Terry Lee

A Randomized Trial of Multisystemic Therapy With Hawaii's Felix Class Youths.

Examined 6-month post-recruitment clinical and placement outcomes for 31 youths with serious emotional disturbance (SED) at imminent risk of out-of-home placement in the Hawaii Continuum of Care (COC). Youths were randomly assigned to multisystemic therapy (MST) adapted for SED populations or to Hawaiis existing COC services.Assessments were conducted at intake and 6 months after referral. In comparison with counterparts in the comparison condition, youths in the MST condition reported significant reductions in externalizing symptoms, internalizing symptoms,and minor criminal activity; their caregivers reported near significant increases in social support; and archival records showed that MST youths experienced significantly fewer days in out-of-home placement. The findings generally replicate the favorable short-term outcomes observed previously for MST with youths experiencing SED.

Second Opinions Improve ADHD Prescribing in a Medicaid-Insured Community Population

OBJECTIVE The appropriate use of psychotropic medications in youths is an important public health concern. In this article, we describe a review process developed to monitor the use of stimulants and atomoxetine for attention-deficit/hyperactivity syndrome (ADHD) in youths receiving fee-for-service Medicaid services. METHOD Washington State Medicaid developed threshold safety parameters for ADHD medications through a process involving the community. A second opinion was mandated when safety thresholds based on dose, combination therapies, or age was exceeded. Use and cost were compared 2 years before and after the program began. RESULTS From May 2006 to April 2008, 5.35% of ADHD prescriptions exceeded safety thresholds, resulting in 1,046 second-opinion reviews. Of those, 538 (51.4%) resulted in a prescription adjustment. Adjustments were made to primary care physician (52%), psychiatrist (50%), nurse practitioner (54%), and physician assistant-written (51%) prescriptions. When the preperiod and postperiod were compared, second opinions reduced ADHD medication at high doses (53%), in combinations (44%), and for patients 5 years of age and younger (23%). The review process resulted in a savings of

Transitioning to Adulthood from Foster Care

1.2 million, with 538 fewer patients exceeding safety thresholds. This was a 10:1 return over administrative costs; however, the overall Medicaid expenditures for ADHD medication still increased because of higher unit costs and the preferential use by clinicians of newer brands entering the market. CONCLUSIONS A statewide second-opinion process reduced outlier ADHD medication prescription practices and was cost-effective. Suggestions for process and quality improvements in prescribing to children diagnosed with ADHD are discussed.

School-based interventions for disruptive behavior.

Transitional age foster youth do not typically receive the types of family supports their nonfoster peers enjoy. Many foster youth experience multiple adversities and often fare worse than nonfoster peers on long-term functional outcomes. Governments increasingly recognize their responsibility to act as parents for state dependents transitioning to adulthood and the need to provide services to address social/emotional supports, living skills, finances, housing, education, employment, and physical and mental health. More research is needed to inform the development of effective programs. Transitional age foster youth benefit from policies promoting a developmentally appropriate, comprehensive, and integrated transition system of care.

An Interdisciplinary University-Based Initiative for Graduate Training in Evidence-Based Treatments for Children’s Mental Health

Youth disruptive behavior is a concern for youth, school personnel,families, and society. Early childhood disruptive behaviors negatively impact the classroom, and are associated with negative academic, social, behavioral, emotional, substance use, health, and justice system outcomes in adolescence and adulthood. Effective, comprehensive, multicomponent interventions targeting risk/protective factors and pathways associated with antisocial behavior reduce and/or mitigate these negative outcomes. Positive effects have been demonstrated for universal and indicated programs for participating youth and families in early childhood, and for high-risk youth in adolescence and young adulthood. These empirically supported programs inform the treatment of complex and difficult-to-treat disruptive behavior.

Children’s Clinical Complexity Drives Psychiatric Medication Costs to Rival Hospital Costs

States and jurisdictions are under increased pressure to demonstrate the use of evidence-based treatments (EBTs) for children’s mental health, increasing the demand for a workforce trained in these practices. Universities are a critical pipeline for this workforce. This article describes the genesis and evolution of a university-based initiative for training in EBTs for children, youth, and families. Given both the need to make training in EBTs available to future providers in a range of disciplines and that mental health providers increasingly find themselves on interdisciplinary teams (despite university-based training being relatively siloed along disciplinary lines), the initiative has had an interdisciplinary focus. Two tracks are described: (a) Practitioner Track, a course series in which students learn a specific EBT, and (b) Referral Track, a monthly lecture series designed to engage a wider university and community audience. Results of the program evaluation component of this initiative revealed that students can significantly increase their skills and self-efficacy in components of EBT delivery through participation in the active, skill-focused courses. Furthermore, the results of the lecture series evaluation appear to meet an important need for community-based providers and other supportive individuals in transferring useful knowledge about best practices. Implications and future directions are discussed.

Pediatric Bipolar Disorder.

Mental disorders are the costliest health conditions of childhood with associated services accounting for more than one third of children’s Medicaid expenditures. Concerned with managing these costs, Washington State’s Medicaid authority collaborated with the University of Washington and King County’s (Seattle area) public mental health authority to investigate cost predictors. Mental health costs to the state over a 1-year period were examined with respect to psychiatric medications, emergency department (ED) visits, and hospitalizations for a psychiatric diagnosis (DSM-V codes 290–319) for children (age 0–18 years) in King County who had at least one claim for these services. As with privately insured children, state mental health costs (

What Happens After the Innovation Is Identified

8,783,221) for the 5,873 children examined were evenly split between psychiatric hospitalization (48%) provided to a small group (N = 157) and psychiatric medications (49%) provided to most of the children (N = 5,470); with ED use accounting for only 3% of the costs. Hospital costs were predicted by neurodevelopmental disorders (most frequently attention-deficit or autism spectrum disorders), psychotic disorders, substance use, and homelessness. The bulk (73.3%) of medication costs were for children with neurodevelopmental disorders, consistent with household surveys. Of the 200 children with the highest medication costs, the greatest costs were for atypical antipsychotic medications, especially ariprazole (Abilify), which accounted for 42% of the subsample’s medication costs. Consistent with national data, only about half (56%) of the sample had received outpatient mental health services during the study year (outpatient costs were not available). Chart reviews of the 20 highest-cost youth revealed that high clinical complexity (e.g., developmental delays, co-

Demographic and Clinical Characteristics of Adolescents in Hawaii With Obsessive-compulsive Disorder

The diagnosis of bipolar disorder (BD) in youth is confusing and controversial. Controversy notwithstanding, youth diagnosed with BD have high behavioral health needs and are at elevated risk for problematic long-term psychosocial functioning and complex psychiatric medication regimens. Pediatricians and other primary care providers (PCPs) can play an important role in the assessment and treatment of youth diagnosed with BD and the recently created and also controversial diagnosis of disruptive mood dysregulation disorder (DMDD). This article provides information on the definitions, background, and presentation of pediatric bipolar disorder (PBD), how to differentiate PBD from other psychiatric disorders, effective psychiatric and psychosocial interventions for PBD, potential roles for PCPs, and what is known about DMDD. [Pediatr Ann. 2016;45(10):e362-e366.].