Operationalizing and Evaluating Synchronous Virtual Group Health Interventions: Wide-Scale Implementation at a Tertiary Care Academic Hospital.

Group-based health interventions are an important component of health promotion and management. To provide continuity of care throughout the COVID-19 pandemic, our institution undertook a rapid pivot to delivering group-based health interventions via a videoconferencing service which was securely embedded into both the electronic medical record and the patient portal to sustainably address immediate health service delivery needs during the pandemic and beyond. In this paper, we (1) describe the institutionally driven operationalization of a system to provide integrated synchronous video group visits across our hospital and (2) present a proposed strategy to comprehensively evaluate outcomes regarding their implementation, quality, and impact. Lessons for other institutions and the potential future role of synchronous video group visits to enhance how care can be scaled for delivery are discussed.

Suicidality in clinic-referred transgender adolescents.

Gender and sexually diverse adolescents have been reported to be at an elevated risk for suicidal thoughts and behaviors. For transgender adolescents, there has been variation in source of ascertainment and how suicidality was measured, including the time-frame (e.g., past 6 months, lifetime). In studies of clinic-referred samples of transgender adolescents, none utilized any type of comparison or control group. The present study examined suicidality in transgender adolescents (M age, 15.99 years) seen at specialty clinics in Toronto, Canada, Amsterdam, the Netherlands, and London, UK (total N = 2771). Suicidality was measured using two items from the Child Behavior Checklist (CBCL) and the Youth Self-Report (YSR). The CBCL/YSR referred and non-referred standardization samples from both the U.S. and the Netherlands were used for comparative purposes. Multiple linear regression analyses showed that there was significant between-clinic variation in suicidality on both the CBCL and the YSR; in addition, suicidality was consistently higher among birth-assigned females and strongly associated with degree of general behavioral and emotional problems. Compared to the U.S. and Dutch CBCL/YSR standardization samples, the relative risk of suicidality was somewhat higher than referred adolescents but substantially higher than non-referred adolescents. The results were discussed in relation to both gender identity specific and more general risk factors for suicidality.

Psychosocial and Psychological Vulnerability in Adolescents with Gender Dysphoria: A "Proof of Principle" Study.

For adolescents with gender dysphoria, it has become common to be offered hormonal treatment to either delay or suppress pubertal development and/or to masculinize or feminize the body. At the same time, it has been our clinical impression that the psychological vulnerability of at least some of these youth has been overlooked. Fifty consecutive referrals of adolescents with a DSM-IV-TR diagnosis of gender identity disorder (GID) constituted the sample. Information obtained at intake was coded for the presence or absence of 15 psychosocial and psychological vulnerability factors. The mean number of psychosocial/psychological vulnerability factors coded as present was 5.56 (range, 0-13). Over half of the sample had six or more of the vulnerability factors. The number of factors coded as present was significantly correlated with behavioral and emotional problems on the Youth Self-Report Form and the Child Behavior Checklist, but not with demographic variables or IQ. The findings supported the clinical impression that a large percentage of adolescents referred for gender dysphoria have a substantial co-occurring history of psychosocial and psychological vulnerability, thus supporting a "proof of principle" for the importance of a comprehensive psychologic/psychiatric assessment that goes beyond an evaluation of gender dysphoria per se.

The Prevalence of Only-Child Status Among Children and Adolescents Referred to a Gender Identity Service Versus a Clinical Comparison Group.

Several studies indicate that homosexual males have a high proportion of older brothers compared to heterosexual males. Natal males with gender dysphoria who are likely to be homosexual also display this sibship pattern. Until recently, there was little evidence linking homosexuality and/or gender dysphoria in females to unique sibship characteristics. Two studies have indicated that natal female youth clinically referred for gender dysphoria are more likely to be only children (Schagen, Delemarre-van de Waal, Blanchard, & Cohen-Kettenis, 2012; VanderLaan, Blanchard, Wood, & Zucker, 2014). However, these studies did not include control groups of youth clinically referred for other reasons. Thus, it is unclear whether the increased likelihood of only-child status is specific to gender-referred natal females. This study compared only-child status among youth referred to a mental health service for gender dysphoria (778 males, 245 females) versus other reasons (783 males, 281 females). Prehomosexual gender-referred males were less likely to be only children than clinical controls. Contrary to previous findings, gender-referred females were not more likely to be only children, indicating that increased likelihood of only-child status is not specific to gender-referred females, but is characteristic of clinic-referred females more generally.

Evidence for an altered sex ratio in clinic-referred adolescents with gender dysphoria.

INTRODUCTION: The number of adolescents referred to specialized gender identity clinics for gender dysphoria appears to be increasing and there also appears to be a corresponding shift in the sex ratio, from one favoring natal males to one favoring natal females. AIM: We conducted two quantitative studies to ascertain whether there has been a recent inversion of the sex ratio of adolescents referred for gender dysphoria. METHODS: The sex ratio of adolescents from two specialized gender identity clinics was examined as a function of two cohort periods (2006-2013 vs. prior years). Study 1 was conducted on patients from a clinic in Toronto, and Study 2 was conducted on patients from a clinic in Amsterdam. RESULTS: Across both clinics, the total sample size was 748. In both clinics, there was a significant change in the sex ratio of referred adolescents between the two cohort periods: between 2006 and 2013, the sex ratio favored natal females, but in the prior years, the sex ratio favored natal males. In Study 1 from Toronto, there was no corresponding change in the sex ratio of 6,592 adolescents referred for other clinical problems. CONCLUSIONS: Sociological and sociocultural explanations are offered to account for this recent inversion in the sex ratio of adolescents with gender dysphoria.

Delivering Mental Health Care Virtually During the COVID-19 Pandemic: Qualitative Evaluation of Provider Experiences in a Scaled Context.

BACKGROUND: Virtual care delivery within mental health has increased rapidly during the COVID-19 pandemic. Understanding facilitators and challenges to adoption and perceptions of the quality of virtual care when delivered at scale can inform service planning postpandemic. OBJECTIVE: We sought to understand consistent facilitators and persistent challenges to adoption of virtual care and perceived impact on quality of care in an initial pilot phase prior to the pandemic and then during scaled use during the pandemic in the mental health department of an ambulatory care hospital. METHODS: This study took place at Women's College Hospital, an academic ambulatory hospital located in Toronto, Canada. We utilized a multimethods approach to collect quantitative data through aggregate utilization data of phone, video, and in-person visits prior to and during COVID-19 lockdown measures and through a provider experience survey administered to mental health providers (n=30). Qualitative data were collected through open-ended questions on provider experience surveys, focus groups (n=4) with mental health providers, and interviews with clinical administrative and implementation hospital staff (n=3). RESULTS: Utilization data demonstrated slower uptake of video visits at launch and prior to COVID-19 lockdown measures in Ontario (pre-March 2020) and subsequent increased uptake of phone and video visits during COVID-19 lockdown measures (post-March 2020). Mental health providers and clinic staff highlighted barriers and facilitators to adoption of virtual care at the operational, behavioral, cultural, and system/policy levels such as required changes in workflows and scheduling, increased provider effort, provider and staff acceptance, and billing codes for physician providers. Much of the described provider experiences focused on perceived impact on quality of mental health care delivery, including perceptions on providing appropriate and patient-centered care, virtual care effectiveness, and equitable access to care for patients. CONCLUSIONS: Continued efforts to enhance suggested facilitators, reduce persistent challenges, and address provider concerns about care quality based on these findings can enable a hybrid model of patient-centered and appropriate care to emerge in the future, with options for in-person, video, and phone visits being used to meet patient and clinical needs as required.

An overview of traumatic brain injury and suicide.

PURPOSE: There is concerning evidence that people with traumatic brain injury (TBI) may be at increased risk for suicide. This paper aims to provide an overview of traumatic brain injury and suicide in order to enhance the ability of professionals to recognize and manage suicidality in patients with TBI. METHODS: First, the association between TBI and suicide is reviewed. Proposed psychological, psychosocial and neuropathological factors are included in the discussion. Next, identifiable risk factors for suicide in TBI are presented. Suicide assessment tools are then discussed. Assessment is emphasized as the mainstay of suicide prevention and clinicians are encouraged to be vigilant for potential suicidality in their patients with TBI. Finally, biopsychosocial interventions for suicidality are reviewed. CONCLUSIONS: This paper concludes that increasing awareness of depression and suicide risk assessment in the TBI population should be aimed towards staff involved in neuro-rehabilation as well as other professionals who are involved in the care of patients with TBI, because psychoeducation of those most likely to come in contact with at-risk individuals have been shown to increase identification of suicidal patients, lowering suicide rates.

Touching the elephant: The search for fluid intelligence.

Many constructs that we take for granted in modern neuropsychology, fluid intelligence among them, can best be explained by conceptionalizing them as a collection of task specific processes engaged in by an integrated recruited network involved in problem solving. Fractionalizing the network in an attempt to describe elements of its function leads to arbitrarily defined segments that may be interesting to discuss abstractly, but never occur independently in the real world operation of the system. We will seek to demonstrate that the construct of fluid intelligence is like that. It is a description of a type of operation of a network dedicated to solving problems and the composition of the network that is responsible for the activity changes in a task specific manner. As a result, fluid intelligence is not an independent skill, or a thing that lives on its own, or can be measured independently of the other things that contribute to the overall operation of the network as it seeks to solve problems.

Self-Harm and Suicidality in Children Referred for Gender Dysphoria.

OBJECTIVE: This study examined rates of self-harm and suicidality (ideation and behavior) in children referred clinically for gender dysphoria compared with their siblings, and referred and nonreferred children from the Child Behavior Checklist (CBCL) standardization sample. Predictors or correlates of self-harm/suicidality were also examined. METHOD: The sample consisted of 572 gender-referred children, 425 siblings, 878 referred children, and 903 nonreferred children. Parent report for 2 CBCL items was used to assess self-harm and suicidality. CBCL total behavior problems and a metric of peer relationship problems were also used. RESULTS: The gender-referred children and the referred children from the standardization sample had significantly higher scores than siblings and nonreferred children in terms of self-harm/suicidality, total behavior problems, and poor peer relations. Based on logistic regression analyses, gender-referred children were 5.1 times more likely than nonreferred children to talk about suicide and 8.6 times more likely to self-harm/attempt suicide, even after overall behavior problems and peer relationship problems were accounted for. In the final models, group, older age, and more total behavior problems, but not poor peer relations, were significantly associated with an increased likelihood of self-harm/suicidality. CONCLUSION: By parent report, children with gender dysphoria show an increased rate of self-harm/suicidality as they get older. This risk was not simply an artifact of the presence of behavioral and emotional problems, although these problems were significant correlates of self-harm/suicidality. Clinicians should routinely screen for the presence of suicidal ideation and behavior in children with gender dysphoria, particularly during the second half of childhood.

The misnomer of attention-deficit hyperactivity disorder.

We propose that attention-deficit disorder represents an inefficiency of an integrated system designed to allocate working memory to designated tasks rather than the absence or dysfunction of a particular form of attention. A significant portion of this inefficiency in the allocation of working memory represents poor engagement of the reward circuit with distinct circuits of learning and performance that control instrumental conditioning (learning). Efficient attention requires the interaction of these circuits. For a significant percentage of individuals who present with attention-deficit disorder, their problems represent the engagement, or lack thereof, of the motivational and reward circuit as opposed to problems, or disorders of attention traditionally defined as problems with orienting, focusing, and sustaining. We demonstrate that there is an integrated system of working-memory allocation that responds by recruiting relevant aspects of both cortex and subcortex to the demands of the task being encountered. In this model, attention is viewed as a gating function determined by novelty, flight-or-fight response, and reward history/valence affecting motivation. We view the traditional models of attention, rather than describe specific types of attention per se, as representing the description of the behavioral output of this integrated orienting and engagement system designed to allocate working memory to task-specific stimuli.

Toward an integrated model of executive functioning in children.

In this article we review the current status of executive function as a concept, its development, and its assessment during development. Following the review of key issues, we make recommendations for improved conceptualization and definition-the precursors to improved models of assessment of executive functioning.

The sensitivity and specificity of neuropsychological tests in the diagnosis of attention deficit hyperactivity disorder.

The value of neuropsychological assessment in the evaluation of attention disorders is based on assumptions that neuropsychological tests have sufficient sensitivity and specificity to identify specific and discrete patterns of neuropsychological performance associated with the behaviorally defined Diagnostic and Statistical Manual of Mental Disorders criteria. Neuropsychological instruments assessing attentional disorders purport to measure discrete executive management skills, and although there is ample research on the sensitivity of specific neuropsychological tests to damage to certain brain regions, a review of this literature indicates that these instruments are consistent neither in identifying specific regions nor in articulating functional deficits associated with lesions to these areas. We review a number of meta-analyses, which conclude that the assessment of executive functioning by neuropsychological tests inevitably leads to assessment of cortical-subcortical circuitry common to many forms of executive function and by implication, behavioral functioning. We argue that efficacy of neuropsychology is limited by its clinical and research participation in the current behaviorally constructed diagnostic system, which does not adequately or accurately reflect underlying neurophysiological or neuropsychological processes. Recommendations, including the development of a diagnostic nosology reflective of underlying neuropsychological processes, are made.