Faculty Bibliography

OBJECTIVE:To identify optimal strategies to integrate early relational health (ERH) programs in pediatric primary care (PPC) and to describe the development of a best practices toolkit to provide guidance and useful tools that clinicians can use to navigate this process. METHODS:A two-phased approach to develop, assess, and refine a best practices toolkit for the integration of multiple ERH programs in PPC through a modified Delphi process. Phase One included identification and assessment around barriers to ERH program integration and strategies to address them through surveys and focus groups of PPC clinics nationwide. Phase Two then utilized the identified barriers and strategies from Phase One to create a toolkit of best practices on integrating ERH programs in PPC that included two rounds of revision for a final version. RESULTS:126 PPC personnel from 44 clinics nationwide completed the Phase One survey, with respondents reporting many notable strengths and challenges to ERH program integration. 18 survey participants also participated in follow-up focus groups, which reiterated the strengths and challenges found in the surveys. An initial toolkit was then drafted, and experts provided qualitative, free-response feedback around clarity and presentation. Further improvement was made to create the final toolkit, which was rated highly useful and important, though slightly less feasible, by practitioners using formal feedback questions. CONCLUSION/CONCLUSIONS:This study employed a modified Delphi process to create a consensus-based best practices toolkit for integrating multiple ERH programs in PPC to help meet the heterogeneous needs of families to promote optimal child development.

OBJECTIVE/UNASSIGNED:Assessing suicide risk among children is complex, in part due to their developmental differences in identifying, recalling, and verbally describing internal states, alongside cultural differences in how distress is experienced. This study aimed to identify expressions of distress around suicide ideation or attempts through body mapping, a qualitative technique that facilitates both visual and verbal expressions. METHOD/UNASSIGNED: = 16). Children completed the Childhood Suicide Ideation Interview, which included semi-structured questions about their suicide ideation and/or attempt and a body mapping activity, where children illustrated and described their thoughts, feelings, body sensations, and social connections surrounding their suicidal crisis on a printed body silhouette. RESULTS/UNASSIGNED:Analyses conducted with Anthropac yielded 94 expressions of distress. The congruence in overall experiences across children was low (24%), yet specific somatic experiences like "shaking" (70%), "pain" (43%), and "dizziness" (39%) were prevalent. Other frequent experiences included "sad" (48%), "passive suicide ideation" (43%), and "thoughts about family" (39%). CONCLUSIONS/UNASSIGNED:Body mapping was a valuable tool for uncovering unique expressions of distress among ethnoracially diverse children. Somatic expressions, often overlooked in risk assessments, were prominent. Ours and similar studies have the potential to inform the design of culturally and developmentally responsive risk assessment tools and safety planning protocols.

When thoroughly assessed, the prevalence of attention-deficit hyperactivity disorder (ADHD) in children/adolescents is estimated at 5%. There is no evidence that ADHD is over-diagnosed in the UK. Indeed, available data point to under-diagnosis, even though rigorous updated post-COVID-19 pandemic data are not available. Some cases may be misdiagnosed due to low-quality assessment, poor adherence to national guidance or inappropriate differential diagnosis. Beyond the controversy around over- or under-diagnosis and over-medicalisation of ordinary behaviours or emotions, the main issue is that UK clinical services cannot adequately support individuals with ADHD who need help. There is a risk that the narrative claiming 'ADHD is over-diagnosed' could be used to deny people with properly-diagnosed ADHD the care they deserve.

STUDY DESIGN/METHODS:Retrospective cohort study. OBJECTIVE:Due to proximity of the surgical site to important respiratory structures, patients may undergo delayed extubation after adult cervical deformity (ACD) surgery to manage postoperative airway edema/obstruction. Herein, we evaluate relevant relationships with delayed extubation. SUMMARY OF BACKGROUND DATA/BACKGROUND:Delayed extubation is an underreported perioperative occurrence, with only a few studies conducting case-by-case reviews of prolonged intubation. METHODS:Operative ACD patients with baseline (BL) were grouped based on whether they experienced delayed extubation (DE), or leaving the OR while still intubated, versus those who were extubated successfully in the OR (non-DE). Means comparison and regression analyses identified predictors of delayed extubation and associations with peri-operative complications and outcomes. RESULTS:82 patients met inclusion criteria (mean age 62.4±13.0 y, 52.4% female, Edmonton frailty score: 5.10±2.97, ACFI score: 0.30±0.16, CCI: 1.41±1.73). 14 patients left the OR intubated, and 1(1.2%) required reintubation. DE cohort demonstrated greater Edmonton frailty scores (P=0.017) and smoking histories (P=0.031). Intraoperatively, there was a significant difference EBL (P=0.021) and rate of transfusions (DE: 27.3% v non-DE: 4.8%, P=0.12). Upper instrumented vertebra (UIV) was not associated with DE, while lower LIV increased the likelihood of DE (OR 1.1, P=0.029). Post-operatively, as expected, there was a significant difference in rate of SICU admissions (DE: 90.9% v. non-DE: 49.2%, P=0.01), although no significant differences in LOS. Greater cSVA and MGS correction from baseline was associated with increased likelihood of delayed extubation (OR 1.1, CI 95% 1.05-1.17, P<.001; OR 1.14, CI 95% 1.05-1.24, P=0.003). Furthermore, delayed extubation was a significant predictor of increased VR-Physical Component Scores (P=0.013) at 6W, and DE cohort demonstrated significantly higher VR-PCS and VR-MCS Scores at 6W (P=0.01, both). CONCLUSIONS:Baseline frailty and larger radiographic correction can be associated with delayed extubation, which can impact quality of life perioperatively. Considerations like minimizing intraoperative blood loss and degree of correction could minimize delayed extubation.

Autism spectrum disorder (ASD) is a neurodevelopmental condition, with ex vivo studies suggesting its neurobiological origin as early as the first and second trimester of pregnancy. Functional MRI studies using graph-theoretical approaches have isolated features in the global connectome architecture that distinguish toddlers with ASD from their typically developing peers. Additionally, functional connectivity patterns in the infant brain have shown to be predictive of later ASD diagnosis. An important yet unexplored question in the literature is whether graph-theoretical differences are evident prior to infancy, in the brain of fetuses who will later exhibit ASD traits in early childhood. In this study, we address this question using a sample of 88 children with both quality-assured fetal brain resting-state functional MRI data and standardized parent assessment of ASD traits including social-emotional and social communication skills and repetitive and restricted behaviors at age 3. Multiple regression analyses revealed no significant associations between fetal global graph features (e.g., network segregation, integration, and small-world architecture) and ASD traits at age 3 (p's > 0.1). Therefore, our findings do not provide support for prenatal emergence of global topographical differences of brain functional organization in fetuses who later develop ASD traits. However, this does not rule out the possibility of other neural signatures in the fetal functional connectome that may predict autistic traits and future ASD diagnosis.

OBJECTIVES/OBJECTIVE:Adolescents transitioning from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS) may face challenges in accurately identifying and reporting their mental health symptoms, often leading to discrepancies between clinician and patient evaluations. Using data from the MILESTONE project, this study aims to assess clinician-adolescent concordance over 24 months and identify domains of psychopathology with the highest disparities. METHODS:Participants were assessed at baseline, 9, 15, and 24 months using the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) scale and were categorized in four diagnostic groups. Hierarchical cluster analysis identified symptom-based subgroups of patients based on clinician and patient-rated HoNOSCA scores. Concordance was evaluated through multilevel linear regression models, while Bland-Altman plots examined agreement between scores across time points. RESULTS:Two clusters of patients were identified: one characterized by lower severity and greater prevalence, the other by higher complexity and fewer individuals. Clinician-patient concordance increased over time, rising from 77% to 83% by the second time point and stabilizing. Concordance varied across diagnostic categories, with anxiety showing the highest agreement and ADHD the lowest. CONCLUSIONS:Improved communication, psychoeducation, and tailored interventions may facilitate greater patient-clinician alignment, thereby supporting more favorable outcomes during this critical developmental period. TRIAL REGISTRATION/BACKGROUND:ISRCTN83240263; NCT03013595.

Providing care to pediatric oncology patients involves delivering sensitive information to families, addressing diverse psychosocial needs, and navigating patient and family emotions. Psychosocial providers embedded within pediatric oncology clinics are uniquely qualified to address communication gaps between patients and providers, provide support to patients, and facilitate collaborative discussions between patients and the medical team. This quality improvement project aimed to describe the impact of including psychosocial providers in critical conversations between medical teams and families. Through conversation tracking, members of the psychosocial team recorded their involvement in thirty-six critical conversations. The psychosocial team offered various interventions including therapeutic processing, emotional assessment, medical translation, psychosocial support, child-focused support, and facilitation of discussions between families and medical providers. While challenges were identified including time and availability, physicians noted several benefits of psychosocial involvement, particularly in addressing emotional needs and enhancing communication with families. Psychosocial providers also noted benefits including demonstrating alignment with the medical team and enhancing the support that they are able to provide the family following the conversation. By integrating psychosocial support into critical conversations, medical providers can foster a patient-centered approach to care and optimize care delivery to effectively support families facing childhood cancer diagnoses.

In this Personal View, we address key questions to support evidence-based prevention and management of psychotic symptoms that might occur during ADHD pharmacotherapy. We begin by examining evidence showing a significantly increased occurrence of psychotic disorders in individuals with ADHD, independent of ADHD medications (pooled relative risk, odds ratio, or hazard ratio=4·74, 95% CI 4·11-5·46). We then examine whether ADHD medications play a causal role, noting that current evidence does not support such a causal link, at least for methylphenidate. We explore how vulnerability to psychosis varies across individuals with ADHD. Regarding the different steps involved in prescribing ADHD medications, we discuss the importance of balancing potential risks-such as emergence of psychotic symptoms-against the demonstrated benefits of pharmacological treatment for ADHD. Next, we present strategies for screening individuals for vulnerability to psychosis before initiating ADHD medication. We then offer guidance on the clinical management of psychotic symptoms that might arise during ADHD pharmacotherapy, including considerations of dosage and medication type. Finally, we identify key research priorities in this area. Overall, this paper provides an empirical framework, grounded in evidence and clinical practice, to guide the next steps in the field.