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BACKGROUND A third of adolescents experiencing a concussion will suffer from persistent post-concussion symptoms lasting a month or beyond. The ability to cope with concussion symptoms, regulate emotions, and manage stress is an important determinant of risk for prolonged symptoms. Early psychological interventions, such as mindfulness-based interventions, might improve concussion recovery. OBJECTIVE This open-label mixed-methods pilot study assessed the acceptability and credibility of a mindfulness-based intervention delivered through a digital therapeutic (DTx; therapeutic smartphone app) for pediatric concussion. METHODS Participants aged 12-18 years were recruited from an emergency department within 48 hours of a concussion (acute cohort) or from a tertiary care clinic at least 1 month post-concussion (persistent symptom cohort). Participants completed a novel 4-week mindfulness-based intervention, for 10-15 min/day, at a minimum of 4 days/week. At 2 weeks post-concussion, participants completed a credibility questionnaire. At 4 weeks, participants completed questionnaires assessing satisfaction, usability, and working alliance, as well as a semi-structured phone interview. RESULTS 10 participants completed the study outcomes, including 7 acute (5 females; median [IQR] age=14.73 [13.94,16.94] years and 3 persistent symptom patients (2 females; median [IQR] age=17.62 [17.48,17.86] years). Across cohorts, half-way through the intervention, the treatment expectation was moderate (median=6.00 [3.58,7.75], maximum possible=9.00). Moreover, the intervention was perceived as credible (median=6.50 [6.83,8.75], maximum possible=9.00). At 4 weeks, the DTx was considered usable (median=70.00 [55.00,82.50], maximum possible=100.00). Participants rated their satisfaction with the DTx (median=27.00 [24.50,29.50], maximum possible=32.00) and the working alliance with the digital mindfulness guides (median=3.92 [3.38-4.33], maximum possible=5.00) as high. Four themes were identified from the qualitative data: 1) positive attributes (including accessibility, ease of use, perceived effectiveness, variety of features, and meditation guides); 2) negative attributes (technical issues that acted as a barrier to use, and sounds and lights that were triggering headaches); 3) ideas for modifications; and 4) technical issues. CONCLUSIONS Adolescents were very satisfied with a mindfulness-based intervention delivered via a smartphone app and considered it to be usable and credible. Results inform modifications to the DTx, instructions, and mindfulness intervention, and potential ways to increase adherence by leveraging positive attributes. A randomized control trial will assess the effectiveness of the DTx to decrease the risk of persistent symptoms and reduce the symptom burden following pediatric concussion. The present mixed-methods study and the iterative approach to intervention design we are using will ensure better translation and impact of interventions for adolescents with concussions.

Concussion may exacerbate existing mental health issues. Little evidence exists on whether concussion is associated with the onset of new psychopathologies or long-term mental health problems.To investigate associations between concussion and risk of subsequent mental health issues, psychiatric hospitalizations, self-harm, or suicides.This population-based retrospective cohort study including children and youths aged 5 to 18 years with a concussion or orthopedic injury incurred between April 1, 2010, and March 31, 2020, in Ontario, Canada. Participants had no previous mental health visit in the year before the index event for cohort entry and no prior concussion or traumatic brain injury 5 years before the index visit. Data were collected from provincewide health administrative databases. Participants with concussion were included in the exposed cohort, and those with an orthopedic injury were included in the comparison cohort; these groups were matched 1:2, respectively, on age and sex.Concussion or orthopedic injury.The primary outcome was mental health problems, such as psychopathologies and psychiatric disorders, identified from health care visits in emergency departments, hospitalizations, or primary care settings. Secondary outcomes were psychiatric hospitalizations, self-harm health care visits, and death by suicide (identified in health care or vital statistics databases).A total of 152 321 children and youths with concussion (median [IQR] age, 13 [10-16] years; 86 423 [56.7%] male) and 296 482 children and youths with orthopedic injury (median [IQR] age, 13 [10-16] years; 171 563 [57.9%] male) were matched by age and sex. The incidence rates of any mental health problem were 11 141 per 100 000 person-years (exposed group) and 7960 per 100 000 person-years (unexposed group); with a difference of 3181 (95% CI, 3073-3291) per 100 000 person-years. The exposed group had an increased risk of developing a mental health issue (adjusted hazard ratio [aHR], 1.39; 95% CI, 1.37-1.40), self-harm (aHR, 1.49; 95% CI, 1.42-1.56), and psychiatric hospitalization (aHR, 1.47; 95% CI, 1.41-1.53) after a concussion. There was no statistically significant difference in death by suicide between exposed and unexposed groups (HR, 1.54; 95% CI, 0.90-2.61).Among children and youths aged 5 to 18 years, concussion was associated with an increased risk of mental health issues, psychiatric hospitalization, and self-harm compared with children and youths with an orthopedic injury.

The number of event management education programs offered by universities around the world is steadily increasing. However, most programs still focus on operational aspects and the project management of events and fail to consider the critical turn in event research that is currently gathering momentum. Based on critical theory, this article uses a qualitative, intrinsic case study to critically discuss the development and evolution of a bilateral, Sino-German event management education program over 13 years, including an outline of its future direction. Twenty-one semistructured interviews with lecturers, students, and alumni were conducted. Thematic analysis, a method that searches for themes in qualitative data, was used for data analysis. The findings demonstrate how the program gradually matured and developed from an operational focus—with a strong emphasis on exporting (business) event expertise from Germany to China—to its current state, where lecturers from two equal partner universities offer a variety of courses, critically discussing cultural, economic, social, and environmental event issues with students and peers. The findings can guide future critical research on event management education and assist other universities when implementing international cooperation with partner universities in different countries.

Children and youth presenting to the emergency department with mental health concerns present a challenge for clinicians and system capacity. Addressing a significant system gap and sparse strategies in the literature, representative leaders from hospital and community agencies developed a novel pathway to guide efficient and doable risk assessment and ensure timely transition to appropriate community mental health services. This article describes and reflects on our innovative Emergency Department Clinical Pathway for Children and Youth with Mental Health Conditions that bridges traditional barriers between hospital and community settings to address mental health needs for this population.

Objectives: Suicidal ideation (SI) is common in adolescents and increases the risk of completed suicide. Due to the COVID-19 pandemic, healthcare providers rapidly shifted to providing telehealth and virtual options for clients. Building Resilience and Attachment in Vulnerable Adolescents (BRAVA) is a group intervention designed for adolescents and their caregivers to reduce adolescent SI. The objective of this study was to adapt BRAVA for virtual delivery and evaluate the feasibility of this adaptation. Methods: We conducted an 8-week open trial between October and December 2020. Twelve participants (6 adolescents and 6 primary caregivers) were recruited from a pediatric hospital in Eastern Ontario. Through Zoom, adolescents and caregivers completed an intake assessment together, 6 weekly BRAVA group sessions separately, and an exit assessment together 1-week post-BRAVA. The primary adolescent outcome variable was the Suicidal Ideation Questionnaire Junior (SIQ-JR). Data were analyzed in IBM SPSS v.27. Pre-post comparisons on the SIQ-JR were done with a 2-tailed t test for matched pairs. Results: The study uptake rate was 42.9% of the eligible participants. There were no study dropouts. Adolescent (Mean [M] age = 15.3 years;SD age = 1.0;66.7% female) and caregiver attendance rates for BRAVA group sessions were high (median = 6). Overall group satisfaction scores were high for adolescents (M = 4.2;SD = 0.8) and their caregivers (M = 4.2;SD = 0.7). Most youth (83.4%) and caregivers (66.7%) reported that the virtual process worked well. Whereas all caregivers (100%) agreed they would participate in a virtual group session again, youth responses were more variable (50% agree, 33.3% neutral, 16.7% disagree). Adolescent SI decreased after completing the intervention (M pretreatment [tx] = 50.7, SD pretreatment [tx] = 16.7;M post-tx = 29.7, SD post-tx = 20.4;t = 5.7;95% CI, 11.52-30.5;p = 0.002). Conclusions: Study results indicate that the virtual delivery of BRAVA is feasible. Study uptake was good, retention was complete, and satisfaction was high for adolescents and their caregivers. Importantly, initial results suggest that this adaptation of BRAVA may help reduce SI in adolescents. Feedback from participants will inform further changes to improve the adaptation of BRAVA for use in a planned RCT. S, ADOL, FT

ObjectivesThe goal of this study was to examine the mental health needs of children and youth who present to the emergency department (ED) for mental health care and to describe the type of, and satisfaction with, follow-up mental health services accessed.MethodsA 6-month to 1.5-year prospective cohort study was conducted in three Canadian pediatric EDs and one general ED, with a 1-month follow-up post-ED discharge. Measures included 1) clinician rating of mental health needs, 2) patient and caregiver self-reports of follow-up services, and 3) interviews regarding follow-up satisfaction. Data analysis included descriptive statistics and the Fisher’s exact test to compare sites.ResultsThe cohort consisted of 373 children and youth (61.1% female; mean age 15.1 years, 1.5 standard deviation). The main reason for ED presentations was a mental health crisis. The three most frequent areas of need requiring action were mood (43.8%), suicide risk (37.4%), and parent-child relational problems (34.6%). During the ED visit, 21.6% of patients received medical clearance, 40.9% received a psychiatric consult, and 19.4% were admitted to inpatient psychiatric care. At the 1-month post-ED visit, 84.3% of patients/caregivers received mental health follow-up. Ratings of service recommendations were generally positive, as 60.9% of patients obtained the recommended follow-up care and 13.9% were wait-listed.ConclusionsChildren and youth and their families presenting to the ED with mental health needs had substantial clinical morbidity, were connected with services, were satisfied with their ED visit, and accessed follow-up care within 1-month with some variability.

Extensive habitat destruction and pollution have caused dramatic declines in aquatic biodiversity at local to global scales. In rivers, the reintroduction of large woody debris is a common method aimed at restoring degraded ecosystems through "rewilding." However, causal evidence for its effectiveness is lacking due to a dearth of replicated before-after control-impact field experiments. We conducted the first replicated experiment of large woody debris rewilding across multiple rivers and organisational levels, from individual target species populations to entire food webs. For the first time, we demonstrate causal links between habitat restoration, biodiversity restoration and food web responses. Populations of invertebrates and an apex predator, brown trout (Salmo trutta), increased, and food web analysis suggested increased biomass flux from basal resources to invertebrates and subsequently fishes within restored reaches. Synthesis and applications. This study contributes significant new evidence demonstrating that large woody debris rewilding can help to restore human-impacted river ecosystems, primarily through altering the abundance and biomass of consumers and resources in the food web. We also outline a means to gauge the magnitude of ecological responses to restoration, relative to environmental stressors, which could help to prioritise the most effective conservation efforts.

OBJECTIVES: Repeat visits represent up to 45% of mental health (MH) presentations to emergency departments (EDs) and are associated with higher health care costs. We aimed to synthesize available literature on predictors of pediatric MH repeat ED visits and differences between repeat visitors and nonrepeat visitors. METHODS: A systematic review was performed using PsycINFO, PubMed, and CINAHL databases. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement checklist. Methodologic quality was assessed using the following 8 criteria: design, generalizability, breadth of predictors, reporting of effect sizes, additional outcomes, interaction terms, confounding variables, and clear definition of repeat visits. RESULTS: A total of 178 articles were retrieved; 11 articles met inclusion criteria. Quality assessment revealed that all studies used chart review or administrative data. Predictors were grouped into 3 categories: demographic, clinical, and MH care access and utilization factors. Common predictors associated with repeat ED MH visits included socioeconomic status, involvement with child protective services, and previous and current MH service use. For studies using a 6-month repeat window, the most common factors were previous psychiatric hospitalization and currently receiving MH services. Heterogeneity in statistical analyses and determinants explored precluded the use of meta-analysis. CONCLUSIONS: Findings revealed that repeat visits to the ED for MH concerns is a complex phenomenon that can be attributed to various demographic, clinical, and MH care access and utilization factors. To further elucidate the strongest predictors, future prospective research should consider prospective designs and include family factors. Investigating recency and frequency outcomes can also inform clinical practice.

Approximately 45% of youth presenting to the emergency department (ED) for mental health (MH) concerns will have a repeat ED visit. Since youth greatly depend on their caregivers to access MH services, the objective of this study was to determine if family characteristics were associated with repeat ED visits.A retrospective cohort study of youth aged 6-18 years (62% female) treated at a tertiary pediatric ED for a discharge diagnosis related to MH was conducted. Data were gathered from medical records, telephone interviews, and questionnaires. Family factor contribution was analyzed using a multivariable logistic regression model controlling for demographic, clinical and service utilization factors. Variables associated with earlier and more frequent visits were determined using cox regression and negative binomial regression.Of 266 participants, 70 (26%) had a repeat visit. While caregiver history of MH treatment decreased the odds of having a repeat ED visit, family functioning and perceived family burden were not associated with repeat visits. Post-visit MH services, prior psychiatric hospitalization, higher severity of symptoms, and living closer to the hospital increased the odds of repeat visits.This study examined the contribution of multiple family factors in predicting repeat MH visits to the ED. Results suggest caregiver characteristics may impact the decision to return. Healthcare providers should therefore consider caregiver and youth service utilization factors to inform patient management and discharge planning.Environ 45 % des adolescents qui se présentent au service d’urgence (SU) pour des raisons de santé mentale (SM) auront une visite répétée au SU. Puisque les adolescents dépendent beaucoup de leurs aidants pour avoir accès aux services de SM, l’objectif de cette étude était de déterminer si les caractéristiques familiales étaient associées aux visites répétées au SU.Une étude de cohorte rétrospective a été menée sur des adolescents de 6 à 18 ans (62 % de sexe féminin) traités dans un SU pédiatrique tertiaire pour un diagnostic lié à la SM posé au moment du congé. Les données ont été recueillies d’après les dossiers médicaux, les entrevues téléphoniques et les questionnaires. La contribution des facteurs familiaux a été analysée à l’aide d’un modèle de régression logistique multivariable après contrôle des facteurs démographiques, cliniques et d’utilisation des services. Les variables associées à des visites précédentes et plus fréquentes ont été déterminées à l’aide de la régression de Cox et la régression binomiale négative.Sur les 266 participants, 70 (26 %) avaient une visite répétée. Les antécédents de traitement de SM des aidants diminuaient les probabilités d’avoir une visite répétée au SU, et le fonctionnement familial et le fardeau familial perçu n’étaient pas associés à des visites répétées. Les services de SM ultérieurs à la visite, une hospitalisation psychiatrique précédente, une gravité plus élevée des symptômes et le fait d’habiter à proximité de l’hôpital augmentaient les probabilités de visites répétées.Cette étude a examiné la contribution de multiples facteurs familiaux à la prédiction de visites répétées au SU pour raisons de SM. Les résultats suggèrent que les caractéristiques des aidants puissent influer sur la décision de retourner au SU. Les prestataires de soins de santé devraient donc prendre en compte les facteurs d’utilisation des services des aidants et des adolescents afin d’éclairer la prise en charge des patients et la planification du congé.

Objectives This effectiveness study aimed to evaluate the clinical use of the HEADS-ED tool for patients presenting to a pediatric emergency department (PED) for mental health (MH) care. Methods In this pragmatic trial, PED physicians used the HEADS-ED to guide their assessment and identify areas of MH need in 639 patients (mean [SD], 15.16 [1.40] years; female, 72.6%) who presented to the emergency department with MH concerns between May 2013 and March 2014. Results The HEADS-ED guided consultation to psychiatry/crisis, with 86% receiving a recommended consult. Those with a HEADS-ED score of greater than or equal to 8 and suicidality of 2 (relative risk, 2.64; confidence interval, 2.28-3.06) had a 164% increased risk of physicians requesting a consult compared with those with a score of less than 8 or greater than or equal to 8 with no suicidality of 2. The HEADS-ED mean score was significantly higher for those who received a consult (M = 6.91) than those who did not (M = 4.70; P = 0.000). Similarly, the mean score for those admitted was significantly higher (M = 7.21) than those discharged (M = 5.28; P = 0.000). Agreement on needs requiring action between PED physicians and crisis intervention workers was obtained for a subset of 140 patients and ranged from 62% to 93%. Conclusions Results support the HEADS-ED's use by PED physicians to help guide the assessment and referral process and for discussing the clinical needs of patients among health care providers using a common action-oriented language.

BACKGROUND: Over the last few decades, there has been a surge in the use of laboratory testing during patient encounters. Many suggest that laboratory investigations for psychiatric inpatient units are unnecessary, thus warranting further research and support. Furthermore, though the results of completed investigations may fall out of normal range, they are most often deemed not clinically significant and do not affect patient management. OBJECTIVES: Determine the clinical relevance of routine bloodwork completed upon patient admission to a pediatric psychiatric inpatient unitIdentify which blood tests fell most often outside the range of normal and whether they resulted in follow-up. Recommend a more streamlined and cost-efficient approach towards ordering admission bloodwork. DESIGN/METHODS: Through a retrospective chart review, 485 patient admissions to the pediatric inpatient unit at a tertiary care teaching hospital between January 1st and December 31st, 2016 were reviewed and analyzed. Demographics (age, sex) were collected along with results and clinical significance of 17 routinely ordered laboratory tests (CBC and differential, serum glucose, sodium, potassium, chloride, urea, creatinine, bilirubin, ALP, AST, ALT, LDH, GGT, TSH, ferritin, folate and B12 levels). RESULTS: Routine bloodwork was completed for 79.8% (n=387) of patient admissions. However, no more than 1.7% of the completed bloodwork led to changes in patient management. Tests which were most frequently clinically significant included Ferritin (6.1%), TSH (4.7%), and B12 (3.2%). The remaining 14 routine laboratory tests were each clinically significant less than 2.5% of the time. CONCLUSION: The results of this study suggest that not all routine laboratory investigations are useful on admission given few led to changes in patient management. Our study proposes that physicians admitting pediatric patients to the inpatient psychiatry ward order a subset of routine blood work including Ferritin, TSH, B12, and others only when deemed necessary by the attending physician and based on patient presentation.

ObjectivesDespite documented increases in emergency department (ED) mental health (MH) presentations, there are inconsistent findings on the characteristics of patients with repeat presentations to pediatric EDs (PEDs) for MH concerns. Our study sought to explore the characteristics of MH patients with repeat PED visits and determine predictors of return visits, of earlier repeat visits, and of more frequent repeat visits.MethodsWe examined data collected prospectively in a clinical database looking at MH presentations to a crisis intervention program housed within a PED from October 2006 to December 2011. Predictive models based on demographic and clinical variables were constructed using logistic, Cox, and negative binomial regression.ResultsA total of 4,080 presentations to the PED were made by the 2,900 children and youth. Repeat visits accounted for almost half (45.8%) of all presentations. Multivariable analysis identified five variables that independently predicted greater odds of having repeat presentations, greater risk of earlier repeat presentations, and greater risk of frequent repeat presentations. The five variables were: female, living in the metropolitan community close to the PED, being in the care of child protective services, taking psychotropic medications, and presenting with an actionable need in the area of mood disturbances.ConclusionsRepeat visits account for a large portion of all MH presentations to the PED. Furthermore, several patient characteristics are significant predictors of repeat PED use and of repeating use sooner and more frequently. Further research is needed to examine interventions targeting this patient group to ensure appropriate MH patient management.

Droughts are intensifying under climate change. Research into the resilience of stream food webs to drought now shows that ‘rewiring’ of food web structure in the face of species losses helps to buffer changes to the overall network structure. Droughts are intensifying across the globe1,2, with potentially devastating implications for freshwater ecosystems3,4. We used new network science approaches to investigate drought impacts on stream food webs and explored potential consequences for web robustness to future perturbations. The substructure of the webs was characterized by a core of richly connected species5 surrounded by poorly connected peripheral species. Although drought caused the partial collapse of the food webs6, the loss of the most extinction-prone peripheral species triggered a substantial rewiring of interactions within the networks’ cores. These shifts in species interactions in the core conserved the underlying core/periphery substructure and stability of the drought-impacted webs. When we subsequently perturbed the webs by simulating species loss in silico, the rewired drought webs were as robust as the larger, undisturbed webs. Our research unearths previously unknown compensatory dynamics arising from within the core that could underpin food web stability in the face of environmental perturbations.

Most research on the effects of environmental change in freshwaters has focused on incremental changes in average conditions, rather than fluctuations or extreme events such as heatwaves, cold snaps, droughts, floods or wildfires, which may have even more profound consequences. Such events are commonly predicted to increase in frequency, intensity and duration with global climate change, with many systems being exposed to conditions with no recent historical precedent. We propose a mechanistic framework for predicting potential impacts of environmental fluctuations on running-water ecosystems by scaling up effects of fluctuations from individuals to entire ecosystems. This framework requires integration of four key components: effects of the environment on individual metabolism, metabolic and biomechanical constraints on fluctuating species interactions, assembly dynamics of local food webs, and mapping the dynamics of the meta-community onto ecosystem function. We illustrate the framework by developing a mathematical model of environmental fluctuations on dynamically assembling food webs. We highlight (currently limited) empirical evidence for emerging insights and theoretical predictions. For example, widely supported predictions about the effects of environmental fluctuations are: high vulnerability of species with high per capita metabolic demands such as large-bodied ones at the top of food webs; simplification of food web network structure and impaired energetic transfer efficiency; and reduced resilience and top-down relative to bottom-up regulation of food web and ecosystem processes. We conclude by identifying key questions and challenges that need to be addressed to develop more accurate and predictive bio-assessments of the effects of fluctuations, and implications of fluctuations for management practices in an increasingly uncertain world.

OBJECTIVE: The focus of this study was to describe the clinical data that pediatric emergentologists recorded and how they were used in the mental health (MH) care of patients. METHODS: A structured chart review was conducted for all MH presentations to a pediatric emergency department in 2007. Three research assistants extracted clinical chart data and completed the Child and Adolescent Needs and Strengths Tool. RESULTS: The clinical records of 495 children and youth were reviewed. Emergentologists referred 124 (25.4%) for a psychiatric consult, and 46 (37%) of these patients were admitted to either an inpatient psychiatric or eating-disorders unit. Psychosis, suicide risk, eating disturbance, anxiety, and resistance to treatment predicted admission to the psychiatric inpatient unit or the eating-disorders unit. Of the 365 patients discharged back to the community, the majority (n = 189, 51.8%) were referred back to their family physician. For 117 patients (32%), there was no discharge documentation in the medical chart. Age, parent present, currently on medication, currently receiving counseling, depression, anxiety, and adjustment to trauma predicted provision of charted recommendation. CONCLUSIONS: This study revealed that the pediatric emergentologists' charting of MH patients is inconsistent and incomplete. Although recorded clinical data predicted psychiatric consultation and disposition for these patients, missing data were evident in a significant number of records. The results of the study point to a need to develop a more uniform approach to the collection and recording of clinical data for MH patients. Language: en

BACKGROUND AND OBJECTIVE:The American Academy of Pediatrics called for action for improved screening of mental health issues in the emergency department (ED). We developed the rapid screening tool home, education, activities/peers, drugs/alcohol, suicidality, emotions/behavior, discharge resources (HEADS-ED), which is a modification of “HEADS,” a mnemonic widely used to obtain a psychosocial history in adolescents. The reliability and validity of the tool and its potential for use as a screening measure are presented.METHODS:ED patients presenting with mental health concerns from March 1 to May 30, 2011 were included. Crisis intervention workers completed the HEADS-ED and the Child and Adolescent Needs and Strengths-Mental Health tool (CANS MH) and patients completed the Children’s Depression Inventory (CDI). Interrater reliability was assessed by using a second HEADS-ED rater for 20% of the sample.RESULTS:A total of 313 patients were included, mean age was 14.3 (SD 2.63), and there were 182 females (58.1%). Interrater reliability was 0.785 (P < .001). Correlations were computed for each HEADS-ED category and items from the CANS MH and the CDI. Correlations ranged from r = 0.17, P < .05 to r = 0.89, P < .000. The HEADS-ED also predicted psychiatric consult and admission to inpatient psychiatry (sensitivity of 82% and a specificity of 87%; area under the receiver operator characteristic curve of 0.82, P < .01).CONCLUSIONS:The results provide evidence to support the psychometric properties of the HEADS-ED. The study shows promising results for use in ED decision-making for pediatric patients with mental health concerns.

An innovative crisis intervention programme was created at the Children's Hospital of Eastern Ontario in Canada in order to provide emergency assessments for youth presenting with mental health crises. The current investigation presents an overview of the programme and examines the emergency staff's perception and satisfaction with it. Eighty-seven emergency department medical staff completed a survey. Overall, emergency department staff place high value on having access to emergency mental health services, are pleased with the quality of service and appreciate that the crisis intervention worker's presence allows them to spend more time with other patients.

The main purpose of this research was to identify the perceived mental health (MH) concerns of caregivers and youths who present to the emergency department (ED) for MH services. The concordance between caregiver and youth perceptions and clinician ratings of MH concerns were evaluated. Expectations for the visit and perceived stressors that triggered the event are described.This study consisted of 241 youths accompanied by caregivers presenting to the ED for MH concerns requiring crisis intervention services. The Caregiver Perception Survey and Youth Perception Survey were completed. These surveys were designed to identify the caregivers' and youths' main concerns and perceived stressors, as well as their expectations in coming to the pediatric ED. A chi analysis was conducted to determine the percentage of agreement of reported MH concerns between groups (youth, caregiver, and clinician), and kappa statistics are reported.Caregivers' and youths' top 5 concerns were suicide ideation, depression or mood, suicidal attempt, anxiety, and self-injury. The top 3 stresses identified by both youths and their caregivers were school, issues with parents, and problems with friends/peers. The top 3 expectations that were noted by caregivers were help/guidance for child, assessment/ evaluation/diagnosis, and health care professional resources. Concordance rates between caregivers and youths for the top 5 concerns ranged from 39.4% to 80.6%. Concordance rates between clinician rating of concerns (as requiring some or immediate action) and caregiver concerns ranged from 18.4% to 45.2%. Concordance rates between clinician and youth ranged from 11.1% to 59.4%.The top 5 caregivers and youths' main concerns for coming to the ED were similar. However, concordance between perceived concern and clinician assessment is low. Caregivers' expectations for coming to the ED highlight their lack of knowledge of referral procedures and MH services.

Il est demontre que le traitement pharmacologique par des stimulants reduit les symptomes associes au trouble de deficit de l’attention avec hyperactivite (TDAH), et ce traitement fait partie des recommandations therapeutiques de l’American Academy of Pediatrics pour les enfants presentant ce trouble (1,2). Cependant, de recentes decisions en matiere de reglementation sur l’homologation et l’etiquetage des medicaments contre le TDAH (3,4), ainsi qu’un recent document de principes de l’American Heart Association (5), une correction et une reponse (clarification) de l’American Academy of Pediatrics (6,7), ont souleve des questions sur l’evaluation et la therapie du TDAH que preconisent les praticiens canadiens. La pratique canadienne actuelle dans le domaine de la pharmacotherapie du TDAH et du depistage cardiovasculaire est mixte, et il y a peu de consensus quant a l’evaluation pertinente des enfants avant d’instaurer la pharmacotherapie du TDAH (8). Les avis sont encore plus partages au sujet de l’innocuite du traitement des enfants ayant subi une refection ou une palliation de leur cardiopathie congenitale (CPC) et qui prennent des medicaments contre le TDAH (8). Afin d’orienter les medecins canadiens qui soignent les enfants ayant un TDAH et de clarifier la situation, la Societe canadienne de pediatrie, la Societe canadienne de cardiologie et l’Academie canadienne de psychiatrie de l’enfant et de l’adolescent ont prepare conjointement le present document de principes. Il contient des recommandations consensuelles sur l’evaluation du risque cardiaque chez les enfants ayant un TDAH a qui on envisage d’administrer des stimulants. Il ne s’attarde pas au diagnostic de TDAH, ni aux bienfaits therapeutiques des stimulants. De meme, il n’aborde pas le bien-fonde ou les risques relatifs d’un medicament par rapport a un autre au sein de cette population de patients. Enfin, les medicaments non stimulants utilises dans le traitement du TDAH, y compris l’atomoxetine, les antidepresseurs et les agonistes alpha-adrenergiques, ne font pas l’objet d’une analyse particuliere.

The objectives of this prospective study were to determine the demographic and clinical characteristics of children and youth presenting to the emergency department (ED) for mental health concerns through the use of a valid standardized assessment protocol.Children and adolescents, 8 to 17 years, who presented to an ED-based crisis intervention program during fiscal years 2005 to 2006, completed self-report measures of depression, anxiety, and behavior. Clinicians completed the childhood acuity of psychiatric illness based on their assessment.The clinician ratings indicated that 93.1% of the sample had at least 1 risk behavior or clinical symptom in the moderate/severe range. Admittance rate for the sample was 17.9% (low-risk admissions, 5.8%; high-risk deflections, 9%). Significant differences were found in presentations by sex and age as follows: (1) female youths (12-17 years) were more likely than male youth to report clinically significant depressive symptoms and to present with suicidal ideation/gesture and self-injury. (2) Male youths (12-17 years) were more likely to present with aggression to people/objects than female youth. (3) Male children younger than 12 years were more likely to present with high activity level than female children. Self-report measures (depression, anxiety, and behavior) corelated with corresponding clinician ratings.This research, through the use of a multi-informant standardized assessment protocol, presents a comprehensive study of children and youth presenting to the ED with mental health issues. Identifying the clinical characteristics of this population is an important first step toward establishing best practice within an ED.

Many previous attempts to understand how ecological networks respond to and recover from environmental stressors have been hindered by poorly resolved and unreplicated food web data. Few studies have assessed how the topological structure of large, replicated collections of food webs recovers from perturbations. We analysed food web data taken from 23 UK freshwaters, sampled repeatedly over 24 years, yielding a collection of 442 stream and lake food webs. Our main goal was to determine the effect of acidity on food web structure and to analyse the way food web structure recovered from the effects of acidity over time. Long-term monotonic reversals of acidification were evident at many of the sites, but the ecological responses were generally far less evident than chemical changes, or absent. Across the acidity gradient, food web linkage density and network efficiency declined with increasing acidity, while node redundancy (i.e. trophic similarity among species within a web) increased. Within individual sites, connectance, linkage density, trophic height, resource vulnerability and network efficiency tended to increase over time as sites recovered from acidification, while consumer generality and node redundancy tended to decrease. There was evidence for a lag in biological recovery, as those sites showing a recovery in both their biology and their chemistry were a nested subset of those which only showed a chemistry trend. These findings support the notion that food web structure is fundamentally altered by acidity, and that inertia within the food web may be hindering biological recovery. This suggestion of lagged recovery highlights the importance of long-term monitoring when assessing the impacts of anthropogenic stressors on the natural world. This temporal dimension, and recognition that species interactions can shape community dynamics, is missing from most national biomonitoring schemes, which often rely on space-for-time proxies.

The Necropolis sits on a hill high above Glasgow. An interdenominational graveyard, the first burial was of a Jewish man named Joseph Levi in 1932. To the south, crossing the river Clyde, lies the Gorbals, an area which grew in population from the late eighteenth century onwards and has drawn people from the Scottish highlands, Irish people escaping famine, Jewish people fleeing violence in Poland, Russia and Lithuania and, more recently, Indians and Pakistanis.

1. Pesticides can have strong deleterious impacts in fresh waters, but understanding how these effects cascade through natural ecosystems, from microbes to apex predators, is limited because research that spans multiple levels of biological organisation is rare. 2. We report how an accidental insecticide spill altered the structure and functioning of a river across levels ranging from genes to ecosystems. We quantified the impacts on assemblages of microbes, diatoms, macroinvertebrates and fish and measured leaf-litter decomposition rates and microbial functional potential at upstream control and downstream impacted sites 2 months after the spill. 3. Both direct and indirect impacts were evident across multiple levels of organisation and taxa, from the base of the food web to higher trophic levels. At the molecular level, differences in functional gene abundance within the impacted sites reflected a combination of direct and indirect effects of the pesticide, via elevated abundances of microbial populations capable of using chlorpyrifos as a resource (i.e. direct effect) and oxidising ammonia released by decaying macroinvertebrate carcasses (i.e. indirect effect). 4. At the base of the food chains, diatom taxa found only in the impacted sites were an order-of- magnitude larger in cell size than the largest comparable taxa in control communities, following the near extirpation of their consumers. Population biomass of the key detritivore Gammarus pulex was markedly lower, as was the rate of litter decomposition in the impacted sites. This was partially compensated for, however, by elevated microbial breakdown, suggesting another indirect food-web effect of the toxic spill. 5. Although many species exhibited population crashes or local extirpation, total macroinvertebrate biomass and abundance were largely unaffected due to a compensatory elevation in small tolerant taxa such as oligochaetes, and/or taxa which were in their adult aerial life stage at the time of the spill (e.g. chironomids) and thus avoided contact with the polluted waters and were able to repopu- late the river quickly. Mass–abundance scaling of trophic links between consumers and resources revealed extensive restructuring within the food web. 6. This case study shows that pesticides can affect food-web structure and ecosystem functioning, both directly and indirectly across levels of biological organisation. It also demonstrates how an integrated assessment approach, as adopted here, can elucidate links between microbiota, macroinvertebrates and fish, for instance, thus improving our understanding of the range of biological consequences of chemical contamination in natural ecosystems.

Biomonitoring and conservation of freshwaters to date have fallen short of incorporating a fully ecological and evolutionary perspective. Due to this, the predictive capacity of current biomonitoring approaches is restricted and will have a limited ability to adapt in the face of rapid and global habitat modification and climate change. We briefly outline the present state of biomonitoring as well as some of its limitations. We then address how incorporating an ecological and evolutionary approach to biomonitoring and conservation will allow us to better understand interactions between the evolution and ecology of a species. This approach, alongside the incorporation of measures of ecosystem functioning and aided by new technologies such as novel molecular markers or the use of microbes, may facilitate the future development of a more comprehensive and effective biomonitoring framework.

Monitoring anthropogenic impacts is essential for managing and conserving ecosystems, yet current biomonitoring approaches lack the tools required to deal with the effects of stressors on species and their interactions in complex natural systems. Ecological networks (trophic or mutualistic) can offer new insights into ecosystem degradation, adding value to current taxonomically constrained schemes. We highlight some examples to show how new network approaches can be used to interpret ecological responses. Synthesis and applications. Augmenting routine biomonitoring data with interaction data derived from the literature, complemented with ground-truthed data from direct observations where feasible, allows us to begin to characterise large numbers of ecological networks across environmental gradients. This process can be accelerated by adopting emerging technologies and novel analytical approaches, enabling biomonitoring to move beyond simple pass/fail schemes and to address the many ecological responses that can only be understood from a network-based perspective.

Regulatory decisions and scientific statements regarding the management of attention-deficit hyperactivity disorder (ADHD) raise questions about the safety of medications and the appropriate pretreatment evaluation to determine suitability for treatment with medication. This is particularly true in the setting of known structural or functional heart disease. The present paper reviews the available data, including peer-reviewed literature, data from the United States Food and Drug Administration Web site on reported adverse reactions in children using stimulant medication, and Health Canada data on the same problem. A consensus-based guideline on appropriate assessment is provided, based on input from members of the Canadian Paediatric Society, the Canadian Cardiovascular Society and the Canadian Academy of Child and Adolescent Psychiatry, with specific expertise and knowledge in the areas of both ADHD and pediatric cardiology. The present statement advocates a thorough history and physical examination before starting stimulant medications, with an emphasis on the identification of risk factors for sudden death, but does not routinely recommend electrocardiographic screening or cardiac subspecialist consultation unless indicated by history or physical examination findings. A checklist for identifying children who are potentially at risk of sudden death (independent of ADHD or medications used to treat it) is provided. Although recommendations are based on the best evidence currently available, the committee further agrees that more research on this subject is necessary to optimize the approach to this common clinical scenario.

Regulatory decisions and scientific statements regarding the management of attention-deficit hyperactivity disorder (ADHD) raise questions about the safety of medications and the appropriate pretreatment evaluation to determine suitability for treatment with medication. This is particularly true in the setting of known structural or functional heart disease. The present paper reviews the available data, including peer-reviewed literature, data from the United States Food and Drug Administration Web site on reported adverse reactions in children using stimulant medication, and Health Canada data on the same problem. A consensus-based guideline on appropriate assessment is provided, based on input from members of the Canadian Paediatric Society, the Canadian Cardiovascular Society and the Canadian Academy of Child and Adolescent Psychiatry, with specific expertise and knowledge in the areas of both ADHD and paediatric cardiology. The present statement advocates a thorough history and physical examination before starting stimulant medications, with an emphasis on the identification of risk factors for sudden death, but does not routinely recommend electrocardiographic screening or cardiac sub-specialist consultation unless indicated by history or physical examination findings. A checklist for identifying children who are potentially at risk of sudden death (independent of ADHD or medications used to treat it) is provided. Although recommendations are based on the best evidence currently available, the committee further agrees that more research on this subject is necessary to optimize the approach to this common clinical scenario.