Youth, caregiver and healthcare professional perspectives on planning the implementation of a trauma-informed care programme: A qualitative study.

AIMS: To explore youth, caregiver and staff perspectives on their vision of trauma-informed care, and to identify and understand potential considerations for the implementation of a trauma-informed care programme in an inpatient mental health unit within a paediatric hospital. DESIGN AND METHODS: We applied the Interpretive Description approach, guided by complexity theory and the Implementation Roadmap, and used Applied Thematic Analysis methods. FINDINGS: Twenty-five individuals participated in individual or group interviews between March and June 2022, including 21 healthcare professionals, 3 youth and 1 caregiver. We identified two overarching themes. The first theme, 'Understanding and addressing the underlying reasons for distress', related to participants' understanding and vision of TIC in the current setting comprising: (a) 'Participants' understanding of TIC'; (b) 'Trauma screening and trauma processing within TIC'; (c) 'Taking "a more individualized approach"'; (d) 'Unit programming'; and (e) "Connecting to the community". The second theme, 'Factors that support or limit successful TIC implementation' comprises: (a) 'The need for a broad "cultural shift"'; (b) 'The physical environment on the unit'; and (c) 'Factors that may limit successful implementation'. CONCLUSION: We identified five key domains to consider within trauma-informed care implementation: (a) the centrality of engagement with youth, caregivers and staff in trauma-informed care delivery and implementation, (b) trauma-informed care core programme components, (c) factors that may support or limit success in implementing trauma-informed care within the mental health unit and (d) hospital-wide and (e) the importance of intersectoral collaboration (partnering with external organizations and sectors). IMPACT: When implementing TIC, there is an ongoing need to increase clarity regarding TIC interventions and implementation initiatives. Youth, caregiver and healthcare professional participants shared considerations important for planning the delivery and implementation of trauma-informed care in their setting. We identified five key domains to consider within trauma-informed care implementation: (a) the centrality of relational engagement, (b) trauma-informed care programme components, (c) factors that may support or limit successful implementation of trauma-informed care within the mental health unit and (d) hospital-wide and (e) the importance of intersectoral collaboration. Organizations wishing to implement trauma-informed care should consider ongoing engagement with all relevant knowledge user groups throughout the process. REPORTING METHOD: Standards for Reporting Qualitative Research (SRQR). PATIENT OR PUBLIC CONTRIBUTION: The local hospital research institute's Patient and Family Advisory Committee reviewed the draft study methods and provided feedback.

Trauma-Informed Care Interventions Used in Pediatric Inpatient or Residential Treatment Mental Health Settings and Strategies to Implement Them: A Scoping Review.

Trauma-informed care (TIC) is an approach to care emerging in research and in practice that involves addressing the needs of individuals with histories of trauma. The aim of this scoping review was to examine the current literature relating to TIC interventions used in pediatric mental health inpatient and residential settings. We sought to answer the following two research questions: (a) What are the TIC interventions used in pediatric inpatient and residential treatment mental healthcare settings and what are their components? and (b) What are the implementation goals and strategies used with these TIC interventions? We conducted this scoping review according to JBI (formerly Joanna Briggs Institute) methodology for scoping reviews. We included any primary study describing a TIC intervention that was implemented at a specific site which identified and described implementation strategies used. Of 1,571 identified citations and 54 full-text articles located by handsearching, 49 met the eligibility criteria and were included, representing 21 distinct TIC interventions. We present the reported aim, ingredients, mechanism, and delivery (AIMD) of TIC interventions as well as the implementation goals and strategies used, which varied in detail, ranging from very little information to more detailed descriptions. In the context of these findings, we emphasize the complexity of TIC and of TIC interventions, and the importance of identifying and clearly reporting TIC intervention goals, intervention details, and implementation strategies. We suggest applying intervention frameworks or reporting guidelines to support clear and comprehensive reporting, which would better facilitate replication and synthesis of published TIC interventions.

Psychiatric Admissions of Children and Adolescents Across School Periods and Daylight-Saving Transitions.

OBJECTIVES: This study sought to examine fluctuations in admissions to a child and adolescent inpatient psychiatry unit in relation to school breaks, school starts, as well as time change transitions in and out of Daylight-Saving Time (DST). METHODS: Five years (2012-2017) of youth inpatient admissions to a pediatric hospital in Ontario were retrieved (n=2,498). A sub-sample was grouped weekly, starting on the Sunday of each week for a total of 260 weekly time bins. The number of admissions during in and out of school periods, school starts in the fall and winter semester, and time change transitions were compared. RESULTS: Admissions were significantly higher during school periods as opposed to out of school periods, and significantly increased from prior- to post-school starts. No significant difference in admission rates were found in and out of DST changes. Weekly time series analyses for DST changes and monthly time series analyses for school starts did not identify a significant seasonality in admissions. CONCLUSIONS: These findings suggest that school periods and school onset may be significant stressors associated with an increased rate of psychiatric admissions. The presence of potential compensating factors is proposed to explain the lack of relationship between pedopsychiatric admissions and time change transitions.

OBJECTIFS: La présente étude visait à examiner les fluctuations des hospitalisations dans une unité psychiatrique pour enfants et adolescents relativement aux congés scolaires, aux retours en classe, ainsi qu'aux transitions à l'entrée et au sortir de l'heure d'été. MÉTHODES: Cinq ans (2012­2017) d'hospitalisations de jeunes patients dans un hôpital psychiatrique de l'Ontario ont été récupérés (n = 2 498). Un sous-échantillon a été assemblé chaque semaine, débutant le dimanche de chaque semaine pour un total de 260 plages horaires hebdomadaires. Le nombre d'hospitalisations durant les périodes scolaires et en dehors, les retours en classe à l'automne et au semestre d'hiver et les transitions du changement de temps a été comparé. RÉSULTATS: Les hospitalisations étaient significativement plus élevées durant les périodes scolaires par opposition aux périodes non scolaires, et augmentaient significativement d'avant le retour en classe à l'après retour en classe. Aucune différence significative des taux d'hospitalisation n'a été constatée à l'entrée ou à la sortie de l'heure d'été. Les analyses des séries de plages hebdomadaires pour les changements de l'heure d'été et les analyses des séries de temps mensuelles pour les retours en classe n'ont pas identifié de saisonnalité significative des hospitalisations. CONCLUSIONS: Ces résultats suggèrent que les périodes scolaires et le début de l'école peuvent être des stresseurs significatifs associés à un taux accru d'hospitalisations psychiatriques. La présence de facteurs de compensation potentiels est proposée pour expliquer l'absence de relation entre les hospitalisations pédopsychiatriques et les transitions du changement de l'heure d'été.

Sleep problems and complexity of mental health needs in adolescent psychiatric inpatients.

Sleep problems are highly co-morbid with psychiatric disorders and are part of the complex and multiple factors contributing to symptoms and functional disability. The current study aimed to determine how sleep problems in the period preceding psychiatric admission relate to profiles of mental health needs in adolescent inpatients. This retrospective study included 424 adolescents (13-17 years) admitted over a five-year period to an acute crisis stabilization unit in a tertiary care pediatric hospital. Adolescents were divided into two age- and sex-matched groups based on the presence of moderate to severe sleep problems. Profiles of mental health needs were assessed at admission using the Child and Adolescent Needs and Strengths - Mental Health Acute (CANS-MH) and a complexity score was calculated as the total number of actionable CANS-MH items. Results showed a positive association between sleep problems and needs pertaining to eating disturbances, adjustment to trauma, and school attendance. Odds ratios for sleep problems increased progressively as the complexity scores increased, reaching a plateau at six needs beyond which odds ratios remained at their highest level. Adolescents with sleep problems were more likely to undergo medication changes during psychiatric hospitalization and were more likely to be discharged with antipsychotic medication. These findings suggest that sleep difficulties in adolescent inpatients may be associated with distinct and more complex profiles of mental health needs. The evaluation of sleep problems early in the course of psychiatric hospitalization may be an important part of the psychiatric assessment process to inform the global treatment plan.

Development of a Clinical Pathway for the Assessment and Management of Suicidality on a Pediatric Psychiatric Inpatient Unit.

PURPOSE: This article describes steps taken by a mental health inpatient multidisciplinary team to develop a clinical pathway for the assessment and management of suicidality in a pediatric psychiatric inpatient unit. PATIENTS AND METHODS: The setting for this project is a 19-bed inpatient psychiatry unit providing care for children and adolescents (6-17 years of age) in a tertiary care pediatric hospital in Ontario, Canada. Three Lean methodologies were used: 1) The A3 process was used to articulate a problem statement and help clarify expectations, determine goals, and uncover, address and encourage discussion of potential issues; 2) Process mapping was used to show how work process activities are sequenced from the time of the patient's admission to discharge; and 3) Standard work, where consideration was given to the breakdown of the work into categories which are sequenced, organized and repeatedly followed. Generally accepted methodologies for developing clinical pathways were used to create a framework and algorithm for the assessment and management of suicidality in psychiatrically hospitalized children and adolescents. RESULTS: The clinical pathway development resulted in six steps from admission to discharge: intake process, inclusion/exclusion criteria, data integration and treatment formulation, interventions, determination of readiness for discharge, and the discharge process. CONCLUSION: This framework, developed with the aim to standardize care for psychiatrically admitted suicidal children and adolescents, may serve as a flexible template for use in similar settings and could be adapted according to local realities and resources.

Medications for sleep disturbance in children and adolescents with depression: a survey of Canadian child and adolescent psychiatrists.

BACKGROUND: Primary care physicians and child and adolescent psychiatrists often treat sleep disturbances in children and adolescents with mood disorders using medications off-label, in the absence of clear evidence for efficacy, tolerability and short or long-term safety. This study is the first to report Canadian data about prescribing preferences and perceived effectiveness reported by child and adolescent psychiatrists regarding medications used to manage sleep disturbances in children and adolescents with depression. METHODS: Canadian child and adolescent psychiatrists were surveyed on their perception of effectiveness of a range of medications commonly prescribed for sleep disturbances, their ranked preferences for these medications, reasons for avoiding certain medications, and perceived side effects. RESULTS: Sixty-seven active child and adolescent psychiatrists completed the survey. Respondents reported noting significant sleep issues in 40% of all their patients. Melatonin and trazodone were identified as the first treatment of choice by 83% and 10% of respondents respectively, and trazodone was identified as the second treatment of choice by 56% of respondents for treating sleep disturbances in children and adolescents with depression. Melatonin (97%), trazodone (81%), and quetiapine (73%) were rated by a majority of respondents as effective. Doxepin, zaleplon, tricyclic antidepressants, zolpidem, or lorazepam were rarely prescribed due to lack of evidence and/or concerns about adverse effects, long-term safety, suitability for youth, suicidality, and dependence/tolerance. CONCLUSIONS: Melatonin and certain off-label psychotropic drugs are perceived as being more effective and appropriate to address sleep disturbances in children and adolescents with depression. More empirical evidence on the efficacy, tolerability and indications for using these medications and newer group of sleep medications in this population is needed.

Could long-term administration of melatonin to prepubertal children affect timing of puberty? A clinician's perspective.

Exogenous melatonin can be used to treat sleep disturbance in adults, children, and adolescents. While its short-term use is considered safe, there are some concerns that long-term use might delay children's sexual maturation, possibly by disrupting the decline in nocturnal melatonin levels that occur at the onset of puberty. This narrative review aimed to summarize some of the current knowledge about the potential effects of exogenous melatonin on puberty. We found no clinical studies that experimentally tested the effects of melatonin on pubertal timing in children, but we reviewed the small number of observational studies. We also drew on animal data to try to answer our question. The photoperiod and melatonin-mediated seasonal transitions in sexual activity and breeding in some mammals across the seasons have been used as a model of sexual development in mammals, including humans. The switch from non-sexual activity (in the non-breeding period) to sexual activity (in the breeding period) has been likened to the onset of puberty as there are similarities between the two. We conclude that to investigate an association between melatonin and pubertal timing, it will be important to conduct long-term randomized controlled trials of latency age children and also examine the cellular and systems-level interactions between melatonin and kisspeptin, a recently identified neuropeptide with a locus of action at the gonadotropin releasing hormone neurons that is important in contributing to the timing of puberty onset.

Sleep architecture in adolescents hospitalized during a suicidal crisis.

OBJECTIVE/BACKGROUND: Rates of suicide attempts in Canadian youths are concerning. Adolescence is a sensitive period for the emergence of both sleep and mood problems, two major risk factors for suicidality. This naturalistic study aimed to define the sleep profile of adolescents under the combined influence of suicidality, depression and pharmacotherapy during hospitalization for a suicidal crisis. PATIENTS/METHODS: Seventeen suicidal adolescents (15.0 + 1.2years, 82% females) with major depression were recruited from a Canadian pedopsychiatric inpatient unit. Seventeen non-depressed adolescents were retrospectively collated from another database (15.0 + 1.1years, 83% females). None of the participants had a history of sleep disorders or significant medical conditions. RESULTS: Compared to controls, suicidal adolescents had a longer sleep onset latency (Z = -4.5, p < 0.001), longer REM latency (Z = -3.2, p = 0.001), higher percentage of NREM1 sleep t(33) = -2.6, p = 0.020), and higher REM density (Z = -2.8, p = 0.004) than controls. Higher REM density correlated with higher CDI-II scores (r = 0.55, p = 0.27) A significant interaction indicated that the two groups had similar NREM3 percentages in the first two-thirds of the night, but that the suicidal group had significantly lower NREM3 percentage than the controls in the last third of the night (F(2,66) = 3.4, p = 0.041). CONCLUSIONS: Significant sleep abnormalities were observed during hospitalization for a suicidal crisis in a sample of depressed and mostly medicated adolescents. This included sleep initiation and REM sleep latency abnormalities, shallower sleep and high REM density. Future studies should decipher the relative effects of depression, suicidality and medication on sleep. These findings stress the need to address sleep disturbances in the management of suicidality in adolescents.

Event-Related Potential Measures of Attention Capture in Adolescent Inpatients With Acute Suicidal Behavior.

Impaired executive functions, modulated by the frontal lobes, have been suggested to be associated with suicidal behavior. The present study examines one of these executive functions, attentional control, maintaining attention to the task-at-hand. A group of inpatient adolescents with acute suicidal behavior and healthy controls were studied using a passively presented auditory optimal paradigm. This "optimal" paradigm consisted of a series of frequently presented homogenous pure tone "standards" and different "deviants," constructed by changing one or more features of the standard. The optimal paradigm has been shown to be a more time-efficient replacement to the traditional oddball paradigm, which makes it suitable for use in clinical populations. The extent of processing of these "to-be-ignored" auditory stimuli was measured by recording event-related potentials (ERPs). The P3a ERP component is thought to reflect processes associated with the capturing of attention. Rare and novel stimuli may result in an executive decision to switch attention away from the current cognitive task and toward a probe of the potentially more relevant "interrupting" auditory input. On the other hand, stimuli that are quite similar to the standard should not elicit P3a. The P3a has been shown to be larger in immature brains in early compared to later adolescence. An overall enhanced P3a was observed in the suicidal group. The P3a was larger in this group for both the environmental sound and white noise deviants, although only the environmental sound P3a attained significance. Other deviants representing only a small change from the standard did not elicit a P3a in healthy controls. They did elicit a small P3a in the suicidal group. These findings suggest a lowered threshold for the triggering of the involuntary switch of attention in these patients, which may play a role in their reported distractibility. The enhanced P3a is also suggestive of an immature frontal central executive and may provide a promising marker for early identification of some of the risk factors for some of the cognitive difficulties linked to suicidality.

The State of Inpatient Psychiatry for Youth in Ontario: Results of the ONCAIPS Benchmarking Survey.

OBJECTIVE: Little is known about inpatient psychiatry settings and the services they provide for children and adolescents in Ontario. This paper provides the first broad description of unit characteristics, services provided, and patient characteristics in these settings. METHOD: Nominated representatives from Ontario hospitals with generic mental health beds (i.e., providing inpatient care across diagnostic groups) for children and adolescents were surveyed regarding data from April 2009 to March 2010. Response rate was 93%. Additional data were extracted from the Ontario Network of Child and Adolescent Inpatient Psychiatry Services (ONCAIPS) Directory and Ministry of Health and Long Term Care (MOHLTC) website. RESULTS: Settings provided primarily crisis services with some planned elective admissions. Higher rates of involuntary admissions, briefer stays, lower interdisciplinary diversity, and lower occupancy were typical of settings with higher proportions of crisis admissions. Services most commonly provided included stabilization, assessment, pharmacotherapy, and mental health education. Bed numbers provincially, beds per staff, and prominence of suicide risk, mood disorders, and utilization of cognitive and behavioural approaches were comparable to trends internationally. Inter-setting disparities were observed in access to inpatient services for different age and diagnostic groups, and availability of psychiatry and different professions. CONCLUSIONS: Lack of consistent performance and outcome evaluation, common measures, availability of psychiatry and interdisciplinary supports, and dissimilar treatments provincially, suggest the need to consider potential improvements through systematic monitoring of setting performance and outcomes, and development of provincial best practice standards for staffing and treatment.

OBJECTIF: On sait très peu de choses des unités d'hospitalisation en psychiatrie et des services qu'elles prodiguent aux enfants et aux adolescents en Ontario. Cet article offre la première description générale des caractéristiques des unités, des services dispensés, et des caractéristiques des patients de ces unités. MÉTHODE: Des représentants désignés des hôpitaux ontariens offrant des lits génériques de santé mentale, (c.-à-d., dispensant des soins aux patients hospitalisés de tous groupes diagnostiques) pour les enfants et les adolescents ont été interrogés sur les données d'avril 2009 à mars 2010. Le taux de réponse a été de 93%. Des données additionnelles ont été tirées du répertoire du Réseau d'unités de psychiatrie pour enfants et adolescents hospitalisés de l'Ontario (RUPEAHO) et du site Web du ministère de la Santé et des Soins de longue durée (MSSLD). RÉSULTATS: Les unités ont fourni des services principalement de crise et certaines hospitalisations non urgentes planifiées. Des taux plus élevés d'hospitalisations involontaires, de séjours abrégés, de diversité interdisciplinaire plus faible, et d'occupation plus faible étaient typiques des unités ayant des proportions plus élevées d'hospitalisations de crise. Les services les plus souvent dispensés étaient notamment la stabilisation, l'évaluation, la pharmacothérapie, et l'éducation en santé mentale. Le nombre des lits à l'échelle provinciale, les lits par employés, et la proéminence du risque de suicide, des troubles de l'humeur et le recours aux approches cognitives et comportementales étaient comparables aux tendances internationales. Des disparités ont été observées entre unités en ce qui concerne l'accès aux services d'hospitalisation pour différents groupes d'âge et diagnostiques, ainsi que la disponibilité de la psychiatrie et de différentes professions. CONCLUSIONS: L'absence de rendement constant et d'évaluation des résultats, les mesures communes, la disponibilité de la psychiatrie et de soutiens interdisciplinaires, et les traitements différents dans la province indiquent le besoin de songer à des améliorations possibles par la surveillance systématique du rendement et des résultats des unités, et par l'élaboration de normes de pratiques provinciales exemplaires en matière de dotation en personnel et de traitement.

Learning disability subtypes and the role of attention during the naming of pictures and words: an event-related potential analysis.

The role of attention in the processing of pictures and words was investigated for a group of normally achieving children and for groups of learning disability sub-types that were defined by deficient performance on tests of reading and spelling (Group RS) and of arithmetic (Group A). An event-related potential (ERP) recording paradigm was employed in which the children were required to attend to and name either pictures or words that were presented individually or in superimposed picture-word arrays that varied in degree of semantic relation. For Group RS, the ERP waves to words, both presented individually or attended in the superimposed array, exhibited reduced N450 amplitude relative to controls, whereas their ERP waves to pictures were normal. This suggests that the word-naming deficiency for Group RS is not a selective attention deficit but rather a specific linguistic deficit that develops at a later stage of processing. In contrast to Group RS and controls, Group A did not exhibit reliable early frontal negative waves (N280) to the super-imposed pictures and words, an effect that may reflect a selective attention deficit for these children that develops at an early stage of visuo-spatial processing. These early processing differences were also evident in smaller amplitude N450 waves for Group A when naming either pictures or words in the superimposed arrays.