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Objectives: Our goal was to develop an open access nationally disseminated online curriculum for use in graduate and continuing medical education on the topic of pediatric telepsychiatry to enhance the uptake of telepsychiatry among child psychiatry training programs and improve access to mental health care for youth and families. Methods: Following Kern's 6-stage model of curriculum development, we identified a core problem, conducted a needs assessment, developed broad goals and measurable objectives in a competency-based model, and developed educational content and methods. The curriculum was reviewed by experts and feedback incorporated. Given the urgent need for such a curriculum due to the COVID-19 pandemic, the curriculum was immediately posted on the American Academy of Child and Adolescent Psychiatry and American Association of Directors of Psychiatric Residency Training websites. Further evaluation will be conducted over the next year. Results: The curriculum covers the six areas of core competence adapted for pediatric telepsychiatry and includes teaching content and resources, evaluation tools, and information about other resources. Conclusion: This online curriculum is available online and provides an important resource and set of standards for pediatric telepsychiatry training. Its online format allows for ongoing revision as the telepsychiatry landscape changes.

Objective: Telemental health (TMH) is not well described for mental health service delivery during crises. Most child and adolescent psychiatry training programs have not integrated TMH into their curricula and are ill equipped to respond during crises to their patients' needs. In this study, we present the implementation of a home-based TMH (HB-TMH) service during the COVID-19 pandemic. Methods: We describe the technological, administrative, training, and clinical implementation components involved in transitioning a comprehensive outpatient child and adolescent psychiatry program to a HB-TMH virtual clinic. Results: The transition was accomplished in 6 weeks. Most in-clinic services were rapidly moved off campus to the home. Owing to challenges encountered with each implementation component, phone sessions bridged the transition from in-clinic to reliable virtual appointments. Within 3 weeks (March 20, 2020) of planning for HB-TMH, 67% of all appointments were conducted at home, and within 4 weeks (March 27, 2020), 90% were conducted at home. By week 6 (April 3, 2020), reliable HB-TMH appointments were implemented. Conclusions: The COVID-19 pandemic crisis created the opportunity to innovate a solution to disrupted care for our established patients and to create a resource for youth who developed problems during the crisis. Our department was experienced in providing TMH services that facilitated the transition to HB-TMH, yet still had to overcome known and unanticipated challenges. Our experience provides a roadmap for establishing a HB-TMH service with focus on rapid implementation. It also demonstrates a role for TMH during (rather than after) future crises when usual community resources are not available.

Objective A consortium of 8 academic child and adolescent psychiatry programs in the United States and Canada examined their pivot from in-person, clinic-based services to home-based telehealth during the COVID-19 pandemic. The aims were to document the transition across diverse sites and to present recommendations for future telehealth service planning. Method Consortium sites completed a Qualtrics survey assessing site characteristics, telehealth practices, service use, and barriers to and facilitators of telehealth service delivery prior to (pre) and during the early stages of (post) the COVID-19 pandemic. The design is descriptive. Results All sites pivoted from in-person services to home-based telehealth within 2 weeks. Some sites experienced delays in conducting new intakes, and most experienced delays establishing tele−group therapy. No-show rates and use of telephony versus videoconferencing varied by site. Changes in telehealth practices (eg, documentation requirements, safety protocols) and perceived barriers to telehealth service delivery (eg, regulatory limitations, inability to bill) occurred pre−/post−COVID-19. Conclusion A rapid pivot from in-person services to home-based telehealth occurred at 8 diverse academic programs in the context of a global health crisis. To promote ongoing use of home-based telehealth during future crises and usual care, academic programs should continue documenting the successes and barriers to telehealth practice to promote equitable and sustainable telehealth service delivery in the future.

Background Despite the known benefits of early, specialized intervention for toddlers with Autism Spectrum Disorder (ASD), access to such intervention remains limited. This pragmatic trial examines a novel healthcare delivery model (Screen-Refer-Treat [SRT]), which capitalizes upon existing health care and early intervention (EI) infrastructure to increase community capacity for ASD detection and treatment before age 3, when it is likely to have the greatest impact. This model comprises three components: (1) universal use of Stage 1 ASD screening by primary care providers (PCPs) at 18-month well-child visits (i.e., Screen); (2) immediate referral of positive screens to a community-based EI program (i.e., Refer); and (3) provision of an inexpensive, evidence-based ASD-specialized treatment by EI providers, after verifying ASD risk with a Stage 2 screen (i.e., Treat). This paper describes our research design and the initial successes, challenges, and adaptations made during the early implementation phase. Method/design A stepped-wedge cluster RCT was used to implement the SRT model sequentially in four diverse Washington State counties (“clusters”). Counties are randomly assigned to the time of receipt of the SRT intervention, which comprises training workshops and technical assistance focused on the use of evidence-based ASD screening and intervention tools. Separate cohorts of families with toddlers (16–35 months old) with and without ASD concerns are recruited before and after the SRT intervention from participating PCP practices and EI programs. PCPs and EI providers complete measures on their screening, referral, and intervention practices before and after the SRT intervention. Each family cohort completes surveys about their well-being, parenting efficacy, health care satisfaction, and toddler’s social-communicative behaviors. Conclusion This trial is the first of its kind to work simultaneously with two service delivery systems with the goal of improving early detection and treatment for ASD. Our approach was successful in attaining buy-in from PCPs and EI providers, building and maintaining partnerships with providers, and achieving high levels of retention and survey completion. Fostering provider engagement and problem-solving issues together as partners were integral to overcoming the main challenges. Numerous lessons have been learned thus far, which have applicability for implementation researchers in ASD and those in other fields. Trial registration The registration number for this trial is NCT02409303 and it was posted on ClinicalTrials.gov on April 6, 2015.

This concluding commentary offers a brief overview of progress to date in providing telemental health services to children, and then offers a critical vision for future research needed to provide the rigorous empirical foundation for telemental health to be considered a well-established format for the delivery of children's mental health services.We review how recent years have witnessed advances in the science and practice of children's telemental health, and the articles in this special series collectively offered a critical step forward in the establishment of a guiding literature to provide informed direction for child providers incorporating remote technologies to extend their practices.Researchers must be cautious not to develop a "horse race" mentality and a misguided search for a decisive "winner" regarding the ultimate effectiveness of child telemental health versus traditional clinic-based treatments. Instead, research efforts are needed to examine key mediators and moderators of telemental health treatment response. The question should not be simply whether telemental health strategies are supported, but rather when, under what circumstances, and for whom telemental health formats may be most indicated. Barriers to the continued evolution of children's telemental health are discussed, and we consider issues of telemental health reimbursement and matters of cross-state professional jurisdiction.Continued efforts are needed in order to fully actualize the potential of children's telemental health to optimize the quality and transform the accessibility of mental health services for all children, regardless of income or geography.

Telemental health, in the form of interactive videoconferencing, has become a critical tool in the delivery of mental health care. It has demonstrated the ability to increase access to and quality of care, and in some settings to do so more effectively than treatment delivered in-person. This article updates and consolidates previous guidance developed by The American Telemedicine Association (ATA) and The American Psychiatric Association (APA) on the development, implementation, administration, and provision of telemental health services. The guidance included in this article is intended to assist in the development and delivery of effective and safe telemental health services founded on expert consensus, research evidence, available resources, and patient needs. It is recommended that the material reviewed be contemplated in conjunction with APA and ATA resources, as well as the pertinent literature, for additional details on the topics covered.

This article evaluates the additive effects of children's comorbid conditions with attention-deficit/hyperactivity disorder (ADHD) in relation to caregivers' distress, in a clinical trial conducted through telemental health (TMH).The Children's ADHD Telemental Health Treatment Study (CATTS) is examining the effectiveness of treatment delivered via TMH for children with ADHD who are living in underserved communities. The CATTS trial recruited 223 children (μ=9.53±2.06 years) and their caregivers. Diagnoses of ADHD and comorbid oppositional defiant disorder (ODD) and anxiety disorders (ADs) were established with the Child Behavior Checklist and the Computerized Diagnostic Interview Schedule for Children. We took advantage of rich baseline data from the CATTS trial to investigate associations between caregivers' distress and children's comorbid mental health conditions. Caregivers' distress was assessed with the Patient Health Questionnaire-9, Parenting Stress Index, and Caregiver Strain Questionnaire. ANOVAs were used to compare children with ADHD alone with children having one comorbid condition (ODD or ADs) and children having two comorbid conditions (ODD and ADs).Three quarters (75.3%) of participants met criteria for ODD and/or AD comorbid with ADHD: 24.7% had neither comorbidity; 47.5% had ODD or AD; and 27.8% had both ODD and AD comorbidities. The parents of children with multiple comorbid conditions experienced the highest levels of depression, stress, and burden of care.The CATTS sample that was recruited from underserved communities provided evidence of additive effects of child psychiatric comorbidities with caregivers' distress, echoing earlier findings from the Multi-modal Treatment of ADHD (MTA) study that was conducted with a metropolitan sample of youth. Results indicate that caregivers' distress should be addressed in developing treatment models for children with ADHD.http://clinicaltrials.gov/show/NCT00830700 .

Over the past decade telepsychiatry, and more broadly telemental health (TMH), services with children and adolescents have been implemented with diverse populations in many geographic areas across the United States. The feasibility and acceptability of child and adolescent TMH have been well demonstrated, but little research exists on the efficacy and effectiveness of TMH in improving the mental health care and outcomes for underserved youth. This article summarizes the state of research in child and adolescent telemental health TMH and examines studies in other areas of telemedicine that may inspire and guide child and adolescent telepsychiatrists to collect data on the process and outcomes of their own work.

Objective This is the seventh in a series of 10-year reviews of rating scales. Here the authors present scales measuring functional impairment, a sequela of mental illness. The measurement of functional impairment has assumed importance with the recognition that symptom resolution does not necessarily correlate with functional improvement. Method The authors reviewed functional impairment from multiple sources over the past 20 years. Thus, this article includes a variety of scales ranging from those that have been subject to critical review with strong psychometric support to those that have not been critically reviewed but are in widespread use to those that are still finding their niche. Results These scales represent a continuum of constructs from symptoms to functional impairment to contextual factors that affect youths' functioning. Most older scales have focused on developmentally delayed youths. Newer scales strive to measure functional impairment separate from symptomatology. Some newer scales are also keyed to determination of level of service need. Conclusions Scales measuring functional impairment can elucidate the impact of illness on youths, identify targets for treatment, determine service needs, and monitor treatment effectiveness. These scales are widely used in community mental health and health service delivery. They can assist in providing evidence-based treatment.

Objective This is the sixth article in a series of 10-year reviews of rating scales. The current article reviews scales that assess externalizing behaviors such as disruptive behavior disorders and aggression. Method Relevant scales were found by searching popular electronic databases. The search was then broadened by a review of the references in selected articles. Due to the paucity of well-established scales, any such scales with potential utility for elucidating the functioning of youths with externalizing behaviors were selected. Results None of these scales is diagnosis-based, although some correlate with DSM-IV-defined disruptive behavior disorders. Most scales assessing disruptive behavior disorders have a solid normative base, good psychometric functioning, and high clinical utility. Scales assessing aggression comprise a bimodal group. Several have been adapted from the adult literature and are widely used in clinical practice, while others address theoretical aspects of aggression and are used predominantly in research. Empirical support for all of the scales assessing aggression varies widely, although several show potential for routine clinical practice. Conclusions Overall, these scales measure a variety of constructs with considerable utility for assessing youths’ externalizing behaviors, predicting outcome, and evaluating treatment effects. Many need further validation with youth.

Objective: This article summarizes scales assessing trauma and its effects on youths. Method: We sampled trauma-related articles published over the past 25 years, with an emphasis on the past decade, selected scales with at least several publications, and reviewed their properties. Those with minimally adequate psychometric properties and continued literature citations or a special niche are presented. Results: Most of trauma-related scales are relatively new, reflecting the evolving interest in juvenile trauma. Therefore, they do not have the depth of psychometric examination nor the breadth of applications described for previously reviewed scales. However, they have been applied to various traumatic situations. These scales assess a range of trauma-related symptoms and behaviors, including posttraumatic stress disorder, symptoms related to posttraumatic stress disorder, and dissociation. Additionally, several scales assess the trauma itself. Conclusions: Trauma-related scales show promise for research and clinical use in understanding youths’ responses to trauma. However, their utility for treatment planning and for accountability in practice is generally not as clear. The potential user must clearly define the goals of measurement and use these scales within their limited roles. With these caveats, trauma-related scales may assist our work with traumatized youths.

This chapter reviews current research on telemental health (TMH) while developing an agenda for future research. Satisfaction research, the majority of research done in TMH, is positive but methods to obtain a richer understanding of patient’s experience of TMH are discussed. Recent adoption of comparative effectiveness research methods has greatly enhanced the growing research on comparability between same-room care and TMH care. More recently, well-designed effectiveness research studies support the use of telemedicine for psychiatry and psychotherapy and they are reviewed. These studies have yielded interesting findings regarding therapeutic alliance in TMH as well as moderators and mediators of treatment response. This chapter also reviews the literature on online and Internet-based therapies that involve minimal or no real-time interaction with a therapist. Though asynchronous forms of TMH have not been a focus of this book, this is one of the more advanced and sophisticated research areas in TMH with consistently positive evidence of effectiveness. The review concludes with a brief discussion of telehealth adjuncts that may be used in conjunction with same-room or TMH care and with a review and critique of cost-effectiveness research. Themes for future directions in research are then discussed.

Journal of the American Academy of Child & Adolescent Psychiatry - Vol. 42 - N° 2 - p. 257-259

Family interactions appear to play an important role in the timing, intensity, and persistence of depressive disorders in adults. This article reviews the literature on the role of family interactions in depression in children and adolescents. Children’s reports of depressed affect have been associated with a variety of dysfunctional family attributes including maternal hostility, lack of cohesiveness, poor communication, and increased conflict. It is unclear, however, whether these patterns are specific to families of depressed youth or characterize the families of children with varied psychiatric psychosocial difficulties.

This investigation developed a hierarchical multiple regression model to assess the potential risk factors for suicidality in youths 7 to 17 years old. Variables were assessed in three domains: self-perceptions, demography and diagnosis, and home/environment. The model controlled for major depressive disorder (MDD), which has confounded previous investigations, by evaluating potential risks in a diagnostically heterogenous sample, and then evaluating these risks in a subsample with MDD. Conduct problems and depressive thinking emerged as the most powerful predictors in both samples. Hopelessness, life stress, and maternal psychopathology predicted suicidality only in the total sample. Separation anxiety protected MDD youths. These results suggest that suicidal MDD youths may comprise a distinct subgroup of depressed youths.

Journal of the American Academy of Child & Adolescent Psychiatry - Vol. 36 - N° 4 - p. 569-571

Objective This project was designed to provide prospective data on the clinical presentation and longitudinal course of depression in children and adolescents. Method Children and their parent(s) completed a structured diagnostic interview (Schedule for Affective Disorders and Schizophrenia for School Age Children) at intake, and then yearly for 3 years. Collateral data were collected on school, social, and family functioning. Results Mean length of initial depressive episode was 35.6 weeks, SD of 26 weeks. Of the 65 depressed youths who completed the 3-year follow-up, 35 (54%) disclosed another episode of depression. Demographic, family-environment, and diagnostic variables were explored as predictors of characteristics of initial episode, recurrence of depression, and psychosocial competence at follow-up. Female gender and presence of a coexisting anxiety disorder were significantly related to severity of initial depression. Family environment was the only predictor significantly related to overall psychosocial competence over 3 years. Conclusions The findings confirm depression in youth as a valid clinical phenomenon, with substantial risk of recurrence. Increased levels of stress in the family environment were associated with poorer overall outcomes

A boy with encopresis was referred by pediatrics to psychiatry due to concerns about the family's functioning. The parents had recently divorced and the father retained custody of the two preschool children. The children's fearfulness and lack of appropriate social relationships were major problems. The child's encopresis threatened successful kindergarten adaptation. Family therapy led to consistent decrease of soiling. The initial assessment is discussed with respect to both Adlerian and psychoanalytic object-relations theory in order to demonstrate two distinctly different theories for understanding family dynamics and formulating a therapeutic approach. Object-relations theory emphasizes intra-psychic experience and developmental stages in the psychological birth of the individual. Separation-individuation of the child from mother and the resulting ability to handle the oedipal configuration determine psychic functioning. Adlerian theory emphasizes the purposes of behavior. Personality forms ...

This article reports one of the first studies of adult fears, specifically in an elderly population. Results indicated that older women expressed greater fearfulness than older men, a sex differential also observed in children and adolescents. When compared to other adult groups, significant differences were noted on several categories of fears. The elderly group ranked aging and sickness as their foremost fears, although the absolute degree of fearfulness did not differ from the comparison groups. Considered with previous investigations, these results suggest that some fears may change or intensify over the lifespan, and that within each period females report greater fearfulness than males. Additionally, this article describes a new entity, “fisity,” which accounts for the popularity and the intensity of fears in a single measure.

This paper reports one of the first investigations of adult fears. Demographic variables included: sex, race, college degree status, and sibling position for a broadly defined middle class population. Additionally, it reports a new entity, "fisity" which accounts for both the popularity and strength of a fear in a single calculated measure. Women, in general, endorsed greater overall fearfulness than men, but this differential was not observed in an all white subsample. This male-female difference is similar to trends noted in studies of children's foars. However, college degree status did not correlate with fearfulness for the total population, or for an all white male subsample; although non-degreed females did express significantly greater fearfulness than their degreed cohort. Finally, increasing birth order in the sibship also correlated with increasing fearfulness.

The paper reports the first of adult fears according to ethnicity The Chinese endorsed greater fearfulness than the whites. This difference was more marked for the women than the men. However, the Chinese and Japanese, two well-acculturated Asian minorities, expressed no differences in their and Chinese living in two different sites demonstrated only small changes in their pattern of fears. By contrast, Vietnamese "boat people" expressed greatly increased total fearfulness as well as increased fear in all individual fear categories studied, However, unlike the Chinese and whites, sex had no effect on the "boat people's" fears. These results suggest that ethnicity influences overall fearfulness and the patterns of fears held by adults. Furthermore, sex and socioenviromental factors may interact with ethnicity to modify the pattern of these fears.