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.

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.

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)

In Memoriam: Professor Joseph Biederman's Contributions to Child and Adolescent Psychiatry.

OBJECTIVE: To provide an overview of Joe Biederman's contributions to child and adolescent psychiatry. METHOD: Nine colleagues described his contributions to: psychopharmacology, comorbidity and genetics, pediatric bipolar disorder, autism spectrum disorders, Tourette's and tic disorders, clinical and neuro biomarkers for pediatric mood disorders, executive functioning, and adult ADHD. RESULTS: Joe Biederman left us with many concrete indicators of his contributions to child and adolescent psychiatry. He set up the world's first pediatric psychopharmacology clinic and clinical research program in child adolescent psychiatry. As a young faculty member he began a research program that led to many awards and eventual promotion to full professor at Harvard Medical School. He was for many years the most highly cited researcher in ADHD. He achieved this while maintaining a full clinical load and was widely respected for his clinical acumen. CONCLUSION: The world is a better place because Joe Biederman was here.

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.

Pediatric Consultation-Liaison (C-L) Psychiatry Training Pathways.

This perspective piece reviews the current training pathways for pediatric consultation-liaison psychiatry. Significant workforce shortages of child and adolescent psychiatry over the past 3 decades have led to the creation of new training pathways between pediatrics and child and adolescent psychiatry training programs to care for children whose medical and psychiatric management has become increasingly complex. There are now several options available to receive excellent training in pediatric consultation-liaison. Efforts to foster continued interactions and shared education between adult and pediatric consultation-liaison providers are likely to be beneficial to both disciplines given the astonishing advances in technology over the years that have allowed many patients with complex childhood medical disorders to survive into adulthood today.

[Genetic Diagnostics in Everyday Clinical Practice in Child and Adolescent Psychiatry: Indications, Framework Conditions, Hurdles, and Proposed Solutions]. / Genetische Diagnostik im klinischen Alltag der Kinder- und Jugendpsychiatrie ­ Indikationen, Rahmenbedingungen, Hürden und Lösungsvorschläge.

Genetic Diagnostics in Everyday Clinical Practice in Child and Adolescent Psychiatry: Indications, Framework Conditions, Hurdles, and Proposed Solutions Abstract: Health insurance covers medically necessary genetic testing in Germany. Diagnostic genetic testing has become increasingly important for child and adolescent psychiatry (CAP), reflected by the rising number of national guidelines relevant to CAP, including genetic testing in the recommended diagnostic work-up. However, implementation of theses guidelines in routine clinical care is lacking. This article provides a concise overview of the relevance of genetic testing in CAP-related national guidelines. It outlines the legal and financial framework for genetic testing in Germany. Furthermore, it points out barriers to implementation and offers potential solutions. It then provides examples from clinical practice highlighting the potential benefits patients and their family members might have from receiving a genetic diagnosis. The article closes by outlining future CAP-relevant areas in which genetic testing may become clinically relevant.

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).

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.

AACAP's Strategic Plans to Enhance the Diversity of the Child Psychiatry and Child Mental Health Workforce Across all Mission Areas.

The American Academy of Child and Adolescent Psychiatry (AACAP) promotes the healthy development of children, adolescents, and families through advocacy, education, and research. This requires effectively meeting the mental health needs of historically minoritized communities. A diverse clinician workforce is an essential component of meeting those needs. This article will discuss AACAP's strategic plan for diversifying the workforce, this will be done with 3 main points: promoting diversity, equity, and inclusion (DEI) across all mission area, creating a pipeline of child and adolescent psychiatrists, and monitoring DEI activities and progress on an organizational level.

Psychiatry trainee experience of working in a child and adolescent eating disorder program.

OBJECTIVES: Eating disorders are serious psychiatric conditions that affect people of all ages. Many psychiatry trainees' first and only experience with eating disorders during training is their Child and Adolescent Psychiatry (CAP) rotation. This study aimed to explore the learning experience of psychiatry trainees working within an Eating Disorder Program (EDP) during their CAP rotation. METHODS: Fifteen trainees who participated in the EDP were recruited to complete an online survey and focus groups; a thematic analysis design was used to identify themes emerging from their responses. RESULTS: Themes emerged from the trainee learning experience of working in the EDP around what they found they learnt, what aided that process, what was difficult, and recommendations for future improvement. CONCLUSIONS: This study provided insight into the trainee experience in an EDP as one example of how trainees can learn about eating disorders and one way that could inform future workforce and training initiatives.

Clinical utility of new cut-off scores for the world health organization ADHD self-report scale among adolescents in psychiatric outpatient care

Previous analyses of the proposed cut-off score for the 18-item World Health Organization ADHD Self-Report Scale (ASRS-18) among psychiatrically referred adolescents have shown limited clinical utility. This prospective study examined the diagnostic accuracy and clinical utility of new cut-off scores of the ASRS-18 in a consecutive sample of 111 Swedish adolescent psychiatric outpatients. Using the Kiddie Schedule of Affective Disorders and Schizophrenia (K-SADS) as the reference standard and based on predefined sensitivity and specificity criteria, multiple new general and sex-specific cut-off scores were evaluated. Results showed that clinical utility was greater for sex-specific cut-off scores than for general cut-off scores. The greatest change in pre-test to post-test probability of ADHD diagnosis was observed with a balanced, high-specificity diagnostic cut-off score for girls, where the probability of ADHD increased from 40% pre-test to 82% post-test. The proposed new cut-off levels for the ASRS-18 are useful for the detection and identification of ADHD among adolescents in general psychiatric outpatient settings. (AU)

[Does Provision of Care in Child and Adolescent Psychiatry End when Viruses Come? Hometreatment in Times of Covid-19]. / Hört KJP Versorgung auf, wenn Viren kommen? Hometreatment in Zeiten von Covid-19.

During the Covid-19 pandemic, provision of care in child and adolescent psychiatry was a challenge: Emergency presentations as well as psychiatric problems in children and adolescents increased, while at the same time capacity of inpatient treatment was reduced due to closed inpatient departments and staff shortage. Altogether quarantine, social distancing, testing and hygenic measures complicated daily life as well as inpatient treatment. This article describes the change in numbers of inpatient emergency admissions and prevalent mental health diagnoseses, as well as the role of hometreatment during Covid-19 pandemic. It can be demonstrated that the hometreatment team was able to operate without reduction of treatment capacities throughout the Covid-19 pandemic as long as they took care that basic hygienic measures were in place, Not one single case of Covid-19 infection was transmitted. Hometreatment proved to be an effective treatment alternative for children and adolescents with mental health problems and their families during Covid-19.