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Editorial: From Bipolar Disorder to DMDD: Challenges to Diagnostic and Treatment Specificity in Traumatized Youths [Editorial]

Havens, Jennifer F; Marr, Mollie C; Hirsch, Emily
This valuable contribution by Findling et al. reports on trends in diagnostic patterns since the inclusion of disruptive mood dysregulation disorder (DMDD) in the DSM-5. As the authors note, the introduction of the DMDD diagnosis was designed to address the problematic over-diagnosis of bipolar disorder and the associated rise in antipsychotic and polypharmacy use in youths.1 Using a large, national, electronic health record database (n = 14,157), this study showed a clear increase in the treated prevalence of DMDD from 2016 to 2018 (0.08-0.35%, p < .0001) coupled with a decrease in the treated prevalence of bipolar disorder from 2015 to 2018 (0.42%-0.36%, p < .0001).1 This suggests that the introduction of DMDD did seem to achieve the aim of reducing the rates of bipolar diagnoses. In what is discouraging but not surprising news, the study demonstrates a troubling increase in the use of antipsychotics (58.9% DMDD vs 51.0% bipolar disorder) and polypharmacy in the DMDD cohort compared to the bipolar disorder cohort (45.0% DMDD vs 37.4% bipolar disorder).1.
PMID: 34363964
ISSN: 1527-5418
CID: 5006042

Friendly Faces: Characteristics of Children and Adolescents With Repeat Visits to a Specialized Child Psychiatric Emergency Program

Marr, Mollie; Horwitz, Sarah M; Gerson, Ruth; Storfer-Isser, Amy; Havens, Jennifer F
OBJECTIVES/OBJECTIVE:Pediatric mental health emergency department (ED) visits continue to rise with 19% to 62% of youth presenting to the ED ultimately returning for a mental health-related complaint. To better understand the needs of children returning to the ED, this study examines the clinical, demographic, and environmental factors associated with revisits to a dedicated child psychiatric ED. METHODS:Clinical factors, home environment, and mental health service utilization of 885 children presenting to a dedicated child psychiatric ED over a 1-year period were abstracted by retrospective chart review. Bivariate analyses comparing demographic and clinical characteristics for children with and without revisits and a multivariable logistic regression were performed. RESULTS:Of the children presenting to the ED, 186 (21.0%) had at least 1 revisit in the subsequent 180 days. Thirty-one percent of initial visits presented as urgent, 55% presented as emergent. Children presenting with more severe symptoms at their initial visit were more likely to return within 6 months. Female gender, suicidal and disruptive behavioral symptomatology, and a diagnosis of oppositional defiant disorder were associated with repeat visits. Children with mental health system involvement were more likely to have revisits than those who were "treatment naive." CONCLUSIONS:Revisits to the ED are driven by both clinical factors, including severity and psychosocial complexity, and barriers to accessing services. Addressing the problem of return ED visits will require the development of a robust mental health service system that is accessible to children and families of all socioeconomic levels.
PMID: 29438124
ISSN: 1535-1815
CID: 2956152

Staff Perceptions and Implementation Fidelity of an Autism Spectrum Disorder Care Pathway on a Child/Adolescent General Psychiatric Inpatient Service

Donnelly, Lauren J; Cervantes, Paige E; Okparaeke, Eugene; Stein, Cheryl R; Filton, Beryl; Kuriakose, Sarah; Havens, Jennifer; Horwitz, Sarah M
While youth with autism spectrum disorder (ASD) are psychiatrically hospitalized at high rates, general psychiatric settings are not designed to meet their unique needs. Previous evaluations of an ASD-Care Pathway (ASD-CP) on a general psychiatric unit revealed sustained reductions in crisis interventions (intramuscular medication use, holds/restraints; Cervantes et al. in J Autism Dev Disord 49(8):3173-3180,, 2019; Kuriakose et al. in J Autism Dev Disord 48(12):4082-4089,, 2018). The current study investigated staff perceptions of the ASD-CP (N = 30), and examined rates of ASD-CP implementation fidelity in relation to patient outcomes (N = 28). Staff identified visual communication aids and reward strategies as most helpful. The number of days of reward identification early in the inpatient stay was associated with fewer crisis interventions later in a patient's stay.
PMID: 32394312
ISSN: 1573-3432
CID: 4438022

Changes in Attitudes and Knowledge after Trainings in a Clinical Care Pathway for Autism Spectrum Disorder

Donnelly, Lauren J.; Cervantes, Paige E.; Guo, Fei; Stein, Cheryl R.; Okparaeke, Eugene; Kuriakose, Sarah; Filton, Beryl; Havens, Jennifer; Horwitz, Sarah M.
ISSN: 0162-3257
CID: 4688322

Sustainability of a Care Pathway for Children and Adolescents with Autism Spectrum Disorder on an Inpatient Psychiatric Service

Cervantes, Paige; Kuriakose, Sarah; Donnelly, Lauren; Filton, Beryl; Marr, Mollie; Okparaeke, Eugene; Voorheis, Katherine; Havens, Jennifer; Horwitz, Sarah
Children with autism spectrum disorder (ASD) are frequently hospitalized within general psychiatric settings, which are not usually designed to meet their needs. An initial evaluation of a care pathway developed for youth with ASD receiving services in a general psychiatric inpatient unit (ASD-CP) showed promise in improving outcomes while using few resources (Kuriakose et al. in J Autism Dev Disord 48:4082-4089, 2018). As sustainability of inpatient psychiatric initiatives is imperative but rarely investigated, this study examined the stability of ASD-CP outcomes during an 18-month follow-up period (n = 15) compared to the 18-month initial evaluation (n = 20) and 18-month pre-implementation (n = 17) periods. Decreased use of crisis interventions, including holds/restraints and intramuscular medication use, was sustained in the 18 months after the initial implementation period. Implications and limitations are discussed.
PMID: 31065864
ISSN: 1573-3432
CID: 3908872

Impact of a Trauma-Informed Intervention for Youth and Staff on Rates of Violence in Juvenile Detention Settings

Baetz, Carly Lyn; Surko, Michael; Moaveni, Mahtab; McNair, Felicia; Bart, Amanda; Workman, Sara; Tedeschi, Frank; Havens, Jennifer; Guo, Fei; Quinlan, Carol; Horwitz, Sarah McCue
The majority of youth in the juvenile justice system have experienced multiple traumatic events in their lives, including community violence, physical abuse, neglect, and traumatic loss. These high prevalence rates, coupled with the known negative consequences of trauma in childhood and adolescence, have led to a greater emphasis on implementing trauma-informed services and practices within juvenile justice settings. However, although many stakeholders and government entities have expressed support for creating more trauma-informed juvenile justice systems, there is still limited empirical knowledge about which interventions are most effective at improving outcomes, particularly at the organizational or facility level. In an effort to fill this gap, the current study evaluated the impact of a trauma-informed milieu intervention, including skills training for youth and training for staff, on rates of violence at two secure juvenile detention facilities (N = 14,856) located in a large Northeastern city. The analyses revealed that the intervention was significantly related to a reduction of violent incidents in Facility A, with no impact on incidents in Facility B. Follow-up analyses revealed that a larger proportion of eligible youth in Facility A completed the skills group program as compared with eligible youth in Facility B (16% vs. 9%). This finding has important implications for the implementation of trauma-informed interventions for youth in juvenile detention settings, as it suggests that to impact outcomes at the facility level, a minimum threshold of youth may need to be exposed to the intervention. In addition, reductions in violence at Facility A were only realized after both staff training and youth skills components were implemented, suggesting that both components are necessary to create change at the facility level. Future research is needed to further explore the impact of organizational and implementation-level factors on trauma-informed care outcomes in juvenile justice settings.
PMID: 31253054
ISSN: 1552-6518
CID: 4009982

Post-traumatic stress and related symptoms among juvenile detention residents: Results from intake screening

McNair, Felicia Debbra; Havens, Jennifer; Surko, Michael; Weinberger, Emily; Baetz, Carly; Moaveni, Mahtab; Bart, Amanda; Marr, Mollie; Quinlan, Carol; Horwitz, Sarah McCue
BACKGROUND:Juvenile justice-involved youth have high rates of trauma exposure, physical and sexual abuse and PTSD. Several factors have been found to be related to PTSD symptoms in youth including number and chronicity of traumatic events. OBJECTIVE:To simultaneously examine the relationships between allostatic load (defined here as number of traumatic experiences), poly-victimization (exposure to two or more forms of victimization based on 5 of the 6 categories in Ford et al.'s 2010 study), physical/sexual abuse and PTSD in justice-involved youth. PARTICIPANTS AND SETTING/METHODS:The sample consisted of 1984 youth in juvenile detention in a Northeastern city. The sample was 73.4% male and the majority of youth were either African American or Hispanic. METHODS:Clinicians collected demographic and psychosocial information, and measured symptoms of PTSD, depression, and problematic substance use. RESULTS:Results showed that youth with more traumas, those who experienced poly-victimization and those who experienced physical/sexual assault/abuse were not only more likely to have PTSD, but also more likely to have depression, thoughts of suicide/self-harm, and problematic substance use (as indicated by the presence of 2 or more of 6 possible indicators). Poly-victimization was a stronger correlate of PTSD than number of traumas or physical/sexual assault/abuse. However, among youth with PTSD, number of traumas was associated with co-occurring problems while poly-victimization and physical/sexual assault/abuse were not. CONCLUSIONS:Findings can be used to help direct resources to juvenile justice-involved youth who are most in need of treatment.
PMID: 30903924
ISSN: 1873-7757
CID: 3763142

Does an Autism Spectrum Disorder Care Pathway Improve Care for Children and Adolescents with ASD in Inpatient Psychiatric Units?

Kuriakose, Sarah; Filton, Beryl; Marr, Mollie; Okparaeke, Eugene; Cervantes, Paige; Siegel, Matthew; Horwitz, Sarah; Havens, Jennifer
Youth with autism spectrum disorder (ASD) are psychiatrically hospitalized at high rates. Though specialized psychiatric units are effective, few specialized units exist. The ASD Care Pathway (ASD-CP) was developed as a scalable approach to improving care in general psychiatric units through staff training and a package of autism-specific intervention strategies. An evaluation of the effectiveness of the ASD-CP in a public hospital child psychiatric service compared 18 months (n = 17) versus 18 months (n = 20) post implementation. Average length of hospital stay decreased 40% (22.4-13.4 days) and use of crisis interventions decreased 77% (holds/restraints; 0.65/day to 0.15/day), though each result only approached statistical significance (p = 0.07; 0.057). This study provides preliminary evidence for improved outcomes after implementation of an ASD-CP.
PMID: 29971653
ISSN: 1573-3432
CID: 3185622

The State of Emergency Child and Adolescent Psychiatry: Raising the Bar

Mroczkowski, Megan M; Havens, Jennifer
The current state of emergency child and adolescent psychiatry includes common historical challenges to safe and effective care as well as recent innovations in multiple settings that increase the quality of that care. These include (1) enhancements within pediatric emergency departments (EDs), (2) specialized and dedicated child psychiatry emergency programs that are hospital based, (3) telepsychiatry programs that spread access to child psychiatric evaluation and treatment planning, and (4) community-based mobile programs diverting youth from EDs. Together, these highlight the work in North America over the past 5 years to improve the care of youth in psychiatric crisis.
PMID: 29933787
ISSN: 1558-0490
CID: 3158392

Utilization Patterns at a Specialized Children's Comprehensive Psychiatric Emergency Program

Gerson, Ruth; Havens, Jennifer; Marr, Mollie; Storfer-Isser, Amy; Lee, Mia; Rojas Marcos, Carolena; Liu, Michelle; Horwitz, Sarah McCue
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.
PMID: 28617206
ISSN: 1557-9700
CID: 2595162