Penelope Knapp

Evolution and Revolution in Child Psychiatry: ADHD as a Disorder of Adaptation

Current knowledge about early plasticity and childrens responsiveness to environmental modifications as well as the atheoretical nature of current nosological systems necessitate alternative models to explain the phenomena of childhood behavioral and emotional disturbances. Evolutionary biology provides one such framework. It organizes data from the behavioral and cognitive sciences and parallels similar efforts in other areas of medicine and biology. Through an evolutionary biological lens, some mental disorders are better viewed as an adaptive response to early pathogenic environments and/or reflect the optimization of brain function to some environments at the cost of poorer response to the demands of other environments. As an example, the authors examine attention-deficit/hyperactivity disorder (ADHD) in relation to evolutionary theories of psychology and biology and clarify the potentially adaptive nature of characteristics of inattention, impulsivity, and motoric hyperactivity, depending on the nature of childs environments. Reframing ADHD characteristics according to evolutionary theory has important treatment implications for clinicians and offers researchers opportunities for novel scientific discoveries.

Consultation-Liaison in Child Psychiatry: A Review of the Past 10 Years. Part I: Clinical Findings

OBJECTIVE To critically review clinical reports on pediatric consultation-liaison psychiatry over the past 10 years. METHOD Articles contributing to the understanding of child psychiatric consultation in medical settings were reviewed. RESULTS Information related to clinical issues was organized into categorical (disease-oriented), noncategorical, and family studies. Newer articles on ethical considerations in caring for medically ill children are summarized. CONCLUSIONS Research has continued to focus on and reflect the importance of the emotional and behavioral needs of children in pediatric settings and the adaptation and stress within families who care for chronically ill children. Given the increased complexity and demands of medical care, the training and skills of a child psychiatrist in pediatric consultation remain a valuable component of comprehensive care for children.

Consultation-Liaison in Child Psychiatry: A Review of the Past 10 Years. Part II

OBJECTIVE To critically review the research and reports on consultation-liaison psychiatry in the past 10 years. METHOD Articles contributing to the conceptualization of child psychiatric consultation in medical, epidemiological, and nonmedical domains were reviewed. RESULTS Information was organized into methodology and treatment outcome categories. Nonmedical consultation articles were briefly reviewed. Articles reporting therapeutic techniques in consultation-liaison work and outcome studies are described. CONCLUSIONS In spite of constraints imposed by managed care upon referral to specialists, the current epoch finds child psychiatrists both better equipped and more compelled to use their skills in innovative ways to help children in different domains.

Common and Costly Hospitalizations for Pediatric Mental Health Disorders

BACKGROUND AND OBJECTIVES: Inpatient pediatric mental health is a priority topic for national quality measurement and improvement, but nationally representative data on the patients admitted or their diagnoses are lacking. Our objectives were: to describe pediatric mental health hospitalizations at general medical facilities admitting children nationally; to assess which pediatric mental health diagnoses are frequent and costly at these hospitals; and to examine whether the most frequent diagnoses are similar to those at free-standing children’s hospitals. METHODS: We examined all discharges in 2009 for patients aged 3 to 20 years in the nationally representative Kids’ Inpatient Database (KID) and in the Pediatric Health Information System (free-standing children’s hospitals). Main outcomes were frequency of International Classification of Diseases, Ninth Revision, Clinical Modification–defined mental health diagnostic groupings (primary and nonprimary diagnosis) and, using KID, resource utilization (defined by diagnostic grouping aggregate annual charges). RESULTS: Nearly 10% of pediatric hospitalizations nationally were for a primary mental health diagnosis, compared with 3% of hospitalizations at free-standing children’s hospitals. Predictors of hospitalizations for a primary mental health problem were older age, male gender, white race, and insurance type. Nationally, the most frequent and costly primary mental health diagnoses were depression (44.1% of all mental health admissions;

Treatment of Maladaptive Aggression in Youth: CERT Guidelines I. Engagement, Assessment, and Management

1.33 billion), bipolar disorder (18.1%;

Diabetes Screening Among Underserved Adults With Severe Mental Illness Who Take Antipsychotic Medications

702 million), and psychosis (12.1%;

Child Sociodemographic Characteristics and Common Psychiatric Diagnoses in Medicaid Encounter Data: Are they Valid?

540 million). CONCLUSIONS: We identified the child mental health inpatient diagnoses with the highest frequency and highest costs as depression, bipolar disorder, and psychosis, with substance abuse an important comorbid diagnosis. These diagnoses can be used as priority conditions for pediatric mental health inpatient quality measurement.

Clinical Implications of Current Findings in Neurodevelopment

OBJECTIVE: To develop guidelines for management and treatment of maladaptive aggression in the areas of family engagement, assessment and diagnosis, and initial management, appropriate for use by primary care clinicians and mental health providers. Maladaptive aggression in youth is increasingly treated with psychotropic medications, particularly second-generation antipsychotic agents. Multiple treatment modalities are available, but guidance for clinicians’ assessment and treatment strategies has been inadequately developed. To address this need, the Center for Education and Research on Mental Health Therapeutics and the REACH Institute convened a steering group of national experts to develop evidence-based treatment recommendations for maladaptive aggression in youth. METHODS: Evidence was assembled and evaluated in a multistep process that included a systematic review of published literature; a survey of experts on recommended treatment practices; a consensus conference that brought together clinical experts along with researchers, policy makers, and family advocates; and subsequent review and discussion by the steering committee of successive drafts of the recommendations. The Center for Education and Research on Mental Health Therapeutics Treatment of Maladaptive Aggression in Youth (T-MAY) guidelines reflect a synthesis of the available evidence, based on this multistep process. RESULTS: The current article describes 9 recommendations for family engagement, assessment, and diagnosis as key prerequisites for treatment selection and initiation. CONCLUSIONS: Recognizing the family and social context in which aggressive symptoms arise, and understanding the underlying psychiatric conditions that may be associated with aggression, are essential to treatment planning.

Integrating Mental Health Care Into Pediatric Primary Care Settings

RESEARCH LETTER Adults in the United States with severe mental illness (SMI), such as schizophrenia and bipolar disorder (totaling approximately 7 million), are estimated to die, on average, 25 years earlier than the general population, largely of premature cardiovascular disease.1 The Institute of Medicine2 has called for improvements in health care for this population. Severe mental illness is associated with elevated risk for type 2 diabetes mellitus.3 Treatment with antipsychotic medications contributes to risk, with most evidence focused on second-generation antipsychotic medications, but similar increases in risk are reported with older and newer medications.4 The American Diabetes Association5 recommends annual diabetes screening for patients treated with antipsychotic medications, and public health administrators have targeted this population for improved health screening.6 To our knowledge, no studies have examined screening rates in this highest-risk population of adults with SMI because of limitations in public health medical records. We examined diabetes screening among publicly insured adults with SMI taking antipsychotic medications using matched administrative data for physical and mental health care services in a large health care system. We measured diabetes screening prevalence among patients with SMI treated with antipsychotic medications and assessed characteristics predictive of screening.

Low Rates of HIV Testing Among Adults With Severe Mental Illness Receiving Care in Community Mental Health Settings

This study describes the rate that Medicaid encounter data on gender, race/ethnicity, and diagnosis matched information in the medical record, among a statewide sample of Medicaid children who received ongoing care for attention deficit hyperactivity disorder (ADHD), conduct disorder (CD), and major depression (MD) in outpatient specialty mental health clinics in 1998–1999. The match rate for gender was 99%; and for race/ethnicity it was 71.8%, 90.5%, and 89.7% for Caucasian, African American, and Hispanic children, respectively. Misidentified Caucasian children were more likely to be recorded as African American or Hispanic than misidentified minority children to be recorded as Caucasian. Diagnosis match rates were high (ADHD: 98%, CD: 89%, MD: 89%). If the California Department of Mental Health relied solely on Medicaid encounter data, misclassification of African American or Hispanic children as Caucasian could produce an underestimate of their service use.