The Transition of Academic Mental Health Clinics to Telehealth During the COVID-19 Pandemic.

OBJECTIVE: A consortium of 8 academic child and adolescent psychiatry programs in the United States and Canada examined their pivot from in-person, clinic-based services to home-based telehealth during the COVID-19 pandemic. The aims were to document the transition across diverse sites and to present recommendations for future telehealth service planning. METHOD: Consortium sites completed a Qualtrics survey assessing site characteristics, telehealth practices, service use, and barriers to and facilitators of telehealth service delivery prior to (pre) and during the early stages of (post) the COVID-19 pandemic. The design is descriptive. RESULTS: All sites pivoted from in-person services to home-based telehealth within 2 weeks. Some sites experienced delays in conducting new intakes, and most experienced delays establishing tele-group therapy. No-show rates and use of telephony versus videoconferencing varied by site. Changes in telehealth practices (eg, documentation requirements, safety protocols) and perceived barriers to telehealth service delivery (eg, regulatory limitations, inability to bill) occurred pre-/post-COVID-19. CONCLUSION: A rapid pivot from in-person services to home-based telehealth occurred at 8 diverse academic programs in the context of a global health crisis. To promote ongoing use of home-based telehealth during future crises and usual care, academic programs should continue documenting the successes and barriers to telehealth practice to promote equitable and sustainable telehealth service delivery in the future.

Measurement-Based Care in the Treatment of Attention-Deficit/Hyperactivity Disorder and Disruptive Behavior Disorders.

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common childhood psychiatric diagnoses. The core symptoms of ADHD include inattention, impulsivity, and hyperactivity. ADHD entails impairments that have extensive and profound detrimental effects on many critical developmental areas. As a valid neurobiologic condition that causes significant impairments in those affected, it is one of the best-researched disorders in medicine. Measurement-based care in treatment of ADHD is critical in establishing a diagnosis, determining a treatment target, and assessing treatment response. This article highlights the rationale for measurement-based care in ADHD, how to implement measurement-based care in clinical practice, and common challenges encountered.

The Importance of Second-Generation Antipsychotic-Related Weight Gain and Adherence Barriers in Youth with Bipolar Disorders: Patient, Parent, and Provider Perspectives.

Objectives: The objective of this research was to understand physician, patient, and parent perspectives on barriers to second-generation antipsychotic (SGA) medication adherence in youth with bipolar spectrum disorders, and attitudes toward treatment of SGA-related weight gain. Methods: Patients diagnosed with bipolar disorder before age 18, parents of children diagnosed before 18, and clinicians with experience prescribing SGAs for these patients completed surveys regarding SGA-related side effects, adherence barriers, and acceptability of weight management strategies. Results: Patients (n = 225), parents (n = 128), and clinicians (n = 54) reported weight gain as the most concerning SGA-related side effect (45.6%, 38.9%, and 70.4%, respectively). Weight gain was also the top adherence barrier for patients (35.9%), but was ranked fourth (41.8%) by parents. Patients (61.5%) were more likely "definitely" willing to co-initiate another medication to manage weight gain upon SGA initiation than parents (20.1%) or clinicians (1.9%). Conversely, parents (54.9%) and clinicians (84.9%) were "definitely" willing to accept/prescribe a second medication aiming to reverse weight gain of ≥10 lbs., and patients (61.1%) were willing to add another medication to reverse any weight gain. Conclusion: SGA-related weight gain impairs medication adherence in young patients with bipolar disorder. Many young patients would start pharmacologic treatment to mitigate SGA-related weight gain at treatment initiation, parents and clinicians are more hesitant. This research informs patient-centered perspectives on SGA adherence barriers and strategies to minimize potential side effects, which may improve adherence in this vulnerable patient population.

Demographics and Outcomes of Patients With Eating Disorders Treated in Residential Care.

The use of residential eating disorder (ED) treatment has grown dramatically in the United States, yet there has been minimal evaluation of treatment outcomes. Thus, outcome data on weight restoration, purging behaviors, and/or Global Assessment of Functioning (GAF) for 1,421 patients treated over an 8-year period in residential ED programs are described. Results suggest that, (1) for patients who needed weight restoration upon admission, adolescent and adult patients gained 2.0 and 2.1 lb/week, respectively; (2) of patients who reported purge behavior the month before admission, 89.1% were able to completely cease purging while in treatment; (3) although improvement of approximately 10 mean GAF points was made during treatment, patients were still quite impaired at discharge; and (4) mean length of stay was 12 days longer for adolescents than adults, and 10-15 days longer for patients diagnosed with anorexia compared to bulimia or ED Not Otherwise Specified (EDNOS), respectively. Other demographic statistics and additional analyses are presented. Limitations include the high variance of purging data and reliance on self- and parent-report for admission data. The data on the 1,421 patients, which represents 96% of all patients treated during the study period, more than doubles the number of residential ED patients with outcome in the literature.

Excessive exercise among adolescents with eating disorders: examination of psychological and demographic variables.

Background While a large number of patients with eating disorders (EDs) engage in excessive exercise (EE), both for weight control and mood regulation, there has been minimal research evaluating the relationship between EE and demographic and psychological factors, especially in adolescent patients. Purpose The goals of this study were to identify the occurrence of EE compared to other ED behaviors and to develop a regression model examining psychological, behavioral and demographic predictors of EE among adolescents with EDs. Methods Demographic and clinical information was determined for 217 adolescent patients in several levels of care (126 outpatient, 61 day program, 28 inpatient) with diagnoses of anorexia nervosa (AN) (24.9%), bulimia nervosa (BN) (25.8%), and eating disorder not otherwise specified (EDNOS) (49.3%). These patients presented to a large ED program and completed a series of questionnaires on admission to the program. Descriptive statistics, t-tests, chi-square analyses and multiple logistic regression were utilized to describe the population of adolescent patients and develop the model for predicting EE. Results Forty-seven percent of patients indicated they participated in EE in the past 4 weeks, compared to 32% for binge eating, 35% for vomiting and 15% for laxative use; 42% of patients with anorexia nervosa participated in EE, compared to 54% with bulimia nervosa and 49% with EDNOS. The regression model that was developed to predict EE, which included factors of depression, anxiety, dietary restraint, age, body mass index (BMI), diagnosis and level of care, correctly classified EE in 71.5% of cases. Dietary restraint and BMI were the two factors found to be significantly associated with EE. Conclusions Forty-seven percent of adolescent patients presenting for treatment of an ED reported participating in EE. This was larger than the numbers of patients reporting other ED behaviors that are commonly assessed, indicating the need for psychoeducation for multidisciplinary treatment teams, assessment, prevention, and clinical treatment services for this problematic behavior. It is important that those who treat patients with ED assess for and monitor EE behaviors that can complicate the treatment.

Correlates of Subjective Caregiver Strain in Caregivers of Youth Evaluated in a Pediatric Psychiatric Emergency Room.

BACKGROUND: Although caregiver burden is relevant to the outcome for psychiatrically ill youth, most studies have focused on caregiver burden in the community or research settings. Therefore, we aimed at evaluating the subjective caregiver strain (SCS) at the time of presentation of youth to a pediatric psychiatric emergency room (PPER), assessing potential correlates to provide leads for improvements in formal support systems. METHODS: In this retrospective cohort study, the internalized, externalized, and total SCS were assessed in caregivers of youth <18 years of age consecutively evaluated at a PPER during a 1 year period using the Caregiver Strain Questionnaire. Sociodemographic and a broad range of clinical data were collected during the PPER visit using a 12-page semistructured institutional evaluation form. The Appropriateness of Pediatric Psychiatric Emergency Room Contact scale, incorporating acuity, severity and harm potential, was used to rate appropriateness of the visit. RESULTS: In caregivers of 444 youth, the internalized SCS was significantly higher than the externalized SCS (p < 0.001). Multivariable analyses indicated that higher total and externalized SCS were associated with disruptive behavior or substance abuse/dependent disorder diagnosis, presenting complaint of aggression, and discharge plan to the police. Higher total and internalized SCS were associated with lower child functioning, whereas total and internalized SCS were lower in adopted children. In addition, higher externalized SCS was associated with investigator-rated inappropriateness of the emergency visit, presenting complaint of defiance, and a lack of prior psychiatric ER visits. CONCLUSIONS: High levels of CS in PPER highlight the necessity to adhere to existing guidelines regarding the inclusion of caregivers' perceptions into comprehensive psychiatric assessments. The particularly high strain in caregivers of children with externalizing disorders and in families with low-functioning youth may need to prompt PPER staff to provide efficient information on appropriate treatment options for these children and on support facilities for the parents.

Eating disorders in adolescents: review of treatment studies that include psychodynamically informed therapy.

In clinical practice, psychodynamic approaches represent an important component of the treatment for young people with eating disorders (EDs), even though the research literature remains modest regarding the most effective treatment for children, adolescents, or adults with an ED. Although there are very few clinical research studies of individual or family psychodynamic treatments of EDs, there is some evidence for efficacy from clinical trials. This article reviews studies of psychodynamically informed therapies for the treatment of EDs and discusses how the findings, although limited, suggest that further research into psychodynamic treatments of EDs in youth is warranted.

Frequency and correlates of inappropriate pediatric psychiatric emergency room visits.

BACKGROUND: Despite increasing pediatric psychiatric emergency room service (PPERS) visits, data are lacking regarding visit characteristics and appropriateness. METHOD: This retrospective cohort study consecutively assessed youngsters aged < 18 years between January 1 and December 31, 2002, utilizing data from a 12-page semistructured institutional evaluation form. Appropriateness, severity, acuity, and harm potential of PPERS visits were rated on a Likert scale. RESULTS: Of 1,062 PPERS patient visits (mean +/- SD age: 13.5 +/- 3.1 years, 51.1% male, and 51.2% white), 305 (28.7%) led to hospitalization. Although most patients (68.7%) were in outpatient care, only 21.9% sought and 11.5% completed an outpatient evaluation prior to reaching the emergency room. As many as 34.4% of PPERS visits were somewhat/very inappropriate (optimal care: outpatient evaluation/treatment, even if delayed), 26.6% were somewhat appropriate/neutral (best served by outpatient evaluation/treatment, but timely appointment unavailable), and only 39.0% were fully appropriate. Main reasons for inappropriate PPERS visits were direct emergency room referral from school (P = .0056) or mental health provider (P = .0438) without prior psychiatrist evaluation, or unavailable appointment (P = .0304). Multivariate predictors of inappropriate PPERS visits (r(2) = .296, P < .0001) included current Global Assessment of Functioning score > 48 (P < .0001), absent suicidal ideation/attempt (P < .0001), low harm potential (< 4.4, P < .0001) and severity (< 4.8, P = .0136) (1- to 7-point scale) of presenting complaint, and absent psychosis (P = .0008). CONCLUSIONS: Over one third of PPERS visits were inappropriate, characterized by better functioning, low harm potential or severity of presenting complaint, and absent suicidality or psychosis. Development of and improved access to urgent child and adolescent psychiatric outpatient care services in the community and referral agent educational programs may minimize inappropriate PPERS visits.

Anorexia nervosa and pregnancy: having a baby when you are dying to be thin--case report and proposed treatment guidelines.

OBJECTIVE: Pregnant women with anorexia nervosa (AN) are at risk for multiple complications to both the woman and fetus. This report examines when to obtain a psychiatric evaluation or admission to an inpatient psychiatric unit to ensure the safety of both the woman and fetus. METHOD: A case report of a pregnant woman with AN describes the risks of extreme weight loss during pregnancy and the deleterious effects on the fetus's viability and mother's health. RESULTS: Psychiatric intervention was not requested until late in gestation, when the patient's mental status and low weight had already deteriorated to a point of high risk to both the mother and fetus. DISCUSSION: We propose the development of treatment guidelines for the pregnant patient with AN to ensure the delivery of optimal care for both the mother and the fetus.

Is perceived family dysfunction related to comorbid psychopathology? A study at an eating disorder day treatment program.

The role of the family in the development of eating disorders has been a predominant research focus. However, few studies of patients in an eating disorder (ED) day treatment program (DTP) have explored the relationship between self-reported family system functioning, self-reported comorbid psychopathology and current comorbid psychological symptom status. This study examined patients at presentation to an ED DTP, their self-reported perception of family functioning and the relationship with characteristics of their own comorbid psychopathology characteristics. Medical records of 51 day treatment female patients, ranging in age from 12 to 26 years, were examined by ED diagnosis and family type (using the FACES-II), and for significant differences on four self-report measures: SCL-90, EDI-2, BDI and TAS-20. Using MANOVA analyses and Bonferroni comparisons, significant differences on the self-report instruments for the entire sample and for the AN and BN patients were obtained when studying patients within different family types as defined by FACES-II. These data specific to DTP patients support previous findings for both IP and OP ED family studies. Overall, as family functioning was perceived to be more dysfunctional, the level of self-reported eating pathology and current comorbid psychological symptoms was also more severe.

What may underlie differing perceptions of family functioning between mothers and their adolescent daughters with eating disorders?

UNLABELLED: Daughters with eating disorders (ED) were found to perceive family functioning more negatively than their mothers. This study examined variables that may underlie these differences in a subgroup of adolescent girls and their mothers from the original study. METHODS: Participants were 77 mother-adolescent daughter dyads. Daughters met current DSM-IV criteria for Anorexia Nervosa, Bulimia Nervosa or ED Not Otherwise Specified. Daughters and mothers completed the Family Assessment Device (FAD), which measures perceptions of family functioning with seven subscales. Daughters also completed the Eating Disorders Inventory (EDI). Backward elimination stepwise regressions were conducted on difference scores between mothers and daughters for each FAD subscale. Daughter's EDI subscales (except Bulimia) were entered as possible predictors. RESULTS: Interpersonal Distrust was the only predictor of the differences between daughters and mothers on Problem Solving, Communication, Affective Responsiveness and General Functioning, accounting for 24%, 14%, 10% and 23% of the variance, respectively. CONCLUSIONS: Differences in viewpoints between mothers and daughters regarding the family environment may be understood in terms of the daughters' level of distrust of people in general and their overall feelings of inadequacy. Addressing these psychological difficulties may have powerful implications both for individual and family treatment in the recovery from an eating disorder. Could this be part of the dynamic that led to the eating disorder, a result of the stress on the whole family related to the eating disorder or some combination?

A review of eating disorders and suicide risk in adolescence.

This review examines the literature during the past 10 years about suicide risk and suicide during adolescence and young adulthood of individuals with eating disorders. Epidemiological surveys are summarized, including suicide rates, parasuicidal behaviors, associated risk factors, and comorbid psychopathology. Critical implications for the comprehensive assessment and treatment planning, including safety considerations, are discussed. Two clinical cases of women with long-standing eating disorders are described to highlight both the pragmatic considerations and the complex clinical challenges of working with patients with eating disorders who become suicidal. The potentially life-threatening issues of safety have not received sufficient attention, neither in the medical literature nor by the treating clinicians. All health care professionals who are treating patients with an eating disorder must be keenly aware of the serious risks of suicidal behavior and of suicide in this population.

Do daughters with eating disorders agree with their parents' perception of family functioning?

OBJECTIVE: The current study compared the perceptions of family functioning between daughters with eating disorders (EDs) and their parents. This investigation was an expansion of the Fornari et al (Compr Psychiatry 1999;40:434-441) study, which investigated the relationship between the perceived family functioning and depressive symptoms in individuals with ED patients receiving outpatient services. METHOD: One hundred twenty-six female subjects, ranging in age from 13 to 34 years (mean 18.3 years) completed the Beck Depression Inventory (BDI) (Arch Gen Psychiatry 1961;4:561-571) and the Family Assessment Device (FAD) (J Marital Fam Ther 1983;9:171-180) on admission to an outpatient ED program. The patient's parent(s) (118 mothers and 96 fathers) also completed the FAD. Eating disorder subgroup diagnosis and major depressive disorder diagnosis were established according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition , criteria, using the Schedule for Affective Disorders and Schizophrenia-Lifetime (Arch Gen Psychiatry 1987;35:837-844). Repeated measures analysis of covariance was performed comparing family members on each of the 7 subscales of the FAD with BDI entered as the covariate. RESULTS: Statistically significant differences were found between patient and parental perceptions of overall family functioning. Mothers rated family functioning as significantly healthier and less chaotic than their daughters did. There were fewer significant differences between maternal and paternal perceptions of family functioning, and no significant differences between fathers' and daughters' perceptions of the family. Eating disorder diagnosis did not contribute to these differences in perception of family functioning. In addition, high self-reported depressive symptoms of the daughters were related to the perception of high family dysfunction for all 3 informants; depressive symptoms did not, however, alter the differences in perception between family members. DISCUSSION: Differences in viewpoints between parents and daughters regarding the family environment may contribute to the continuation of a dysfunctional family pattern and maintenance of the ED and/or impact negatively on the course of treatment. Possible implications for treatment are discussed, particularly because of the differences of the mothers' views. The results of this study strongly support the importance of including the patient's family in the initial evaluation, regardless of the patient's age.

Psychosexual development and eating disorders.

The relationship among eating disorders (EDs), psychosexual and identity development, and physical maturation (puberty) is reviewed. The developmental tasks of adolescence are summarized, and research from both community studies and clinical samples on the association between the development of an ED and putative risk factors that include pubertal development and psychosexual behaviors and attitudes for children and adolescents is reviewed. Specific issues explored include the role of child and adolescent abuse and EDs in males. Overall evidence suggests the following: there are inconsistent findings regarding early pubertal development as a risk factor; there is some support for differences between the ED subtypes in sexual attitudes, behaviors, and experiences; sexual abuse is not a specific risk factor; and gender identity issues may play more of a role for adolescent males than females. However, psychosexual issues are neither sufficient nor necessary for the development of an ED in a young person. It should be considered as only one factor in the multidimensional, multifactorial framework needed to clarify this complex and still poorly understood set of disorders.

The relationship between eating pathology and perceived family functioning in eating disorder patients in a day treatment program.

This study examines the perceived levels of family functioning and their relationships with eating pathology across three eating disorder diagnostic groups. Charts of 65 day treatment female patients, ranging in age from 12 to 27 years, were studied by diagnosis and assessed using the FACES-II and EDI-2. Using multiple regression analyses, it was determined that perceived family functioning yielded significant predictions for various EDI-2 subscales within both Anorexia Nervosa and Eating Disorder Not Otherwise Specified diagnoses. Significant correlations were found between FACESII and the EDI-2 for all three diagnostic groups. Using ANOVA analyses and Bonferroni comparisons, significant differences among diagnoses on the EDI-2 subscales were obtained when studying patients within different family types as defined by FACES-II. These data support previous findings that suggest that as family functioning is perceived to be more dysfunctional the severity level of eating pathology increases.

Three case reports on the relationship between anorexia nervosa and obsessive compulsive disorder.

The literature has demonstrated that both food-related and non food-related obsessions and compulsions are common in patients with eating disorders and that eating disorders are common in patients with obsessive-compulsive disorder (OCD). It has become increasingly important, therefore, to evaluate the clinical and etiological relationships between these disorders. The authors present three patients with anorexia nervosa and obsessive-compulsive disorder. In two of the cases, OCD symptoms preceded onset of the eating disorder by several years. In the third case, OCD symptoms began after the onset of weight loss. In all three cases, obsessive-compulsive symptoms had a significant effect on attempts to treat the eating disorder. Medication, utilized in one of the three patients, was helpful in treatment of the OCD but did not have a major effect on the eating disorder. There remains much to learn about the epidemiology, etiology, treatment and outcome of those who have comorbid eating disorders and OCD. These cases highlight some of the issues encountered in management of patients with these combined conditions.

Cultural factors in orthodox Jewish adolescents treated in a day program for eating disorders.

This study explores the specific role of culture and religion in the development of eating disorders (ED) in Orthodox Jewish female adolescents. We present eight cases admitted to a Day Treatment Program (DTP) for Eating Disorders. Additionally, some preliminary comparisons are examined between Orthodox and all other patients, and also between ultra and modern Orthodox patients. All eight adolescents were transferred from inpatient care, three met program treatment goals, two left prematurely, and three required re-hospitalization. The only significant differences between the Orthodox group and all other patients were on length of stay in the DTP and current use of psychotropic medications. Overall, results suggest that Orthodox patients and all other patients show similar ED presentation and course. However, there are unique cultural and religious circumstances, which require consultation with rabbinic authorities.