Faculty Bibliography

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

Despite high rates of trauma exposure (46%-96%) and significant posttraumatic stress disorder (PTSD; 21%-29%) symptoms in adolescent psychiatric inpatients, there is a dearth of research on effective interventions delivered in inpatient settings. The current report describes the development of Brief STAIR-A, a repeatable 3-module version of skills training in affective and interpersonal regulation (STAIR) developed for adolescents in inpatient care. An uncontrolled design was used to conduct a preliminary examination of the group intervention's effectiveness. Adolescent psychiatric inpatients (N = 38; ages 12 years-17 years) admitted to a public hospital participated in Brief STAIR-A and attended a median of 6 sessions (range 3-36). They completed measures of PTSD and depressive symptom severity, coping skill use, and coping efficacy upon admission and again prior to discharge. Participants reported significant reductions in symptom severity (d = 0.65-0.67), no change in the absolute level of coping skills used (d = 0.16), but greater coping efficacy when discharged from care (d = 0.75). Results from this pilot study suggest that this brief group treatment shows promise for treating adolescents' trauma-related difficulties in inpatient psychiatry settings, but additional research examining its effectiveness is essential.

Trauma exposure and posttraumatic stress disorder (PTSD), though prevalent among adolescent psychiatric inpatients, are underidentified in standard clinical practice. In a retrospective chart review of 140 adolescents admitted to a psychiatric inpatient unit, we examined associations between probable PTSD identified through the Child PTSD Symptom Scale and adolescents' service use and clinical characteristics. Results suggest a large discrepancy between rates of probable PTSD identified through standardized assessment and during the emergency room psychiatric evaluation (28.6% vs. 2.2%). Adolescents with probable PTSD had greater clinical severity and service utilization, an increased likelihood of being diagnosed with bipolar disorder (27.5% vs. 9.2%) and being prescribed antipsychotic medications (47.5% vs. 27.6%), and were prescribed more psychotropic medications. Upon discharge, those with probable PTSD were more than those without to be assigned a diagnosis of PTSD (45% vs. 7.1%), a comorbid diagnosis of major depressive disorder (30% vs. 14.3%), to be prescribed an antidepressant medication (52.5% vs. 33.7%), and to be prescribed more medications. The underidentification of trauma exposure and PTSD has important implications for the care of adolescents given that accurate diagnosis is a prerequisite for providing effective care. Improved methods for identifying trauma-related problems in standard clinical practice are needed.

The renin-angiotensin system (RAS) and its active peptide angiotensin II (AngII) have major involvements not only in hypertension but also in mood and anxiety disorders. Substantial evidence supports the notion that AngII acts as a neuromodulator in the brain. In this review, we provide an overview of the link between the RAS and anxiety or mood disorders, and focus on recent advances in the understanding of AngII-linked, NADPH oxidase-derived oxidative stress in the central nervous system, which may underlie pathogenesis of mood and anxiety disorders.

This presentation reviewed clinical issues related to the under-recognition of trauma exposure and PTSD in acute care settings serving children and adolescents and describes strategies for integrating and evaluating systematic screening and developmentally appropriate intervention in the inpatient milieu. In addition, it reviewed clinical characteristics of a sample of adolescent inpatients identified with probable PTSD. 2012 Bentham Science Publishers