Clinical management of pediatric patients with cystic fibrosis and autism spectrum disorder.

BACKGROUND: Cystic Fibrosis (CF) and autism spectrum disorder (ASD) are life-long conditions with intense treatment burdens for patients and families. Patients with a concurrent diagnosis (CF-ASD) experience unique obstacles to CF care. This study describes the experiences of our multidisciplinary CF team in caring for patients with CF-ASD and provides insight into provider and parental perspectives on clinical management. METHODS: This is a three-part qualitative study involving (1) retrospective chart review of patients with CF-ASD, (2) surveys with multidisciplinary care team members, and (3) semistructured interviews with caregivers of patients with CF-ASD. Challenges in clinical management of this specific cohort were compiled using data from chart review and care team surveys. Strategies to address these concerns were identified and rated by individual families based on relevance and practicality. RESULTS: Within our CF center, 12 patients have an official diagnosis of ASD. Median age of patients with CF-ASD was 8.5 years (range 3-20 years), 67% were male, and 83% were on highly effective modulator therapy. Clinical barriers included sensory processing issues, environmental overstimulation, intolerance to procedures and to disrupted routines. Potentially impactful strategies include patient-specific coping plans, guided behavioral interventions, parental advocacy, and improved communication between the family and multidisciplinary team. CONCLUSION: Children with CF-ASD face extraordinary challenges beyond the experience of neurotypical children with CF. Increased awareness of this complex dual diagnosis will help providers be sensitive to the unique needs of these patients, help build consistent and trustworthy relationships with their families and deliver effective clinical care despite limitations.

The Importance of Sibling Relationships for Children in Foster Care.

There are approximately 500,000 children in the foster care system in the United States of America. With exposure to chronic and cumulative trauma, they constitute a population with an increased risk of developing mental health concerns and adverse outcomes in later life, including contact with the forensic system. Legislative frameworks that have been developed to facilitate improved outcomes are outlined, although these vary between states, and the focus is often on the parental relationship. Several studies have emphasized the importance of sibling relationships and that placing siblings in the same foster home is associated with higher rates of placement stability, reunification, adoption and guardianship, and fostering positive sibling relations. The multifaceted role of the clinician in promoting recovery from trauma, enhancing resiliency, and thoughtfully prescribing and advocating for familial relationships is discussed.

Ethical and Clinical Considerations During the Coronavirus Era.

The practice of child and adolescent psychiatry is evolving during an unprecedented global health catastrophe, the coronavirus disease 2019 (COVID-19) pandemic. As child and adolescent psychiatrists grapple with COVID-19's enormous medical, educational, social, and economic toll, a mental health crisis is co-occurring. Pre-existing disparities are recognized as contributors to the disproportionate impact of the COVID-19 pandemic on racial and ethnic minorities.1 The magnitude of COVID-19's effects on child and family mental health has yet to be fully revealed. child and adolescent psychiatrists are in a unique position to address this mental health crisis. Child and adolescent psychiatrists must stay up-to-date regarding federal, state, local, and institutional mandates, regulations, and policies informed by the Centers for Disease Control and Prevention2 and other public health institutions, while also navigating the ethical dilemmas unique to child and adolescent psychiatry during the coronavirus era.

The Ethics of Creating a Resource Allocation Strategy During the COVID-19 Pandemic.

The coronavirus disease 2019 pandemic has affected nearly every aspect of medicine and raises numerous moral dilemmas for clinicians. Foremost of these quandaries is how to delineate and implement crisis standards of care and, specifically, how to consider how health care resources should be distributed in times of shortage. We review basic principles of disaster planning and resource stewardship with ethical relevance for this and future public health crises, explore the role of illness severity scoring systems and their limitations and potential contribution to health disparities, and consider the role for exceptionally resource-intensive interventions. We also review the philosophical and practical underpinnings of crisis standards of care and describe historical approaches to scarce resource allocation to offer analysis and guidance for pediatric clinicians. Particular attention is given to the impact on children of this endeavor. Although few children have required hospitalization for symptomatic infection, children nonetheless have the potential to be profoundly affected by the strain on the health care system imposed by the pandemic and should be considered prospectively in resource allocation frameworks.

Theory can be relevant: an overview of bioethics for the practicing child and adolescent psychiatrist.

Familiarity with medical ethical theory and the history of bioethics is helpful for the understanding of the current state of bioethics, as well as possible future developments that will affect physicians and patients alike. This article reviews major schools of thought in bioethics and their relevance to clinical work with children, adolescents, and families. Child and adolescent psychiatrists need to be familiar with major ethical issues in general medicine, psychiatry, and pediatrics, in addition to those controversies that are more specific to their subspecialty. Employing a systematic approach for the identification and analysis of ethical concerns, such as the Four Topics Model of Jonsen and colleagues, improves child and adolescent psychiatrists' confidence that they are aware of ethical quandaries in practice and are addressing these issues in a transparent, well-informed manner.

Ethics and the prescription pad.

This article reviews the considerations that inform ethical psychotropic medication prescription processes at the clinical level with child and adolescent patients and their families or guardians. Physician attributes, cultural and religious factors, and the psychodynamic aspects of psychopharmacology are reviewed, in addition to the applications of basic ethical principles and concepts to the act of dispensing psychotropic medications. Attention is given to the processes of informed consent, assent, and challenges encountered to ethical prescribing for special populations such as children in foster care and juvenile justice systems. Ramifications of black box warnings and off label prescribing are discussed. Finally, the authors offer practical tips to guide clinicians in ethical psychopharmacologic management of their child and adolescent patients.

PANDAS with catatonia: a case report. Therapeutic response to lorazepam and plasmapheresis.

This is a report of an 11-year-old, prepubertal boy with acute-onset urinary urgency and frequency, obsessions and compulsions related to urination, severe mood lability, inattention, impulsivity, hyperactivity, and intermittent periods of immobilization. Fever, cough, otitis, and sinusitis preceded neuropsychiatric symptoms. Antistreptolysin O and DNAse B antibody titers were elevated, and magnetic resonance imaging revealed bilateral diffuse caudate nuclei swelling. Plasmapheresis resulted in significant and rapid clinical improvement of obsessive-compulsive disorder symptoms and a simultaneous decrease in basal ganglia swelling, consistent with an immune-mediated pathophysiological process involving group A beta-hemolytic streptococci. Hyperactivity, impulsivity, and inattention improved with lorazepam, suggesting that the attention-deficit/hyperactivity disorder symptoms could be manifestations of catatonia.

The ipsilateral silent period in boys with attention-deficit/hyperactivity disorder.

OBJECTIVE: Characterize maturation of transcallosal inhibition (ipsilateral silent period [iSP]) in attention deficit/hyperactivity disorder (ADHD) using transcranial magnetic stimulation (TMS). BACKGROUND: Maturation of the iSP is related to acquisition of fine motor skills in typically developing children suggesting that dexterous fine motor skills depend upon mature interhemispheric interactions. Since neuromotor maturation is abnormal in boys with ADHD we hypothesized that iSP maturation in these children would be abnormal. We studied iSP maturation in 12 boys with ADHD and 12 age-matched, typically developing boys, 7-13 years of age. METHODS: Surface electromyographic activity was recorded from right first dorsal interosseus (FDI). During background activation, focal TMS was delivered at maximal stimulator output over the ipsilateral motor cortex. RESULTS: Maturation of finger speed in boys with ADHD was significantly slower than that in the control group. The iSP latency decreased with age in the control group but not in the ADHD group. CONCLUSIONS: These findings suggest the presence of a complex relationship between abnormalities of certain interhemispheric interactions (as represented by iSP latency) and delayed maturation of neuromotor skills in boys with ADHD. SIGNIFICANCE: These data provide preliminary physiologic evidence supporting delayed or abnormal development of interhemispheric interactions in boys with ADHD.

Identifying the Unique Aspects of Adolescent and Young Adult Palliative Care: A Case Study to Propel Programmatic Changes in Pediatric Hospitals.

Using a case study, in this article we seek to highlight how the distinct developmental needs of adolescent and young adult patients facing a life-threatening condition require a different approach to patient care by pediatric health care workers. The case underscores pitfalls in using a pediatric construct of care in areas of pain management, social stressors, and advanced care planning, and suggests programs to implement for improvement, including partnership with psychiatry, substance abuse, and palliative care specialists.

Clinical correlates of episodicity in juvenile mania.

OBJECTIVE: Researchers debate whether the diagnostic criteria for mania should differ between children and adults. Specifically, although the Diagnostic and Statistical Manual of Mental Disorders (fourth edition; DSM-IV) requires episodic mood changes, children commonly are diagnosed as manic on the basis of chronic irritability. In this preliminary study, children carrying a diagnosis of bipolar disorder (BPD) in the community were classified as having either episodic or chronic symptoms. We hypothesized that the episodic group would be more likely to have a history of psychosis and a parental history of BPD, whereas the chronic group would be more likely to have conduct disorder. METHODS: Parents of children carrying the BPD diagnosis were interviewed on the telephone to obtain psychiatric and family histories. Children were considered episodic (n = 34) if they had a history of one or more DSM-IV manic/hypomanic episodes meeting full duration criteria and chronic (n = 53) if they had no discernable episodes. RESULTS: The episodic group was more likely to have had psychosis, parental history of BPD, and to have experienced each manic symptom except for irritability and psychomotor agitation. Children in the episodic group were also more likely to have had a depressive episode meeting full DSM-IV criteria and were more likely to have made a suicide attempt. Children in the chronic group were not more likely to meet criteria for conduct disorder but were more likely to exhibit violence toward others. CONCLUSIONS: These preliminary data indicate that, among children being treated for BPD in the community, those with discrete episodes of mania may be more likely to have a lifetime history of psychosis and a parental history of BPD. The latter hypothesis should be tested in a sample where relatives are interviewed directly.

Religious professionals and institutions: untapped resources for clinical care.

In the vast majority of situations, religious professionals and institutions are competent, caring, and respectful of child and adolescent psychiatrists and mental health workers and welcome the opportunity to collaborate to meet the religious/spiritual, medical, physical, and emotional needs of children, adolescents, and families. Clinicians are well advised to familiarize themselves with the religious professionals, institutions, and resources in the geographic areas in which they practice.

Religion and spirituality in child and adolescent psychiatry: a new frontier.

This article introduces the interface between child and adolescent psychiatry and religion and spirituality. Developmental psychopathology has become increasingly diverse in its study of risk and protective factors for child and adolescent psychopathology. The effect of religion and spirituality on clinical conditions is among those factors. This review addresses (1) historical aspects of the relationship between psychiatry and religion/spirituality, (2) definitional issues, and (3) unique factors in child and adolescent work. Considering these factors and some general principles of intervention, it prepares the reader for other articles in this issue. The article concludes with some observations on the "secular family".

Stages of faith and identity: birth to teens.

In closing, some of the strengths, limitations, and criticisms of faith development theory need to be acknowledged. Fortunately, there was gender balance in the formative sample of 359 interviews from which the theory of faith development derived (50% each of male and female respondents). In the original sample, Protestants made up 45% of the interviewees, Catholics represented 36.5%, 11.2% were Jews, and 3.6% were Orthodox Christians. A remaining 3.6% were "other." Given the growth in the numbers of adherents to other major traditions in the United States, interview research needs to be conducted to widen the sample to include Muslim, Buddhist, and secular respondents. Interviewees have not been studied longitudinally. Furthermore, most of the foundational research was conducted in the 1 980s and early 1990s. A new major round of faith development interviews could shed light on the impacts on peoples' faith of "globalization" and the features of experience that have come to be called the "postmodern condition." These phenomena reflect patterns of radical secularization and the erosion of religious and moral authority on the one hand and, paradoxically, the worldwide growth of fundamentalist and conservative faith practices on the other. Add to these phenomena the interest of many "nonchurched" persons in "spirituality" and we begin to grasp the richness and diversity that faith development research encounters today. Professor Heinz Streib of the University of Bielefeld is conducting the most significant research in the faith development tradition. The research he and his colleagues are conducting in Europe and in the United States promises to yield some tangible data and insights into these issues. To date, faith development theory has not been incorporated into child, adolescent, and family psychiatric interviewing and case formulation to any appreciable or measurable degree. These perspectives and inroads into the interior lives and thought processes of young people, however, may be helpful in the understanding of normal and pathologic development and of healthy and psychiatrically ill children and adolescents. Further collaborative work in this area is needed among psychiatrists, clinical psychologists, psychologists of religion, religious educators, and theologians.

Child and adolescent depression: psychotherapeutic, ethical, and related nonpharmacologic considerations for general psychiatrists and others who prescribe.

Depression is a common, recurring disorder affecting millions of youth at some point before they reach mature adulthood. Given the shortage of and uneven distribution of psychiatrists who have completed specialized fellowships in child and adolescent psychiatry, a significant number of depressed youth will receive their pharmacotherapy from general psychiatrists and other prescribers with varying degrees of interest, training, and even willingness to treat children and adolescents. For general psychiatrists who will prescribe antidepressants for minors, knowledge of the training and expertise of nonphysician mental health professionals, the psychotherapies they may employ, and familiarity with school services are essential. Physicians who typically work only with adults will also need familiarity with differing ethical, legal, and regulatory issues and standards applicable to pediatric psychopharmacology. General psychiatrists, pediatricians, family physicians, nurse practitioners, and others contribute greatly to the care of depressed children, adolescents, and their families, and many find this work to be a very rewarding part of their professional practices.

A review of neurocognitive and behavioral profiles associated with 22q11 deletion syndrome: implications for clinical evaluation and treatment.

22q11 deletion syndrome (22q11DS) is a chromosomal disorder that results in variable multisystem abnormalities, including conotruncal cardiac malformations, aplasia or hypoplasia of the thymus and/or parathyroid glands, immunodeficiency, dysmorphic facial features, and cleft palate and other nasopharyngeal and dental anomalies. Individuals with 22q11DS also exhibit cognitive and behavioral difficulties, including delayed motor and speech-language development, mental retardation, low academic achievement, impaired spatial reasoning, poor attentional and executive functioning, attention-deficit hyperactivity disorder, autism spectrum disorders, mood disorders, and/or schizophrenia spectrum disorders. Interventions should be designed based on the results of periodic developmental and neuropsychological assessments and psychiatric screening. Future research should focus on understanding deletion-related gene-environment interactions and their effects on developmental and behavioral outcomes, identifying neurodegenerative processes in 22q11DS, and developing preventive models of behavioral and psychopharmacologic treatment.