BACKGROUND:Attention-Deficit/Hyperactivity Disorder (ADHD) is highly heritable; thus, parents and children frequently experience ADHD-related impairments. Parent ADHD is associated with poorer developmental and treatment outcomes for children with ADHD, in part due to executive functioning and emotion regulation difficulties that interfere with parenting and treatment follow-through. Few studies have evaluated multi-modal, family-based approaches that directly address both parent ADHD and parenting to ultimately improve child outcomes. METHODS:We compared a telehealth-delivered, integrated behavioral parent training program (I-BPT) alone or preceded by a parent stimulant medication titration (PSM + I-BPT) for parents with ADHD (N = 120; 25% fathers; 27% Black/African-American; 11% Hispanic) and their 3-8-year-old, stimulant-naïve children. I-BPT dually targeted parenting and parent ADHD and was implemented by providers in urban pediatric clinics. TRIAL REGISTRATION:ClinicalTrials.gov identifier NCT04240756; Treating Parents with ADHD and Their Young Children Via Telehealth: a Hybrid Type I Effectiveness-Implementation Trial. Registered at https://clinicaltrials.gov/study/NCT04240756 on 01/21/2020. RESULTS:Children whose parents received PSM + I-BPT showed significantly steeper declines in Clinical Global Impressions ratings than those receiving I-BPT alone (d = 0.37; p = .001). Parents receiving PSM + I-BPT also demonstrated faster reductions in their own CGI-S ratings (d = 0.33) and reported greater improvements in inconsistent discipline (d = 0.22) and positive parenting (d = 0.24). Self-reported punitive parenting and observed parenting behaviors improved similarly across I-BPT groups. CONCLUSIONS:PSM + I-BPT led to benefits on parent and child clinical severity and targeted parenting skills compared to I-BPT without parental ADHD medication; broader parenting improvements occurred across both I-BPT conditions. Addressing parent ADHD pharmacologically may enhance the effectiveness of parenting interventions for multiplex ADHD families.

Considering the complexity of pediatric bipolar disorder (BPD), there is a great need to identify safe, effective treatments. Treatment approaches can differ depending on the phase of BPD (acute manic/mixed, acute depressive, or maintenance). Monotherapy treatments include second-generation anti-psychotics (SGAs) or mood stabilizers. SGAs appear to be more effective, with five medications approved by the Food and Drug Administration (FDA), but the metabolic side effects are concerning. Lithium is the only mood stabilizer approved by the FDA. There is less focus on pharmacological treatment of depressive episodes, with two FDA-approved treatments: olanzapine/fluoxetine and lurasidone. There is also less focus on maintenance treatment, as only aripiprazole and lithium are FDA approved. Other research has focused on adjunctive treatments with additional medications and psychotherapy. Overall, there has been progress in diagnosis and treatment for pediatric BPD. Further research should explore double-blind, placebo-controlled studies of promising medications, along with long-term effects of medications and efficacy of adjunctive treatments.

Changing practice patterns caused by the pandemic have created an urgent need for guidance in prescribing stimulants using telepsychiatry for attention-deficit hyperactivity disorder (ADHD). A notable spike in the prescribing of stimulants accompanied the suspension of the Ryan Haight Act, allowing the prescribing of stimulants without a face-to-face meeting. Competing forces both for and against prescribing ADHD stimulants by telepsychiatry have emerged, requiring guidelines to balance these factors. On the one hand, factors weighing in favor of increasing the availability of treatment for ADHD via telepsychiatry include enhanced access to care, reduction in the large number of untreated cases, and prevention of the known adverse outcomes of untreated ADHD. On the other hand, factors in favor of limiting telepsychiatry for ADHD include mitigating the possibility of exploiting telepsychiatry for profit or for misuse, abuse, and diversion of stimulants. This Expert Consensus Group has developed numerous specific guidelines and advocates for some flexibility in allowing telepsychiatry evaluations and treatment without an in-person evaluation to continue. These guidelines also recognize the need to give greater scrutiny to certain subpopulations, such as young adults without a prior diagnosis or treatment of ADHD who request immediate-release stimulants, which should increase the suspicion of possible medication diversion, misuse, or abuse. In such cases, nonstimulants, controlled-release stimulants, or psychosocial interventions should be prioritized. We encourage the use of outside informants to support the history, the use of rating scales, and having access to a hybrid model of both in-person and remote treatment.

Family navigation (FN) and phone-based care coordination may improve linkages from primary care to community-based mental health referrals, but research on their differential impact is limited. This mixed-methods study compared FN and phone-based care coordination in connecting families to mental health services from primary care. Families of children (56.3% male, mean age = 10.4 years, 85.4% Black) were sequentially assigned to either receive FN through a family-run organization or phone-based coordination via the child psychiatry access program (CPAP). Caregiver-reported children’s mental health improved in both groups and both groups were satisfied with services. More families in the CPAP group had appointments made or completed (87%) than families in the FN group (71%) though the difference was not statistically significant. Future research with a larger sample that matches family needs and preferences (e.g., level and type of support) with navigation services would be beneficial.

Background: Antidepressant medications, including selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), are commonly used to treat depressive, anxiety, and obsessive-compulsive disorders in youth. Yet, data on discontinuing these medications, withdrawal symptoms, and strategies to switch between them are limited.Methods: We searched PubMed and ClinicalTrials.gov through June 1, 2024, to identify randomized controlled trials assessing antidepressant discontinuation in youth. We summarized pediatric pharmacokinetic data to inform tapering and cross-titration strategies for antidepressants and synthesized these data with reports of antidepressant withdrawal.Results: Our search identified 528 published articles, of which 28 were included. In addition, 19 records were obtained through other methods, with 14 included. The corpus of records included 13 randomized, double-blind, placebo-controlled trials (3026 patients), including SSRIs (K = 10), SNRIs (K = 4), and TCAs (K = 1), ranging from 4 to 35 weeks. Deprescribing antidepressants requires considering clinical status, treatment response, and, in cross-titration cases, the pharmacokinetics and pharmacodynamics of both medications. Antidepressant withdrawal symptoms are related to the pharmacokinetics of the medication, which vary across antidepressants and may include irritability, palpitations, anxiety, nausea, sweating, headaches, insomnia, paresthesia, and dizziness. These symptoms putatively involve changes in serotonin transporter expression and receptor sensitivity, impacting the serotonin, dopamine, and norepinephrine pathways.Conclusions: Although approaches to deprescribing antidepressants in pediatric patients are frequently empirically guided, accumulating data related to the course of relapse and withdrawal symptoms, as well as the pharmacokinetic and pharmacodynamic properties of medications, should inform these approaches. Recommendations within this review support data-informed discussions of deprescribing-including when and how-that are critically important in the clinician-family-patient relationship.

This study aimed to identify factors that may impact the no-show rate (NSR) for follow-up appointments at a child and adolescent psychiatry clinic and to assess the effectiveness of quality improvement projects, including the implementation of a no-show policy and improvement of phone call responses.

ObjectivesBipolar disorder can affect up to 1% of youth, with early onset and comorbidity conferring greater risk of adverse psychosocial outcomes. As the field has advanced, psychopharmacologic trials have focused on several common comorbid illnesses and the metabolic consequences of treatment.MethodsThe Symposium reviews registration trials, NIH trials, and clinical program findings to examine the prognosis for youth with bipolar depression, bipolar disorder comorbid with ADHD and ASD, and the metabolic consequences of pharmacologic management of bipolar disorder.ResultsWhile multiple treatment options for mixed and manic bipolar episodes exist, the field has very few successful treatments for bipolar depression. Youth who spend a larger time in depressive episodes have more adverse psychosocial outcomes. Failed and successful options will be covered. Many registration trials examined youth with ADHD comorbid with bipolar disorder. Trials have frequently allowed participants to remain on stimulants, but such ADHD treatment can affect response to some mood stabilizers. The presentation of bipolar mood disorder in youth with ASD may vary dramatically from neurotypical youth with bipolar disorder. Because ASD is frequently an exclusion criterion for bipolar disorder trials, findings for this talk will come from a large program in the Northeast. Finally, successful long-term treatment includes monitoring for both acute and chronic side effects of medications. The development of metabolic syndrome can complicate the patient's willingness to continue treatment and adversely affect a child's health.ConclusionsBipolar disorder can present in a variety of contexts including comorbid medical and mental illness. Careful diagnostic assessment and use of medication can optimize a child's functioning and ability to function in all aspects of their lives.BRD, CM, PPC ObjectivesBipolar disorder can affect up to 1% of youth, with early onset and comorbidity conferring greater risk of adverse psychosocial outcomes. As the field has advanced, psychopharmacologic trials have focused on several common comorbid illnesses and the metabolic consequences of treatment. Bipolar disorder can affect up to 1% of youth, with early onset and comorbidity conferring greater risk of adverse psychosocial outcomes. As the field has advanced, psychopharmacologic trials have focused on several common comorbid illnesses and the metabolic consequences of treatment. MethodsThe Symposium reviews registration trials, NIH trials, and clinical program findings to examine the prognosis for youth with bipolar depression, bipolar disorder comorbid with ADHD and ASD, and the metabolic consequences of pharmacologic management of bipolar disorder. The Symposium reviews registration trials, NIH trials, and clinical program findings to examine the prognosis for youth with bipolar depression, bipolar disorder comorbid with ADHD and ASD, and the metabolic consequences of pharmacologic management of bipolar disorder. ResultsWhile multiple treatment options for mixed and manic bipolar episodes exist, the field has very few successful treatments for bipolar depression. Youth who spend a larger time in depressive episodes have more adverse psychosocial outcomes. Failed and successful options will be covered. Many registration trials examined youth with ADHD comorbid with bipolar disorder. Trials have frequently allowed participants to remain on stimulants, but such ADHD treatment can affect response to some mood stabilizers. The presentation of bipolar mood disorder in youth with ASD may vary dramatically from neurotypical youth with bipolar disorder. Because ASD is frequently an exclusion criterion for bipolar disorder trials, findings for this talk will come from a large program in the Northeast. Finally, successful long-term treatment includes monitoring for both acute and chronic side effects of medications. The development of metabolic syndrome can complicate the patient's willingness to continue treatment and adversely affect a child's health. While multiple treatment options for mixed and manic bipolar episodes exist, the field has very few successful treatments for bipolar depression. Youth who spend a larger time in depressive episodes have more adverse psychosocial outcomes. Failed and successful options will be covered. Many registration trials examined youth with ADHD comorbid with bipolar disorder. Trials have frequently allowed participants to remain on stimulants, but such ADHD treatment can affect response to some mood stabilizers. The presentation of bipolar mood disorder in youth with ASD may vary dramatically from neurotypical youth with bipolar disorder. Because ASD is frequently an exclusion criterion for bipolar disorder trials, findings for this talk will come from a large program in the Northeast. Finally, successful long-term treatment includes monitoring for both acute and chronic side effects of medications. The development of metabolic syndrome can complicate the patient's willingness to continue treatment and adversely affect a child's health. ConclusionsBipolar disorder can present in a variety of contexts including comorbid medical and mental illness. Careful diagnostic assessment and use of medication can optimize a child's functioning and ability to function in all aspects of their lives.BRD, CM, PPC Bipolar disorder can present in a variety of contexts including comorbid medical and mental illness. Careful diagnostic assessment and use of medication can optimize a child's functioning and ability to function in all aspects of their lives.

Introduction: Pediatric bipolar disorder (PBD) is a severe psychiatric illness diagnosed before the age of 18, which is associated with extreme shifts in mood characterized by manic and depressive episodes. In 2005, AACAP published algorithms to guide pharmacological treatment of manic/mixed episodes associated with PBD. At that time, lithium was the only Food and Drug Administration (FDA)-approved treatment for pediatric bipolar manic/mixed episodes. The goal of this article is to review evidence that has emerged since the AACAP algorithm in 2005. Methods: Literature searches were conducted through PubMed and limited to studies published between 2005 and 2021, using keywords that focused on randomized controlled trials (RCTs) for available psychopharmacological medications. In addition, the authors conducted in-depth searches for articles providing evidence for agents included in the 2005 AACAP algorithm. Results: Since the publication of the AACAP algorithm in 2005, multiple RCTs have been conducted in PBD, leading to FDA approval of five medications (aripiprazole, asenapine, olanzapine, quetiapine, and risperidone) for the treatment of manic/mixed episodes and two medications (lurasidone and olanzapine-fluoxetine combination) for the treatment of depressed episodes. Divalproex sodium and oxcarbazepine were studied in pediatric RCTs and failed to separate from placebo. Conclusions: We offer an update to the 2005 AACAP algorithms for the treatment of pediatric bipolar mixed/manic episodes and added an evidence-based algorithm for the treatment of depression in PBD. In addition to treatment algorithms, we review current evidence for efficacy of agents proposed in the AACAP algorithm and provide tables summarizing medication side effects and efficacy.

ObjectiveTo develop a new approach to prescribing guidelines as part of a pragmatic trial, Safer Use of Antipsychotics in Youth (SUAY; ClinicalTrials.gov Identifier: NCT03448575), which supports prescribers in delivering high-quality mental health care to youths.MethodA nominal group technique was used to identify first- to nth-line treatments for target symptoms and potential diagnoses. The panel included US pediatricians, child and adolescent psychiatrists, and psychopharmacology experts. Meeting materials included information about Medicaid review programs, systematic reviews, prescribing guidelines, and a description of the pragmatic trial. Afterward, a series of 4 webinar discussions were held to achieve consensus on recommendations.ResultsThe panel unanimously agreed that the guideline should focus on target symptoms rather than diagnoses. Guidance included recommendations for first- to nth-line treatment of target mental health symptoms, environmental factors to be addressed, possible underlying diagnoses that should first be considered and ruled out, and general considerations for pharmacological and therapeutic treatments.ConclusionPrescribing guidelines are often ignored because they do not incorporate the real-world availability of first-line psychosocial treatments, comorbid conditions, and clinical complexity. Our approach addresses some of these concerns. If the approach proves successful in our ongoing pragmatic trial, Safer Use of Antipsychotics in Youth (SUAY), it may serve as a model to state Medicaid programs and health systems to support clinicians in delivering high-quality mental health care to youths.Clinical trial registration informationSafer Use of Antipsychotics in Youth; http://clinicaltrials.gov/; NCT03448575

AACAP has recently called for caution regarding the use of pharmacogenetic testing to guide mental health care. This Symposium will review the available evidence examining the moderating effects of genetic variants on psychotropic efficacy and tolerability.

MDD is a serious illness affecting 1 in 5 adolescents in their lifetime. In positive pharmacologic trials of fluoxetine and escitalopram, response rates ranged from 63.6% on escitalopram to 56% on fluoxetine. Other SSRIs had similar response rates to the active agent but higher placebo response rates. This response also means that between 40% and 50% of youth do not respond to their first antidepressant. The second treatment trials discussed in this lecture include switching, augmentation, and neurotherapeutics as options in treating youth who do not respond to the initial agent.

Delivery of mental health treatment in the home can close gaps in care. Telehealth also provides access to healthcare that has been disrupted due to the COVID-19 pandemic. In 2016, a home direct-to-consumer telehealth program was initiated. Mental health encounters made up a significant portion of all telehealth encounters and COVID-19 had a significant impact on accelerating the utilization of telehealth. Telemental health has been more successful at meeting targeted volumes than the overall health system. Of all the mental health diagnoses before and during COVID-19, attention deficit hyperactivity disorder, Autism Spectrum Disorder, and Anxiety Disorder were most common. The direct-to-consumer telehealth program saved patients a significant amount of travel miles and associated time, based on data from the period before COVID-19. Payment reimbursement for direct-to-consumer telehealth professional services was similar to reimbursement for in-person visits. This program demonstrates direct-to-consumer telehealth is a feasible and acceptable care modality for a variety of youth mental health disorders.

Importance:The Padova Chart for Health in Children (PCHC) aims to gather the evidence of healthcare promotion and protection for chidren and adolescents (i.e., aged <18 y) into a single document in order to guide families, healthcare providers and social actors on healthy choices. No more than 2% of Europeans and North Americans aged <30 y have a healthy lifestyle. This, together with metabolic and brain plasticity during childhood, creates the ideal opportunity to implement preventive strategies. Guided interventions promoting healthy lifestyle in children and families therefore have a key role in abating the unprecedented pandemic of non-communicable diseases (NCDs) in adulthood. Observations:The PCHC is divided into four sections: nutrition, cardiovascular health, respiratory health, and mental and social health. Each section is structured in an ALICE approach (assessment, lobbying, intervention, call-for-action, evaluation): assessment of necessity, describing relevance to healthcare; lobbying to identify those who can effect the proposed interventions; interventions involving family, school and peers; a call-for-action to define priorities among the proposed interventions; and objective evaluation measures that can be applied on a population basis. Conclusions and Relevance:Interventions promoting health in childhood require joint action from multiple institutional, local and family representatives, with the shared goal of promoting health across the entire age group. These lifestyle interventions have the potential to change the lifetime risk trajectory for NCDs.

BACKGROUND/PURPOSE: Mental health disorders have a high prevalence among children. Each year, 1 in 6 U.S. youth aged 6-17 experience a mental health disorder. There are many obstacles to accessing care that could be overcome by telehealth. Delivery of mental health treatment in the home can close geographical gaps and address other patient concerns, as well as provide unique diagnostic potential through visualization of the home environment. We present our initial experience with home direct-to-consumer telehealth in a metropolitan area. METHODS: In 2016, a tertiary care hospital in a metropolitan area initiated …

The goal of this Advanced Psychopharmacology Institute is to provide advanced knowledge of psychopharmacology for the child and adolescent psychiatrist. We will focus on several different areas from comorbidity in common disorders (ADHD and autism spectrum disorder [ASD]), treatment of problematic symptoms (aggression), psychosis, cannabis abuse, delirium, and adherence to treatment in pediatric bipolar disorder. The individual presenters are experts in their areas of presentation. Their methods of presentation include literature reviews as well as results from completed and ongoing clinical trials in the different topic areas. Evidence-based practices and patient vignettes will ensure that participants have the latest data on the topic areas that can enhance their clinical practice. The participants will gain information and tools on identifying common comorbidities in both ADHD and ASD. They will be able to use staged psychopharmacologic interventions in treating the comorbid disorders alongside the primary disorders. The presentation on aggression will allow participants to identify and treat primary disorders in youth with out-of-control and dangerous behaviors and use combined pharmacotherapy when monotherapy is ineffective. Cannabis use is a frequent substance use disorder and often complicates other Axis I disorders. This talk allows participants to become more comfortable in managing dual-diagnosis patients. Delirium is one of the most frequent disorders seen in emergency and consultation psychiatry practices. This presentation provides valuable information on the subtypes of delirium and the best way to manage them both behaviorally and pharmacologically. Finally, promoting adherence to treatment including medication is a struggle for child and adolescent patients. The presentation on adherence in pediatric bipolar disorder will review the literature and describe findings from a current NIH-funded trial in adolescent adherence. Pharmacotherapy serves an important role in the treatment of specific psychopathology in youth. The variety of sessions presented in this Institute will help participants gain a better understanding of complex mental health conditions, symptoms, and treatment considerations applicable in a variety of clinical settings.