Editorial: It's Not Just a Phase, and We Know What to Do: Children With Early-Onset Mental Health Concerns Deserve Care Now.

Suicide is the 2nd leading cause of death in 10-14 year old and the prevalence of suicidal thoughts and behaviors young children is as high as 7.5%.1 Importantly, children 5 to 11 years old account for 43% of STB-focused emergency department visits in the United States.2 Despite the public health implications of STBs, limited research has focused on the longitudinal development of STBs. In this issue of the Journal, Hennefield et al.3 provide valuable insight into the persistence of preschool-onset major depressive disorder (PO-MDD) and STBs in preadolescents, highlighting opportunities for clinical systems of care.

A Relational Agent Intervention for Adolescents Seeking Mental Health Treatment: Protocol for a Randomized Controlled Trial.

BACKGROUND: Unmet pediatric mental health (MH) needs are growing as rates of pediatric depression and anxiety dramatically increase. Access to care is limited by multiple factors, including a shortage of clinicians trained in developmentally specific, evidence-based services. Novel approaches to MH care delivery, including technology-leveraged and readily accessible options, need to be evaluated in service of expanding evidence-based services to youths and their families. Preliminary evidence supports the use of Woebot, a relational agent that digitally delivers guided cognitive behavioral therapy (CBT) through a mobile app, for adults with MH concerns. However, no studies have evaluated the feasibility and acceptability of such app-delivered relational agents specifically for adolescents with depression and/or anxiety within an outpatient MH clinic, nor compared them to other MH support services. OBJECTIVE: This paper describes the protocol for a randomized controlled trial evaluating the feasibility and acceptability of an investigational device, Woebot for Adolescents (W-GenZD), within an outpatient MH clinic for youths presenting with depression and/or anxiety. The study's secondary aim will compare the clinical outcomes of self-reported depressive symptoms with W-GenZD and a telehealth-delivered CBT-based skills group (CBT-group). Tertiary aims will evaluate additional clinical outcomes and therapeutic alliance between adolescents in W-GenZD and the CBT-group. METHODS: Participants include youths aged 13-17 years with depression and/or anxiety seeking care from an outpatient MH clinic at a children's hospital. Eligible youths will have no recent safety concerns or complex comorbid clinical diagnoses; have no concurrent individual therapy; and, if on medications, are on stable doses, based on clinical screening and as well as study-specific criteria. RESULTS: Recruitment began in May 2022. As of December 8, 2022, we have randomized 133 participants. CONCLUSIONS: Establishing the feasibility and acceptability of W-GenZD within an outpatient MH clinical setting will add to the field's current understanding of the utility and implementation considerations of this MH care service modality. The study will also evaluate the noninferiority of W-GenZD against the CBT-group. Findings may also have implications for patients, families, and providers looking for additional MH support options for adolescents seeking help for their depression and/or anxiety. Such options expand the menu of supports for youths with lower-intensity needs as well as possibly reduce waitlists and optimize clinician deployment toward more severe cases. TRIAL REGISTRATION: ClinicalTrials.gov NCT05372913; https://clinicaltrials.gov/ct2/show/NCT05372913. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/44940.

Mental Health in Infants and Young Children.

This Patient Page describes how caregivers can help children organize their feelings and emotions to promote mental health.

Structure of Psychopathology in Romanian Preschool-Aged Children in an Epidemiological and a High-Risk Sample.

Objective: Research on bifactor models of psychopathology in early childhood is limited to community samples with little longitudinal follow-up. We examined general and specific forms of psychopathology within 2 independent samples of preschool-aged Romanian children. Within a sample with children exposed to psychosocial deprivation, we also examined antecedents and longitudinal outcomes of the general factor. Method: One sample consisted of 350 Romanian children (mean age = 39.7 months, SD = 10.9) from an epidemiological study; the second sample consisted of 170 Romanian children (mean age = 55.6 months, SD = 1.9) exposed to severe early-life deprivation, as well as community comparison children, with longitudinal follow-up at 8 and 12 years. Psychopathology symptoms were assessed through caregiver-reported structured clinical interviews. Results: An SI-1 bifactor model of psychopathology was supported in both samples and included specific factors for externalizing, internalizing, and disturbed relatedness symptoms. In the second sample, longer duration of psychosocial deprivation and lower-quality caregiving were associated with higher scores on the general and all specific factors. Higher scores on the general factor were associated with later cognitive function, competence, and psychopathology symptoms. Considering all factors together, only the general factor explained variance in later childhood outcomes and was slightly stronger compared to a total symptom count for some, but not all, outcomes. Conclusion: General psychopathology in early childhood explains meaningful variance in child outcomes across multiple domains of functioning in later childhood. However, important questions remain regarding its clinical utility and usefulness, given complex measurement and limited explanatory power beyond the more accessible approach of a total symptom count. Clinical trial registration information: The Bucharest Early Intervention Project; https://clinicaltrials.gov/; NCT00747396.

Psychiatry Match Rates Increase After Exposure to a Medical Student Mentorship Program: A Multisite Retrospective Cohort Analysis.

OBJECTIVE: Since 2002, the Klingenstein Third Generation Foundation (KTGF) has supported a network of medical student mentorship programs (MSMPs) across the USA with the explicit aim of enhancing interest in, and eventual recruitment into the field of child and adolescent psychiatry (CAP). The authors conducted a multisite, retrospective cohort analysis to examine the impact of the program on career selection, as reflected by graduation match rates into psychiatry or pediatrics. METHODS: The authors collected graduating match information (2008-2019) from fourteen participating medical schools (Exposed) and thirteen non-participating schools (Control). Control schools were selected based on region, comparable student body and faculty size, national standing, and rank in NIH funding. Match rates into psychiatry and pediatrics were compared between Exposed and Control groups. RESULTS: Exposed schools had significantly higher match rates into psychiatry as compared to unexposed schools (6.1% and 4.8%, respectively; OR [95%CI] = 1.29 [1.18, 1.40]; X2 = 32.036, p < 0.001). In contrast, during the same time period, exposed schools had significantly lower match rates into pediatrics than unexposed ones (11.6 and 10.5%, respectively; OR [95%CI] = 0.89 (0.83, 0.95); X2 = 12.127, p < 0.001). These findings persisted even after adjustment for secular trends in match rates. CONCLUSIONS: Seventeen years after its inception, the KTGF medical student mentorship program network has had a positive impact on match rates into general psychiatry. Future studies will address whether these results translate to trainees' eventual selection of careers in CAP.

Sexual Health in Child and Adolescent Psychiatry: Multi-Site Implementation Through Synchronized Videoconferencing of an Educational Resource Using Standardized Patients.

Objective: Matters of sexuality and sexual health are common in the practice of child and adolescent psychiatry (CAP), yet clinicians can feel ill-equipped to address them with confidence. To address this gap in training and practice, we developed, implemented, and evaluated an educational module enhanced by videotaped depictions of expert clinicians interacting with professional actors performing as standardized patients (SPs). Methods: We developed an educational resource highlighting common issues of sexual health relevant to CAP practice, including sexual development, psychotropic-related side effects, and sexuality in children with autism. We wrote original scripts, based on which two clinicians interacted with three SPs. Digital recordings were edited to yield 5 clips with a cumulative running time of 20 min. The clips were interspersed during a 90-min session comprising didactic and interactive components. Due to the COVID-19 pandemic, we used synchronous videoconferencing, which allowed content dissemination to several training programs across the country. Results: We recruited 125 learners from 16 CAP training programs through the American Academy of CAP's Alliance for Learning and Innovation (AALI). Routine inquiry into adolescent patients' sexual function was uncommon, reported by only 28% of participants, with "awkward" and "uncomfortable" the most common terms mentioned in reference to the clinical task. The didactic intervention led to measurable improvements after 2 weeks in skills and knowledge (p = 0.004) and in attitudes (p < 0.001). The three items with the greatest improvement were: (a) availability of developmentally tailored resources; (b) comfort in addressing sexual development with underage patients; and (c) with parents or guardians of neuroatypical or developmentally disabled patients (p < 0.001 for each). Conclusions: A sexual health curriculum enriched by video-based examples can lead to measurable improvement in outcomes pertinent to the clinical practice of CAP. These educational materials are available for distribution, use and adaptation by local instructors. Our study also provides proof-of-principle for the use of multisite educational initiatives in CAP through synchronized videoconferencing.

Disinhibited Social Engagement Disorder in Early Childhood Predicts Reduced Competence in Early Adolescence.

Psychosocial deprivation is associated with the development of socially aberrant behaviors, including signs of disinhibited social engagement disorder (DSED). In longitudinal studies, signs of DSED have been shown to decrease over time, especially as children are removed from conditions of deprivation. What is less clear is whether signs of DSED in early childhood are associated with poorer functioning in early adolescence, including among children who no longer manifest signs of DSED at this age. In a sample of 136 Romanian children from the Bucharest Early Intervention Project (BEIP), who were exposed to early psychosocial deprivation in the form of institutional care, we examined caregiver-reported (ages 30, 42, and 54 months and 12 years) and observer-rated (age 54 months) signs of DSED. Competent functioning in early adolescence (age 12 years) was assessed across seven domains (i.e., family relationships, peer relationships, academic performance, physical health, mental health, substance use, and risk-taking behavior). A diagnosis of DSED in early childhood was associated with reduced competence in early adolescence. Furthermore, this association was significant even when signs of DSED diminished by age 12 years. We conclude that signs of DSED in early life are associated with reduced likelihood of competent functioning many years later in adolescence, even if signs of the disorder remit.

Editorial: Young Children and Suicidal Ideations: Developmentally Specific Symptoms Call for Developmentally Specific Interventions.

The field of psychopathology in young children has made substantial strides in the past 3 decades, moving from discussions of whether disorders can be reliably diagnosed to sophisticated analyses of specific symptoms. In this issue, Hennefield et al.1 explore the presentation of suicidal ideations (SIs) in children younger than 7 years. The validity of criteria for major depression in this age group is well established, but suicidality is a newer focus of research that, like the disorder itself, requires careful study to identify developmental similarities with and differences from the presentation in older children and adults.2 Prior reports have suggested that young children with psychiatric disorders talk about suicide at rates of 4% to 13% and that these early SIs predict school-age SI.2-4 Publications about suicidality in children younger than 7 have predictably elicited discussions about the challenges in interpreting the statements and behaviors in a developmentally specific manner.4.

Pediatric Attention-Deficit/Hyperactivity Disorder in Louisiana: Trends, Challenges, and Opportunities for Enhanced Quality of Care.

Background: Attention-deficit/hyperactivity disorder (ADHD) is a common pediatric condition with significant developmental, social, educational, and safety implications. The American Academy of Pediatrics has developed guidelines to support quality care of children with ADHD, but studies demonstrate that the guidelines are variably followed. Methods: This review highlights patterns of diagnosis and treatment of children with ADHD nationally and in Louisiana and provides examples of system- and practice-level opportunities to improve adherence to quality standards. Results: Possible contributors to the higher prevalence of ADHD and medication use in Louisiana compared to the nation are specialty workforce shortages, factors in the educational system, and factors associated with race and geography. Innovative system approaches have been developed to address workforce shortages and training limitations. Practice-level innovations include improving the use of validated measures, offering adequate scheduling, and identifying relevant resources and sharing the information with families. Conclusion: Despite the availability of evidence-based recommendations and resources, significant opportunities exist to provide enhanced ADHD care at the primary care level, especially in Louisiana where the high prevalence of some risk factors for ADHD and the high rates of ADHD and medication prescriptions have been noted nationally and at the state level. Attention to these factors can potentially help address these disproportionalities. Additionally, innovative models of training and collaboration in pediatrics are imperative. Pediatric clinicians, mental health providers, and families can work together to increase awareness about the needs of children and families affected by ADHD in medical, educational, and policy arenas and move the system forward for children.

Starting Early: Promoting Emotional and Behavioral Well-Being in Infant and Toddler Well-Child Care.

A child's experiences during the first 3 years of life can have a profound impact on mental health outcomes later in childhood and across the lifespan. Safe and effective therapies for mental health concerns in early childhood exist, but access to them is limited. Pediatricians have a unique opportunity to identify risk and resilience factors and support healthy emotional, behavioral, and social development during infancy and toddlerhood. This article presents a developmentally focused approach to integrating the growing science of early childhood social-emotional development into primary care practice, providing both empiric and practical rationales. [Pediatr Ann. 2018;47(8):e317-e322.].

Preparing Trainees for Integrated Care: Triple Board and the Postpediatric Portal Program.

Training combining the disciplines of pediatrics, psychiatry, and child and adolescent psychiatry dates back to World War II, but formal combined programs began more than 3 decades ago as the Triple Board Program and 10 years ago as the Postpediatric Portal Program (PPPP). Triple board training was rigorously examined as a pilot program and ongoing surveys suggest that it provides successful training of physicians who can pass the required board examinations and contribute to clinical, academic, and administrative/advocacy endeavors. As evidence grows showing the value of integrated care, physicians with combined training will offer a unique perspective for developing systems.

A National Profile of Attention-Deficit Hyperactivity Disorder Diagnosis and Treatment Among US Children Aged 2 to 5 Years.

OBJECTIVE: Clinical guidelines provide recommendations for diagnosis and treatment of attention-deficit hyperactivity disorder (ADHD), with specific guidance on caring for children younger than 6 years. This exploratory study describes ADHD diagnosis and treatment patterns among young children in the United States using 2 nationally representative parent surveys. METHODS: The National Survey of Children's Health (2007-2008, 2011-2012) was used to produce weighted prevalence estimates of current ADHD and ADHD medication treatment among US children aged 2 to 5 years. The National Survey of Children with Special Health Care Needs (2009-2010) provided additional estimates on types of medication treatment and receipt of behavioral treatment among young children with special health care needs (CSHCN) with ADHD. RESULTS: In 2011 to 2012, 1.5% of young children (approximately 237,000) had current ADHD compared to 1.0% in 2007 to 2008. In 2011 to 2012, 43.7% of young children with current ADHD were taking medication for ADHD (approximately 104,000). In young CSHCN with ADHD, central nervous system stimulants were the most common medication type used to treat ADHD, and 52.8% of young CSHCN with current ADHD had received behavioral treatment for ADHD in the past year. CONCLUSION: Nearly a quarter million In young CSHCN have current ADHD, with a prevalence that has increased by 57% from 2007 to 2008 to 2011 to 2012. The demographic patterns of diagnosis and treatment described in this study can serve as a benchmark to monitor service use patterns of young children diagnosed with ADHD over time.

Clinical Assessment of Young Children.

Mental health assessment of young children provides valuable information to shape a formulation and guide treatment. Early childhood mental health assessment can occur in an increasing number of settings beyond traditional mental health practices, including childcare settings, primary care settings, and other settings where children and family are regularly seen. Although many of the components of an early childhood mental health assessment are included in the assessment of older children, assessment of very young children requires some specific developmental adjustments and additional considerations including attention to the parent-child relationship and caregiving context and rapid development.

Feasibility of Screening for Preschool Behavioral and Emotional Problems in Primary Care Using the Early Childhood Screening Assessment.

The American Academy of Pediatrics recommends screening young children for behavioral and emotional problems (BEP) during primary care visits. Because of time constraints, few primary care providers (PCPs) use standardized screening tools to detect BEP. The Early Childhood Screening Assessment (ECSA) is a brief screening tool developed specifically to meet the needs of pediatric primary care providers (PCPs). The ECSA has established psychometric properties, but the feasibility and acceptability of the ECSA have not been established. This study examines the degree to which PCPs would incorporate ECSA screening and how PCPs value the ECSA as a tool to detect children with BEP. Twenty-seven pediatric PCPs were trained to implement ECSA screening. Six months after training, 96% of PCPs reported that the ECSA was practical for use at well-visits, 70% were still screening and 89% agreed that it helped detect more cases of BEP than by routine history-taking alone.

Addressing Early Childhood Emotional and Behavioral Problems.

More than 10% of young children experience clinically significant mental health problems, with rates of impairment and persistence comparable to those seen in older children. For many of these clinical disorders, effective treatments supported by rigorous data are available. On the other hand, rigorous support for psychopharmacologic interventions is limited to 2 large randomized controlled trials. Access to psychotherapeutic interventions is limited. The pediatrician has a critical role as the leader of the medical home to promote well-being that includes emotional, behavioral, and relationship health. To be effective in this role, pediatricians promote the use of safe and effective treatments and recognize the limitations of psychopharmacologic interventions. This technical report reviews the data supporting treatments for young children with emotional, behavioral, and relationship problems and supports the policy statement of the same name.