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No greater obligation exists for child and adolescent psychiatrists than understanding how to take care of the most complex youths-those with serious emotional disorders (SEDs), co-occurring conditions, and multi-system involvement. Child and adolescent psychiatrists have the highest levels of training to assess the confluence of biological, environmental, and psychological factors affecting youths with complex behavioral health needs and to guide their treatment. With allied professionals expanding their capacity to take care of more straightforward behavioral health concerns, a clear domain of the child and adolescent psychiatrist becomes consultation, and at least a familiarity with working directly with the youths that are hardest to treat. Thus, it is vital that child and adolescent psychiatrists have an understanding of the treatment modalities available to treat youths with SED and complex behavioral health needs.

Objectives: This Clinical Perspectives will provide an overview of the key principles and concepts of systems of care to child and adolescent psychiatrists. The presentation will also review training issues and recent challenges addressed by systems of care and discuss the ongoing evolution of the approach. Methods: These presentations will result from a review of the literature with a focus on the recent AACAP Clinical Updates and Systems-Based Practice Tool Kits for trainees. In addition, speakers will present from their experiences as clinicians and policymakers in child-serving systems of care organizations. Results: William David Lohr, MD, will define the core values and guiding principles of systems of care. Kaye McGinty, MD, will review training issues related to preparing future child and adolescent psychiatrists for a systems-based practice. Lisa Fortuna, MD, MPH, will address current trials including disaster readiness and the COVID-19 pandemic, and how the systems of care philosophy may address these challenges. Jeff Bostic, MD, EdD, will review strategies that the National Training and Technical Assistance Center for Child, Youth, and Family Mental Health (NTTAC) employs to implement more effective systems of care programs. Melinda Jane Baldwin, PhD, LCSW, will address the future structure that systems of care may take as they evolve to better serve youth and families. Justine Larson, MD, will take themes of all presentations to summarize the essential elements of systems of care that are crucial for child and adolescent psychiatrists to understand. Conclusions: Systems of care approaches continue to evolve to improve the lives of youth and families to overcome challenges and reduce disparities. Training the future generation of child and adolescent psychiatrists in systems of care philosophies and practices will help clinicians better utilize their talents and skills within a systems-based practice. CC, DEI, PUP

The developmental impact of opioid use during pregnancy is a subject of ongoing debate. Short-term neonatal outcomes, such as lower birth weight and neonatal abstinence syndrome, are the most well-recognized outcomes. However, knowledge gaps exist regarding longer-term neurocognitive and mental health outcomes. In this article, we summarize an expert panel discussion that was held in April 2018 by the Substance Abuse and Mental Health Services Administration and attended by national experts in the field of perinatal opioid exposure and its impact on child development. Despite the challenges with research in this area, there is emerging literature revealing an association between neonates exposed to opioids in utero and longer-term adverse neurocognitive, behavioral, and developmental outcomes. Although adverse sequalae may not be apparent in the neonatal period, they may become more salient as children develop and reach preschool and school age. Multiple variables (genetic, environmental, and biological) result in a highly complex picture. The next steps and strategies to support families impacted by opioid use disorder are explored. Model programs are also considered, including integrated care for the child and mother, parenting supports, and augmentations to home visiting.

Objective Rapid growth of antipsychotic use among children and adolescents at the turn of the 21st century led Medicaid programs to implement 3 types of system-wide interventions: antipsychotic monitoring programs, clinician prescribing supports, and delivery system enhancements. This systematic review assessed the available evidence base for and relative merits of these system-wide interventions that aim to improve antipsychotic treatment and management. Method Using PRISMA guidelines, eligible studies were written in English and evaluated system-wide interventions to monitor antipsychotic treatment or promote antipsychotic management among children and adolescents (0–21 years of age). Studies were identified through Ovid MEDLINE and PsychInfo (years 1990–2018) and an environmental scan. From an initial review of 824 publications, 17 studies met eligibility criteria. Two authors independently conducted quality assessments using the Crowe Critical Appraisal Tool. Findings were summarized descriptively. Results Identified studies (n = 17) evaluated prior authorization programs (n = 10), drug utilization reviews (n = 2), quality improvement (n = 4), care coordination programs (n = 1), and multimodal initiatives (n = 2). Studies were predominantly pre-post analyses, without a comparison group. With the exception of care coordination and drug utilization reviews, more than half of the interventions in each category were associated with significant reduction in antipsychotic treatment or promotion of best practice parameters. Conclusion This evidence review concludes that evaluations of prior authorization programs demonstrate reductions in antipsychotic treatment, though evidence of impact of other system-wide interventions and other outcomes is limited. Additional research is necessary to investigate whether interventions influenced antipsychotic prescribing independent of secular trends, the comparative effectiveness and cost-effectiveness of interventions, the effect on functional outcomes, and the potential for unintended consequences.

Background and Objective. This study is a qualitative analysis examining caregivers’ expectations for pediatricians with regard to behavioral health care. Methods. Fifty-five parents/caregivers of children seen in an urban primary care clinic participated in semistructured interviews. Participants were parents or guardians of children between the ages of 2 and 17 years, referred from the pediatric clinic to the mental health center. Interviews were analyzed using grounded theory methods. Results. Pertinent themes were the following: expected range of care, components of an effective primary care provider (PCP) relationship, action of the PCP, and parent reaction to PCP intervention. Forty-seven percent of caregivers saw the PCP role as strictly for physical health care; 53% expected the PCP to have a role in both physical and behavioral health. Responses were overwhelmingly positive from caregivers when the PCP asked about or conducted a behavioral health intervention. Conclusion. Caregivers did not consistently expect but responded positively to PCPs engaging around behavioral health concerns.

In the past decade, there has been an increasing recognition by the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry of the need for pediatricians to improve competencies in assessing and treating behavioral health issues. 1The increased efforts dedicated to pediatrician education in behavioral health has resulted in significantly improved access to mental health services.2 A large proportion of children receiving services for behavioral health problems are now managed in primary care settings. 3 Despite these advances, surveys of pediatricians have demonstrated that while many recognize their role in identifying behavioral health problems, there are many pediatricians who are not regularly treating these disorders.4 They may not see treatment as their role or they may feel they lack the expertise, and time to provide these services. 4 Results of the American Academy of Pediatrics 2009 periodic survey revealed that less than one-third of the 1600 pediatricians surveyed saw it as their role to manage mental health issues beyond ADHD.3 Although some pediatricians don’t feel prepared to provide behavioral health care or see this as their role, a number of researchers have pointed out that some pediatricians possess many qualities that make them well-suited to provide such services.1The medical home literature has also cited the value of providing behavioral and mental health services in the pediatric setting, where there is less stigma, high levels of trust, and more familiarity for families.1,2,5 A qualitative analysis of semi-structured interviews with families was conducted to understand the parents’ expectations regarding the role of pediatricians in regards to behavioral health care. This qualitative analysis was part of a mixed-methods study of 55 parents whose children were referred for mental health care by their pediatrician; 36 of these 55 parents participated in a semi-structured interview. Parents were asked about their previous experience with the pediatrician providing behavioral health care, what role they see their pediatrician as playing in regards to the child’s behavioral health, the clinical encounter that resulted in a referral, and the parent’s reaction to these interventions. These interviews were analyzed using grounded theory methods by three independent coders. Through the analysis, themes emerged, out of which a code book was developed. Consensus regarding the themes was obtained through group discussion. An interesting theme entitled “truth discovery” emerged from the interviews, in which a number of families were reporting changes in the family dynamics and family structure through one clinical encounter with the pediatrician. In this report, we illustrate this process, which we are calling “family truth discovery,” by describing in some detail two parents’ accounts of the clinical encounter with the pediatrician. The pediatrician’s interaction with the child and family members was instrumental in revealed some truth in the family that was not known previously, altering the family dynamics that had been playing a role in the child’s behavioral health symptoms.

The aim of this study was to evaluate the association of parent-reported barriers on the likelihood of attending a mental health evaluation after referral from pediatric primary care. As the part of procedure, parents of children (N = 55) referred for mental health from primary care completed a 23-item questionnaire (three subscales; Cronbach alpha > 0.7): intangible barriers, tangible barriers, and child functioning. Logistic regression examined associations between responses and referral follow-through. The results showed that the high levels of intangible barriers were associated with decreased odds of attending the mental health evaluation (OR = 0.20, 0.06–0.83; P = 0.03). Therefore, we conclude that parental concerns about mental health care may be important for engagement in treatment.

This study examined how prior experiences of caregivers of children with attention-deficit hyperactivity disorder (ADHD) leading up to treatment related to later service use.The investigators interviewed caregivers of 48 children with ADHD recruited from outpatient clinic settings and recorded the children's medication use and clinic attendance six and 12 months later. Interview transcripts were analyzed to identify characteristic experiences, or themes, felt by the caregivers before seeking treatment. The investigators also looked for patterns in the way themes were endorsed.Caregivers' experiences with the children's ADHD were characterized by six main themes-caregiver strain, attribution of meaning, perception of responsibility, problem-solving approach, beliefs about ADHD treatment, and response to societal influences. Based on distinct patterns in which they endorsed the six themes, caregivers were classified as motivated by observation (high on theme of perception of responsibility and low on theme of caregiver strain; 27%), motivated by experience (positive attribution of meaning and beliefs about ADHD treatment and low on strain; 19%), motivated by strain (high on strain, uncertain attribution of meaning, and contradictory societal influences; 23%), and struggling with meaning (high on strain, nonmedical attribution of meaning; 31%). At 12 months, children of caregivers who were motivated by experience were the most likely and those struggling with meaning were the least likely to attend clinic appointments (89% and 53%, respectively, p=.017). The groups did not vary in medication use.Early identification of the factors influencing caregivers' use of services for children with ADHD may have implications for treatment retention.

Anxiety disorders are extremely common in the pediatric population, with prevalence estimates ranging from 12 to 20% (Achenbach, Howell, McConaughy, & Stanger, 1995; Costello, Mustillo, Erkanli, Keeler, & Angold, 2003; US Surgeon General, 1999). In the last 10 years, important advances in the psychopharmacologic treatment of childhood anxiety disorders include the increasing evidence of the efficacy of selective serotonin reuptake inhibitors (SSRIs) (Birmaher et al., 2003; Research Unit on Pediatric Psychopharmacology Anxiety Study Group, 2001; Rynn, Siqueland, & Rickels, 2001; Walkup et al., 2008). The major pediatric anxiety disorders can be divided into the following four main groups: (1) generalized anxiety disorder (GAD), separation anxiety disorder (SAD), social phobia (SoP), and specific phobia, which are often considered together and is the most common group of childhood anxiety disorders; (2) panic disorder with and without agoraphobia is less common in children, and is considered separately; (3) acute stress disorder and posttraumatic stress disorder (PTSD); and (4) obsessive–compulsive disorder (OCD). Selective mutism has also been included as a childhood anxiety disorder as it may be a form of SoP (Black & Uhde, 1994).

There is a critical shortage of child and adolescent psychiatrists in the United States. Increased exposure, through mentorship, clinical experiences, and research opportunities, may increase the number of medical students selecting child and adolescent psychiatry (CAP) as a career choice. Between 2008 and 2011, 241 first-year participants of a program to increase exposure to CAP, funded by the Klingenstein Third-Generation Foundation (KTGF) at 10 medical schools completed baseline surveys assessing their opinions of and experiences in CAP, and 115 second-year participants completed follow-up surveys to reflect 1 year of experience in the KTGF Program. Students reported significantly increased positive perception of mentorship for career and research guidance, along with perceived increased knowledge and understanding of CAP. Results suggest that the KTGF Program positively influenced participating medical students, although future studies are needed to determine whether these changes will translate into more medical students entering the field of CAP.

The handwashing practices and bacterial hand flora of 62 pediatric staff members of a teaching hospital in Lima, Peru, were studied. Handwashing followed patient contact 29.3% of the time (204/697 contacts). Mean duration was 14.5 seconds, and significant differences in practices were found by unit (rehydration or neonatal intensive care), type of staff member (nurses or physicians), and type and duration of patient contact. Mean count of colony-forming units was log 10 5.87 ± 0.41, with significant differences in density of flora found between patient care and kitchen staffs. There was no significant effect of handwashing on counts of colony-forming units. Significant differences were also found by unit and by staff position with regard to species isolated and antimicrobial resistance of isolates. A more efficacious and cost-effective form of hand hygiene and a more prudent use of antimicrobial agents are indicated.