school, and transition to adulthood issues (i.e., employment and romantic relationships). With a cutoff of 75% consensus for inclusion, identified experts produced a set of initial guidelines for clinical care. Primary themes include the importance of assessment for GD in ASD, and vice versa, as well as an extended diagnostic period, often with overlap/blurring of treatment and assessment.

Recruitment, Retention, and Wellbeing of LGBTQ-Serving Child Psychiatrists and Mental Health Providers.

The workforce of mental health providers serving lesbian, gay, bisexual, transgender, queer, and/or questioning (LGBTQ+) youth lags far behind the demand for LGBTQ-focused mental health care. Unsatisfactory training and a lack of standardized training metrics for accredited programs perpetuate the lack of preparedness among providers. The presence of LGBTQ+ faculty and mentors in medical education increases the amount of LGBTQ+ content taught to trainees and improves professional development for LGBTQ+ trainees. Inclusive workplace practices and affirming care policies may also improve retention and recruitment of LGBTQ-serving mental health providers.

Family Discordance in Gender Identification Is Not Associated with Increased Depression and Anxiety Among Trans Youth.

Purpose: We examined the relationship between parent- and child-reported gender identity of the youth with internalizing symptoms in transgender and gender-diverse (TGD) youth. In addition, we investigated differences in sex assigned at birth ratios and pubertal development stages in TGD and cisgender youth. Methods: We analyzed longitudinal data from the Adolescent Brain Cognitive Development study (ABCD), corresponding to baseline and 1st-to-3rd-year follow-up interviews (n = 6030 to n = 9743, age range [9-13]). Sociodemographic variables, self- and parent-reported gender identity, and clinical measures were collected. Results: TGD youth showed higher levels of internalizing symptoms compared with cisgender youth. However, this was not worsened by discordance in gender identification between TGD youth and parents. Over the 3-year follow-up period, the proportion of TGD participants increased from 0.8% (95% confidence interval (CI) [0.6-1.0]) at baseline to 1.4% (95% CI [1.1-1.7]) at the 3rd-year follow-up (χ2 = 10.476, df = 1, false discovery rate (FDR)-adjusted p = 0.00256), particularly among those assigned female at birth (AFAB) in relation to people assigned male at birth (AMAB) (AMAB:AFAB at baseline: 1:1.9 vs. AMAB:AFAB at 3rd-year follow-up: 1:4.7, χ2 = 40.357, df = 1, FDR-adjusted p < 0.0001). Conclusions: TGD youth in ABCD reported higher internalizing symptoms than cisgender youth, although this was not affected by parental discordance in gender identification. A substantial increase over time in TGD children AFAB was documented. More research is needed to understand the clinical implications of these preliminary results, for which the longitudinal design of ABCD will be crucial.

Suicide Risk Identified among Transgender and Gender Diverse Youth in the Emergency Department (2019-2022).

BACKGROUND AND OBJECTIVES: Suicide risk identified via universal screening in healthcare settings is associated with subsequent suicidal behavior and is an important prevention strategy. The prevalence of positive suicide risk screening among transgender and gender diverse (TGD) youth in the emergency department (ED) has not been described. The current study examined the association between gender identity and suicide risk screening results, adjusted for other demographic and clinical characteristics. METHODS: Retrospective cross-sectional study of electronic medical record data from ED visits November 2019-August 2022 in an urban academic children's hospital. Participants were youth ages 8-25 who received the Ask Suicide-Screening Questions suicide risk screening tool. RESULTS: Of 12,112 ED visits with suicide risk screening performed (42% male, median age 14 [12, 16]), 24% had positive screens. Of 565 visits by TGD youth, 78.1% had positive screens and 9.5% had active suicidal ideation. Compared to visits by cisgender females, the adjusted odds of positive screens was 5.35 times higher (95% CI 3.99, 7.18) among visits by TGD youth and 0.45 times lower (95% CI 0.40, 0.52) among visits by cisgender males. Compared to visits by cisgender females, the adjusted odds of active suicidal ideation was higher for cisgender males (aOR 1.34, 95% CI 1.07, 1.68) but did not significantly differ for TGD youth. CONCLUSIONS: TGD youth have high rates of positive suicide risk screening in the ED, demonstrating substantial mental health needs. Opportunities may be available to improve detection, evidence-based brief interventions, and linkage to mental health services for this population.

Complex Psychiatric Histories and Transgender and Gender Diverse Youth.

Transgender and gender diverse (TGD) individuals face higher rates of stressors driving disproportionate health risks. Although psychiatric conditions are important to consider in the context of greater health-promoting efforts for TGD youth, any mental health concerns may or may not be related to gender identity or associated dysphoria. Nevertheless, it is essential to consider the impact of complex mental health factors on decisional capacity and gender care discussions. Psychiatric care of TGD youth includes stratifying risk factors through a minority stress lens, balancing acute needs with patient and caregiver priorities, and bolstering resilience using affirming care principles.

Supporting the Mental Health of Transgender and Gender-Diverse Youth.

Increasing numbers of youth are identifying as transgender or gender diverse (TGD), meaning their gender identity or expression do not conform to culturally defined expectations for their designated sex at birth. The mental health needs of TGD youth are diverse, and to effectively address these needs requires knowledgeable general pediatric providers, who often are families' first resource for education and support around gender diversity. To help general pediatric providers work more effectively with TGD youth, we describe the role of mental health providers working with TGD youth and how best to support TGD youth's access to gender-affirming mental health and medical interventions. [Pediatr Ann. 2023;52(12):e456-e461.].