Search

PURPOSE: In the United States, primary care practices rely on scarce resources to deliver evidence-based care for children with behavioral health disorders such as depression, anxiety, other mental illness, or substance use disorders. We estimated the proportion of practices that have difficulty accessing these resources and whether practices owned by a health system or participating in Medicaid accountable care organizations (ACOs) report less difficulty. METHODS: This national cross-sectional study examined how difficult it is for practices to obtain pediatric (1) medication advice, (2) evidence-based psychotherapy, and (3) family-based therapy. We used the National Survey of Healthcare Organizations and Systems 2017-2018 (46.9% response rate), which sampled multiphysician primary and multispecialty care practices including 1,410 practices that care for children. We characterized practices’ experience as “difficult” relative to “not at all difficult” using a 4-point ordinal scale. We used mixed-effects generalized linear models to estimate differences comparing system-owned vs independent practices and Medicaid ACO participants vs nonparticipants, adjusting for practice attributes. RESULTS: More than 85% of practices found it difficult to obtain help with evidence-based elements of pediatric behavioral health care. Adjusting for practice attributes, the percent experiencing difficulty was similar between system-owned and independent practices but was less for Medicaid ACO participants for medication advice (81% vs 89%; P = .021) and evidence-based psychotherapy (81% vs 90%; P = .006); differences were not significant for family-based treatment (85% vs 91%; P = .107). CONCLUSIONS: Most multiphysician practices struggle to obtain advice and services for child behavioral health needs, which are increasing nationally. Future studies should investigate the source of observed associations.

The authors examined the prevalence and correlates of psychotropic medication prescribing among outpatient youths with intellectual and developmental disabilities.The authors reviewed cross-sectional data on medications for 1,333 youths (ages 5-21 years) with intellectual and developmental disabilities who were referred to a community-based mental health crisis service. Descriptive statistics and regression analysis were used to describe the study group and to identify correlates of psychotropic polypharmacy, antipsychotic use, and anticonvulsant use in the absence of a seizure disorder.Most youths were taking psychotropic medications (N=1,139, 86%), often three or more medications (N=733, 55%) from two or more drug classes (N=919, 69%). Most youths received antipsychotics (N=863, 65%), and a third (N=432, 32%) were taking anticonvulsants in the absence of a seizure disorder. Greater severity (number of psychiatric diagnoses and recent psychiatric hospitalization), older age, and living in a group home were significantly correlated with these practices.Polypharmacy, antipsychotic use, and anticonvulsant use in the absence of seizure disorders were common among youths with intellectual and developmental disabilities referred to the crisis service. Older age, number of psychiatric diagnoses, living in a group home, and psychiatric hospitalization correlate with these prescribing practices. These elevated prescribing rates in a very vulnerable population warrant further study.

We examined caregiver’s knowledge, attitudes, and concerns about their child’s psychotropic medication regimen and the potential side effects, describe how they seek information regarding treatment, and ascertain their perspectives toward deprescribing. We surveyed 48 caregivers of children 6–17 years old treated with two or more psychotropic medications or an antipsychotic medication, analyzing outcomes using descriptive statistics. Almost all (N = 44, 92%) participants reported feeling very knowledgeable about why medications were prescribed, but only one-third (N = 16, 33%) reported feeling very knowledgeable about potential problems with long-term use or polypharmacy. Half of respondents (N = 24, 50%) reported asking their provider about reducing/stopping medications due to concerns about harmful effects, and nearly half (N = 20, 42%) reported stopping medications earlier than recommended. Interventions to engage caregivers in shared decision-making about complex medication regimens and to support prescribers to safely deprescribe psychotropic medications are needed to address caregivers’ concerns regarding psychotropic medication use.

Individuals with intellectual and developmental disabilities disproportionately use emergency psychiatric services compared with their neurotypical peers, suggesting that such individuals and their supports are at increased risk for crisis events. This prospective study examined the timing, outcomes, and predictors of mental health crises for this population.The data came from Systemic, Therapeutic, Assessment, Resources, and Treatment (START), a national model that provides mental health crisis services for those with intellectual and developmental disabilities in the United States. The study included 1,188 individuals from four U.S. regions enrolled between 2018 and 2019. The outcome was urgent crisis contacts with the START program. Baseline and clinical predictors were examined with multivariate regression analyses.More than a quarter had at least one crisis contact, and 9% had three or more. Contacts increased within the initial 3 months of START enrollment, followed by a steep drop-off thereafter; few contacts happened after 1 year. Almost 45% of the contacts occurred after hours, and 30% involved police. Clinical factors predicted crisis contact most robustly, followed by lack of occupational supports. After START crisis intervention, 73% of individuals remained in their primary setting.For individuals with intellectual and developmental disabilities and mental health needs, crisis stabilization resources are needed, including after hours. Results clearly identify times and risk factors for mental health crisis contacts, including frequent involvement with emergency responders. Importantly, gainful employment conveyed benefits for community stabilization. Findings may be leveraged to develop effective mental health crisis intervention services and supports for this underserved group.

ImportanceApproximately 1 in 6 youth in the US have a mental health condition, and suicide is a leading cause of death among this population. Recent national statistics describing acute care hospitalizations for mental health conditions are lacking.ObjectivesTo describe national trends in pediatric mental health hospitalizations between 2009 and 2019, to compare utilization among mental health and non–mental health hospitalizations, and to characterize variation in utilization across hospitals.Design, Setting, and ParticipantsRetrospective analysis of the 2009, 2012, 2016, and 2019 Kids’ Inpatient Database, a nationally representative database of US acute care hospital discharges. Analysis included 4 767 840 weighted hospitalizations among children 3 to 17 years of age.ExposuresHospitalizations with primary mental health diagnoses were identified using the Child and Adolescent Mental Health Disorders Classification System, which classified mental health diagnoses into 30 mutually exclusive disorder types.Main Outcomes and MeasuresMeasures included number and proportion of hospitalizations with a primary mental health diagnosis and with attempted suicide, suicidal ideation, or self-injury; number and proportion of hospital days and interfacility transfers attributable to mental health hospitalizations; mean lengths of stay (days) and transfer rates among mental health and non–mental health hospitalizations; and variation in these measures across hospitals.ResultsOf 201 932 pediatric mental health hospitalizations in 2019, 123 342 (61.1% [95% CI, 60.3%-61.9%]) were in females, 100 038 (49.5% [95% CI, 48.3%-50.7%]) were in adolescents aged 15 to 17 years, and 103 456 (51.3% [95% CI, 48.6%-53.9%]) were covered by Medicaid. Between 2009 and 2019, the number of pediatric mental health hospitalizations increased by 25.8%, and these hospitalizations accounted for a significantly higher proportion of pediatric hospitalizations (11.5% [95% CI, 10.2%-12.8%] vs 19.8% [95% CI, 17.7%-21.9%]), hospital days (22.2% [95% CI, 19.1%-25.3%] vs 28.7% [95% CI, 24.4%-33.0%]), and interfacility transfers (36.9% [95% CI, 33.2%-40.5%] vs 49.3% [95% CI, 45.9%-52.7%]). The percentage of mental health hospitalizations with attempted suicide, suicidal ideation, or self-injury diagnoses increased significantly from 30.7% (95% CI, 28.6%-32.8%) in 2009 to 64.2% (95% CI, 62.3%-66.2%) in 2019. Length of stay and interfacility transfer rates varied significantly across hospitals. Across all years, mental health hospitalizations had significantly longer mean lengths of stay and higher transfer rates compared with non–mental health hospitalizations.Conclusions and RelevanceBetween 2009 and 2019, the number and proportion of pediatric acute care hospitalizations due to mental health diagnoses increased significantly. The majority of mental health hospitalizations in 2019 included a diagnosis of attempted suicide, suicidal ideation, or self-injury, underscoring the increasing importance of this concern.

Background Many people with intellectual and developmental disabilities (IDD) are treated with psychotropic medications, and polypharmacy is common. Although few studies address psychotropic side effects in the population, people with IDD have been found more likely to experience side effects than others who do not have IDD. Because many individuals with IDD may not report side effects reliably, there is risk that side effects may be missed. Methods Psychotropic use and side effects of 71 adults with IDD admitted for a 30-day crisis stay to a Systemic, Therapeutic, Assessment, Resources, and Treatment (START) Resource Center were reviewed. START is a specialised behavioural health outreach, training and crisis programme for individuals with IDD. During crisis stays, centre nurses administer the Matson Evaluation of Drug Side Effects screen, a psychometrically established psychotropic medication side effects screen developed for use with people with IDD. Data reviewed were de-identified data used to inform day-to-day practices and assess outcomes for individuals START served. Results The average age was 28 years, and 56% of the sample was male. All individuals were taking at least one psychotropic, while 79% were taking three or more. The average number of psychotropics used was 3.94. Antipsychotics were the most commonly prescribed medications taken by 85% of the sample; 49% of whom were not reported to have psychosis. Although the overall number of psychotropics did not correlate with Matson Evaluation of Drug Side Effects scores, the average scale scores for all participants was high in contrast to prior studies of people with IDD not taking psychotropics, with central nervous system side effects being the most commonly reported. Conclusion In the present study, data for individuals experiencing a crisis were reviewed and indicated high rates of psychotropic polypharmacy and side effects rates higher than previously reported for people with IDD not taking psychotropics. Prospective study in larger samples is needed to determine if missed or under-appreciated psychotropic side effects may play a role in behavioural health challenges of some people with IDD.

We examined caregiver's knowledge, attitudes, and concerns about their child's psychotropic medication regimen and the potential side effects, describe how they seek information regarding treatment, and ascertain their perspectives toward deprescribing.We surveyed 48 caregivers of children 6-17 years old treated with two or more psychotropic medications or an antipsychotic medication, analyzing outcomes using descriptive statistics.Almost all (N = 44, 92%) participants reported feeling very knowledgeable about why medications were prescribed, but only one-third (N = 16, 33%) reported feeling very knowledgeable about potential problems with long-term use or polypharmacy. Half of respondents (N = 24, 50%) reported asking their provider about reducing/stopping medications due to concerns about harmful effects, and nearly half (N = 20, 42%) reported stopping medications earlier than recommended.Interventions to engage caregivers in shared decision-making about complex medication regimens and to support prescribers to safely deprescribe psychotropic medications are needed to address caregivers' concerns regarding psychotropic medication use.

CONTEXT:The growing prevalence of pediatric mental and behavioral health disorders, coupled with scarce psychiatric resources, has resulted in a substantial increase in the number of youth waiting in emergency departments (EDs) and medical units for inpatient psychiatric care.OBJECTIVE:To characterize the prevalence of pediatric mental health boarding and identify associated patient and hospital factors.DATA SOURCES:Medline and PsycINFO.STUDY SELECTION:All studies describing frequencies, durations, processes, outcomes, and/or risk factors associated with pediatric mental health boarding in youth ≤21 years of age.DATA EXTRACTION:Publications meeting inclusion criteria were charted by 2 authors and critically appraised for quality.RESULTS:Eleven studies met inclusion criteria; 10 were retrospective cohort studies and 9 were conducted at single centers. All of the single-center studies were conducted at children’s hospitals or pediatric EDs in urban or suburban settings. Study sample sizes ranged from 27 to 44 328. Among youth requiring inpatient psychiatric care, 23% to 58% experienced boarding and 26% to 49% boarded on inpatient medical units. Average boarding durations ranged from 5 to 41 hours in EDs and 2 to 3 days in inpatient units. Risk factors included younger age, suicidal or homicidal ideation, and presentation to a hospital during nonsummer months. Care processes and outcomes were infrequently described. When reported, provision of psychosocial services varied widely.LIMITATIONS:Boarding definitions were heterogeneous, study sample sizes were small, and rural regions and general hospitals were underrepresented.CONCLUSIONS:Pediatric mental health boarding is prevalent and understudied. Additional research representing diverse hospital types and geographic regions is needed to inform clinical interventions and health care policy.

Children with intellectual and developmental disabilities (IDD) are likely to receive high-risk prescribing practices, such as polypharmacy, long-term use of psychotropic medications, and overuse of antipsychotics. Behavioural interventions, such as applied behavioural analysis, are evidence-based practices for children with IDD and should be the first-line treatment. Short-term use of psychotropic medications may be helpful in reducing the severity and frequency of challenging behaviours while evidence-based behavioural interventions are pursued. In this essay, we offer practical guidelines for better care.

At least 20% of children in the U.S. are highly vulnerable because they lack healthcare and protection. Several factors produce vulnerability: trauma, disruptions of parenting, poverty, involvement in the juvenile justice and/or child welfare systems, residence in restrictive settings, and problems related to developmental disabilities. These children receive psychotropic medications at high rates, raising numerous concerns.The authors begin this review with a description of the population of highly vulnerable children. They then follow this with a review of the effectiveness and side effects of psychotropic medications for their most common diagnoses, using the highest-quality systematic reviews identified by multiple database searches.Highly vulnerable children receive numerous psychotropic medications with high rates of polypharmacy, off-label use, and long-term use, typically in the absence of adjunctive psychosocial interventions. The current evidence contravenes these trends. Future studies of psychotropic medications in vulnerable children should include long-term effectiveness trials and polypharmacy in conjunction with evidence-based, family-centered, psychosocial treatments.

Objectives: This study evaluated changes in cardiometabolic monitoring for children and adolescents who were prescribed an antipsychotic medication in a state mental health system before and after a quality improvement intervention. Methods: The intervention included education for prescribers, auditing on metabolic monitoring, and feedback to mental health center leaders regarding their monitoring. Research staff extracted yearly data on cardiometabolic monitoring from randomly selected community mental health center records before and after the intervention. Pre- and postintervention changes in monitoring were assessed with chi-squared tests. Results: Evidence of past year monitoring increased: for glucose 18.9%–42.1% (χ2 = 6.75, p

Objective:The survey assessed self-reported monitoring by child psychiatrists of children prescribed second-generation antipsychotics, facilitators and barriers to monitoring, and steps taken to adhere to monitoring.Methods:The authors anonymously surveyed 4,144 U.S. child psychiatrists. Descriptive statistics and multiple linear regressions were utilized to describe results and identify correlates of monitoring.Results:Among responders (N=1,314, 32%), over 95% were aware of all guidelines, over 80% agreed with most guidelines, but less than 20% had adopted and adhered to most guidelines. Awareness of guidelines, working within an academic practice, and fewer years in practice predicted adherence.Conclusions:Child psychiatrists have generally not adopted the guidelines for monitoring children on second-generation antipsychotics. Interventions to improve monitoring should target child psychiatrists in nonacademic practices and those who have been out of training for longer periods. Future research should a...

Background and ObjectivePrescriptions for psychotropic medications to children have risen dramatically in recent years despite few regulatory approvals and growing concerns about side effects. Government policy and numerous programmes are attempting to curb this problem. However, the perspectives of practising clinicians have not been explored. To characterise the perspectives and experiences of paediatric primary care clinicians and mental health specialists regarding overprescribing and deprescribing psychotropic medications in children.MethodsWe conducted 24 semistructured interviews with clinicians representing diverse geographic regions and practice settings in the USA. Interview questions focused on clinician perspectives surrounding overprescribing and experiences with deprescribing. We transcribed audio files verbatim and verified them for accuracy. We analysed transcripts using a grounded theory approach, identifying emergent themes and developing a conceptual model using axial coding.ResultsAnalysis yielded themes within four domains: social and clinical contextual factors contributing to overprescribing, opportunities for deprescribing, and facilitators and barriers to deprescribing in paediatric outpatient settings. Most participants recognised the problem of overprescribing, and they described complex clinical and social contextual factors, as well as internal and external pressures, that contribute to overprescribing. Opportunities for deprescribing included identification of high-risk medications, routine reassessment of medication needs and recognition of the broader social needs of vulnerable children. Facilitators and barriers to deprescribing were both internal (eg, providing psychoeducation to families) and external (eg, parent and child preferences) to clinicians.ConclusionOur findings highlight a discrepancy between clinicians’ concerns about overprescribing and a lack of resources to support deprescribing in outpatient paediatric settings. To successfully initiate deprescribing, clinicians will need practical tools and organisational supports, as well as social resources for vulnerable families.

OBJECTIVE: To inform resource allocation towards a continuum of care for youth at risk of suicide, we examined unplanned 30-day readmissions after pediatric hospitalization for either suicide ideation (SI) or suicide attempt (SA). METHODS: We conducted a retrospective cohort study of a nationally representative sample of 133,516 hospitalizations for SI or SA among 6- to 17-year-olds to determine prevalence, risk factors, and characteristics of 30-day readmissions using the 2013 and 2014 Nationwide Readmissions Dataset (NRD). Risk factors for readmission were modeled using logistic regression. RESULTS: We identified 95,354 hospitalizations for SI and 38,162 hospitalizations for SA. Readmission rates within 30 days were 8.5% for SI and SA hospitalizations. Among 30-day readmissions, more than one-third (34.1%) occurred within 7 days. Among patients with any 30-day readmission, 11% had more than 1 readmission within 30 days. The strongest risk factors for readmission were SI or SA hospitalization in the 30 days preceding the index SI/SA hospitalization (Adjusted Odds Ratio [AOR]: 3.14, 95% Confidence Interval [CI] 2.73–3.61) and hospitalization for other indications in the previous 30 days (AOR: 3.18, 95%CI: 2.67–3.78). Among readmissions, 94.5% were for a psychiatric condition and 63.4% had a diagnosis of SI or SA. CONCLUSIONS: Quality improvement interventions to reduce unplanned 30-day readmissions among children hospitalized for SI or SA should focus on children with a recent prior hospitalization and should be targeted to the first week following hospital discharge.

There is significant comorbidity between autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD). For children with ASD, their functional impairment becomes more pronounced when ADHD is present. Despite ASD and ADHD being different disorders, they share etiological factors such as environmental factors, genetic factors, and neural pathways. If the referral questions regard ASD and ADHD, the clinician should establish a multistep approach for determining the presence, absence, or co-occurrence of these disorders. Assessment strategies for children with ASD and ADHD such as utilizing rating scales, obtaining a detailed history and examination of the child are reviewed. Furthermore, psychosocial interventions and psychopharmacologic interventions for children with ASD and ADHD are also discussed.

[Author Affiliation]Presenters: Hun Millard. 1 Geisel School of Medicine at Dartmouth, Department of Psychiatry, Lebanon, New Hampshire.Jennifer L. McLaren. 1 Geisel School of Medicine at Dartmouth, Department of Psychiatry, Lebanon, New Hampshire.Discussant: Barbara J. Coffey. 2 Icahn School of Medicine at Mount Sinai, Department of Psychiatry, New York, New York.Address correspondence to: Barbara J. Coffey, MD, MS, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1230, New York, NY 10029, E-mail: Barbara.coffey@mssm.eduChief Complaint and Presenting ProblemD. is a 13-year-old boy with intellectual disability and autism spectrum disorder (ASD), referred for evaluation of irritability and aggressive behavior.History of Present IllnessD.'s mother initially became concerned about his development in his first year of life. She described D. as an irritable, colicky, and fussy baby with whom it was difficult to bond. He made little eye contact, preferred to play alone, had sensory sensitivities (e.g., to rough textured foods and clothing tags), and lacked a reciprocal social smile. At 18 months of age he had no language and was delayed in gross and fine motor skills. By 19 months of age, he had undergone a comprehensive early developmental evaluation which included audiology and ophthalmology assessment, chromosomal analysis and fragile X study, magnetic resonance imaging (MRI) scan, Achenbach Behavior Checklist, and child development specialty consultation. Genetic testing revealed normal Fragile X study, normal Neogen screen, and normal DNA analysis. MRI scan was normal. Results indicated a diagnosis of pervasive developmental disorder.Subsequently, D. began to receive early intervention services including speech therapy, occupational therapy, and physical therapy. At 28.5 months, he was diagnosed with autism spectrum disorder by a developmental pediatrician because of his marked impairment in eye contact, lack of shared enjoyment, and poor social/emotional reciprocity. He enjoyed playing alone, and if left on his own he was reported to play for hours at a time, stacking blocks, aligning toys, and working with puzzles. D.'s language development remained delayed; he produced a variety of sounds, including humming and repetitive noises, but was unable to produce meaningful sounds or single words.D. struggled throughout his early childhood with underlying irritability and temper tantrums. Mother felt that his challenging behaviors could be managed with behavioral interventions, and D. received behavioral supports from an applied behavior analysis based program.D.'s mother described him as a fun-loving child who was active and enjoyed the Special Olympics. He was reported to have a strong interest in computers, and a fascination with Google images of movie covers, fires, and all things related to McDonald's and Burger King. Mother reported that D. often perseverated with one of these special interests, resulting in loss of temper and repeated aggressive behavior such as hitting himself when attempts were made to redirect him. Other aggressive behaviors included slamming the wall, throwing himself on the floor, hitting objects, and at times lashing out toward his mother, breaking her finger on one occasion. D.'s mother struggled with his insomnia, perseveration, anxiety, affective impulsivity, emotional dysregulation, self-abuse, and aggressive behaviors.By age 12, D.'s irritability, temper tantrums, and aggression had escalated. At times he punched himself so hard he was giving himself black eyes. He was also struggling with significant hyperactivity and impulsivity and needed constant redirection, as reported by mother and observed on office visits.Past Psychiatric HistoryThere was no past psychiatric history other than what was described.Developmental HistoryD. …

of hospitalization, and extra costs. Infect Control Hosp Epidemiol 1999;20:725–730. 3. Bratzler DW, Hunt DR. The surgical infection prevention and surgical care improvement projects: national initiatives to improve outcomes for patients having surgery. Clin Infect Dis 2006; 43:322–330. 4. ACOG practice bulletin number 47, October 2003: prophylactic antibiotics in labor and delivery. Obstet Gynecol 2003;102:875– 882. 5. Abramowicz M. Antimicrobial prophylaxis for surgery. Medical Letter 2004;2:27–32. 6. ASHP Therapeutic Guidelines on Antimicrobial Prophylaxis in Surgery. American Society of Health-System Pharmacists. Am J Health Syst Pharm 1999;56:1839–1888. 7. Bratzler DW, Houck PM. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis 2004;38:1706–1715.