Inpatient Youth Research Articles

Wearable Biosensing to Predict Imminent Aggressive Behavior in Psychiatric Inpatient Youths With Autism

Aggressive behavior is a prevalent and challenging issue in individuals with autism. To investigate whether changes in peripheral physiology recorded by a wearable biosensor and machine learning can be used to predict imminent aggressive behavior before it occurs in inpatient youths with autism. This noninterventional prognostic study used data collected from March 2019 to March 2020 from 4 primary care psychiatric inpatient hospitals. Enrolled participants were 86 psychiatric inpatients with confirmed diagnoses of autism exhibiting operationally defined self-injurious behavior, emotion dysregulation, or aggression toward others; 16 individuals were not included (18.6%) because they would not wear the biosensor (8 individuals) or were discharged before an observation could be made (8 individuals). Data were analyzed from March 2020 through October 2023. Research staff performed live behavioral coding of aggressive behavior while inpatient study participants wore a commercially available biosensor that recorded peripheral physiological signals (cardiovascular activity, electrodermal activity, and motion). Logistic regression, support vector machines, neural networks, and domain adaptation were used to analyze time-series features extracted from biosensor data. Area under the receiver operating characteristic curve (AUROC) values were used to evaluate the performance of population- and person-dependent models. There were 70 study participants (mean [range; SD] age, 11.9 [5-19; 3.5] years; 62 males [88.6%]; 1 Asian [1.4%], 5 Black [7.1%], 1 Native Hawaiian or Other Pacific Islander [1.4%], and 63 White [90.0%]; 5 Hispanic [7.5%] and 62 non-Hispanic [92.5%] among 67 individuals with ethnicity data). Nearly half of the population (32 individuals [45.7%]) was minimally verbal, and 30 individuals (42.8%) had an intellectual disability. Participant length of inpatient hospital stay ranged from 8 to 201 days, and the mean (SD) length was 37.28 (33.95) days. A total of 429 naturalistic observational coding sessions were recorded, totaling 497 hours, wherein 6665 aggressive behaviors were documented, including self-injury (3983 behaviors [59.8%]), emotion dysregulation (2063 behaviors [31.0%]), and aggression toward others (619 behaviors [9.3%]). Logistic regression was the best-performing overall classifier across all experiments; for example, it predicted aggressive behavior 3 minutes before onset with a mean AUROC of 0.80 (95% CI, 0.79-0.81). This study replicated and extended previous findings suggesting that machine learning analyses of preceding changes in peripheral physiology may be used to predict imminent aggressive behaviors before they occur in inpatient youths with autism. Further research will explore clinical implications and the potential for personalized interventions.

Hard-to-treat or hard-to-catch? Clinical features and therapeutic outcomes of help-seeking foster care youths with mood disorders.

The high level of emotional problems in youths placed in foster care contrasts with the limited use of evidence-based treatments. This study aims to better characterize the clinical features and therapeutic outcomes of foster care youths with mood disorders. A secondary analysis of data collected in the context of a French-Canadian clinical research network on pediatric mood disorders in four sites was conducted to compare three groups of patients with depressive or bipolar disorder: those without exposure to child welfare intervention (WCWI, n = 181), those who received non-placement psychosocial intervention (NPI, n = 62), and those in placement interventions (PI, n = 41). We observed a very high rate of academic problems in patients in the groups NPI/PI compared to those in the WCWI group. Patients in the PI group had more disruptive behavioral disorders (OR = 6.87, 95% CI [3.25-14.52]), trauma-related disorders (OR = 3.78, 95% CI [1.6-8.94]), and any neurodevelopmental disorders (OR = 2.73, 95% CI [1.36-5.49]) compared to the other groups (NPI/WCWI). Among inpatients, the Clinical Global Impression-Improvement scale and the change in the Children Global Assessment Scale during the hospital stay did not differ across the three groups. We observed a higher prescription rate of antipsychotics in the PI group compared to the NPI/WCWI groups, but no significant difference for antidepressants and mood stabilizers. These findings support the view that, when provided with dedicated support, fostered inpatient youths can improve in a range comparable to other inpatients. Undetected neurodevelopmental disorders and academic problems are likely important contributors of the burden of mood disorders in these youths.

Best practice recommendations on the application of seclusion and restraint in mental health services: An evidence, human rights and consensus-based approach.

INTRODUCTION: Seclusion and restraint still regularly occur within inpatient mental health services. Professionals lack clarity on safe and humane procedures. Nevertheless, a detailed policy on for instance age limits, techniques and time limits is required. We developed recommendations on the humane and safe application of seclusion, physical intervention and mechanical restraint in inpatient youth and adult mental health services, including forensic facilities. After developing a questionnaire based on a rapid scientific literature review and an analysis of human rights sources stemming from the Council of Europe, 60 expert-professionals and 18 experts-by-experience were consulted in Flanders (Belgium) through a Delphi-study. After two rounds, all but one statement reached the consensus-level of 65% in both panels. The study resulted in 77 recommendations on teamwork, communication, materials and techniques, maximum duration, observation, evaluation, registration, second opinion and age limits. Combining an evidence, human rights and consensus-based approach allowed for the first time to develop recommendations on time limits, asking for second opinion and registration. When combined with a preventive approach and collaboration between service managers, staff (educators) and experts-by-experience, the recommendations will improve safety and humane treatment, and reduce harm to service users and staff.

Interest of clonidine for seven inpatient youths with intellectual disability and other severe neurodevelopmental disorders.

Interest of clonidine for seven inpatient youths with intellectual disability and other severe neurodevelopmental disorders.

Typologies of Non-Suicidal Self-Injury Functions and Clinical Correlates Among Inpatient Youth.

This study identified typologies of specific non-suicidal self-injury (NSSI) functions among youth admitted for psychiatric hospitalization and investigated clinically relevant correlates. Inpatient youth (n = 68) aged 10-17years reported on their reasons to engage in NSSI, frequency and severity of NSSI, and symptoms of borderline personality disorder (BPD). A latent class analysis using youth's specific NSSI functions as indicators found two NSSI function typologies, which were differentially associated with clinical correlates. The Multiple Functions class (n = 28) endorsed to "feel something," "punish self," "escape feelings," "relieve anxiety," "stop feeling self-hatred," "stop feeling angry," "show much they are hurting," and "create a hurt that can be soothed." Conversely, the Single/Avoidant Function class (n = 40) endorsed one primary function-i.e., to "escape feelings." Youth in the Multiple Functions class reported significantly more frequent self-injury and greater BPD symptomology. The present study illustrates the importance of examining constellations of specific NSSI functions in inpatient care settings, given their unique associations with NSSI frequency and features of BPD. These findings could inform targeted psychological screening and, in turn, guide the implementation of interventions for elevated NSSI frequency and BPD symptomology among inpatient youth, based on NSSI functions endorsed.

49.8 LEGAL PROBLEMS AND NONSUICIDAL SELF-INJURY IN YOUTH WITH CHILD PROTECTIVE SERVICES INVOLVEMENT

Review of the psychiatry literature showed that inpatient adolescents with sexual and physical abuse histories are at increased risk for nonsuicidal self-injury (NSSI). Mood disorders are also shown to be associated with future legal problems and NSSI. The study’s objective is to explore the likelihood of developing legal issues and NSSI in inpatient youth with Child Protective Services Involvement (CPSI), PTSD, or both.

Engaging hospitalized youth with medication education groups during the COVID-19 pandemic.

According to the World Health Organization, prior to the pandemic, 50% of people with chronic disease in developed countries did not take their prescribed medication.1 Two studies by Mishra et al2,3 found that patients diagnosed with bipolar disorder and schizophrenia receiving pharmacist-led education had improved medication adherence and quality of life. Patient medication education groups (PMEGs) as defined by the College of Psychiatric and Neurologic Pharmacists allow patients the unique opportunity to interact with individuals who may share similar life experiences during the educational session.4 The PMEGs have been shown to improve clinical outcomes for a variety of disease states, including reduction in emergency department visits for psychiatric reasons following repeated attendance on an inpatient psychiatric unit.5 At a 121-bed inpatient psychiatric hospital in Indianapolis, Indiana, PMEGs began in 2005. Fifteen years later, 5 psychiatric pharmacists work together to provide weekly PMEGs to patients with a wide variety of mental illnesses and ages. The PMEGs are generally well attended and highly interactive. Activities and handouts provide patients with the opportunity to meet their unit pharmacist, ask questions, and learn about resources available after discharge.In March 2020, during the COVID-19 pandemic, psychiatric pharmacists transitioned to working remotely, and PMEGs ceased. A month later, a behavioral health clinician suggested a solution to restart PMEGs on the inpatient youth unit. Over the next several weeks, the clinician and psychiatric pharmacy resident formed a team to implement and continuously improve the newly established remote PMEG. The process included the resident connecting to the unit via Cisco WebEx (Milpitas, CA), a HIPAA (Health Insurance Portability and Accountability Act)-compliant video-conferencing software utilized by providers for remote patient care. The resident was able to see and hear the unit via the computer camera and microphone. A video of the resident and presentation was projected onto a wall in the main room of the unit, allowing patients to spread out across the unit to maintain social distancing while still being able to view the presentation. Patients had an opportunity to approach the computer and ask individual questions; following the first weeks, many common questions were incorporated into the presentation. The main tool utilized by the resident was a slide deck that included material from handouts and activities developed for in-person PMEGs.The COVID-19 pandemic has inspired creative minds to stretch the limits of technology to allow continued connection during a time of physical distance. With the help of technology and dedicated unit staff, remote pharmacist-led PMEGs are possible and allow the continued delivery of quality, patient-centered care. This presents exciting opportunities for technology-enabled patient medication education. By utilizing similar techniques, treatment facilities without dedicated onsite clinical pharmacists may offer group education to their patients for the first time. With the help of new processes and technology born out of necessity, innovative solutions have been developed that may have continued utility beyond pandemic times.A special thanks to Bobby Wade and Shannon Saldaña for their efforts to improve patient medication education groups and for reviewing this article.

Racial Disparities in a Sample of Inpatient Youth with ASD.

Although more than one in 10 youth with Autism Spectrum Disorder (ASD) is admitted to a psychiatric facility before they reach adulthood, the inpatient population is underrepresented in research. Furthermore, Black youth are more likely to be psychiatrically hospitalized, compared to their White counterparts. Yet, prior research has been inconsistent in potential racial differences in ASD symptoms and severity. This study examined differences in the symptom presentation of psychiatrically hospitalized Black and White youth with ASD. Researchers collected data as part of a larger study of youth admitted to one of six US specialized inpatient psychiatric units between 2013 and 2017. We used bivariate and multivariate models to analyze the data. The study included 654 youth diagnosed with ASD, with an average age of 13 years. While bivariate analyses found that Black youth had lower written language and daily living skills and more impaired social affect and inappropriate speech, multivariate regression models suggested that overall ability level and age may be driving these differences. Specifically, the only variables that significantly predicted adaptive functioning (written language, daily living) and behavioral profiles (social affect, inappropriate speech) were verbal ability, IQ, and age. Race was not a significant predictor in any of the models. Cultural diversity and competency are vital to the identification and treatment of ASD clinical care. Thus, understanding the role race may play in early detection and accurate diagnosis is important to improving ASD identification, diagnosis, and treatment. Autism Res 2020, 13: 532-538. © 2020 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: This study examined differences in autism symptoms between Black and White youth in psychiatric hospitals. We found that while it initially appeared that Black and White youth differed in written language and daily living skills, these racial differences were not significant once we accounted for differences in IQ, age, and verbal ability. Our findings suggest that providers should pay greater attention to other potential reasons for racial disparities in autism services.

80.2 TECHNOLOGY IN GOOD HANDS: PATIENT ENGAGEMENT AND TREATMENT MONITORING IN HOSPITALIZED YOUTH

This presentation will review implications and challenges of integrating electronic screening, symptom self-reporting, and actigraphy measures into routine care for inpatient youth with mood disorders.

Effective use of atomoxetine to treat six inpatient youths with disruptive mood dysregulation disorder without attention deficit disorder

Effective use of atomoxetine to treat six inpatient youths with disruptive mood dysregulation disorder without attention deficit disorder

Experiential avoidance in adolescents with borderline personality disorder: comparison with a non-BPD psychiatric group and healthy controls

ABSTRACTPrevious research has identified experiential avoidance (EA) as related to a host of adolescent internalizing and externalizing problems, as well as borderline personality disorder, suggesting that it is a crosscutting factor for adolescent psychopathology. It remains unclear whether EA differs among adolescents with BPD compared to adolescents with other psychiatric disorders and healthy adolescents. The aims of this study were to 1) examine EA in adolescents with BPD compared to non-BPD inpatient adolescents and healthy adolescents, and 2) to evaluate whether EA has a unique relationship to borderline pathology over and above internalizing and externalizing. Self-report measures of BPD features, EA, and psychopathology were completed by 692 adolescents (64.5% female, Mage= 15.20). This sample included a group of psychiatric inpatient youth (n = 197 BPD; n = 403 non-BPD) and a group of healthy adolescents (n = 92). Results revealed that EA differed significantly across all three groups, with the highest level of EA evidenced in adolescents who had BPD. Furthermore, there was a significant, unique association between BPD symptoms and EA over afnd above internalizing and externalizing pathology. These findings pinpoint EA as an important risk marker and possible target of prevention or intervention for adolescent BPD.

Parental threats and adolescent depression: The role of emotion dysregulation

Childhood exposure to parental threatening behaviors places adolescents at greater risk for depression. However, the association between parental threatening behaviors and depressive symptoms among trauma-exposed inpatient youth, and potential factors that exacerbate the harmful effects of such parenting, have remained unexplored. One factor that may contribute to depression is low emotional clarity, which is characterized by difficulties recognizing and understanding one's emotions. The current investigation examined the interactive effects of childhood exposure to maternal threatening behaviors and emotional clarity deficits in relation to depressive symptoms among inpatient psychiatric youth who had been exposed to a potentially traumatic event (i.e., exposure to actual or threatened death, serious injury, or sexual violence). Participants (N = 50, Mage = 15.1 years, SD = 0.51, range 12–17) completed measures of emotion dysregulation, childhood exposure to maternal threatening behavior, and depressive symptoms. A significant interaction was found between exposure to maternal threatening behaviors and deficits in emotional clarity in relation to depressive symptom severity. Greater exposure to maternal threatening behaviors was related to more severe depressive symptoms, yet only among children with greater deficits in emotional clarity. Findings underscore the need for interventions that target emotional clarity among trauma-exposed youth who have experienced parental threats.

Prevalence and Correlates of Psychiatric Symptoms in Minimally Verbal Children and Adolescents With ASD.

Despite many studies documenting the prevalence of various co-occurring psychiatric symptoms in children and adults with ASD, less is known about how these symptoms relate to subtypes defined by particular phenotypic features within the ASD population. We examined the severity and prevalence of comorbid symptoms of psychopathology, emotion dysregulation, and maladaptive behaviors, as well as adaptive functioning, in a group of 65 minimally verbal children (n = 33) and adolescents (n = 32) with ASD. On the Child and Adolescent Symptom Inventory (CASI-5), for all the symptom classifications except oppositional defiant disorder and conduct disorder, more participants in our sample showed elevated or clinically concerning severity scores relative to the general population. On the Emotion Dysregulation Inventory (EDI), the mean scores for Reactivity and Dysphoria factors in our sample were lower than in the autism calibration sample, which included a large number of inpatient youth with ASD. Overall, few differences were found between the children and adolescents within this severely impaired group of ASD individuals based on clinical cutoff scores on the CASI-5 and EDI factor scores. Psychiatric comorbidities and emotion dysregulation measures were not correlated with autism symptom severity or with measures of adaptive functioning, and were largely unrelated to IQ in our sample. The number of clinically significant psychiatric symptoms on the CASI-5 emerged as the main predictor of maladaptive behaviors. Findings suggest a wide range of co-occurring psychopathology and high degree of maladaptive behavior among minimally verbal children and adolescents with ASD, which are not directly attributable to autism symptom severity, intellectual disability or limitations in adaptive functioning.

Arts-based interventions for youth with mental health challenges

SummaryWe facilitated an arts-based mindfulness group program with youths who were receiving short-term in-patient mental health supports within hospital. We aimed to explore the challenges and benefits these marginalized youths experienced through their exposure to the group intervention. Forty pregroup and 24 postgroup interviews were analyzed using a thematic analysis framework.Findings:The qualitative findings are presented using creative nonfiction in the form of a composite vignette. The composite vignette portrays the content within the themes, creatively telling a more compelling story that illustrates key points and themes within the data set. The vignette shows how mental health challenges created problems in the youths’ lives. Although most of the youths were initially nervous about participating in the program, the strengths and arts-based nature of the program helped them to connect with others in the group and express themselves. All of the youths reported that the group program was enjoyable and beneficial. They learned to identify what they were feeling/thinking and to express these feelings/thoughts using creative means of expression. Making art helped them to develop their self-awareness and created enjoyment in the group and with the group methods. Also, learning about mindfulness helped them to think in different ways, and to focus and relax more.Application:The results of this pilot project warrant further investigation into the benefits of creative strengths-based mindfulness-based interventions for in-patient youths experiencing mental health challenges. The composite vignette centers the youths’ voices and provides a comprehensive account of their experiences.

56.2 Integrating Technology in Screening, Monitoring, and Diagnosing Inpatient Youth

56.2 Integrating Technology in Screening, Monitoring, and Diagnosing Inpatient Youth

Sexual orientation, gender, and attempted suicide among adolescent psychiatric inpatients.

Lesbian, gay, bisexual, and queer (LGBQ) and female youth report disproportionately high rates of attempted suicide. Previous studies have not addressed the association between sexual orientation, gender, and attempted suicide among adolescent psychiatric inpatients. This study examined LGBQ orientation as a correlate of attempted suicide above and beyond other risk factors (e.g., age, rurality, trauma exposure, psychopathology), and also examined the interaction between gender and sexual orientation with regard to attempted suicide. We conducted a chart review study that included 550 adolescent psychiatric inpatients admitted to a public psychiatric hospital. Adolescents completed standardized intake assessments and self-report measures of sociodemographics, history of attempted suicide, psychopathology, and trauma history. Sexual orientation, gender, and their interaction were evaluated as predictors of attempted suicide using sequential logistic regression. LGBQ youth were more than 3 times more likely (odds ratio [OR] = 3.08) than non-LGBQ peers to have attempted suicide, and female youth were more than twice as likely to have attempted suicide compared with male patients (OR = 2.44). There was not a significant LGBQ orientation by gender interaction. These findings demonstrate the importance of LGBQ orientation and female gender as risk factors for suicidal behavior in a sample of adolescent psychiatric inpatients. Although limited by the self-report and retrospective nature of the data collected, these findings suggest the importance of initial and ongoing assessment of gender, sexual orientation, and suicidality in inpatient youth and the need for additional research to inform effective intervention efforts in this high-risk population. (PsycINFO Database Record

The Role of Anxiety Sensitivity in the Relationship Between Emotion Dysregulation and Internalizing Psychopathology Among Trauma-Exposed Inpatient Adolescents

The present investigation examined the underlying role of anxiety sensitivity and its facets in the association between emotion dysregulation and three of the most prevalent and debilitating symptom classes among trauma-exposed psychiatric inpatient youth: posttraumatic stress disorder (PTSD), anxiety, and depression symptoms. Participants (N = 50; 52.0% female; Mage = 15.1 years, SD = .51, range 12–17 years) completed an assessment battery that included measures of emotion dysregulation anxiety sensitivity, PTSD, anxiety, and depression symptoms. Consistent with hypotheses, the global construct of anxiety sensitivity, as well as its mental incapacitation concerns and disease concerns facets, explained, in part, associations between emotion dysregulation and the three symptom classes. The study results provide novel and clinically meaningful findings regarding the potential mechanistic role of anxiety sensitivity in the relation of emotion dysregulation to PTSD and internalizing symptoms among trauma-exposed inpatient adolescents. As such, findings underscore the potential value of targeting anxiety sensitivity in general, and mental incapacitation and disease concerns specifically, as a means of reducing risk for internalizing psychopathology among trauma-exposed inpatient youth.

T68. Hope and Borderline-Personality Disorder as Predictors of Study Drop-Out Among Inpatient Youth Receiving Psychotherapy Treatment for an Episode of Deliberate Self-Harm

T68. Hope and Borderline-Personality Disorder as Predictors of Study Drop-Out Among Inpatient Youth Receiving Psychotherapy Treatment for an Episode of Deliberate Self-Harm

Risk Factors for Self-injurious Behavior in an Inpatient Psychiatric Sample of Children with Autism Spectrum Disorder: A Naturalistic Observation Study.

Limited information about self-injurious behavior (SIB) is known for children and adolescents with Autism Spectrum Disorder (ASD) who require intensive behavioral health interventions. We examined risk-factors for SIB in 302 individuals with ASD (ages 4-20) admitted to six specialized psychiatric inpatient units. Seventy-four percent were reported by a caregiver to display SIB, however, only 25% were observed to engage in daily SIB during hospitalization. Those exhibiting SIB across environments had significantly higher ratings on caregiver questionnaires of SIB severity. Tree-structured classification was used to develop and validate two predictive models, one indicating which inpatient youth with ASD are likely to have SIB and a second indicating which individuals with SIB at home are likely to continue in an inpatient setting.

Improved Metabolic and Psychiatric Outcomes with Discontinuation of Atypical Antipsychotics in Youth Hospitalized in a State Psychiatric Facility.

To assess the impact of antipsychotic tapering and discontinuation on measures of metabolic functioning and psychiatric symptom severity in severely impaired youth hospitalized in a psychiatric state hospital. The study examined psychiatric and metabolic measures in 67 hospitalized children and adolescents (mean age 11.9; 56 with discontinued use of antipsychotics, 10 with continued use of antipsychotics, and 1 started on an antipsychotic) from admission to discharge. Upon admission, 56 youth were tapered off of antipsychotic medications, started on other forms of pharmacotherapy (92.9% were started on medications used to treat attention-deficit/hyperactivity disorder), and received evidence-based behavioral programming and were ultimately discharged from the hospital. The mean duration of treatment was 228 days for the discontinuation group and 204 days for the continuation group. Significant decreases in body mass index [BMI; t(53) = 7.12, p = 0.0001] and BMI percentile [t(53) = 6.73, p = 0.0001] were found from admission to discharge in the antipsychotic discontinuation group. Changes in BMI, BMI percentile, or systolic blood pressure were not found in the group (n = 10) who were maintained on antipsychotics. Both groups experienced a significant increase in their Global Assessment of Functioning score [t(52) = 19.98, p = 0.0001 for discontinued; t(8) = 5.092, p = 0.001 for maintained]. Psychiatric symptom severity scores significantly improved in many subscales relevant to disruptive behaviors and mood disorders for those who were removed from the medications. For those maintained on the antipsychotics, there were fewer changes in psychiatric symptom scores. Discontinuation of atypical antipsychotic medications in conjunction with tailoring treatment to presenting diagnoses resulted in metabolic and psychiatric symptom improvement among severely impaired state hospital inpatient youth. These results serve as a feasibility demonstration that discontinuation of antipsychotics does not provoke psychiatric destabilization, particularly among disruptive behavior disordered youth.