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Children with attention-deficit/hyperactivity disorder (ADHD) and conduct problems exhibit significant variability in functioning and treatment response that cannot be fully accounted for by differences in symptom severity. Reward responsivity (RR) is a potential transdiagnostic means to account for this variability. Irritability and callous-unemotional (CU) traits moderate associations between both ADHD and conduct problems with multiple realms of functioning. Both are theorized to be associated with RR, but associations in clinical samples are unknown. In 48 youth ages 5-12 with ADHD referred for treatment of conduct problems, we examined RR using a guessing task where participants select a door icon to win and lose money. Analyses focused on the reward positivity (RewP) event-related potential in response to gain and loss feedback, which reliably peaks approximately 300 ms after feedback. Frequentist and Bayesian approaches assessed main effects of ADHD, Conduct Disorder (CD) and non-irritable Oppositional Defiant Disorder (ODD) symptoms with RR, plus interactions between symptoms and affective dimensions (irritability, CU). CD and ODD were hypothesized to be associated with altered RR, with irritability and CU moderating these associations. Across models, a reliable CD x irritability interaction emerged, indicating enhanced RewP when irritability was elevated and CD symptoms were low. CU did not moderate any associations with RR, and little support was found for associations between RR and other symptom domains. As neural response to reward varied with levels of irritability and CD symptoms, RR may hold potential as a clinically-relevant biomarker in youth with ADHD and conduct problems.

There are multiple pharmacological and psychosocial interventions that are tolerable and efficacious for the treatment of attention deficit hyperactivity disorder (ADHD). However, many youth with ADHD have elevated levels of mood and anxiety symptoms that can complicate treatment. In this review, we summarize the relevant treatment studies on the treatment of youth with ADHD and comorbid anxiety or mood disorders. Treatment of ADHD, specifically CNS stimulants, often translates to reduced irritability in youth with ADHD, but appears to have limited impact on other mood or anxiety symptoms. The presence of ADHD does not appear to reduce the efficacy of pharmacological treatments of mood and anxiety disorders. There is less data on the impact of ADHD on psychosocial treatments for internalizing disorders. In children with elevated levels of mood or anxiety, ADHD can be safely and effectively treated with either evidence-based pharmacological or psychosocial interventions. However, additional treatments are often needed to achieve significant improvements in other mood or anxiety symptoms.

Objectives: The COVID-19 pandemic prevented a group-based partial hospitalization program (PHP) from running in-person care intermittently due to social distancing guidelines. The healthcare system adapted during a time of very high stress to develop novel and feasible care models, including the tele-PHPs. Presenters will discuss the development, implementation, and challenges of child and adolescent tele-PHPs. Methods: Presenters will share their personal experiences in establishing tele-PHPs. Presenters discuss the process of transitioning or developing new tele-PHPs and various challenges throughout this process. Presenters of this Clinical Perspectives are coming from different PHPs, including the general child and adolescent program, DBT-based, eating disorder, substance abuse, and OCD. Results: In the first talk, Meenal Pathak, MD, presents her experience in developing child and adolescent tele-PHPs in an academic setting. In the second talk, Shikha Verma, MD, discusses procedural and technological challenges associated with creating a virtual setup and other difficulties, including patient engagement, specific treatment-related challenges, and system-related changes. Jamal Essayli, PhD, presents experience in virtual intensive treatment for eating disorders. Joyce Chen, MD, discusses experience and challenges in developing a new in-person PHP enhanced with telehealth during this pandemic. As a discussant, Ujjwal Ramtekkar, MD, integrates these presentations and discusses the future of virtual care integration of the future of telehealth. Conclusions: Initial experiences with tele-PHP suggest that this can be a viable long-term treatment option in the future, during both a disaster and routine times, to improve access for those who otherwise cannot take advantage of such services. The outcome of this presentation is that attendees will have a better understanding of integration of virtual care in tele-PHP, challenges in developing this program, and the future of teleservices. TVM, PAH

Bullying is a significant international problem, and parent–teacher agreement on identifying perpetrators and victims is poor in general population studies. The goal of our study is to assess informant discrepancies in children with mental health disorders. Parents and teachers completed the Pediatric Behavior Scale as part of a diagnostic evaluation for 1,723 children (ages 2–16 years) referred to a psychiatry clinic over the past 10 years. Mother and father bullying and victimization ratings on the Pediatric Behavior Scale were similar, but parent–teacher agreement was poor. Half of parents considered their child a victim, twice the percentage for teachers. Parents were 1.2 times more likely than teachers to perceive their child as a bully. Most parents reported their child was a victim or bully, whereas most teachers reported the children were neither. For both parents and teachers, victim and bully percentages for our psychiatric sample were twice as high as in general population studies. Clinicians should obtain information from multiple informants and consider that teacher report is likely to be lower than parent report.

Disruptive mood dysregulation disorder (DMDD) was introduced as a new diagnostic entity under the category of depressive disorders in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). It was included in DSM-5 primarily to address concerns about the misdiagnosis and consequent overtreatment of bipolar disorder in children and adolescents. DMDD does provide a home for a large percentage of referred children with severe persistent irritability that did not fit well into any DSM, Fourth Edition (DSM-IV) diagnostic category. However, it has been a controversial addition to the DSM-5 due to lack of published validity studies, leading to questions about its validity as a distinct disorder. In this article, the authors discuss the diagnostic criteria, assessment, epidemiology, criticism of the diagnosis, and pathophysiology, as well as treatment and future directions for DMDD. They also review the literature on severe mood dysregulation, as described by the National Institute of Mental Health, as the scientific support for DMDD is based primarily on studies of severe mood dysregulation.

Tourette syndrome (TS) often presents with other comorbid conditions in clinical settings. The most common comorbidities are obsessive-compulsive disorder or obsessive-compulsive behaviors, attention deficit hyperactivity disorder, learning disabilities, autism, mood and anxiety disorders, and personality disorders. Comorbid disorders and coexistent psychopathologies are often associated with impaired functioning, more severe course, and poorer long-term outcome. The overall presentation of TS with and without comorbidities can be significantly different and comorbid neuropsychiatric conditions may also change with age. Thus, frequent reassessment of symptoms and re-ordering of treatment priorities are needed when following the child over the developmental timeline.

Disruptive mood dysregulation disorder (DMDD) is a controversial diagnosis introduced in the DSM-5 that is particularly relevant to autism and other disorders in which DMDD symptoms (irritable-angry mood and temper outbursts) are common. Mothers rated DMDD symptoms in 1593 children with autism, ADHD, and neurotypical development (6–16 years, IQ ≥ 80). Percentages with DMDD symptoms (often or very often) were autism 45%, ADHD-Combined type 39%, ADHD-Inattentive type 12%, and neurotypical 3%. Almost all (91%) with DMDD symptoms met DSM-5 criteria for ODD, and 79% with ODD had DMDD symptoms. Only 5% without ODD had DMDD symptoms, and most of these had autism. Children with autism had significantly higher DMDD scores than all other groups, even when the oppositional behavior score (excluding the two DMDD symptoms) was controlled. The findings suggest that DMDD and ODD are not meaningfully differentiated based on their symptoms and that DMDD symptoms are particularly common in autism, more so than expected by comorbid ODD alone.

Attention-deficit hyperactivity disorder (ADHD) affects an estimated 5-7 % of schoolchildren worldwide. School functioning and academic achievement are frequently impaired by ADHD and represent one of the main reasons children start ADHD medication. Multiple potential causal pathways exist between ADHD and impaired school performance. In this review, we decompose school performance into three components and assess the impact of ADHD and its treatments on academic performance (assessed by grade point average [GPA], time on-task, percentage of work completed as well as percent completed correctly), academic skills (as measured by achievement tests and cognitive measures), and academic enablers (such as study skills, motivation, engagement, classroom behavior and interpersonal skills). Most studies examined only the short-term effects of medication on school performance. In these, ADHD medications have been observed to improve some aspects of school performance, with the largest impact on measures of academic performance such as seatwork productivity and on-task performance. In a subset of children, these benefits may translate into detectable improvements in GPA and achievement testing. However, limited data exists to support whether these changes are sustained over years. Optimizing medication effects requires periodic reassessment of school performance, necessitating a collaborative effort involving patients, parents, school staff and prescribers. Even with systematic reassessment, behavioral-based treatments and additional school-based services may be needed to maximize academic performance for the many youth with ADHD and prominent impairments in school performance.

Little is known about psychiatric diagnoses that place children at risk for bullying and victimization. Mothers of 1,707 children 6–18 yr. rated their child as a bully and a victim (not at all, to very often a problem) on the Pediatric Behavior Scale. Children with psychiatric diagnoses were evaluated in an outpatient psychiatry clinic ( M age = 9.2 yr., 68.4% male). Control children were community children not on psychotropic medication and with no neurodevelopmental disorder ( M age = 8.7 yr., 43.5% male). Children with autism, intellectual disability, and ADHD-Combined type had higher victim and bully maternal ratings than children in the ADHD-Inattentive, depression, anxiety, eating disorder, and control groups. Eating disorder and controls were the only groups in which most children were not rated a victim or a bully. Comorbid oppositional defiant disorder accounted for the higher bully ratings for ADHD-Combined, autism, and intellectual disability. Victimization ratings did not differ between psychiatric groups. Except for eating disorders, victimization ratings were greater in all groups than in control children, suggesting that most psychiatric disorders place children at risk for victimization, as perceived by their mothers.

This is the first study determining correlates of suicide behavior in children with eating disorders using multiple sleep, psychological, and demographic variables. Mothers rated suicide ideation and attempts in 90 children ages 7–18 with bulimia nervosa or anorexia nervosa. Suicide ideation was more prevalent in children with bulimia nervosa (43%) than children with anorexia nervosa (20%). All children with bulimia nervosa who experienced ideation attempted suicide, whereas only 3% of children with anorexia nervosa attempted suicide. Correlates of ideation were externalizing behavior problems and sleep disturbances. Correlates of attempts were bulimia nervosa, self-induced vomiting, nightmares, and physical or sexual abuse. These problems should be assessed and targeted for intervention because of their association with suicide behavior.

In this paper, we describe the sociodemographic profile, clinical characteristics and treatment outcome of 20 children with trichotillomania. These children presented to the Child Adolescent Psychiatry Clinic over a period of 6 years, with a prevalence of 1.24% . Most subjects were females (85%), hindu by religion (65%), and belonged to urban nuclear family (70%). The mean age at first presentation was 10.1 yr (SD = 4.4). Comorbid psychiatric illness and family history of psychiatric disorders was present in 40% and 20% cases, respectively. Nearly two-third of these had associated impulse; 75% denied resistance to pluck. Children who continued treatment, showed improvement.