Faculty Bibliography

Objectives: This clinical perspectives session presents preliminary data on the outcomes of a clinical pathway (CP) for children and adolescents with autism spectrum disorder (ASD) or intellectual disability (ID) who were hospitalized in a general child psychiatric unit at a public hospital. Methods: Children with ASD are at greater risk of psychiatric hospitalization than their neurotypical peers. Although care in specialized psychiatry units has preliminary evidence for positive outcomes, the vast majority of children in the United States are treated in general units that are not designed for this challenging population. Review of best practices and expert consensus was used to design and implement a CP in three child and adolescent inpatient units at Bellevue Hospital Center. Fidelity to the CP was examined by use of a checklist. Retrospective chart review was used to identify patients eligible for the CP in the 18 months before implementation and compare outcomes (mean length of stay, use of intramuscular medications, and use of restraint) of patients exposed to the CP in the first 18 months of implementation. Results: Treatment fidelity to the CP was acceptable based on checklist review. Record review identified over 70 patients with ASD who were admitted in the 18 months before implementation. Of these patients, approximately 50 percent met CP eligibility criteria. Outcomes for these admissions were compared with outcomes for 30 admissions to the CP. Preliminary analysis indicated improved outcomes post-CP implementation. Conclusions: Expert consensus has indicated that expanded, targeted admission assessment; basic supports for functional communication; predictable routines; developmentally appropriate milieu of activities, including physical activities; and increased density of positive reinforcement are critical elements for effective inpatient care of children with ASD or ID. The design and pilot implementation of a clinical pathway using these elements at Bellevue Hospital Center over 18 months showed that it is feasible to incorporate these principles in a general inpatient child psychiatry unit and may improve outcomes

Objectives: The five presenters and discussant in this Clinical Perspectives highlight the challenges associated with pediatric psychiatric crises in standard emergency care settings. Each presenter will focus on a crisis care model that can address urgent patient needs, improve access to mental health care, and decrease unnecessary time or treatments in hospitals Methods: A literature review of pediatric mental health emergencies and crisis care systems will be provided. Each presenter will share her experience in creating, implementing, and/or practicing a particular crisis care model, including phone triage systems, mobile crisis clinics, and crisis stabilization and residential units. Presenters will discuss funding and community resources that have made such projects feasible and highlight key components of program development. Results: Communities and agencies are responding to increased emergent pediatric mental health needs by shifting treatment from standard emergency department settings to a continuum of team-based and nonhospital services. Each of the crisis care models included here has improved community access to behavioral health providers and helped triage children to more appropriate locations/programs of care. Data collected from individual sites indicate improved quality of care and interagency relationships, decreased length of stay or need for emergency department visits, increased outpatient follow-up, and decreased need for inpatient hospitalizations. Conclusions: Providing quality care to youth in mental health crises has become a challenge in our current health care system, with the decline of inpatient beds, lack of providers with mental health training, and limited access to community mental health services. A continuum of psychiatric crisis care services can better meet community and patient needs, thereby relieving burden on emergency departments and linking children and families to the services they need. More research on additional outcomes, as well as establishment of national standards of pediatric psychiatric crisis care, is needed

OBJECTIVE: Most youths experiencing a psychiatric crisis present to emergency departments (EDs) that lack the specialized staff to evaluate them, so youths are often discharged without appropriate mental health assessment or treatment. To better understand the needs of this population, this study described clinical details and disposition associated with visits for psychiatric emergencies to a specialized ED staffed 24/7 by child psychiatrists. METHODS: Through retrospective chart review, 1,180 visits to the ED during its first year of operation were reviewed for clinical characteristics, prior service utilization, and demographic characteristics. Bivariate analyses (chi-square test and Wilcoxon rank sum test) compared differences in disposition (evaluate and release, brief stabilization, and inpatient psychiatric admission) associated with characteristics of the children's first visit (N=885). Measures with bivariate association of p<.10 were further assessed by using multinomial logistic regression analyses. RESULTS: For most visits (59%), children were evaluated and released, 13% were briefly stabilized, and 28% were admitted for psychiatric treatment. Youths with mood or psychotic disorders were more likely to be admitted, as were those with current suicidality or aggression. Many youths who presented with aggression were also identified as having suicidality or self-harm. CONCLUSIONS: Clinical factors, especially suicidality, predicted psychiatric admission. Admission rates for youths with suicidality were significantly higher in this study than previously reported, suggesting the availability of child psychiatrists in this ED allowed greater ascertainment of suicide risk (and thus hospitalization to mitigate that risk) than occurs in EDs without such staffing.

Objectives: Poor access to necessary outpatient psychiatric care and therapeutic support services increasingly drive youth with autism and their families to the emergency department (ED) to seek psychiatric care, yet EDs nationwide have not risen to meet this increased demand. Patients with autism often require 1:1 monitoring, require restraint and seclusion more frequently than their peers who do not suffer from autism, and overall can be costly and difficult for EDs to manage. The dearth of outpatient resources for patients with autism makes discharge from the ED difficult, yet few inpatient units will accept these complex patients. Insurance companies often reimburse poorly or not at all for ED visits for behavioral complaints. Unlike specialized inpatient psychiatric units that have contracted increased rates for their high-needs patients, EDs, in general, receive no additional reimbursement for caring for youth with autism, despite their complexity. EDs that seek to provide more specialized care for youth with autism face not only administrative challenges, including the challenges of cross-departmental collaboration within the institution (including psychiatry, pediatrics, emergency medicine, occupational therapy, and child life), but also the difficulty of collaboration across different service systems that assist patients with autism. This program will review the service system challenges faced by children with autism and their families and by those looking to improve emergency care for these youth as well as strategies to overcome these barriers. Methods: This presentation will review administrative and cross-service challenges that forces patients with autism into the ED and that complicate efforts to care for them there. The presentation then will identify strategies for overcoming these hurdles by using cross-systems collaboration and advocacy. Results: Participants will gain tools to more effectively implement enhanced services for youth with autism in the ED. Conclusions: Although many barriers to improving emergency psychiatric care for youth with autism exist, they are not insurmountable with strong administrative leadership and advocacy

The majority of individuals working with justice-involved youth receive limited training addressing the impact of childhood trauma. There is a need for trauma-related training for staff, as well as valid measures to evaluate the effectiveness of training. The National Child Traumatic Stress Network designed a training curriculum, Think Trauma, which educates staff about the impact of trauma on justice-involved youth. A 45-item Think Trauma Evaluation Questionnaire (TTEQ) was developed to assess participants' changes in knowledge and attitudes. This article examines the factor structure and internal consistency of this questionnaire. Two-hundred and ninety-six employees at two secure juvenile detention centers completed the TTEQ. The results suggest that the questionnaire is feasible to administer to a large group and has a factor structure corresponding to areas covered in the curriculum. A reliable and valid measure of trauma knowledge and attitudes is important to identifying the training needs for a particular facility