Living on Site While Renovating; Flexible Instructional Design of Post-Graduate Medical Training.

Background: Developing theoretical courses for post-graduate medical training that are aligned to current workplace-based learning practices and adaptive to change in the field is challenging, especially in (sub) specialties where time for re-design is limited and needs to be performed while education continues. Approach: An instructional design method was applied based on flexible co-design to improve post-graduate theoretical courses in child and adolescent psychiatry (CAP) in the Netherlands. In four phases over a period of three years, courses were re-designed at a national level. Evaluation: Once common vision and learning goals were agreed upon and the prototype was developed (phases 1 and 2), the first courses could be tested in daily practice (phase 3). Phase 4 refined these courses in brief iterative cycles and allowed for designing additional courses building on and adding to previous experiences in brief iterative cycles. The resulting national theoretical courses re-allocated resources previously spent on a local level using easily accessible online tools. This allowed trainees to align content with their clinical rotations, personal preferences and training schedules. Reflection: The development of theoretical courses for post-graduate medical training in smaller medical (sub-)specialties with limited resources may profit from a flexible instructional design method. We consider the potential merit of such a method to other medical specialties and other (inter-)national efforts to develop theoretical teaching courses. A longer-term implementation evaluation is needed to show to what extent the investment made in the re-design proves to be future-proof and enables rapid adaptation to changes in the field.

Editorial: Equity, diversity and inclusion in child and adolescent mental health - a perspective from the American Academy of Child and Adolescent Psychiatry (AACAP).

Advancing diversity, equity and inclusion (DEI) are key priorities for the American Academy of Child and Adolescent Psychiatry (AACAP). AACAP was founded in 1953. The mission of the AACAP includes promoting the healthy development of all children, adolescents, and families through advocacy, education, and research. AACAP's Presidential Initiative of CAPture Belonging's goal was to prioritize diversity, equity, inclusion and belonging to create transformational and sustainable changes in the organization and child and adolescent psychiatry. The presidential initiative's strategy had three pillars: advancing diversity, equity, inclusion, and belonging (DEIB) in all program and services, creating a pipeline for diverse child and adolescent psychiatrists, and monitoring DEIB activities and progress. A presidential task force was created and charged with implementing a 2-year action plan and strategy. A 5-point action plan prioritized: awareness, advocacy, workforce and professional development, national partnerships, and sustainability. Focusing on DEIB for any organization enriches the work, community and success that can be achieved. AACAP is proud to have committed to this DEIB path and has already experienced success through continuous membership growth, membership engagement, and record attendance at annual meetings and volunteer involvement. These accomplishments can only enhance AACAP's ability to serve the mission of promoting the healthy development of all children, adolescents, and families through advocacy, education, and research.

Forensic Psychiatry Education in Child and Adolescent Psychiatry (CAP) Fellowship: Results from a Multi-site Survey.

OBJECTIVE: This study examined the current state of forensic education among child and adolescent psychiatry (CAP) fellowship programs, regarding specific forensic topics, teaching resources, methods, and experiences. The authors aimed to gather and analyze this data to assess the need for additional standardization of forensic psychiatry education in CAP fellowship, such as broader access to resources, and/or inform the development of a standardized curriculum, including milestones, in child and adolescent forensic psychiatry. METHODS: The authors collaboratively developed a survey instrument on child and adolescent forensic psychiatry education, which was then sent to 135 accredited CAP fellowship programs. The items included in the survey instrument were designed based on literature review, expert consensus, and a 1992 American Association of Directors of Psychiatric Residency Training survey on teaching ethics and forensic psychiatry. RESULTS: Completed response data was returned by 25 of the 135 programs surveyed. Complete responses came primarily from academic institutions (52% public, 36% private) with small- or medium-sized programs (1-12 total fellows, 88%; 11-29 faculty members, 56%). Programs reported on CAP forensic rotation sites, faculty members' level of expertise and involvement in forensic CAP, common forensic topics and experiences offered, and programs' attitudes towards specific topics and experiences. CONCLUSIONS: Child and adolescent psychiatrists must gain a clear understanding of the essential components of CAP forensic psychiatry during CAP fellowship, to mitigate discomfort when interacting with the legal system and meet the rising need for forensic CAP expertise across systems and structures impacting youth populations.

Trayectorias diagnósticas de los trastornos mentales en 10 años de seguimiento de una cohorte de niños y adolescentes / Diagnostic trajectories of mental disorders in a 10-year follow-up cohort of children and adolescents

Los trastornos psiquiátricos en la infancia y adolescencia pueden persistir, cambiar, remitir o aumentar en la edad adulta. Este estudio explora la estabilidad y las trayectorias diagnósticas de 311 niños y adolescentes entre 3 y 17 años hasta la edad adulta. Se encuentra que la estabilidad diagnóstica varía en función de la enfermedad. Los cambios de diagnóstico son más frecuentes en el trastorno de conducta y los trastornos afectivos, mientras que la mayor estabilidad diagnóstica se da en las dificultades del aprendizaje, trastorno de déficit de atención con hiperactividad y trastornos del espectro autista. La remisión completa es más frecuente en los trastornos de ansiedad. Los diagnósticos psiquiátricos tienen implicaciones sociales, emocionales y prácticas. Es necesario adaptar los recursos de salud mental a las necesidades de cada grupo de edad. (AU)

Psychiatric disorders in childhood and adolescence may persist, change, remit or increase in adulthood. This study explores the diagnostic stability and trajectories of 311 children and adolescents aged 3-17 years into adulthood. Diagnostic stability is found to vary according to pathology. Diagnostic changes are more frequent in conduct disorder and affective disorders, while the highest diagnostic stability was found in learning difficulties, attention deficit learning disabilities, attention deficit hyperactivity disorder and autism spectrum disorders. Complete remission is more frequent in anxiety disorders. Psychiatric diagnoses have social, emotional and practical implications. Mental health resources need to be adapted to the needs of each age group. (AU)

The association between pain and psychiatric conditions in adolescents: The impact of gender and ADHD diagnosis

Background and objectives The relationship between pain and psychiatric conditions in children and adolescents has been understudied. This study aimed to investigate the influence of gender on the association between pain and psychiatric diagnoses, as well as the specific relationship between pain and attention deficit/hyperactivity disorder (ADHD), in a sample of adolescents from the general population. Additionally, the study explored whether pain frequency or intensity in individuals with ADHD was influenced by coexisting psychiatric disorders and ADHD medications. Methods This cross-sectional study included 1608 conveniently sampled Swedish upper secondary school students aged 15–19 years. Data were collected at the end of 2020 using the electronic "Mental and Somatic Health without borders" survey. Results A significant positive association (p < 0.001) was observed between pain frequency, intensity, and the presence of any psychiatric diagnosis. Female adolescents reported more frequent and intensive pain in the groups with or without any psychiatric diagnosis and in those with ADHD, however the presence of a psychiatric diagnosis had a comparatively lesser impact on pain frequency in females when compared to males. In adolescents with ADHD, pain frequency, but not intensity, showed a significant further increase. Moreover, the presence of coexisting depression and/or anxiety further heightened the association between pain frequency and ADHD. Notably, common ADHD medications did not have a significant impact on pain experiences. Headache emerged as the most prevalent type of pain across all groups of adolescents. Back pain specifically appeared as the next most common type of pain among adolescents with ADHD. Conclusion The findings suggest a positive association between pain and the presence of psychiatric diagnoses, including ADHD, in adolescents. Gender modified this association. Back pain arised specifically coupled to ADHD. ... (AU)

Mental telehealth in a public child and adolescent psychiatry unit during the pandemic: a qualitative implementation study. / Telesalud mental en una unidad pública de psiquiatría infanto-juvenil en pandemia: estudio cualitativo de implementación.

Background: The COVID-19 pandemic led to a prompt implementation of remote care, especially in mental health care. The evidence supporting this modality of care is still emerging, with few qualitative studies describing its implementation in Latin American countries. This study aims to understand the perspectives of therapists and patients regarding the use of telehealth in a child and adolescent mental health unit of a Chilean public service. Methods: This is a qualitative study. Two focus groups were defined with 14 professionals, and 16 in-depth interviews were conducted with users of an outpatient child and adolescent psychiatry unit. The data were analyzed using the grounded theory model. Results: In the group of therapists, four main categories emerged: background of mental telehealth, implementation, mental telehealth from the therapist's position, and projections. Three main categories emerged in the patient's group: implementation, evaluation of mental telehealth users, and projections. Conclusions: There are elements in common between the opinions of patients and therapists. Something to note within the patient's group is that, despite accepting remote care and recognizing its positive aspects, aside from the pandemic context, they prefer face-to-face or mixed care.

Antecedentes: La pandemia por COVID-19 generó una implementación súbita de las atenciones a distancia, especialmente en atenciones de salud mental. La evidencia que sustenta esta modalidad de atención es aún emergente, con escasos estudios cualitativos que representen su implementación en países latinoamericanos. El objetivo de este trabajo es conocer la perspectiva de terapeutas y de usuarios, respecto del uso de la telesalud en una unidad de salud mental infantil y de la adolescencia de un servicio público chileno. Métodos: Estudio cualitativo. Se establecieron dos grupos focales con 14 profesionales en total, y 16 entrevistas en profundidad con usuarios de una unidad ambulatoria de psiquiatría infanto juvenil.. Los datos se analizaron utilizando el modelo de teoría fundamentada. Resultados: En el grupo de terapeutas surgen cuatro categorías fundamentales; antecedentes de la telesalud mental, implementación, telesalud mental desde la posición del terapeuta y proyecciones. En el grupo de usuarios surgieron tres categorías principales: implementación, evaluación de los usuarios de la telesalud mental y proyecciones. Conclusiones: Existen elementos en común entre la opinión de los usuarios y terapeutas. Un elemento importante dentro del grupo de los usuarios es que, a pesar de aceptar la atención remota y reconocer aspectos positivos en esta, fuera del contexto de pandemia prefieren atenciones presenciales o mixtas.

Retaining Interest in Child and Adolescent Psychiatry Among General Residency Trainees.

OBJECTIVES: This study aimed to identify factors affecting current general psychiatry residents' interest in child and adolescent psychiatry (CAP) at Lehigh Valley Health Network (LVHN). Furthermore, it aimed to identify areas for improvement in clinical education to address the shortage of child psychiatrists at the institution at the time of this study. METHODS: An electronic anonymous pre-implementation survey was sent to all the current general psychiatry residents at LVHN. It assessed the most important factors for trainees in deciding their career paths into CAP, their comfort level with children and families, and overall CAP and related systems-based knowledge. Interventions based on the survey results were implemented in the LVHN psychiatry residency program. The residents then completed a post-intervention survey to assess the impact of these interventions on their perspectives toward CAP. RESULTS: CAP rotation experience and work with families were strong influencers for general psychiatry residents at LVHN in pursing CAP. Systems-based knowledge was particularly lacking compared to overall CAP knowledge. Educational interventions that were implemented at LVHN led to improvements in residents' sense of competence working with children and families with no net loss of interest in CAP. CONCLUSIONS: Educational modifications enhanced attitudes toward CAP among LVHN general psychiatry residents. Implementing such modifications at other residency programs may be likewise effective in retaining interest in CAP among their general psychiatry residents.

Pharmacogenetics in Child and Adolescent Psychiatry: Background and Evidence-Based Clinical Applications.

The efficacy and tolerability of psychotropic medications can vary significantly among children and adolescents, and some of this variability relates to pharmacogenetic factors. Pharmacogenetics (PGx) in child and adolescent psychiatry can potentially improve treatment outcomes and minimize adverse drug reactions. This article reviews key pharmacokinetic and pharmacodynamic genes and principles of pharmacogenetic testing and discusses the evidence base for clinical decision-making concerning PGx testing. This article reviews current guidelines from the United States Food and Drug Administration (FDA), the Clinical Pharmacogenetics Implementation Consortium (CPIC), and the Dutch Pharmacogenetics Working Group (DPWG) and explores potential future directions. This review discusses key clinical considerations for clinicians prescribing psychotropic medications in children and adolescents, focusing on antidepressants, antipsychotics, stimulants, norepinephrine reuptake inhibitors, and alpha-2 agonists. Finally, this review synthesizes the practical use of pharmacogenetic testing and clinical decision support systems.

Predictors and Correlates of Positive Urine Drug Screening in a Retrospective Cohort Analysis of Child and Adolescent Psychiatry Inpatients Throughout the COVID-19 Pandemic.

BACKGROUND AND OBJECTIVES: Youth substance use is associated with significant psychological, neurological, and medical complications. Risk factors for substance use among children and adolescents in the general population include peer and/or parental substance use, certain psychiatric illnesses (eg, Attention-Deficit/Hyperactivity Disorder, depression), and history of maltreatment. Co-occurring substance use and psychiatric illness have been associated with increased suicidality, but few prior studies have characterized substance use among child/adolescent inpatients. As such, it remains unclear how substance use contributing to acute psychiatric presentations has changed since the start of the COVID-19 pandemic. METHODS: This is a retrospective cohort study of 816 unique child/adolescent psychiatry inpatients with urine drug screening (UDS) results from a diverse urban setting. Charts of patients hospitalized between June 1, 2018 and November 30, 2021 were reviewed for sociodemographic characteristics, indication for admission, psychiatric history, hospital course, treatment plan, and discharge diagnosis. Differences in sociodemographic and clinical characteristics, such as age, race, and diagnoses, between patients with and without positive UDS were explored throughout various periods of the COVID-19 pandemic. Descriptive and comparative statistics were performed, as well as a logistic regression model to identify the predictors of positive UDS. RESULTS: Of the study sample, 18% had a positive UDS. Older age, diagnosis of impulsive or behavioral disorder, and a history of violence were found to be predictors of positive UDS. Asian/South Asian or Hispanic/LatinX race and history of a developmental or intellectual disability were found to be negative predictors. The frequency of positive UDS in this population did not change based on COVID-19. DISCUSSION AND CONCLUSIONS: Multiple factors may predispose children and adolescents to substance use. Though no impact of COVID-19 was found in this sample, longer-term studies are needed. SCIENTIFIC SIGNIFICANCE: This study identifies independent predictors of active substance use in the child and adolescent psychiatric inpatient population.

Emergency-related inpatient admissions in child and adolescent psychiatry: comparison of clinical characteristics of involuntary and voluntary admissions from a survey in Bavaria, Germany.

Emergency inpatient admissions of children and adolescents are more difficult if the patient is admitted involuntarily and/or the caregivers or custodians of institutional care are absent. The present study aimed to clinically characterize involuntary versus voluntary admissions by examining the reasons for presentation and associated factors. We retrospectively analyzed patients who presented to the emergency department of a hospital for child and adolescent psychiatry in Bavaria, Germany, and were admitted as inpatients for crisis intervention in the 4th quarter of 2014-2018. Reasons for presentation, clinical and sociodemographic characteristics, and type of admission (voluntary versus involuntary) were analyzed for 431 emergency inpatient admissions. A total of 106 (24.6%) patients were involuntarily admitted. In a binominal logistic regression, presentation due to alcohol consumption, deviant social behavior, and psychosocial burden was positively associated, whereas difficulties at school and depression were negatively associated, with the likelihood of involuntary admission. 58.5% of the 123 unaccompanied patients were admitted involuntarily. Reasons for the presentation of unaccompanied and voluntary inpatient admissions were suicidal thoughts, psychosocial burden, and externalized aggression. A substantial number of child and adolescent psychiatric admissions represent emergency admissions. Involuntarily admitted patients and unaccompanied children/adolescents represent a non-negligible proportion of clinical routine and the clinical and legal background factors need to be further clarified in future studies. This study is registered in the German Clinical Trials Register (24 September 2019, DRKS00017689).

Advocacy Training in Residency and Addressing Needs in Child and Adolescent Psychiatry: A 30-Year Review.

Historically providing specialized advocacy training to Child and Adolescent Psychiatrists (CAP) beyond traditional medical education has been ambiguous at best. This is alarming particularly in light of the National Emergency in Child and Adolescent Mental Health and the increasing concern about health inequities resulting from social determinants of health (SDH). While Graduate Medical Education (GME) programs are adopting advocacy curricula, the authors argue that the shortage of trained CAPs and the growing need for advocacy makes it essential to focus on advocacy training that targets patients, organizations, or entire populations. The authors performed a systematic literature review across all medical specialties, highlighting the inadequacy of current advocacy training for CAPs, particularly in comparison to pediatrics, and the Accreditation Council of Graduate Medical Education (ACGME) requirements. The article suggests that advocacy training should be more emphasized in CAP training to address health inequities and promote better outcomes for children and adolescents. The training focused on medical-legal partnerships (MLP) is particularly crucial in addressing the social causes of health disparities and addressing unmet needs such as food, housing, and income that drive disparities, especially amongst vulnerable populations. The article concludes that providing an informed and evidence-based representation of current practices and methodologies used to train residents around advocacy is essential to ensure that CAPs are prepared to advocate for their patients and address health disparities resulting from SDH. Given the growing demand for mental health services and the unprecedented need for advocacy, specialized training for CAPs can no longer be ignored.

Dimensional profiling of psychopathology in children and adolescents based on the K-SADS-PL and an analysis of the construct validity of two ADHD symptom dimensions.

OBJECTIVES: The traditional view on psychiatric disorders as categorical and distinct is being challenged by perspectives emphasizing the relevance of dimensional and transdiagnostic assessment. However, most diagnostic instruments are based on a categorical view with a threshold-approach to disease classification. METHODS: We here describe algorithms for dimensionalizing the psychopathological ratings of the widely used diagnostic interview for children and adolescents, the Kiddie-Schedule for Affective Disorders and Schizophrenia - Present and Lifetime Version (K-SADS-PL). We further evaluate the criterion-related construct validity of the dimensionalized attention-deficit/hyperactivity disorder (ADHD) scales using Rasch models in a sample of 590 children (mean age 10.29 (.36), 49% girls). RESULTS: The algorithms generate scores of current symptom load, i.e., the sum of clinician-rated symptoms within each disorder assessed with the interview. We found support for counting symptoms of inattention and hyperactivity/impulsivity, respectively, but not for a single combined ADHD scale. CONCLUSIONS: The algorithms constitute an initial step in creating a framework for clinician-rated dimensional analyses of symptoms derived from the K-SADS-PL, but future studies are needed to further evaluate the construct validity of the remaining scales and the reliability and clinical utility of the method. We believe that our proposed algorithms offer a novel method of dimensional psychopathological assessment, which can be applied in multiple branches of child and adolescent psychiatry.