Faculty Bibliography

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

Objectives: Participants who attend this workshop will learn how to identify their current skills and how to advance and get their papers published. Relatively few students, trainees, and clinicians publish scientific or other educational manuscripts because of limitations in time, experience, and access to mentorship. Improving access to publishing opportunities is important because the process of authoring and publishing scientific manuscripts can increase competency in research literacy, engagement in evidence-based practices, and other skills needed to increase mastery in child and adolescent psychiatry. Methods: We aim to overcome these limitations by providing a "back stage pass" experience, combining hands-on training with practical instruction to build the early foundation for getting published. Topics include choosing a publishable topic of interest, practical steps toward publication, searching the literature and harnessing electronic library resources, writing using organizing principles, preparing an effective abstract, optimizing cover and revision letters, thinking like an editor, dealing with revisions, and the inevitability of rejection and constructively moving forward. Results: Attendees will learn practical steps toward getting published in scholarly journals and strategies to overcome current limitations and obstacles. Interested participants will also have the opportunity to get started with mentored-publishing experiences available through JAACAP and JAACAP Connect. Conclusions: Participating in this workshop will provide the preliminary knowledge and skills necessary for getting published

Objectives: Temper outbursts are frequently considered symptoms of irritability within the context of ODD, mood disorder, and anxiety disorder. However, even when chronic irritability is not present, they are associated with significant functional impairments. We will provide an overview of our research program that takes a multimodal approach to understanding severe temper outbursts in young children. Methods: We evaluated 216 boys and girls (ages 5-9 years; 73% boys) from diverse socioeconomic backgrounds who comprised three groups: 1) children with severe temper outbursts (STO; n = 80); 2) children with ADHD without outbursts (ADHD; n = 79); and 3) typically developing children (TDC; n = 57). Severe temper outbursts were defined as follows: 1) occurring at least three times per week; 2) lasting >10 minutes; 3) excessive for developmental level; and 4) causing significant impairment. Parents completed a semistructured diagnostic interview about their child and questionnaires about their child's behavior and emotion regulation skills. Children completed brief IQ and language screeners, questionnaires about their emotions and behavior, and tasks assessing frustration tolerance and emotion regulation. A number of these children (64 percent) successfully completed an MRI session that included resting-state, structural, and diffusion tension imaging scans. Results: Approximately 84 percent of the STO group received an ADHD diagnosis, 67 percent were diagnosed with ODD, 28 percent were diagnosed with an anxiety disorder, and 12 percent were diagnosed with a mood disorder. Few exhibited chronic irritabilities based on parent report. On an emotion regulation task, the STO group demonstrated deficits in regulating negative affect in response to frustration. Findings from the resting-state fMRI analyses suggest disruptions in dorsal anterior cingulate cortex (dACC) circuitry associated with tantrum severity. Tantrum severity was also related to cortical thickness of the dACC. Conclusions: Children with severe temper outbursts represent a highly impaired group, even when chronic irritability is not present. Evidence suggests an association between these outbursts and disruptions in dACC circuitry, a region implicated in the expression and regulation of frustration. Such findings have important implications for future conceptualization and treatment of young children with severe temper outbursts

Objectives: The hospitalization of a child can precipitate significant stress among caregivers and impact the long term health of both the child and family caregivers. Given a lack of evidence-based inpatient models for systematically identifying and addressing family stress, a Hassenfeld Children's Hospital interdisciplinary quality improvement team aimed to co-design, test, and implement the use of a co-designed family stress screening and response system. Methods: The improvement initiative was conducted in the pediatric intensive care unit (PICU) of an embedded children's hospital within a large, urban academic medical center. The interdisciplinary improvement team was led by a child psychiatrist with improvement science and family engagement expertise and included PICU nursing leaders and champions, critical care physicians, psychosocial team representatives, and two family advisors who are parents with PICU experience. The improvement team co-designed the following: 1) a family stress screening tool adapted from a research-validated distress thermometer and 2) a standardized yet individualized family-centered response protocol. Results: The percentage of PICU families screened for stress increased from 0 to 96 percent over a 12-month period. Stress scores ranged from 0 to 10 ("no stress" to "high stress"). Of the 361 families screened, 53 percent rated their stress as five or greater, which was categorized as a positive screen and activated a matched response protocol. Top stressors included their child's medical condition (69% of families) and their child's level of comfort and well-being (55%). Other top stressors included caring for other children in the home (55%), issues with a partner/spouse (35%), and work problems (36%). Forty-nine percent of families reported problems with fatigue, and 84 percent of families reported feeling worried and anxious. The stress thermometer identified several "near misses," including parents with postpartum depression and safety concerns in the home, allowing for improved discharge planning and facilitation of ongoing community-based support. Conclusions: The successful implementation of a co-designed family stress screening tool and matched response protocol has improved the timely deployment and coordination of support services and demonstrated reductions in family stress with potential for generalizability across the pediatric care continuum

Objectives: The goal of this session is to provide practicing clinicians with valuable advanced knowledge on the epidemiology, pathophysiology, and pharmacological and behavioral treatment of insomnia as commonly seen among children, adolescents, and young adults with psychiatric conditions Methods: This session will include a comprehensive literature review and case-based presentations. Results: Dr. Lewin will present on epidemiology of insomnia and neurobehavioral consequences of insufficient sleep. Dr. Johnson will focus on sleep requirements throughout development and evaluation of insomnia. Physiology of sleep states and circadian rhythm will be covered by Dr. Baroni. In his two presentations, Dr. Shatkin will provide practical guidelines on the use of sleep education and hygiene, in addition to an overview of cognitive behavioral therapy for insomnia with children, adolescents, and young adults. Dr. Owens will review a systematic approach to using medications for the treatment of pediatric insomnia. Finally, Dr. Ivanenko will address common challenges in the treatment of sleep problems in mental health settings. Conclusions: Learning how to address sleep disorders using behavioral and pharmacological treatments will provide clinicians with essential tools for their psychiatric practice

Objectives: This presentation will provide participants with an understanding of standard sleep hygiene recommendations and their utility, along with other less commonly addressed interventions, to promote a good night's sleep. At the end of this presentation, participants will be able to 1) describe the evidence base for typical sleep hygiene recommendations; 2) identify the effects of exercise, napping, caffeine, alcohol, tobacco, and marijuana on sleep; and 3) determine which sleep hygiene practices are likely to be most effective for children and adolescents. Methods: This presentation will draw upon a comprehensive literature review, the physiology of sleep, and case-based material. Results: Sleep hygiene is ubiquitously recommended by psychiatrists, psychologists, and healthcare providers for the treatment of insomnia. However, many commonly suggested techniques are not founded upon convincing research and have not been proven effective in trials. In addition, there are other methods based on findings from sleep physiology studies that may be effective and worth using with children and adolescents who struggle with sleep. This presentation will describe the current knowledge base and deficit in sleep hygiene and then make sensible, evidence-based recommendations for improving sleep in children and adolescents. Common behavioral and exogenous factors, such as exercise, napping, caffeine, alcohol, and tobacco, and their effects on sleep will also be addressed. Conclusions: Understanding the physiology and circadian rhythmicity of sleep is key to understanding and applying sleep hygiene effectively. This presentation will summarize the core components of sleep hygiene that are likely to be of use for children and adolescents

Objectives: Youths increasingly present to emergency departments (EDs) with agitated behavior or aggression attributed to psychosis, anxiety, mania, or intoxication or related to underlying behavioral disorder. They can be dangerous to themselves, staff, and other patients in the ED and may require restraint. Although reduction of restraint and injury is a priority of every ED, there are little published data on the use and effectiveness of PRN medications to treat or prevent acute agitation. Further work is needed to understand PRN usage and identify efficacy of different PRN medications to guide clinical practice. Methods: This report describes the use of PRN medications during restraint events in a specialized child psychiatric emergency program between the program's opening in 2011 until December 2016. During this period, 8,800 youth (ages 2-17 years) were seen, and 185 experienced restraint. Chart review examined patient demographics, diagnosis, medication utilization, and efficacy. Results: The youth who experienced restraint ranged in age from six to 17 years. Diagnoses included internalizing, externalizing, and developmental disorders, as well as substance intoxication. The medications used predominantly included most commonly diphenhydramine, chlorpromazine, haloperidol, lorazepam, and risperidone, among others, at a range of doses. Documented efficacy of medication varied significantly as we will report. Conclusions: There are currently no published consensus guidelines for the psychopharmacological management of agitation and little published literature comparing effectiveness of different PRN medications or comparing those medications to placebo. A review of PRN prescribing practices in a specialized child psychiatric emergency program, where all patients are treated by child and adolescent psychiatrists, illustrates the range of medication usage and the varying degree of efficacy of these medications. Further research is needed into the effectiveness of PRN medications, as is professional guidance for choice of medication and dose

Objectives: Dasotraline, a novel dopamine and norepinephrine reuptake inhibitor, provides stable plasma concentrations over 24 hours with once-daily dosing. This study evaluated dasotraline in children aged 6-12 years meeting DSM-5 criteria for ADHD (NCT02428088). Methods: Patients were randomized to either six weeks of once-daily, fixed-dose dasotraline (2 or 4 mg/day), or placebo. The primary efficacy endpoint was change from baseline (CFB) in ADHD Rating Scale-IV Home Version (ADHD-RS-IV HV) total score at week six, using a mixed model for repeated measures in the intent-to-treat (ITT) population. Secondary endpoints included Clinical Global Impression-Severity (CGI-S) score and safety. Results: The mean age of 342 randomized patients was 9.1 ( 1.9) years; 66.7 percent were male. Overall, 79 percent of patients completed the study. In the ITT population (N = 336), ADHD RS-IV HV total score improved significantly with dasotraline 4 mg/day versus placebo [least squares (LS) mean CFB at week 6: -17.53 (95% CI: -20.12, -14.95) vs -11.36 (-13.89, -8.83), respectively, p < 0.001; effect size (ES): 0.48]. Inattentiveness and hyperactivity/impulsivity subscale scores significantly improved with 4 mg/day versus placebo at week six (p = 0.001, p = 0.003, respectively). The 2 mg/day arm did not significantly differ from placebo on ADHD RS-IV HV total score [LS mean CFB at week 6: -11.80 (-14.37, -9.22), p = 0.812; ES: 0.03). Improvement in CGI-S score was statistically significant with dasotraline 4 mg/day versus placebo [LS mean CFB at week 6: -1.39 (-1.63, -1.15) vs -1.04 (-1.28, -0.80), respectively, p = 0.040; ES: 0.29]. No significant improvement was observed on the CGI-S for dasotraline 2 mg/day versus placebo [LS mean CFB at week 6: -0.94 (-1.18, -0.70), ns]. The most frequent treatment-emergent AEs ( 5% and higher than placebo) were (2 mg/day; 4 mg/day; placebo): insomnia (15.3%; 21.7%; 4.3%, all terms combined), decreased appetite (12.6%; 21.7%; 5.2%), weight loss (5.4%; 8.7%; 0%), irritability (3.6%; 7.0%; 6.0%), nasopharyngitis (0.9%; 5.2%; 0.9%), and nausea (0%; 5.2%; 2.6%). Conclusions: Dasotraline 4 mg/day significantly improved ADHD symptoms in children compared to placebo, assessed by ADHD RS-IV HV total score and inattentiveness and hyperactivity/impulsivity subscale scores. Dasotraline was generally well tolerated; most common AEs included insomnia, decreased appetite, weight loss and irritability

Objectives: CBT for insomnia (CBT-I) in adolescents and young adults is a brief intervention that includes both behavioral and psychological procedures. At the end of this presentation, participants will be able to 1) describe when and for whom CBT-I is an appropriate form of treatment intervention; 2) provide practical guidelines for conducting CBT-I, including stimulus control, sleep restriction, cognitive restructuring, and sleep hygiene; and 3) practice arousal reduction and biofeedback for the treatment of insomnia. Methods: This session will provide a comprehensive literature review, lecture, and discussion. Results: Medications for the treatment of insomnia are sometimes necessary but most often are insufficient to fully address the problem. CBT-I, by contrast, represents an easily taught series of skills that are portable and time and cost effective. The utility of CBT-I has been repeatedly demonstrated for adults and adolescents. The goal of CBT-I is to alter the factors that perpetuate insomnia and include the following: 1) behavioral factors, such as poor sleep habits, and irregular sleep schedules; 2) psychological factors, such as unrealistic expectations, and rumination over the consequences of insomnia; and 3) physiological factors, such as hyperarousal and somatic and mental tension. CBT-I is indicated for primary and secondary insomnia in adolescents and adults and can be delivered on a one on one basis; in groups; and via telephone, telemedicine, and video. This presentation will describe the use of CBT-I and necessary adjustments when applying these techniques with children. Participants will practice arousal reduction and biofeedback techniques. Conclusions: The use of cognitive-behavior therapy for insomnia will be described, and participants will engage in a series of applied exercises to enhance their therapeutic skills

Objectives: We aim to present four integrated care models across the continuum of care in subspecialty pediatrics. We will share case examples and pilot data of clinical programs that incorporate unique and shared elements. Methods: A brief review of the need for integrated care within subspecialty pediatrics will be conducted followed by an overview of a multidisciplinary program for enhancing resilience in children dealing with the stress of medical illness in inpatient settings. We will discuss a quality improvement initiative that systematically assesses family stress and coordinates matched interventions within pediatric intensive care. Systematic screening in outpatient settings will be discussed by the next two presenters who will describe assessment of family stress, quality of life, and mental health in patients with medical illnesses, such as cystic fibrosis and epilepsy, amongst others. Finally, our discussant will review the opportunities and challenges in program implementation and evaluation. Results: Mounting evidence suggests that chronic illness management and hospitalizations can have significant psychological and health repercussions for both children and their family caregivers. Evidence-based models of pediatric specialty care for the systematic identification of stress and risk, as well as the deployment of coordinated, matched supports, remain scant. Integrated family-engaged care refers broadly to models of care in which multidisciplinary teams work in partnership with youth and families to plan, deliver, manage, and continuously improve the integration of health and behavioral health services, systems, and outcomes. New York University and the University of California, San Francisco have implemented four models for increasing integration and family engagement across the pediatric specialty care continuum. Key drivers of success and challenges in implementation have been analyzed through in-depth case studies. Teams evaluated both process and outcomes measures, such as treatment engagement, family stress/coping, and healthcare utilization. Conclusions: Outcome-driven engagement of families and teams toward greater levels of integration has the potential to both improve the lives of youth and families we serve and help transform our health care system toward the quadruple aim of better culture, better health, and better care at lower costs