The Development a Pediatric Catatonia Clinical Roadmap for Clinical Care at Vanderbilt University Medical Center.

INTRODUCTION: Pediatric catatonia is associated with a high degree of morbidity and mortality in children. However, pediatric catatonia is highly responsive to treatment if rapidly identified and appropriate interventions are administered. To our knowledge, there are no current publications which propose a systematic approach for the management of pediatric catatonia. The aim of our report was to create multidisciplinary clinical care roadmap for catatonia in the inpatient pediatric setting within Vanderbilt University Medical Center (VUMC). METHODS: At VUMC, we formed a team of pediatric providers from child and adolescent psychiatry, rheumatology, neurology, pediatric hospital medicine, and pediatric psychology. Our team met on a regular basis over the course of 2022 - 2024 to review the current literature on pediatric catatonia and develop a consensus for clinical assessment and management. RESULTS: We determined consensus recommendations from our VUMC multidisciplinary team for the following domains of pediatric catatonia inpatient clinical care: initial assessment of pediatric catatonia in the inpatient pediatric settings, medical and psychiatric work up for pediatric catatonia, the lorazepam challenge in pediatric populations, behavioral and environmental considerations, and the use of electroconvulsive therapy and alternative psychopharmacologic interventions in pediatric catatonia. CONCLUSIONS: Pediatric catatonia is a condition associated with a high degree of morbidity and mortality but is responsive to treatment if diagnosed and treated early. The inpatient pediatric medical setting provides a unique opportunity for identification and treatment. Our clinical care roadmap provides tools for inpatient clinicians at VUMC to identify pediatric catatonia and initiate an evidence-based approach to medical workup, management, and clinical care. This approach has the potential to significantly improve longitudinal outcomes and quality of life improvements for children at VUMC with catatonia and their families.

Risk of neuropsychiatric adverse events associated with montelukast use in children and adolescents: a population-based case-crossover study.

PURPOSE: Montelukast is used extensively in children and adolescents for allergic rhinitis and asthma. However, concerns have been raised regarding the increased risk of neuropsychiatric adverse events (NPAEs) associated with montelukast use. Therefore, our case-crossover study was conducted to observe whether there is an increased risk of NPAEs associated with montelukast use in children and adolescents. MATERIALS AND METHODS: A population-based case-crossover study using the customised Health Insurance Review and Assessment (HIRA) dataset was conducted. Paediatric patients aged between 0 and 19 years diagnosed with allergic rhinitis and/or asthma with a history of at least one montelukast prescription between 1 January 2018 and 31 December 2021 were included. Exposure to montelukast was assessed during 3-, 7-, 14-, 28- and 56-day hazard periods prior to each patient's NPAE. Stratified analyses according to age group, gender and season for the risk of NPAEs associated with montelukast use in the previous 7 days and 14 days were performed, respectively. Conditional logistic regression analysis was used to calculate adjusted ORs (aORs) with their corresponding 95% CIs, adjusting for concomitant medications. RESULTS: A total of 161 386 paediatric patients was identified. An increased risk of NPAEs associated with montelukast was found in all time window periods, including 3-day (aOR 1.28, 95% CI 1.24 to 1.32), 7-day (aOR 1.29, 95% CI 1.26 to 1.33), 14-day (aOR 1.34, 95% CI 1.31 to 1.37), 28-day (aOR 1.38, 95% CI 1.36 to 1.41) and 56-day (aOR 1.21, 95% CI 1.19 to 1.22) preceding hazard periods compared with use in the four control periods. CONCLUSION: Children and adolescents with allergic rhinitis and/or asthma should be prescribed montelukast with caution considering clinical benefits.

Association between methylphenidate use and long-term cardiovascular risk in paediatric patients with attention deficit and hyperactivity disorder.

BACKGROUND: There have been concerns about the potential cardiovascular (CV) adverse effects associated with methylphenidate (MTH) use. However, only limited evidence exists on the long-term safety of MTH. OBJECTIVE: To evaluate whether MTH use is associated with long-term CV risk. METHODS: This was a retrospective cohort study using 2003-2017 data from the Health and Welfare Database in Taiwan. Patients newly diagnosed with attention deficit and hyperactivity disorder (ADHD) and between 3 and 18 years of age were included. Two treatment statuses were assessed: initial treatment ≥7 days and ≥180 days. Patients treated with MTH were compared with those receiving non-medication therapy. One-to-one propensity score matching was used to balance between-group differences. Study outcomes included major CV events, chronic CV disease, cardiogenic shock and all-cause mortality. Cox proportional hazard models were used to estimate HRs between the two groups. RESULTS: We began with 307 459 patients with ADHD. After exclusion, 224 732 patients were included in the final cohort. The results showed that compared with non-ADHD medication users, patients who were treated with MTH for more than 7 days had a similar risk of major CV events (HR 0.85, 95% CI 0.72 to 0.99; p=0.040). Identical trends were found in groups who were treated for more than 180 days (HR 0.83, 95% CI 0.69 to 1.00; p=0.050). The results of the sensitivity analyses were consistent with the main analyses across all groups and individual outcomes. CONCLUSION: Short-term MTH use did not increase CV risk among patients with ADHD. More evidence on long-term MTH use and risk of cardiogenic shock and death is warranted.

Effect of Providing Evidence-Based Mental Health Treatment on Retention in Care Among Medicaid-Enrolled Youths.

OBJECTIVE: Youths who start behavioral health treatment often stop before completing a therapeutic course of care. To increase treatment engagement and quality of care, the Evidence-Based Practice and Innovation Center in Philadelphia has incentivized use of evidence-based practices (EBPs) for mental health care of youths. The authors aimed to compare treatment outcomes between youths who received EBP care and those who did not. METHODS: Using EBP-specific billing codes and propensity score matching, the authors compared treatment retention among youths who received trauma-focused cognitive-behavioral therapy (TF-CBT; N=413) or parent-child interaction therapy (PCIT; N=90) relative to matched samples of youths in standard outpatient therapy (N=503). RESULTS: Youths with a minimum of one session of TF-CBT or PCIT attended a second session at higher rates than did youths in the matched control group (TF-CBT: 96% vs. 68%, p<0.01; PCIT: 94% vs. 69%, respectively, p<0.01). On average, these returning youths attended more sessions in the EBP groups than in the control group (TF-CBT: 15.9 vs. 11.5 sessions, p<0.01; PCIT: 11.2 vs. 6.9 sessions, p<0.01). CONCLUSIONS: These findings indicate that, in addition to improving quality of care, EBP implementation helps address the major challenge that most youths who engage with treatment are not retained long enough for care to have therapeutic effects. Future research should examine the mechanisms through which EBPs can improve treatment retention.

Children in Mental Health Crisis: Pediatric Primary Care Providers' Role in Bridging Treatment Following Higher Levels of Care.

The current study examines the role of pediatric PCPs in bridging treatment for youth who have experienced mental health crises and the characteristics of these patients for whom PCPs sought psychiatric consultation and referral support from a child psychiatry access program, Maryland Behavioral Health Integration in Pediatric Primary Care. Psychiatric consultation and referral calls between 2012 and 2021 were included if a) the patient was recently seen in a higher level of care and b) the PCP was bridging treatment following the patient's discharge; 208 calls met criteria. The most common mental health concerns included depressed mood, suicidal thoughts/gestures, and anxiety. Acute concerns of aggression, suicide attempts, and hallucinations were also reported. Over half of the patients had two or more mental health diagnoses. At the time of the call, only one quarter of these patients had outpatient therapy services while about half were receiving medication treatment. Most of these patients were discharged from the higher level of care without a care plan. Pediatric PCPs are managing their patients' complex mental health concerns following receipt of higher levels of care. Improvements in collaboration and care coordination between pediatric PCPs and emergency department providers are needed.

A history of childhood schizophrenia and lessons for autism.

The diagnosis of childhood schizophrenia was widely employed in the U.S. from the 1930s to the late 1970s. In this paper I will provide a history of the diagnosis. Some of the earliest publications on childhood schizophrenia outlined the notion that childhood schizophrenia had different types. I will outline the development of these types, outlining differing symptoms and causes associated with various types. I outline how different types of childhood schizophrenia were demarcated from one another primarily on age of onset and the type of psychosis which was believed to be present. I will outline how various child psychiatrists viewed the types of childhood schizophrenia posited by other child psychiatrists. I will outline the process of abandoning childhood schizophrenia. I use my history to challenge what I believe are misconceptions about childhood schizophrenia. Also, I will use my history to draw lessons for thinking about modern notions of autism. It shows potential problems around formulating psychiatric diagnoses around causes and how compromises might be needed to prevent those problems. Additionally, childhood schizophrenia shows that psychiatrists could formulate subtypes that are not based upon functioning levels and that we can conceive of subtypes as dynamic whereby someone can change which subtype they exhibit over time.

Management of medically unexplained symptoms in children and young people: a secondary analysis of a 10-year audit of referrals to a Paediatric Psychology Service.

This study evaluated service use of children and young people with medically unexplained symptoms (MUS) referred to a Paediatric Psychology Service between 2008 and 2017. Univariate analyses of activity data indicated that the MUS group (n=268) required more clinical sessions than other patients (n=3577) (inpatient MUS: 7.5 (12.5) vs general: 4.0 (6.0), p=0.006; outpatient: MUS 10.7 (15.0) vs general 6.3 (8.9), p<0.001). Multivariate analyses confirmed that MUS group status remained significantly associated (p<0.001) with a higher number of contacts, even when age and gender were controlled for. Although both groups benefitted equally from psychological input, MUS referrals required more contact time than general referrals.

Mindfulness-Based Interventions in Schools: Assessing the Evidence Base.

OBJECTIVE: Mindfulness-based interventions are increasingly being used in schools to improve students' mental, emotional, and behavioral development. Although many mindfulness programs exist, the types of programs that are effective for specific age groups remain unclear. In this systematic review, the authors used established rating criteria to describe the level of evidence for school-based mindfulness interventions. METHODS: A search of major databases, gray literature, and evidence base registries was conducted to identify studies published between 2008 and 2022 that focused on mindfulness interventions within school settings. The authors rated mindfulness interventions as having high, moderate, or low levels of evidence based on the number and rigor of studies with positive outcomes. RESULTS: Of the 24 interventions identified across 41 studies, three interventions-Learning to BREATHE, Mindfulness in School Project, and mindfulness-based stress reduction (MBSR)-received a rating of high level of evidence. Three interventions-Gaia Program, MindUP, and a blended version of MBSR and mindfulness-based cognitive therapy-received a rating of moderate level of evidence. The interventions rated as having a high level of evidence were conducted with middle or high school students, and interventions with moderate evidence were also conducted with elementary students, demonstrating effectiveness of mindfulness across a range of age groups. Few studies examined outcomes for underserved populations. CONCLUSIONS: With greater use and more research, mindfulness interventions have the potential to promote student well-being and prevent mental health conditions.

One-to-one counselling and school attendance in the UK: a single group pre-post study.

OBJECTIVE: Absence rates remain high in UK schools, with negative implications for attainment, life chances and inequality. Reasons for non-attendance are complex but include psychosocial factors. Few UK-based studies have evaluated psychosocial interventions for school attendance outcomes or its moderators. This pre-post evaluation examined the potential influence of school-based one-to-one counselling on school attendance and possible moderators. DESIGN AND SETTING: Secondary analysis of routine data, collected by a national mental health provider in primary and secondary schools. PARTICIPANTS: 7405 pupils aged 4-19 years, with complete school attendance records at Time1 (pre-counselling term) and Time2 (the term when counselling ended). INTERVENTION: All participants received school-based one-to-one counselling with a trained counsellor between August 2016 and December 2019. OUTCOMES: Percentage of school sessions attended (continuous) and persistent absence (binary; attending ≤90% of sessions) in a term. Potential moderators included sociodemographics, mental health and school engagement/enjoyment. RESULTS: Median Time1 attendance was 96%. 23.6% of participants were persistently absent. The intervention was not associated with improved percentage attendance (0.028%, 95% CI -0.160-0.216%) but was associated with 18.5% reduced odds of persistent absence (OR=0.815, 95% CI 0.729-0.911). We identified five moderators of change in attendance (interaction terms p<0.05): age group (improvements for 4-9 s; worsening for 15-19 s), improvement for some ethnicities and lower parent/carer education. Mental health and school engagement/enjoyment co-varied with attendance in expected directions. CONCLUSIONS: One-to-one counselling may improve school attendance among persistently absent pupils, particularly at younger ages. Improving mental health and pupil engagement/enjoyment are potential intervention targets. Our hypotheses require confirmation with controlled designs.

The effectiveness of the lorazepam challenge test in pediatric catatonia: A multisite retrospective cohort study.

OBJECTIVE: Catatonia is a neuropsychiatric disorder associated with changes in behavior and affect. In adults, catatonia can respond rapidly to treatment with benzodiazepines as part of the "lorazepam challenge test." The acute effectiveness of benzodiazepine treatment in pediatric catatonia, however, has received less study. This study reports catatonia severity as measured by the Bush Francis Catatonia Rating Scale (BFCRS) in pediatric patients before and after treatment with lorazepam. METHODS: Multicenter retrospective cohort study from 1/1/2018 to 6/1/2023 of patients aged 18 and younger with a clinical diagnosis of catatonia and assessment using the BFCRS before and after treatment with lorazepam. RESULTS: Among 54 patients, median age was 16, and 26 (48.1 %) were female. Neurodevelopmental disabilities were present in 24 (44.4 %) of patients. Prior to treatment, patients had a mean BFCRS score of 16.6 ± 6.1, which significantly reduced to 9.5 ± 5.3 following treatment with lorazepam (mean paired difference 7.1; t = 9.0, df = 53, p < 0.001), representing a large effect size (Hedges's g = 1.20; 95 % CI: 0.85 to 1.55). No significant association was found between lorazepam dose or route of administration and clinical response, nor were age, sex, study site, the presence of a neurodevelopmental disorder, the presence of hyperactive catatonic features, or the time between treatment and reassessment associated with post-treatment BFCRS. CONCLUSIONS: Lorazepam resulted in a rapid improvement in BFCRS score in pediatric patients, with a large effect size. Further research is needed into optimal dosing and route of administration of the lorazepam challenge test in pediatric patients.

Practice Pearls for Stimulant Treatment of Attention-Deficit/Hyperactivity Disorder in Youth.

Over half of youth with attention-deficit/hyperactivity disorder (ADHD) have co-occurring psychiatric or medical conditions that present treatment challenges. Stimulants are the most effective pharmacologic treatment of ADHD for preschoolers to adults but questions about safety with co-occurring conditions frequently arise. In addition, stigma surrounding diagnosis and treatment can negatively impact care. This manuscript presents evidence-based practice pearls to guide treatment decisions for youth with ADHD and common coexisting psychiatric and medical conditions. Recommendations address specific stimulant adverse effects (i.e., anxiety, cardiac, growth, mania, psychosis) along with management strategies. Pearls were developed for the most common clinical questions, controversial topics, or therapeutic issues that may not be widely known. The goals of this manuscript are to: 1) provide a detailed resource for interprofessional teams regarding stimulant use in youth with ADHD, 2) improve therapeutic outcomes for youth with ADHD and co-occurring psychiatric and/or medical conditions through evidence-based recommendations, and 3) decrease stigma associated with stimulant use through education.

Exploring the Trajectory of Catatonia in Neurodiverse and Neurotypical Pediatric Hospitalizations: A Multicenter Longitudinal Analysis.

Objective: Catatonia is a neuropsychiatric disorder that occurs in pediatric patients with a range of associated medical, psychiatric, and neurodevelopmental disorders (NDDs). This study describes hospital care of pediatric catatonia patients and compares treatments for neurotypical patients and those with NDDs. Methods: Retrospective cohort study from 1/1/2018 to 6/1/2023 of two academic medical centers of patients aged 18 and younger with catatonia. Patients were retrospectively assessed using the clinical global impressions-improvement (CGI-I) by two independent reviewers. Results: One hundred sixty-five patients were hospitalized for catatonia, of whom 50.3% had an NDD. Median age was 15. One hundred sixty-four patients were treated with a benzodiazepine, with a median maximum 24-hour dose of 6 mg lorazepam-equivalents, which did not differ for patients with and without NDDs. Electroconvulsive therapy (ECT) was utilized in 14.5% of patients. Median length of medical hospitalization was 5 days and hospitalizations were longer in neurotypical patients than in patients with NDDs. In an ordinal regression model, the probability of observing at least "much improvement" (CGI < 3) was 88.3% (95% CI: 82.4% to 92.3%), with NDD diagnosis associated with a lower odds of clinical response. Conclusions: The probability of patients achieving a CGI-I score indicating at least "much improvement" was 88.3%. Administered benzodiazepine dose and ECT treatment were similar for all patients, but neurotypical patients had longer hospitalizations than those with NDDs and had a higher odds of a more favorable clinical response. Research under controlled conditions is needed to optimize and endure equitable catatonia treatment in youth.

A national research survey of childhood autism assessment services in the UK: empirical evidence of diagnostic practice, challenges and improvement opportunities.

BACKGROUND: The UK National Health Service (NHS) Long Term Plan aims to reduce waiting times for childhood autism diagnostic assessment and improve parent and child satisfaction. This empirical research investigated current childhood diagnostic practice provision, and changes made by teams to address challenges faced. METHODS: Data were collected using an online semi-structured research questionnaire. UK childhood autism diagnostic assessment services (for children aged 1-18 years) were invited to participate through multidisciplinary clinical networks, special interest groups and professionals mailing lists. The study was on the National Institute for Health Research Clinical Research Network portfolio. RESULTS: 128 clinicians from diverse NHS services responded including: 10 (8%) integrated services, 46 (36%) Child and Adolescent Mental Health Services (CAMHS) and 72 (56%) paediatric services. A minority of services (23, 17.9%) reported always meeting the National Institute for Health and Care Excellence guidance for assessment. Referrals rose 115% between 2015 and 2019. Clinicians described increased child and family complexity compared with previously; children had more co-occurring physical, mental health and neurodevelopmental conditions and there were more frequent family health problems and safeguarding concerns. Most services (97, 75.8%) reported recent funding stayed constant/decreased. Incomplete multidisciplinary teams (MDTs) were frequently reported; a minority of services reported increased availability of professionals, and some experienced reductions in key professionals. Many teams were unable to undertake assessments or make recommendations for associated neurodevelopmental and co-existing conditions. Teams described improvement strategies implemented (eg, adapting professionals' roles, supporting parents). CONCLUSIONS: Most UK autism paediatric and CAMHS diagnostic teams experience significant challenges affecting the assessment of children with possible autism, and recommendations regarding treatment/intervention. Where CAMHS or paediatric services work in isolation, there are often competency gaps in MDTs and ability to deliver full neurodevelopmental and mental health assessments. Teams identified service improvement strategies; however, investment in MDT expertise is required to enable services to implement changes to meet the needs of children and families.

A Statewide Consultation Helpline for Rapid Linkage to Services for Youths With Opioid Use Disorder and Other Substance Use.

OBJECTIVE: The authors examined the initial implementation of the Indiana Adolescent Addiction Access (AAA) program, modeled on the widely disseminated Child Psychiatry Access Program framework. The AAA program developed a statewide consultation helpline to connect health care providers with adolescent addiction specialists. METHODS: The AAA line was staffed by a coordinator, who fielded initial questions, and on-call clinical specialists (social workers, nurse practitioners, psychiatrists, and psychologists), who were paged to complete telephone consultations and provide care recommendations. When necessary, AAA providers offered urgent clinical assessments and initiated treatment. Descriptive analyses were performed for key variables over the first 21 months of AAA operations. RESULTS: From July 2021 to March 2023, a total of 125 consultations were completed. Most callers were health care providers (71%) or parents (27%). Calls pertained to youths ages 10-18 years (mean±SD age=16.4±1.3; 62% of callers were male, 84% White, and 11% Black), with concerns around cannabis (63%), opioids (38%), and other substances. About 26% of calls related to an overdose, and 41% of cases were rated as severe. Recommendations included starting new medications (17%) or outpatient therapy (86%), and 17% of consultations resulted in urgent evaluations. CONCLUSIONS: The Indiana AAA program helps overcome key barriers to adolescent substance use treatment. Increasing the capacity to initiate medication for opioid use disorder and other treatment rapidly through consultation and direct care is a promising, scalable approach for preventing overdose deaths among youths.

The Development of Disinhibited Social Engagement Disorder: A Case Report on the Psychiatric Implications of Prenatal Fentanyl Use.

Exposure to drugs during pregnancy can result in neonatal abstinence syndrome (NAS), low birth weight, attention-deficit/hyperactivity disorder (ADHD), and behavioral issues, particularly during the school-age years. Recent research has expanded our understanding of the consequences of fentanyl exposure during pregnancy beyond the more commonly recognized effects, including respiratory complications, neurodevelopmental effects, increased risk of substance use disorders, gastrointestinal complications, cardiovascular effects, epigenetic changes, behavioral and emotional regulation disruptions, and long-term cognitive impairments. We present the case of a five-year-old female placed in foster care with a past medical history of asthma and a past psychiatric history of ADHD, oppositional defiant disorder (ODD), and disinhibited social engagement disorder. Her mother has a long history of substance use during pregnancy. From our interaction with the patient presented, we see that prenatal exposure to substances such as fentanyl and the disruption of attachment figures can have profound and lasting effects on a child's life, encompassing behavioral and cognitive aspects.

The clinical pathway in ADMiRE, Ireland's first public specialist service for children and adolescents with attention deficit hyperactivity disorder.

Attention deficit hyperactivity disorder (ADHD) is a highly prevalent neurodevelopmental disorder occurring in approximately one in twenty young people in Ireland, and in one-third of those attending Irish Child and Adolescent Mental Health Services (CAMHS). It is important to treat ADHD, as un/poorly treated ADHD is associated with a raft of negative health and socio-economic outcomes. Effective interventions for ADHD are available, and the use of standardised, evidence-based pathways for assessment and management of ADHD optimises outcomes. Despite this, there is no national standardised clinical pathway for assessment and treatment of ADHD in Ireland. ADMiRE, the first public healthcare specialist service for children and adolescents in Ireland, has developed a strongly evidence-based, efficient, effective and safe clinical pathway for assessment and management of ADHD. This paper describes the ADMiRE Clinical Pathway and references ADMiRE resources that are available to other services.

[The place and function of the gender of child psychiatric carers]. / Place et fonction du genre des soignants en pédopsychiatrie.

In a child psychiatry unit, where it is said that men are reassuring and women are mothering, the group experience of carers on the function of their gender in child care was explored. Gender is relevant to institutional care, but creates a divide. Representations focus on fear, sexuality, violence and fragility. Caregivers, ambivalent about neutralising gender, suffer from representations of what it does to children and to the institution.