Faculty Bibliography

Autistic youth visit the emergency department (ED) for psychiatric concerns, including suicidal ideation and behavior, at elevated rates. However, clinicians often report low levels of training and confidence in addressing suicide risk in autistic youth. In this pilot study, clinicians in a pediatric psychiatric emergency service were trained on community- and evidence-informed recommendations to improve suicide-related care for autistic youth and provided with resources to use with autistic youth for a 3-month period. Ratings on attitudes and confidence were obtained from ten providers before and after the training/implementation period and compared. Ratings of feasibility and utility of strategies and resources were obtained from 15 providers after training/implementation and analyzed. While no changes were found across attitudes items, confidence scores were significantly higher after the training/implementation period than before, particularly in the area of suicide risk assessment. Feasibility and utility ratings were generally high, with endorsement patterns aligning with common organizational and systems-level barriers. This pilot study demonstrated that targeted training and evidence-informed recommendations to improve suicide-related care for autistic youth were associated with increased clinician confidence. As research continues in the development of adapted suicide risk assessment tools and management strategies for autistic youth, it is important that both clinical guidance on best practices is provided and that systems-level barriers are addressed.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Unaccompanied migrant youths often confront traumatic experiences elevating their risk for mental health symptoms. However, United States-based research on mental health services for this population, particularly Indigenous youths, is limited. Objectives were to examine mental health screening and referral, characteristics associated with referrals, and clinical rationale for screening result/referral discordance. METHODS:All unaccompanied migrant youths with pediatric intake visits at a healthcare-legal clinic between 3/2020-2/2023 were included (N=100). Retrospective cohort data were extracted from medical chart and program registry, including pediatricians' rationale for referrals. Chi-square and t-tests were used to compare rates of screening, evaluation, and discordant referrals by sociodemographic characteristics. Logistic regression was used to identify associations with mental health referral. Exploratory analyses examined referrals by Indigenous group. RESULTS:Youths had a mean (SD) age of 17.5 (2.5) years, most were assigned male at birth (66 [66%]), from Central America (83 [83%]), and one-third were Indigenous. Odds of mental health referral were higher for youths who were assigned female at birth (adjusted OR, 3.00 [95% confidence interval, 1.13-7.87), non-Indigenous (adjusted OR, 2.73; 95% confidence interval, 1.01-7.40), and reported more trauma types (adjusted OR, 1.38; 95% confidence interval, 1.02-1.87). One-third of referrals were for trauma or mental health symptoms identified by pediatricians, but not screeners. CONCLUSION/CONCLUSIONS:Most unaccompanied migrant youths had mental health referrals, one-third of which were for mental health symptoms undetected by screeners at pediatric visit. Findings highlight sociodemographic differences in mental health referrals, with non-Indigenous and female youths having higher odds of referral.

OBJECTIVE:Rates of suicide, anxiety, and depression have soared in US youth, and professional organizations strongly urge earlier identification, particularly in pediatric emergency departments (PEDs). However, there are few commonly used suicide screeners that also identify other mental health (MH) problems. A new, electronically administered instrument, the K-CAT, screens for suicide and multiple MH problems. We hypothesized that the K-CAT would enhance suicide identification compared with routine screening and identify significant anxiety and depression in youth presenting with non-MH chief complaints. METHODS:This observational study was conducted in 2 PEDs. Eligible youth were 7 to 17 accompanied by a caregiver without: severe medical concerns, difficult behaviors, limited verbal language, or only a psychiatric complaint. Of the 341 eligible, 241 (70.7%) were screened, and 228 both presented with a non-MH problem and had complete K-CAT data. A Fisher exact test determined whether suicidal behaviors/ideation rates differed between the K-CAT and retrospective chart review data. RESULTS:Seventy-four or 32.46% of youth scored positive for suicide, anxiety, and/or depression on the K-CAT. Females were more likely to screen positive (P<0.001). Compared with the retrospective data, more youth were identified with suicide risk by the K-CAT (3.95% vs. 0%; P=0.004). Youth identified by the K-CAT were 62.5% female and 33.3% 7 to 11 years. CONCLUSIONS:The K-CAT increases the identification of suicidal ideation and behaviors overall and in younger children. It identifies significant rates of depression and anxiety in youth and could be an important first step in identifying MH problems in youth.

BACKGROUND:The prevalence of trauma among individuals with HIV has prompted efforts to integrate trauma-informed care (TIC) into HIV care and treatment to improve health outcomes. A TIC Implementation Model, developed by a US capacity-building organization focuses on organizational changes, aligning cultural and physical environments, emphasizing values like safety and trustworthiness, engaging leadership, and training staff in skills-based TIC services. Despite growing research, gaps remain in understanding the relationship between organizational capacity, provider knowledge, and the dosage of technical assistance (TA) required to sustain TIC integration. Researchers investigated how the project team adapted the type and amount of TA based on initial Cultural Assessment scores (measuring core TIC values) and its impact on Implementation Status scores. METHODS:This study focuses on eight of 20 HIV care agencies in New Jersey that had largely met their TIC implementation goals by Spring 2022. As part of the TIC Implementation Model to measure agency capacity and implementation progress over time, agency staff and clients completed a Cultural Assessment (n = 72) and Physical Assessment (n = 43); staff completed a Pre/Post Training Survey (n = 296); and implementation teams at 8 agencies completed an Implementation Status Assessment Tool. Additionally, TA Logs capturing the details of TA meetings with the eight agencies were recorded by project staff. Data from these tools were analyzed in aggregate by agency using descriptive and correlational analyses. RESULTS:Results demonstrated responsive TA correlated with agencies' baseline capacity. Agencies with lower capacity received significantly more frequent and extended TA encounters, which were associated with higher implementation scores and improvements in cultural environments for staff and clients (e.g., new protocols for staff response plans). CONCLUSIONS:These findings underscore the importance of tailored TA in fostering diverse organizational cultures conducive to TIC implementation. For HIV care agencies, successful TIC implementation can impact health behaviors and outcomes for clients impacted by trauma. The TIC Implementation Model significantly advanced organizations' ability to transform their culture and systems, increasing their capacity to implement and sustain TIC integration. These results align with existing research that emphasizes when time is invested to shift organizational culture and develop leadership, new practices can effectively be implemented and scaled-up.

UNLABELLED:ABSTRACT: Purpose: Emergency department (ED) visits for suicidal ideation and self-harm are more prevalent in autistic than non-autistic youth. However, providers are typically offered insufficient guidance for addressing suicide risk in autistic youth, likely impacting confidence and care. METHODS:In this pilot study, we conducted semi-structured interviews with 17 key members of the autism community (i.e., autistic youth with a history of suicidality, caregivers of autistic youth with a history of suicidality, autism specialist clinicians, ED clinicians) to inform the development of recommendations for modifying ED care for autistic patients, with a focus on suicide risk screening and management. RESULTS:Participants reported on challenges they encountered receiving or providing care and/or recommendations for improving care. Participant perspectives were aligned, and four main categories emerged: accounting for autism features, connection and youth engagement in care, caregiver and family involvement, and service system issues. CONCLUSION/CONCLUSIONS:As research continues in the development of autism-specific suicide risk assessment tools and management strategies, it is essential we better equip providers to address suicide risk in autistic patients, particularly in ED settings.

While the emergency department (ED) is an important setting for identifying youth with psychiatric symptoms and connecting them to services, the demands of the ED make efficient and accurate measurement essential in the implementation of mental health screening. The Kiddie-Computerized Adaptive Test (K-CAT) scales, a new electronically administered measure that offers quick and comprehensive assessment across several mental health domains, may be particularly useful in this setting. Given current recommendations for youth suicide risk screening in EDs, this study compared the K-CAT-Suicide Scale (K-CAT-SS) and the Ask Suicide-screening Questions (ASQ), a widely used measure in EDs, in a sample of participants presenting to a pediatric, psychiatric emergency setting. The measures agreed on the presence of suicide risk in over 85% of cases (κ=0.59), and the characteristics of youth who screened at risk on both were similar. Cases of disagreement were more often male and more often had educational accommodations. They had lower symptom levels of and were less often diagnosed with internalizing disorders and were less often identified as high risk by ED psychiatrists and psychologists. Examination of item endorsement patterns in cases of disagreement revealed important areas of future study, including the role of caregiver report in suicide risk screening, item comprehension concerns, and the validity of assessing youth with neurodevelopmental disabilities. While additional research would be beneficial into its psychometrics when deployed in real-world settings, the K-CAT-SS should be considered a viable alternative for suicide risk screening in EDs.

OBJECTIVE:Because understanding barriers to universal suicide risk screening in pediatric emergency departments (PEDs) may improve both identification and management of suicidal behaviors and ideation, this study assessed barriers to a quality improvement initiative examining the use of a novel computerized adaptive test (CAT), the Kiddie-CAT, in 2 PEDs. METHODS:Research assistants (RAs) trained in Rapid Assessment Procedures-Informed Clinical Ethnography methods documented barriers related to the environment, individuals, and workflow as encountered during screening shifts, categorizing the barriers' impacts as either general to a screening shift or related to screening an individual youth/caregiver dyad. Using thematic content analysis, investigators further categorized barriers based on type (eg, workflow, language/comprehension, clinician attitudes/behaviors) and relationship to the limited integration of this initiative into clinical protocols. Reasons for refusal and descriptive data on barriers are also reported. RESULTS:Individual screen barriers were most often related to workflow (22.9%) and youth/caregiver language/comprehension challenges (28%). Similarly, workflow issues accounted for 48.2% of all general shift barriers. However, many of these barriers were related to the limited integration of the initiative, as RAs rather than clinical staff conducted the screening. CONCLUSIONS:Although this study was limited by a lack of complete integration into clinical protocols and was complicated by the COVID-19 pandemic impacts on PEDs, the findings suggest that considerable attention needs to be directed both to physician education and to workflow issues that could impede universal screening efforts.

The purpose of this study was to examine the impact of childhood trauma exposure, posttraumatic stress disorder, and trauma-related comorbid diagnoses on the risk for readmission to juvenile detention among youth in a large metropolitan area (N = 1282). The following research questions were addressed: 1) Does a greater number of childhood traumas increase the risk for readmission to detention following release? 2) Does the risk for readmission differ by type of trauma? 3) Do PTSD and other co-morbid diagnoses increase the risk for readmission? and 4) What role do demographic factors play in the relationship between trauma-related variables and risk for readmission? This study utilized the screening results of 1282 youth who were voluntarily screened for PTSD, depressive symptoms and substance use during their initial intake to detention. More than half of the sample was readmitted during the three-year study period, with readmissions most likely to occur within one year of release. Returning to detention within one year was also associated with increased risk for multiple readmissions. Youth readmitted to detention were more likely to have a history of sexual abuse and problematic substance use. No other significant relationships were found between risk for readmission and trauma-related variables. Although trauma-related symptoms may be crucial targets for treatment, focusing solely on trauma exposure and traumatic stress symptoms without considering the impact of other risk factors may not be enough to decrease the likelihood of readmission for youth of color in a large urban environment.

The course of childhood-onset attention deficit hyperactivity disorder (ADHD) varies across individuals; some will experience persistent symptoms while others' symptoms fluctuate or remit. We describe the longitudinal course of ADHD symptoms and associated clinical characteristics in adolescents with childhood-onset ADHD. Participants (aged 6-12 at baseline) from the Longitudinal Assessment of Manic Symptoms (LAMS) study who met DSM criteria for ADHD prior to age 12 were evaluated annually with the Kiddie Schedule for Affective Disorders and Schizophrenia for eight years. At each timepoint, participants were categorized as meeting ADHD criteria, subthreshold criteria, or not having ADHD. Stability of course was defined by whether participants experienced consistent ADHD symptoms, fluctuating symptoms, or remission. The persistence of the symptoms was defined by symptom status at the final two follow-ups (stable ADHD, stable remission, stable partial remission, unstable). Of 685 baseline participants, 431 had childhood-onset ADHD and at least two follow-ups. Half had a consistent course of ADHD, nearly 40% had a remitting course, and the remaining participants had a fluctuating course. More than half of participants met criteria for ADHD at the end of their participation; about 30% demonstrated stable full remission, 15% had unstable symptoms, and one had stable partial remission. Participants with a persistent course and stable ADHD outcome reported the highest number of symptoms and were most impaired. This work builds on earlier studies that describe fluctuating symptoms in young people with childhood-onset ADHD. Results emphasize the importance of ongoing monitoring and detailed assessment of factors likely to influence course and outcome to help young people with childhood-onset ADHD.