Arguments for Keeping Child & Adolescent Psychiatry Focused on Persons Under 18 Years of Age.

Child and adolescent psychiatrists and their associations are grappling with the idea of restructuring their subspecialty to including transitional age youth (TAY), sometimes operationalized as persons 18-25 years of age. This consideration is currently before the Canadian Academy of Child and Adolescent Psychiatry (CACAP). This essay identifies several concerning and potentially harmful consequences of widening the age range of child and adolescent psychiatry. A key concern is the consequential and substantial increase in the population mandate which will significantly dilute already strained and limited child and adolescent psychiatry resources. Furthermore, the nature of some of the needs of TAY may preferentially divert resources away from younger patients. The change in age range will also disrupt existing partnerships which facilitate multidisciplinary care and needed efficiencies for the child and adolescent population, such as close working ties with pediatrics and schools. This is not to say that there may not be merit in child and adolescent psychiatrists contributing to the care of TAY, just as our members already contribute to other areas of mental health outside our immediate mandate. However, to advance such a mandate change, a threshold of evidence of a net beneficial impact including a systematic evaluation of potential harms and opportunity costs is needed. Unfortunately, such an assessment has not yet occurred and therefore a mandate and name change is premature. We recommend a much more deliberate evaluation of the role child and adolescent psychiatrists and their associations might play in contributing to the needs of TAY.

Les psychiatres pour enfants et adolescents et leurs associations sont aux prises avec l'idée de restructurer leur surspécialité en y incluant des jeunes d'âge transitionnel (JAT), parfois concrétisés comme étant des personnes de 18 à 25 ans. L'idée est présentement prise en considération par l'Académie canadienne de psychiatrie de l'enfant et de l'adolescent (ACPEA). Le présent essai identifie plusieurs conséquences préoccupantes et éventuellement nuisibles d'élargir le groupe d'âge de la psychiatrie de l'enfant et de l'adolescent. Une préoccupation essentielle est l'augmentation conséquente et substantielle du mandat dans la population, qui diluera significativement les ressources déjà grevées et limitées de la psychiatrie de l'enfant et de l'adolescent. En outre, la nature de certains besoins des JAT peut détourner préférentiellement des ressources des patients plus jeunes. Le changement de groupe d'âge dérangera aussi les partenariats existants qui facilitent les soins multidisciplinaires et les efficacités nécessaires pour la population des enfants et adolescents, comme des liens de travail étroits avec des pédiatres et des écoles. Cela ne veut pas dire qu'il ne puisse pas y avoir de mérite à ce que des psychiatres pour enfants et adolescents contribuent aux soins des JAT, tout comme nos membres contribuent déjà à d'autres domaines de la santé mentale, hors de notre mandat immédiat. Cependant, pour mettre de l'avant un tel changement de mandat, il faut un niveau de preuve d'un effet bénéfique net, notamment une évaluation systématique des dommages potentiels et des coûts de renonciation. Malheureusement, cette évaluation n'a pas encore eu lieu et par conséquent, un changement de mandat et de nom est prématuré. Nous recommandons une évaluation beaucoup plus consciente du rôle que peuvent jouer les psychiatres pour enfants et adolescents et leurs associations dans la contribution aux besoins des JAT.

Caution Is Needed When Adding Etiology to Mental Disorder Criteria: The Case of Neurobehavioral Disorder Associated With Prenatal Alcohol Exposure.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) has been cautiously restrictive in incorporating etiological variables into diagnostic criteria. This etiologically agnostic approach seems appropriate given the lack of evidence for single dominant causal factors for most mental disorders. Moving toward an etiologically based diagnostic system was, however, articulated as one of the research goals for DSM-5.1 Unfortunately, the threshold of evidence justifying inclusion of an etiology in the criteria of a mental disorder in the DSM has not, to our knowledge, been explicitly articulated. Nevertheless, DSM-5 proposes a new exception with the introduction of "Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure" (ND-PAE) in the chapter on "Conditions for Further Study."2 Criteria for this new diagnosis include (A) "more than minimal exposure to alcohol during gestation…," (B) "impaired neurocognitive functioning as manifested by one or more…" from a list of five domains, and (C) impaired self-regulation (p.798).2 The basis for an exception for this particular etiologic variable, prenatal alcohol exposure (PAE), along with the implied hypothesis that it is causal for this cluster of neurobehavioral abnormalities, is not detailed in the DSM-5.

A Critique of the New Canadian Fetal Alcohol Spectrum Disorder Guideline.

A new Fetal Alcohol Spectrum Disorder (FASD) guideline was published in the Canadian Medical Association Journal in 2016. This is relevant to the mental health field as mental health symptoms and psychiatric disorders are often identified as associated with and/or part of FASD presentations. Unfortunately, the new guideline has not advanced understanding of the interface between FASD and mental health problems; rather it may contribute to additional confusion. For example, a new recommendation to include additional mental health symptoms, such as anxiety and affect dysregulation, as manifestations contributing to a diagnosis of FASD is particularly concerning given the paucity of evidence supporting this assertion and the potential to distort delivery of mental health interventions for mental health problems. In addition, the guideline recommendation for introducing an "at risk for FASD" designation is not without risk. An appeal is made for greater scrutiny in the construction of diagnostic criteria and guidelines and for a more careful delineation of causal relationships and comorbidities to better inform the delivery of evidence-based mental health care.

De nouvelles lignes directrices sur le trouble du spectre de l'alcoolisation foetale (TSAF) ont été publiées dans le Journal de l'Association médicale canadienne, en 2016. Ceci est utile au domaine de la santé mentale car les symptômes de santé mentale et les troubles psychiatriques sont souvent identifiés comme étant associés aux présentations du TSAF et/ou comme en faisant partie. Malheureusement, les nouvelles lignes directrices n'ont pas fait progresser la compréhension de l'interface entre le TSAF et les problèmes de santé mentale; elles peuvent plutôt ajouter à la confusion. Par exemple, une nouvelle recommandation consistant à inclure des symptômes de santé mentale additionnels, comme l'anxiété et la dysrégulation de l'affect, comme étant des manifestations qui contribuent à un diagnostic de TSAF est particulièrement préoccupante étant donné la pénurie de données probantes soutenant cette assertion et le potentiel de fausser la prestation d'interventions de santé mentale pour des problèmes de santé mentale. En outre, la recommandation des lignes directrices qui introduit une désignation « à risque de TSAF ¼ n'est pas sans risque. Nous en appelons à une surveillance accrue dans la construction des critères et des directives diagnostiques, et à une description plus prudente des relations causales et des comorbidités afin de mieux éclairer la prestation des soins de santé mentale fondés sur des données probantes.

A Youth Suicide Prevention Plan for Canada: A Systematic Review of Reviews.

OBJECTIVE: We conducted an expedited knowledge synthesis (EKS) to facilitate evidence-informed decision making concerning youth suicide prevention, specifically school-based strategies and nonschool-based interventions designed to prevent repeat attempts. METHODS: Systematic review of review methods were applied. Inclusion criteria were as follows: systematic review or meta-analysis; prevention in youth 0 to 24 years; peer-reviewed English literature. Review quality was determined with AMSTAR (a measurement tool to assess systematic reviews). Nominal group methods quantified consensus on recommendations derived from the findings. RESULTS: No included review addressing school-based prevention (n = 7) reported decreased suicide death rates based on randomized controlled trials (RCTs) or controlled cohort studies (CCSs), but reduced suicide attempts, suicidal ideation, and proxy measures of suicide risk were reported (based on RCTs and CCSs). Included reviews addressing prevention of repeat suicide attempts (n = 14) found the following: emergency department transition programs may reduce suicide deaths, hospitalizations, and treatment nonadherence (based on RCTs and CCSs); training primary care providers in depression treatment may reduce repeated attempts (based on one RCT); antidepressants may increase short-term suicide risk in some patients (based on RCTs and meta-analyses); this increase is offset by overall population-based reductions in suicide associated with antidepressant treatment of youth depression (based on observational studies); and prevention with psychosocial interventions requires further evaluation. No review addressed sex or gender differences systematically, Aboriginal youth as a special population, harm, or cost-effectiveness. Consensus on 6 recommendations ranged from 73% to 100%. CONCLUSIONS: Our EKS facilitates decision maker access to what is known about effective youth suicide prevention interventions. A national research-to-practice network that links researchers and decision makers is recommended to implement and evaluate promising interventions; to eliminate the use of ineffective or harmful interventions; and to clarify prevention intervention effects on death by suicide, suicide attempts, and suicidal ideation. Such a network could position Canada as a leader in youth suicide prevention.

Transforming Child and Youth Mental Health Care via Innovative Technological Solutions.

Live interactive videoconferencing and other technologies offer innovative opportunities for effective delivery of specialized child and adolescent mental health services. In this article, an example of a comprehensive telepsychiatry program is presented to highlight a variety of capacity-building initiatives that are responsive to community needs and cultures; these initiatives are allowing children, youth and caregivers to access otherwise-distant specialist services within their home communities. Committed, enthusiastic champions, adequate funding and infrastructure, creativity and a positive attitude represent key elements in the adaptation of this demonstrated user-friendly modality.

Child and youth telepsychiatry in rural and remote primary care.

Young people with psychological or psychiatric problems are managed largely by primary care practitioners, many of whom feel inadequately trained, ill equipped, and uncomfortable with this responsibility. Accessing specialist pediatric and psychological services, often located in and near large urban centers, is a particular challenge for rural and remote communities. Live interactive videoconferencing technology (telepsychiatry) presents innovative opportunities to bridge these service gaps. The TeleLink Mental Health Program at The Hospital for Sick Children in Toronto offers a comprehensive, collaborative model of enhancing local community systems of care in rural and remote Ontario using videoconferencing. With a focus on clinical consultation, collaborative care, education and training, evaluation, and research, ready access to pediatric psychiatrists and other specialist mental health service providers can effectively extend the boundaries of the medical home. Medical trainees in urban teaching centers are also expanding their knowledge of and comfort level with rural mental health issues, various complementary service models, and the potentials of videoconferencing in providing psychiatric and psychological services. Committed and enthusiastic champions, a positive attitude, creativity, and flexibility are a few of the necessary attributes ensuring viability and integration of telemental health programs.

Infectivity of arbuscular mycorrhizal fungi after wetting and drying.

In a mediterranean environment, a hot and dry summer is followed by a cool and rainy winter, the growing season. Arbuscular mycorrhizal (AM) fungi survive in dry soil in the summer and are able to colonize newly emerged plants in winter. However, late summer and autumn rains are frequently followed by periods of drought, resulting in the wetting and drying of the soil before the onset of regular winter rains. The results of three experiments investigating the effect of wetting and drying of soil on the subsequent infectivity of different AM fungi and their individual propagules are presented. In a first experiment, pot-culture inoculum of Acaulospora laevis Gerd. & Trappe, Glomus invermaium Hall, or fine endophytes, each containing a mixture of propagule forms, was mixed into pots of steam-sterilized soil with low phosphorus content. Pots were treated with a wetting and drying cycle where the soil was watered to field capacity for three consecutive days and then left to dry to a water content of less than 1.5% g g-1 . Infectivity was assessed in a subsequent growth cycle planted with clover. In a second experiment, the infectivity of spores of A. laevis, Glomus monosporum Gerd. & Trappe or Scutellospora calospora (Nicol & Gerd.) Walkers & Sanders, and of dried mycorrhizal root fragments of G. invermaium or S. calospora was assessed after a wetting and drying cycle in which the soil was watered to field capacity for seven consecutive days before drying. In a third experiment, the infectivity of the extraradical hyphae of G. invermaium after wetting and drying was assessed. AM fungi and their individual propagules responded differently to wetting and drying. The infectivity of pot-culture inoculum of A. laevis, G. invermaium and fine endophytes was increased, decreased and unaffected, respectively, by wetting and drying. The infectivity of spores of A. laevis and G. monosporum was increased by wetting and drying but the infectivity of spores of 5. calospora was not affected. Infectivity of mycorrhizal root fragments of G. invermaium and S. calospora was decreased and increased, respectively, by wetting and drying. Finally, the infectivity of the extraradical hyphae of G. invermaium was eliminated by a wetting and drying cycle. These results indicate that the development and function of mycorrhizas after late summer and early autumn rains may be limited by the occurrence and predominance of propagules of different AM fungi.