Addressing the Multidimensional Aspects of Trauma in Emergency Department Boarding for Neurodiverse Youth.

Psychiatric boarding in pediatric emergency departments is a predictable outcome of escalating psychiatric acuity and inadequate mental health services in hospital systems and the community at large. Guidelines are offered to support initiating treatments in nonpsychiatric hospital settings to reduce pediatric boarding. Treatments call for interdisciplinary approaches, care coordination, and addressing systemic disparities in access and quality of care. Telemental health interventions offer a promising means of reducing inequalities in access. Creating a crisis continuum of care will help minimize strict reliance on inpatient settings, which are increasingly challenging to access and only sometimes fully address the crises, even when used.

Acute Liver Failure With Liver Enzymes >5,000 in Sickle Cell Disease.

Sickle cell disease is a hemoglobinopathy often complicated by painful vaso-occlusive episodes, acute chest syndrome, stroke, and myocardial infarction. Sickle cell intrahepatic cholestasis (SCIC) is a rare and potentially fatal complication of sickle cell disease. SCIC is thought to involve progressive hepatic injury due to sickling within sinusoids. We present the case of a young patient with SCIC and acute liver failure, requiring prompt treatment with exchange transfusion. Our case describes features that should raise suspicion for hepatic failure in SCIC and highlights exchange transfusion as a successful management approach in similar patients with an otherwise high risk of mortality.

Systematic Review: Patient Outcomes in Transdiagnostic Adolescent Partial Hospitalization Programs.

OBJECTIVE: Partial hospitalization programs (PHPs) are designed to help stabilize patients with acute mental health problems and are considered more cost-effective than inpatient care for patients who do not require 24-hour monitoring. Many PHPs treat transdiagnostic adolescents to reduce suicidality, self-harm, and other high-risk behaviors; however, the effectiveness of such programs is unknown. We aimed to review the existing evidence for the effects of PHPs on adolescent mental health symptoms and functioning. METHOD: We retrieved peer-reviewed evaluations of PHPs treating adolescents with a range of disorders that reported quantitative clinical outcomes. We followed PRISMA guidelines for systematic reviews and included studies published since 2000. RESULTS: Fifteen studies of 10 PHPs in North America, Europe, Asia, and Australia met inclusion criteria, 5 of which used comparison groups. Most participants were White and female with depressive disorders. All studies found improvements in adolescents' functioning and mental health from admission to discharge; however, only 1 study tested PHP relative to other levels of care, and only 1 study included follow-up data. Dialectical behavior therapy (DBT) may be an effective theoretical orientation for PHP settings, but evidence is limited. CONCLUSION: Evidence for effectiveness of PHPs relative to other models is limited. Currently available research suggests that many high-risk transdiagnostic adolescents tend to improve during PHP treatment; however, controlled studies with follow-up data are needed to determine whether partial hospitalization is effective and, if so, how effective, and whether treatment gains persist after discharge.

Responding to Acute Mental Health Crises in Black Youth: Is It Safe to Call 911?

Mental health professionals routinely advise the public to call 911 in case of an acute mental health crisis to access emergent care and ensure safety. Although there is no national database collection process, available data shows that individuals experiencing an acute mental health crisis and Black youth are both at a significantly elevated risk of being harmed or killed by law enforcement during any encounter. This brief analytic essay explores whether advising the public to call 911 is truly the best practice recommendation for Black youth in a mental health crisis. An alternative to the traditional law enforcement response is a mobile unarmed crisis response program. The authors describe successful existing programs and advocate for more widespread adoption of such teams, which likely would provide safer, cost-effective, evidence-based alternatives during acute mental health crises.

Bridging the Gap: Impact of dedicated post-discharge services on readmission rates and emergency department visits for psychiatrically hospitalized youth.

BACKGROUND: For psychiatrically hospitalized youth, discharge care coordination can reduce suicide risk and rehospitalization, but studies on effective interventions or programs are sparse. This study aimed to examine the impact of a dedicated post-discharge bridging service including case management and therapeutic supports on readmissions and emergency department presentations. METHODS: This retrospective cohort study compared emergency department mental health visits (EDMH) and psychiatric hospitalizations in the 60 days before the hospitalization which included referral to the bridging service, and in the 60 days post-hospitalization. RESULTS: This diagnostically heterogeneous group of 238 youth had a mean age of 14 years and were of similar racial and ethnic background as the broader inpatient population. There was a nominal decrease in hospitalizations (p = 0.251), and a significant decrease in EDMH (p < 0.001) in the 60 days following referral to this program compared to the 60 days prior. Further, the proportion of patients with at least one EDMH or hospitalization decreased significantly before and after linkage with this service from 42.4% to 27.3% (p < 0.001). CONCLUSION: Dedicated post-discharge bridging services including family-centered, flexible case management and therapeutic supports can reduce EDMH visits and potentially lower readmission for children and adolescents.

Clinical Characteristics of Youth with Autism or Developmental Disability during Inpatient Psychiatric Admission.

Children with autism spectrum disorder and developmental disabilities (ASD/DD) often experience severe co-occurring psychological and behavioral challenges, which can warrant inpatient psychiatric care. However, very little is known about the characteristics and clinical care of children with ASD/DD within the context of inpatient psychiatric settings. In this paper, we describe factors unique to inpatients with ASD or DD, by drawing on electronic health records from over 2300 children and adolescents ages 4-17 years admitted to a pediatric psychiatric inpatient unit over a 3-year period. Patients with ASD/DD accounted for approximately 16% of inpatients and 21% of admissions, were younger, more likely to be readmitted, more likely to be male, and more likely to have Medicaid insurance, as compared to patients without ASD/DD. Clinically, those with ASD/DD more frequently had externalizing concerns documented in their records, in contrast to more frequent internalizing concerns among other patients. Within the ASD/DD group, we identified effects of patient age, sex, and race/ethnicity on multiple dimensions of clinical care, including length of stay, use of physical restraint, and patterns of medication use. Results suggest the need for psychiatric screening tools that are appropriate for ASD/DD populations, and intentional integration of anti-racist practices into inpatient care, particularly with regard to use of physical restraint among youth.

Ethical Considerations in Balancing Use of Seclusion and Restraint With Risk of COVID-19 Exposure: Recommendations for Youth Inpatient Psychiatry Units.

The onset of the COVID-19 pandemic has presented unique challenges for inpatient psychiatry units (IPUs). IPUs, especially those caring for children and adolescents, rely heavily on milieu group programming to provide care and supervision for patients, and have had to adapt unit policies and procedures to maintain a therapeutic milieu while minimizing COVID-19 transmission.1 Simultaneously providing care while preventing transmission of COVID-19 within IPUs is a formidable task, and many IPUs face the additional challenge of treating youth who have been exposed to, or are actively infected with, COVID-19. In addition, given the need to prevent transmission of COVID-19, recommendations include "mandatory quarantine and isolation when patients refuse to adhere to guidelines,"2 potentially leading to the use of restraint when patients attempt to leave isolation; thus a conflict between the potential risks of enforcing infection prevention policies in order to reduce virus transmission and best practices of eliminating seclusion and restraint (S/R) creates an ethical dilemma for IPUs.

Commentary: Getting kids what they need, where they are, when they need it: home-based services in a continuum of care - a commentary on Boege et al. (2021).

In this edition of CAMH, Boege and colleague's 4-year follow-up study supports intensive home-based treatment as a viable alternative to inpatient hospitalization. Youth receiving home-based multimodal treatment fared just as well as those who remained hospitalized longer, with higher parental satisfaction. This study contributes to a sparse evidence base regarding longitudinal outcomes of psychiatric inpatient and intensive outpatient treatments for children and adolescents. Although mental illness is prevalent and increasing among youth, existing systems of care are often inadequate to provide flexible, effective, interdisciplinary team-based treatments, and supports for children and their families. Innovative approaches to providing evidence-based care and tracking outcomes are needed to strengthen the continuum of care.

Nowhere to Go: Providing Quality Services for Children With Extended Hospitalizations on Acute Inpatient Psychiatric Units.

The US mental health system is in crisis because of inadequate treatment resources. The number of youths hospitalized for suicidality more than doubled during the last decade,1 and the suicide rate for 10- to 14-year-olds nearly tripled from 2007 to 2017.2 Although hospitalization is intended as a short-term stabilization setting reserved for the most acute and serious mental health problems, discharge is often delayed because of a lack of suitable step-down care such as outpatient, intensive outpatient (IOP), partial hospitalization programs (PHP), or residential psychiatric care. The availability of step-down care options differs vastly depending on region, insurance, and other factors, and the result is a subset of patients who remain hospitalized in acute inpatient units simply because of the absence of safe alternatives.

Health Care Reform, Length of Stay, and Readmissions for Child Mental Health Hospitalizations.

BACKGROUND: Health care reform may impact inpatient mental health services by increasing access and changing insurer incentives. We examined whether implementation of the 2014 Affordable Care Act (ACA) was associated with changes in psychiatric length of stay (LOS) and 30-day readmissions for pediatric patients. METHODS: We conducted an interrupted time-series analysis to evaluate LOS and 30-day readmissions during the 30 months before and 24 months after ACA implementation, with a 6-month wash-out period, on patients aged 4 to 17 years who were discharged from the psychiatry unit of a children's hospital. Differences by payer (Medicaid versus non-Medicaid) were examined in moderated interrupted time series. Logistic regression was used to examine the association between psychiatric LOS and 30-day readmissions. RESULTS: There were 1874 encounters in the pre-ACA period and 2186 encounters in the post-ACA period. Compared with pre-ACA implementation, post-ACA implementation was associated with LOS that was significantly decreasing over time (pre-ACA versus post-ACA slope difference: -0.10 days per encounter per month [95% confidence interval -0.17 to -0.02]; P = .01), especially for Medicaid-insured patients (pre-ACA versus post-ACA slope difference: -0.14 days per encounter per month [95% confidence interval -0.26 to -0.01]; P = .03). The overall proportion of 30-day readmissions increased significantly (pre-ACA 6%, post-ACA 10%; P < .05 for the difference). We found no association between LOS and 30-day readmissions. CONCLUSIONS: ACA implementation was associated with a decline in psychiatric inpatient LOS over time, especially for those on Medicaid, and an increase in 30-day readmissions. LOS was not associated with 30-day inpatient readmissions. Further investigation to understand the drivers of these patterns is warranted.

Experiences with the Child and Adolescent Psychiatry Milestones: Results of Two Nationwide Surveys.

OBJECTIVES: Child and Adolescent Psychiatry began using milestones in 2015 as a way to document observable progress through training. The study is the first assessment of Child and Adolescent Psychiatry (CAP) faculty and fellows' experience with the milestones. METHODS: This study presents findings from two surveys conducted one year apart. The first electronic survey polled CAP fellows and faculty nationwide using five opinion questions; demographic data and comments were also gathered. The second, four-question survey polled CAP faculty at the American Association of Directors of Psychiatry Residency Training annual meeting. RESULTS: Seventy-nine fellows and 101 faculty members responded to the first survey. Averaged over the five questions, 53% of faculty and 49% of fellows responded positively, with 29 and 33% respectively giving neutral responses. Participants were a diverse group in terms of geographic distribution, program size, and experience level. Comments were predominantly negative or mixed. Fifty CAP faculty and fellows responded to the second survey. Of the three opinion questions, positive responses ranged from 62 to 90%. Forty percent of respondents reported having had no faculty development on the milestones. CONCLUSIONS: Implementing the milestones has been a mixed experience for faculty and fellows. Direct comparison between these two surveys is not possible given their different content and format. Future directions include standardization of faculty development sessions, and improved structures to create and share best practices for assessment of trainees.

Substance Abuse and Trauma.

There is a strong, bidirectional link between substance abuse and traumatic experiences. Teens with cooccurring substance use disorders (SUDs) and posttraumatic stress disorder (PTSD) have significant functional and psychosocial impairment. Common neurobiological foundations point to the reinforcing cycle of trauma symptoms, substance withdrawal, and substance use. Treatment of teens with these issues should include a systemic and integrated approach to both the SUD and the PTSD.

SNAP participation in preschool-aged children and prevalence of overweight and obesity.

BACKGROUND: An increased prevalence of overweight and obesity for adults on government-funded nutrition assistance, such as the Supplemental Nutrition Assistance Program (SNAP), has been observed; however, this association among preschool-aged children is not well understood. Longitudinal research designs tracking changes in body mass index-for-age (BMI) in children of low-income households may provide a clearer picture of the association between SNAP participation and overweight and obesity among this age group. To determine if there is a relationship between SNAP participation and overweight and obesity prevalence in low-income, preschool children, we conducted a cross-sectional analysis of children in a Head Start program, and a longitudinal analysis of those children who were enrolled for 2 years. METHODS: Height and weight data and SNAP participation of 386 students (207 male, 179 female, 4.2 ± 0.5 years) enrolled in a Head Start program were analyzed; data for 2 years were available for 167 of the students. Height and weight measures were used to determine BMI percentile per Centers for Disease Control and Prevention guidelines. SNAP participation was obtained through a nutritional questionnaire given to parents at time of Head Start Program enrollment. RESULTS: No significant differences were found between SNAP and non-SNAP participants for BMI percentile in either the cross-sectional or longitudinal analysis. BMI percentile increased for both groups over time, but failed to reach significance (p = .13). CONCLUSION: Future studies are warranted with an inclusion of a larger and more geographically diverse sample to further determine the association between SNAP participation and overweight and obesity in preschool-aged children.