Adolescent Clinic Research Articles

Encouraging improvement in HPV vaccination coverage among adolescent girls in Kampala, Uganda.

WHO recommends vaccination against HPV for girls before sexual debut. Uganda started HPV vaccination in 2008 as pilot programs in 2 districts, followed by national roll out in 2015. Despite the availability of vaccines against human papillomavirus (HPV) in Uganda in the period covered by the study, there was reported low HPV vaccine uptake and completion especially of the second dose in Uganda; with little information available on timely completion of HPV vaccine and the associated factors in Uganda. This study was therefore done to determine the HPV vaccine dose 2 completion and describe the possible factors associated with timely HPV vaccine completion and non-completion among girls of age 9-14 years attending the adolescent clinic at Mulago hospital. A retrospective mixed methods study was conducted in Mulago National Referral hospital adolescent clinic. Data were mainly collected through review of charts and folders for clinic attendance by eligible girls and focus group discussions with eligible girls that completed the 2 doses of HPV vaccine on recommended/scheduled time. Out of the 201 girls studied, 87 girls (43.3%) had timely completion of the HPV vaccination. Knowledge about HPV infection and HPV vaccine benefits, positive peer influence and healthcare worker recommendation to get vaccinated at health facility level positively influenced timely completion of HPV vaccine. Among barriers to completion of HPV vaccine identified were: inadequate information about HPV infection and HPV vaccine, concerns about HPV vaccine efficacy and safety, unclear communication with adolescents/caregivers from healthcare workers and -stock out of the HPV vaccine. Timely completion of the second dose of HPV vaccine among girls attending the adolescent clinic of Mulago hospital was low (at 43.3%) but higher when compared to earlier published reports. Interventions around improved social mobilization, enhanced outreach and static vaccination approach and education of eligible girls on HPV vaccination can help increase vaccine uptake.

Acceptability and Feasibility of Peer-to-Peer Text Messaging Among Adolescents to Increase Clinic Visits and Sexually Transmitted Infection Testing: Interrupted Times-Series Analysis

BackgroundAdolescents are disproportionately affected by sexually transmitted infections (STIs), including HIV. Many youths with asymptomatic STI or related symptoms do not seek treatment and may not be screened if accessing the health care system for other reasons.ObjectiveWe examined intervention completion and changes in the number of new patients, the number of STI or HIV tests, and the sexual risk profile of patients over time to determine the feasibility and acceptability of a peer-driven text messaging strategy to connect youth to STI and HIV services.MethodsThe intervention enlisted consecutive patients at an adolescent medicine clinic to send a text message to 5 peers they believed were sexually active and lived in the clinic’s service area. The intervention was evaluated using an interrupted time-series design in which baseline clinic service levels were documented during a 35-week lead-in period, followed by a 20-week intervention implementation period, and a 16-week period of continued clinic observation. Clinic and patient data were obtained through chart abstraction from intake forms that occurred during the entire study period. Analyses conducted in 2015 used a generalized linear mixed model.ResultsOf the 153 patients approached to participate, 100 agreed to send SMS text messages. Most (n=55, 55%) reported no concerns with sending the text message. No adverse events or negative outcomes were reported. Adolescent STI testing, positive test results, and reported risk behavior increased post intervention, although this was not statistically significant, likely because of the small sample size.ConclusionsGiven low youth uptake of health care services, and STI/HIV screening, in particular, new strategies are needed to address access barriers. Common approaches for reaching youth are resource-intensive and often miss those not connected to school or community programs. The peer-based text messaging strategy showed promise for both increasing the number of youths accessing health services and finding youths engaging in sexual risk behaviors and most in need of sexual health screening and services.

Cognitive behavioural group therapy as addition to psychoeducation and pharmacological treatment for adolescents with ADHD symptoms and related impairments: a randomised controlled trial

BackgroundCognitive behavioural therapy (CBT) is recommended for attention-deficit/hyperactivity-disorder (ADHD) in adolescents. However, all CBTs are not created equal, and the guidelines do not specify which CBT interventions are the most effective for this patient group. This study examines the efficacy of a group CBT without parent involvement as follow-up treatment compared to no additional CBT in adolescents with persistent and impairing ADHD symptoms after a short psychoeducational intervention and medical treatment.MethodsThe authors conducted a two-arm parallel randomized controlled trial in two child and adolescent mental health outpatient clinics in Norway. One hundred patients aged 14–18 years with a diagnosis of ADHD (66%) or subthreshold ADHD (34%) were randomized to either a 12-week group CBT program (N = 50) or a non-CBT control condition (N = 50). Assessments were made at admission to the clinic, two weeks before and two weeks after treatment. The primary outcomes were parent-, teacher- and self-ratings of ADHD symptoms (ADHD Rating Scale-IV), and the secondary outcomes were ratings of ADHD symptom severity, executive function, functional impairment, and emotional problems. Evaluators blinded to group allocation rated ADHD symptom severity with the Clinical Global Impression Scale for Severity (CGI-S) at baseline and post-treatment.ResultsAnalyses using mixed-effects models showed no difference between the treatment arms from baseline to post treatment in primary and secondary outcomes.ConclusionsContrary to our hypothesis, we found no incremental treatment effect on the part of a group CBT as follow-up to psychoeducation and pharmacological treatment on ADHD symptoms and accompanying impairments. Limitations with the CBT was the large number and low dosage of treatment components, causing restricted time for practice. Unlike evidence-based, individualized targeted CBTs with parent involvement, a group CBT directed solely at the adolescents with no parent involvement does not appear effective for treating ADHD.Trial registrationNCT02937142, 18/10/2016.

118 Contraception practice and knowledge of IUD among teenagers and young women

Purpose: This study investigates the contraceptive methods used by adolescent and young women and their knowledge and attitudes on the IUD. Materials and methods: A structured questionnaire was filled by 100 participants attending a Pediatric and Adolescent Gynecology clinic. Questions were asked on demographics, relationships, methods of contraception used and perceived effectiveness with emphasis on the IUD and issues associated with it. Results: Young women in Greece use mainly the condom as a method of contraception and 2/3 of them believe that it is very reliable although one third of them uses it consistently.

112 Ovarian cysts and masses in childhood and adolescence

Objective: To determine the presentation, diagnosis and management of ovarian cysts and masses in children and adolescents. Study design: A retrospective cohort study of children and adolescents with ovarian cysts and masses aged 18 years or younger, presenting to a tertiary referral reproductive medicine unit between 2013 and 2018 was performed. Data were primarily collected using computerized medical notes. The following were noted: age at presentation, diagnostic outcomes, types of management and post-intervention follow up. Results: 60 children or adolescents with ovarian cysts or masses were identified. The median age of diagnosis was 14 years. Seventy-one per cent of patients were post-menarche at presentation. The most common presentation was abdominal pain or discomfort with 49 (82%) patients presenting in this way. Imaging identified 41 (65%) simple cysts, 20 (32%) complex cysts and 2 (3%) ovarian torsions. Three (5%) patients had bilateral cysts. Diagnostic laparoscopy was performed in 10 (17%) patients. Ovarian surgery was performed in 27 (45%) patients, with 9 (33%) patients having an oophorectomy and 20 (74%) being laparoscopic. The commonest diagnoses were mature cystic teratoma and hemorrhagic cyst. Two (3%) malignancies were diagnosed. Follow up within a Pediatric and adolescent gynecology clinic occurred in 30 (50 %) patients. Conclusion(s): This retrospective cohort study demonstrates that the majority of children or adolescents presenting with an ovarian cyst or mass present post-menarche. Most patients had a benign cyst, commonly a mature cystic teratoma or hemorrhagic cyst, and were treated conservatively or with minimal access ovary-sparing surgery.

La dysmnésie en mémoire à long terme sémantique ou les difficultés scolaires diffuses : un cas clinique

Semantic Dysmnesia is a disorder that is not often mentioned in the literature and is not well identified in child and adolescent clinics, although some studies on this disorder put forward a prevalence of about 6%. We present the case of Léthé which illustrates both the clinical picture and two hypotheses put forward in the literature to explain the lack of recognition. This clinical case was focused on the realization of a psychological assessment following the first alert in order to propose guidelines to identify the cognitive disorder with the WISC-V as a first intention and complementary batteries on the transversal cognitive functions. This case study completes the literature on the clinical elements to be identified and on the etiology of dysmnesia.

Exploring Use Patterns and Racial and Ethnic Differences in Real Time Affective States During Social Media Use Among a Clinical Sample of Adolescents With Depression: Prospective Cohort Study.

BackgroundIncreasing youth mental health problems over time correlate with increasing rates of social media use (SMU); however, a proposed contributory relationship remains unproven. To better understand how SMU impacts mental health requires a more nuanced understanding of the relationship between different patterns of SMU and specific individual factors. Studies suggest that more active forms of SMU may offer mental health benefits when compared with more passive forms. Furthermore, the literature suggests important differences in patterns of SMU and affective states among those identifying as racial and ethnic minorities.ObjectiveUsing ecological momentary assessment (EMA), this study aims to investigate potential differences in affective states during active and passive forms of SMU and whether such differences vary by race and ethnicity.MethodsWe recruited patients seeking care at a large urban adolescent medicine clinic who exhibited at least mild depressive symptoms based on Patient Health Questionnaire-9 (PHQ-9) scores. Participants completed an enrollment survey and a 7-day EMA protocol, receiving 5 EMA questionnaires per day, which assessed real time SMU behaviors and affective states using the Positive and Negative Affect Schedule–Expanded form subscales. To correct for nonindependent data with EMA responses clustered within individuals, data were analyzed using mixed-effects modeling, allowing for a random intercept at the individual level to examine associations between EMA-reported SMU and affective states while adjusting results for age, gender, race and ethnicity, PHQ-9 score, and EMA response rate.ResultsA racially and ethnically diverse group of 55 adolescents aged 14 to 19 years provided a total of 976 EMA responses, averaging 17.76 (SD 8.76) responses per participant, with a response rate of 51.15%. Participants reported higher mean levels of negative affect during active SMU (F1,215=3.86; SE 0.05; t1,215=1.96; P=.05) and lower mean levels of positive affect during passive SMU (F1,369=3.90; SE 0.09; t1,369=–1.98; P=.049). However, within different racial and ethnic groups, higher levels of negative affect during moments of active SMU were seen only among Black non-Hispanic participants: F1,81=6.31; SE 0.05; t81=2.51; P=.01). Similarly, lower levels of positive affect during passive SMU were seen only among White non-Hispanic participants (F1,295=10.52; SE 0.13; t295=–3.24; P=.001).ConclusionsAlthough in aggregate, adolescents with depressive symptoms experienced more negative affect during active SMU and less positive affect during passive SMU, these mean outcomes were driven solely by greater negative affect during active SMU by Black non-Hispanic participants and lower positive affect during passive SMU by White non-Hispanic participants. Differences in intentionality, content, context, and expectations of SMU among youths across racial and ethnic groups may result in different affective outcomes. Exploration of the interactions among cultural differences in SMU strategies and characteristics will be critical to furthering our understanding of the impact of SMU on youth mental health.

Prevalence of Anxiety Disorders in Chinese Children with Autism Spectrum Disorder in Hong Kong

Background: Autism spectrum disorder (ASD) is a pervasive neurodevelopmental disorder. Children with ASD are faced with various challenges considering their lifelong neurodevelopmental disabilities. Comorbid psychiatric disorders are found to be prevalent among children with ASD. Anxiety disorders are one of the most prevalent psychiatric comorbidities in this population and have been associated with debilitating psychosocial impairment. Objective: This study aimed to examine the prevalence of comorbid anxiety disorders among Chinese school-age children diagnosed with ASD in a child and adolescent psychiatry outpatient clinic in Hong Kong. Methods: This cross-sectional study was conducted at the Yaumatei Child and Adolescent Mental Health Service specialist outpatient clinic from August 2019 to April 2020. The sample consisted of one hundred thirty-two subjects aged 6 to <12 years who were diagnosed with ASD. The Developmental, Dimensional and Diagnostic Interview were administered to confirm the diagnosis of ASD. The National Institute of Mental Health Diagnostic Interview Schedule for Children-Version 5, parent version was administered for the assessment of comorbid anxiety disorders. Results: The one-year prevalence rate of any anxiety disorder was 28.8%. The most common anxiety disorder was specific phobia (22.7%), followed by social anxiety disorder (13.6%), separation anxiety disorder (3.8%), generalized anxiety disorder (3.8%) and selective mutism (1.5%). No subjects were diagnosed with panic disorder or agoraphobia. Conclusion: Anxiety disorders are prevalent among Chinese school-age children with ASD in Hong Kong. Early recognition and identification of comorbid anxiety disorders are necessary in the diagnostic process of ASD.

Changes in Prosocial Behaviors Among Children With Behavioral Problems Following Incredible Years Parenting Program.

Parenting programs often train parents in improving their parenting practices and parent-child relationship to reduce behavioral problems in children. However, the children’s prosocial behaviors are less examined as an intervention outcome in these programs. This study aimed to evaluate the effectiveness of the Incredible Years parenting program (IYPP) for Malaysian parents of school-going children and its sustainability in improving the children’s prosocial behaviors. This randomized controlled study involved pre- and post-intervention assessments at 2 and 14 weeks. Mothers of children aged 6-12 years (n = 70) recruited through the pediatrics and the child and adolescent psychiatric clinics were randomly assigned to the parenting program or a waitlist control condition. The mothers rated their children’s prosocial behaviors using a self-administered questionnaire. The program ran two to three hours weekly for 14 weeks. Several modifications were made to the program to accommodate public health control during the pandemic. Children in the intervention group showed a notable but non-significant increase in prosocial skills. However, subsequent score decline at follow-up may suggest a lack of evidence that the program is potentially effective in improving prosocial behaviors among school children who are at risk of or already having behavioral problems.

Elevated Anxiety and Depression Symptoms in Injured and Uninjured Adolescents

Introduction:Musculoskeletal injuries are common among adolescents with roughly half reporting an injury in the last year. Injury impairs function, but it may impact psychological or behavioral well-being as well. Mental health concerns such as anxiety and depression can negatively affect an adolescent’s quality of life. As mental health disorders are being seen more frequently in the young population it is important to understand their relationship with injury. Athletes who are no longer able to participate in their normal activities due to injury may have elevated symptoms of anxiety and depression from this sudden lifestyle change. The purpose of this study was to determine if a musculoskeletal injury is associated with elevated anxiety and depression in adolescent athletes.Methods:Adolescents between the ages of 12-18 from sports medicine clinics presenting with musculoskeletal injuries were age and sex matched to non-injured adolescents from high school health and weight training classes as well as adolescent medicine clinics. The General Anxiety Disorder-7 and Patient Health Questionnaire-9 were used to assess for anxiety and depression symptoms, respectively. Scores of ≥5 on each questionnaire were considered elevated. Chi-Square analyses analyzed the differences in proportions of elevated anxiety and depression in the injured and uninjured participants.Results:Matched data was available for 108 participants, 54 in each group. Average age was 15.99± 1.58 and 83% were females. Overall, 41% reported elevated anxiety symptoms and 36% reported elevated depressive symptoms. There were no differences in the proportion of injured adolescents that had elevated anxiety or depression compared to uninjured adolescents (p=.386 and p=.071, respectively).Discussion:Elevated anxiety and depressive symptoms are common among injured and non-injured adolescents. High rates in our sample could be impacted by the predominance of female participants, as female are more likely to experience this symptomology than males. It is possible that the severity of the injury may influence anxiety and depression symptoms, which we did not assess. In addition, participants were enrolled during COVID-19, which may have influenced the rates of elevated anxiety and depression symptoms. Elevated anxiety and depressive symptoms are associated with high levels of functional impairment. Therefore, adolescents should be routinely assessed for anxiety and depression, regardless of injured status.

Retrospective Review of Forensic Cases Referred to the Child and Adolescent Psychiatric Outpatient Clinic

Background: The aim of this study is to explore the cause of forensic report orders, socio-demographic characteristics and comorbid mental disorders in children and adolescents passed to court for any reason and referred to a child and adolescent psychiatry outpatient clinical by judicial authority in Şanlıurfa province. Materials and Methods: In this study, we retrospectively reviewed files of 64 cases which referred to a child and adolescent psychiatry outpatient clinic for forensic psychiatric assessment between December, 2018 and December, 2020. The socio-demographic characteristics, the event underlying referral, coverage of question asked by judicial authority, smoking or alcohol and substance abuse, intelligence level, comorbid mental disorders and socio-demographic characteristic of parents were reviewed in children referred by judicial authorities. We used the Chi-square test to compare socio-demographic characteristics and comorbid psychiatric diagnoses and The Mann Whitney U test to compare numerical variables. Results: It was found that 46.9% of the children were referred due to juvenile delinquents while 12.5% due to being subjected to abuse and 25.0% due to early marriage. Of the juvenile delinquents, 90% were boys with median age of 15 years while 62.5% of victims were girls with median age of 13.5 years. The findings show that 63.3% of juvenile delinquents and 62.5% of victims were not attending to school. The incidence of psychiatric diagnosis was 53.3% among juvenile delinquents while it was 50% among victims. All of the children presented with request of early marriage were girls with median age of 16 years. The results show that 43.8% of cases were pregnant at presentation and 93.8% did not receive education appropriate for their age. Conclusions: It was found that more than one-half of juvenile delinquents and victims were not attending school in that study. In addition, it was found that male gender preponderance was observed among juvenile delinquents. There is a need for further studies to determine groups of under risk.

Design of a Rheumatology Transition Clinic for a Resource-Constrained Setting.

To describe the design process of a medical care program for adolescents with pediatric onset rheumatic diseases (PRD) during the transition from pediatric to adult care in a resource-constrained hospital. The model of attention was developed in three steps: 1) the selection of a multidisciplinary team, 2) the evaluation of the state of readiness of patients and caregivers for the transition, and 3) the design of a strategy of attention according to local needs. The results of the first two steps were used in order to develop the strategy of attention. The transition process was structured in three stages: pretransition (at pediatric rheumatology clinic), Transition Clinic for Adolescents with Rheumatic Diseases (TCARD, the main intervention), and post-transition (at adult rheumatology clinic). Each stage was divided, in turn, into a variable number of phases (8 in total), which included activities and goals that patients and caregivers were to accomplish during the process. A multidisciplinary approach was planned by pediatric and adult rheumatologists, nutritionists, physiatrists, psychiatrist, psychologist, nurse, and social worker. During TCARD, counseling, education, nutritional, physical, and mental health interventions were considered. The proposed transition model for patients with rheumatic diseases can be a useful tool in developing countries.

Parental Attitudes and Beliefs toward Attention Deficit Hyperactivity Disorder in Prince Sultan Military Medical City, Riyadh City

The present study was designed to investigate attitudes and beliefs among parents of patients with attention deficit hyperactivity disorder (ADHD), with regard to symptoms, causes, prognosis, and management. The study was of a cross-sectional descriptive design including 283 parents of patients with ADHD (preschool, primary school, and adolescent). It was conducted at child and adolescent outpatient clinics in Prince Sultan Military Medical City, Riyadh to assess parents’ knowledge, attitudes, treatments, and beliefs regarding ADHD. Among 283 parents, 59.8% believed that diet could improve ADHD symptoms. Approximately 75% of parents believed that ADHD is a form of misbehavior rather than a neurodevelopmental disorder, whereas 55.6% believed that ADHD is a genetic disease. In total, 89% of parents wanted to treat their children by receiving specialist advice and recommendations. A significant and nonsignificant correlation between gender and preschool and primary school was recorded, respectively. However, a positive correlation was recorded between age and caregiver’s education in adolescents. Since parents’ attitudes and perceptions were poor overall, the mismanagement of ADHD was noticed. Furthermore, government-level media campaigns should be implemented to enhance parents’ knowledge and debunk myths in order to improve ADHD management.

How did the COVID-19 pandemic affect child and adolescent psychiatry outpatient clinic admissions? A single-center, retrospective study.

Background:The COVID-19 pandemic and the measures for controlling the pandemic adversely affected child and adolescent mental health; however, studies that examined the effects of the pandemic on child and adolescent mental health services are limited. This study aimed to determine the changes in admission to a child and adolescent psychiatry outpatient clinic (CAPOC) in the first year of the COVID-19 pandemic compared with the previous year.Methods:In this study, the information regarding admissions to Başkent University Faculty of Medicine’s CAPOC between March 2019 and March 2021 was examined. Information including age, sex, admission date, the form of admission (first admission/follow-up), and the diagnosis was obtained from the electronic medical record system and the differences between the pre-pandemic period and the pandemic period were assessed.Results:It was found that during the pandemic, there was a decrease in CAPOC admissions; however, both female admissions and median age increased compared with the previous year. Also, admissions due to obsessive-compulsive disorder and somatic symptom-related disorders increased.Conclusions:Although there were fewer CAPOC admissions during the pandemic period compared with the pre-pandemic period, there were differences between the age, sex, and diagnosis distributions of the patients between the pandemic and the pre-pandemic period. Understanding the impact of the COVID-19 pandemic on CAPOC admissions will help plan child and adolescent mental health protective measures.

P027 Challenges and opportunities in embedding quality data into routine clinical practice using electronic health record systems

Abstract Background/Aims The emergence of the electronic health record system (EHRS) creates opportunities for standardising clinical data which can be used for service improvement and research. However, there are also challenges related to EHRS use particularly with respect to data quality and availability. In this project, our goal is to enhance the use of EHRS to enable timely access to reliable high quality clinical data which can be used for research and Quality Improvement. We aimed to improve the entry of structured clinical data starting with problem list, medication list and core outcome variables by 70% within 12 months. Methods We audited our current practice and developed an improvement strategy to incorporate standardized documentation into our adolescent and young adult (AYA) rheumatology clinics. We initially extracted a baseline report for AYA patients to establish our baseline data quality and availability. We also compared structured data to narrative data. Then we organised meetings to develop a shared understanding of the challenges. Subsequent departmental meetings were organised to prioritise and then agree on actions which were summarised in a driver diagram. Then we ran 5 cycles of change and measured data over time including the weekly proportion of clinic encounters using standardised problem lists, medication lists, core outcomes variables. We also measured the use of Smart tools built within our EHRS. Smart-Tools are processes that enable efficiency through easier ordering, navigation and documentation in an EHRS. Using the patient interface ‘MyCare’, we engaged with our patients to encourage them to prepare for their appointment including updating their medication list and completing health questionnaires. Results Initial audit comparing structured and narrative data, revealed poor quality data with 50% of problem lists documented in a structured manner. Of those, 20% were not entered correctly. 70% of medication lists were entered in a non-structured manner. 80% of those with structured medication lists were entered inaccurately. There was no structured documentation of core outcomes variables or joint examination in all encounters which was also inconsistently entered in the free text. Over the last 12 months, 5 cycles of change were implemented testing a number of interventions including developing clinic encounters templates and smart tools within EHRS. The weekly entry of structured problem list improved from 50% to 98%. The Smart-Phrase use and AYA template weekly use rate improved from 0% to 70% and the entry of core outcome variables has improved from 0% to 30% of cases. Conclusion This project supports the feasibility of implementing standardized data into routine clinical practice that can be used for research and service improvement. This has created an opportunity to improve data quality and accuracy. Most importantly, this work has facilitated a standardisation of clinical practice and better engagement between clinicians and patients. Disclosure A. Bouraoui: None. C. Fisher: None. D. Sen: None.

Association between sleep indicators and eating habits in adolescents

Objective: To analyze the association between sleep quality indicators and eating habits in adolescents. Material and Methods: This is a cross-sectional study conducted with adolescents (age 10-19 years) followed up at the Adolescent Outpatient Clinic. Anthropometric and body composition parameters, sleep quality indicators, and eating behavior were evaluated. Body composition was measured using electrical bioimpedance. Sleep quality was assessed by the Pittsburg Sleep Quality Index (PSQI), excessive daytime sleepiness by the Epworth Sleepiness Scale (ESS), eating behavior was assessed by the Brazilian Food Frequency Questionnaire (FFQ). Linear regression analyses were used to verify the association between outcome and independent variables. Results: Thirty-five adolescents (mean age 12.9 ± 2.0 years old) were evaluated. There was a significant association between BMI and daytime sleepiness (p=0.010), fat mass (%), and sleep quality (p=0.046) while drinking at least 5 glasses of water was associated with sleep efficiency (p=0.029). Adjusted linear regression showed that BMI (β= -0.364; p=0.001) and age (β= -0.30; p<0.001) were negatively associated with hours of sleep, whereas blood pressure (β= 0.196; p<0.001) and the frequency of consumption of the group of cereals, tubers, and pasta (β=1.451; p<0.001) were positively associated. Conclusion: Adolescents with a higher % fat mass and BMI showed worse sleep quality and daytime sleepiness. Drinking at least five glasses of water can improve sleep efficiency. The consumption of cereals, tubers, and pasta, can contribute to longer sleep duration.

Research Audit on Clinical Utility of Dimensional Disruptive Mood and Behavior Psychopathologies in Child and Adolescent Psychiatry Practice

To investigate the utility of dimensional psychopathologies of disruptive mood and behavior disorders (DBDs) by applying latent profile analysis (LPA) for characterization of youth referred to the tertiary outpatient clinic of child and adolescent psychiatry clinic and pharmacological treatment choices. One hundred fifty-eight children and adolescents with significant DBDs symptoms participated. Core dimensional psychopathologies of DBDs (irritability, callous-unemotional trait, and reactive-proactive aggressive behavior), DSM diagnoses, prescribed medications, and behavioral and emotional problems (Child Behavior Checklist, CBCL) were measured at baseline (clinic intake) and at 3-month follow-up. Latent Profile Analysis (LPA) was applied to characterize the study population based on the levels and interrelations among the core dimensional DBDs psychopathologies. Following LPA, the differences in clinical and treatment features between the latent classes were analyzed. LPA revealed two latent classes based on severity of DBDs symptoms. Class 1 (the moderate group) was characterized by relatively low scores on all trans-diagnostic indicators, whereas class 2 (the severe/critical group) showed higher levels of the dimensional psychopathologies and the majority of CBCL subscales. In addition, the severe/critical group was more often prescribed antipsychotic medications, and also experienced more frequent medication changes (addition, increasing the dose, and trial of different medications). Our findings suggested that application of LPA to a cluster of dimensional DBDs psychopathologies may provide valuable characterization of the youths referred to a tertiary outpatient child and adolescent psychiatric clinic, and offer insight into the providers' decision making on psychotropic medications, by overall severity of these psychopathologies rather than by single categorical diagnosis or single externalizing psychopathology.

Use of the Levonorgestrel Intrauterine System to Treat Heavy Menstrual Bleeding in Adolescents and Young Adults with Inherited Bleeding Disorders and Ehlers-Danlos Syndrome.

To report on the rate of amenorrhea among adolescents and young adults with a bleeding diathesis after insertion of the 52-mg levonorgestrel intrauterine system (LNG-IUS) DESIGN: Retrospective chart review SETTING: Tertiary care, multidisciplinary Gynecology-Hematology clinic or Adolescent Gynecology clinic PARTICIPANTS: The cohort included 35 females aged 12-25 years presenting from January 2010 to January 2020 with heavy menstrual bleeding, 23 with an inherited blood disorder, and 12 with Ehlers-Danlos syndrome INTERVENTIONS: The 52-mg LNG-IUS MAIN OUTCOME MEASURES: Primary outcome was bleeding profile after LNG-IUS insertion. Secondary outcomes included rates of amenorrhea, intrauterine device (IUD) expulsion, IUD discontinuation, and unplanned pregnancy. Mean age at menarche was 11.6 years, with mean age at insertion of 16.9 (range 11-23). Most participants were white (n=26, 74.3%). Von Willebrand disease was present in 16 patients (45.7%) and Ehlers-Danlos syndrome in 12 (34.3%). Most (91.4%) had tried at least 1 hormonal regimen prior to LNG-IUS. Most participants (81.8%) reported improvement in bleeding, with 60.6% reporting spotting or amenorrhea. LNG-IUS expulsion occurred in 3 participants (9.1%) within the first 21 days, despite hemostatic agents at time of insertion. Mean continuation was 5.08 years (95% CI, 4.24-5.92), with 79% likelihood that participants kept their IUD in place for at least 2.5 years, and some up to 6 years. The 52-mg LNG-IUS is an effective treatment option for adolescents and young adults with heavy menstrual bleeding and a bleeding diathesis, with high rates of amenorrhea. Rates of IUD expulsion appeared higher during the first 30 days, but long-term continuation remained high.

Pharmacists on mental health teams benefit youth

COVID-19 has intensified the “mental health pandemic,” said Julie Dopheide, PharmD, BCPP, FASHP. What’s worse is that access to mental health care continues to be a challenge for individuals. Dopheide and coauthors of a new paper published in Child and Adolescent Psychiatric Clinics of North America believe that clinical pharmacy is underutilized within the mental health space. In the paper, the authors share how clinical pharmacists and psychiatric pharmacists can improve care for children and adolescents with mental health diagnoses. “Youth are increasingly prescribed psychiatric medications, and they are vulnerable to drug interactions and adverse effects and need special monitoring and education on the benefits and potential risks of psychiatric medication,” said Dopheide, who is a professor of clinical pharmacy, psychiatry, and the behavioral sciences at the University of Southern California School of Pharmacy and Keck School of Medicine in Los Angeles. Dopheide said job opportunities for mental health pharmacists, particularly BCPPs, are increasing nationwide. BCPS and BCACP pharmacists also have a role in mental health, she noted. “Mental health settings are inherently multidisciplinary and psychiatric treatment teams are very open to clinical pharmacy,” said Dopheide. While some psychotropic medications are prescribed off-label to youth, many commonly prescribed medications have been studied in this age group with clear labeling on dosing and monitoring to ensure they can be given safely. “Pharmacists need to actively stay abreast of which psychiatric medications are the most well-studied in youth so these can be recommended over off-label, less well-studied mental health medications,” said Dopheide. A 2015 study from the Office of the Inspector General (OIG) on youth prescribing of antipsychotics in 5 states found that two-thirds of the 485 medical records reviewed demonstrated quality-of-care concerns, including poor monitoring (53%) and inappropriate treatment (41%). OIG and FDA even warn that children and adolescents need metabolic syndrome monitoring when prescribed antipsychotic medications. Research has found higher rates of sedation, weight gain, tachycardia, and agitation in youth given psychotropics compared with adults. Not only does evidence point to an increased risk for type 2 diabetes in youth taking antipsychotics, but emerging evidence suggests this is also the case with SSRIs given to youth. However, some county and state mental health departments are waking up to this and partnering with pharmacists to improve medication therapy monitoring. Several states—including Texas, Indiana, and California—have published pediatric psychotropic guidelines or practice parameters developed through collaborations between child psychiatrists and psychiatric pharmacists to elevate the quality of care for children and adolescents. Many states include child psychiatrists collaborating with pharmacists on Medicaid pharmacy and therapeutics committees and drug utilization review boards to improve medication safety. Clinical pharmacists are not regularly involved in mental health treatment teams even though they’ve been able to improve the quality of care for patients. “While medication management is an important component of the care plan, unfortunately, due to limited resources for mental health, the pharmacist is often not included in the mental health care team,” said Debbie Lu, PharmD, MPH, lead author of the paper and assistant professor at Touro University California College of Pharmacy. Psychiatry teams are more likely to hire therapists or case workers as their allied health staff. However, there are health systems, such as Kaiser Permanente, that have benefited from having dedicated mental health pharmacists on the team. The paper presents case studies in different settings to show how a collaboration with a psychiatrist and pharmacist can work in real life. “A psychiatric pharmacist can review medication administration records and screen for drug interactions to discuss with the child psychiatrist and child fellows,” said Dopheide. “The psychiatric pharmacist can participate in daily treatment planning to bring up pertinent drug therapy issues, such as the need for monitoring for metabolic syndrome or hyperprolactinemia with antipsychotics.” Another common way child psychiatrists and clinical pharmacists collaborate is through medication groups for patients and families. Also, interpretation of genetic tests and creation of pediatric guidelines for psychiatric medications is another “real-life” way these providers can collaborate. Payment for these services remains a challenge for pharmacists, but Dopheide said health system administration can justify paying for a psychiatric pharmacist through improved medication outcomes, like better adherence, follow-up, and prevention of adverse drug reactions or interactions. “In many health systems, billing for medication groups and medication reviews is a way to pay for integration of psychiatric pharmacists,” Dopheide said.

Transgender Youths' Sexual Health and Education: A Qualitative Analysis.

To characterize transgender adolescents' sexual behaviors, identities, and their perceived experiences with sex education. Semi-structured interviews were conducted and addressed sexual experiences and perceptions of sex education received from family, school educators, and healthcare providers. Interviews were audio recorded, transcribed, and analyzed utilizing NVivo 12 software for thematic analysis. Child and adolescent gender services clinic at a Midwestern university-based medical center in the United States. 30 transgender adolescents between the ages of 15 to 20. Themes generated during semi-structured interviews. Sexual orientations were inclusive of attractions to a spectrum of gender identities. Libido was perceived to be impacted by gender-affirming hormone therapy, which was unanticipated for some adolescents. Family and school-based sex education was perceived to be relevant only for heterosexual and cisgender adolescents. Inclusive education for transgender adolescents was desired. Counseling provided by gender-affirming providers on sexual health was trusted and other healthcare providers were perceived to lack training on gender-inclusive care. This study demonstrated that families and school educators did not provide sex education perceived to be applicable to transgender adolescents. Similarly, healthcare providers of transgender adolescents were perceived to not provide inclusive or comprehensive medical care in comparison to physicians who routinely provide gender-affirming care. Gaps in education and healthcare could be improved with sex education outreach or training for families and school educators as well as the development and implementation of professional competencies for pediatricians on transgender adolescent healthcare.