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Chronic pain refers to recurrent or persistent pain that extends beyond the expected time of healing. In addition to the negative impact of chronic pain on a child's overall well-being and functioning in social and academic settings, chronic pain negatively impacts family functioning, caregiver well-being, and a family's financial resources.

Attention deficit hyperactivity disorder (ADHD) is a common and impairing behavioral health disorder, impacting over 5% of children worldwide. There are multiple evidence-based pharmacological and psychosocial treatments for ADHD, and greater service utilization is associated with improved acute and long-term outcomes. However, long-term outcomes are suboptimal as multimodal treatments are often not accessed and most care ends prematurely. This narrative review discusses barriers to engagement for children and adolescents with ADHD and their families as well as interventions to overcome these barriers. Families face a variety of structural and attitudinal barriers, ranging from cost and access to stigma and low self-efficacy to successfully implement change. There are multiple interventions that may enhance engagement with ADHD care including psychoeducation, integration of behavioral services in general medical settings, telehealth as well as specific adaptations to existing ADHD treatments, such as the use of motivational interviewing or shared decision making. Integration of behavioral health into general medical settings and telehealth have been found in controlled studies to increase access by reducing both structural and attitudinal barriers. Adding motivational interviewing, shared decision making and other engagement interventions to evidence-based ADHD treatments has been found to reduce attitudinal barriers that translates into improved participation and satisfaction while enhancing outcomes. However, little is known about how to promote extended engagement with ADHD services even though a chronic care model for ADHD is recommended.

Central nervous system stimulants are established treatments for pediatric attention-deficit/hyperactivity disorder with robust efficacy data. Reductions in appetite, weight, and growth velocity are some of the most common concerns regarding the long-term use of central nervous system stimulants in developing children. They are associated with suppression of weight and body mass index in childhood. However, both weight and body mass index often progressively increase over adolescence at rates faster than those seen in non-attention-deficit/hyperactivity disorder youth to the degree that attention-deficit/hyperactivity disorder is associated with elevated body mass index by the end of adolescence regardless of medication use. The capacity of central nervous system stimulants to slow growth was identified 50 years ago. Recent work has established that the growth deficits accumulate during the first 2 years of use and may persist provided medication is used. Early initiation coupled with persistent use through adolescence is most likely to be associated with clinical impactful growth suppression. There has been limited formal investigation of treatments for stimulant-associated reductions in weight and height. The most robust evidence exists for drug holidays improving weight gain. Observational studies suggest that limiting lifetime exposure or discontinuing medication is associated with greater adult height. Additional research is needed to identify the causal mechanisms driving the observed slowing in growth as well as the identification of predictors of clinically impactful growth suppression.

Many children with a range of psychiatric diagnoses manifest impaired levels of emotion dysregulation (ED). Over the past decade, there has been increasing examination of psychosocial interventions for ED. We found preliminary evidence of positive effects for a wide range of psychosocial treatments that were associated with improvements in emotion recognition, emotional reactivity, and emotion regulation. More studies are needed because results are limited by the small number of controlled trials, heavy reliance on parent ratings, and heterogeneity of the samples.

The coronavirus disease 2019 pandemic affects psychiatric patients disproportionately compared to the general population. In this narrative review, we examine the impact of the pandemic on significant global health disparities affecting vulnerable populations of psychiatric patients: People of diverse ethnic background and color, children with disabilities, sexual and gender minorities, pregnant women, mature adults, and those patients living in urban and rural communities. The identified disparities cause worsened mental health outcomes placing psychiatric patients at higher risk for depression, anxiety and posttraumatic stress disorder symptoms. Those psychiatric patients who are ethnic minorities display barriers to care, including collective trauma and structural racism. Sexual and gender minorities with mental illness face discrimination and limited access to treatment. Pregnant women with psychiatric diagnoses show higher exposure to domestic violence. Children with disabilities face a higher risk of worsening behavior. Mature adults with psychiatric problems show depression due to social isolation. Psychiatric patients who live in urban communities face pollutants and overcrowding compared to those living in rural communities, which face limited access to telehealth services. We suggest that social programs that decrease discrimination, enhance communal resilience, and help overcome systemic barriers of care should be developed to decrease global health disparities in vulnerable population.

Objectives This study aims to find the prevalence of medication non-compliance among schizophrenia inpatients and to compare the relative risks of medication non-compliance with cannabis use disorders (CUDs) versus without CUDs. In addition, this study also examines the odds of medication non-compliance in schizophrenia inpatients with CUDs. Methods This is a retrospective cross-sectional analysis of the nationwide inpatient sample. This sample includes 1,030,949 inpatients (age 18 to 65 years) from 2010 to 2014 with primary ICD-9 diagnoses of schizophrenia and other psychotic disorders, that were further sub grouped based on medication non-compliance. CUDs were recognized using the ICD-9 codes. Results The prevalence of medication non-compliance was 26% among schizophrenia inpatients. Multivariable analysis revealed that CUD comorbidity was a significant risk factor for medication non-compliance among schizophrenia patients when unadjusted (OR 1.49, 95%CI 1.469–1.503), and association remained significant even after adjusting for covariates (adjusted OR 1.38, 95%CI 1.268–1.489). Comorbid CUD was seen in young adults (18–35 years, 62.4%), males (80.5%), African Americans (54.1%) and low-income families below 25th percentile (48.6%) with personality disorders (10.5%). Conclusion Medication compliance is a challenge among schizophrenia patients, which has a significant adverse impact on the course of illness. CUD Comorbidity increases the risk of medication non-compliance significantly among schizophrenia patients. In addition to case management, an integrated treatment model to address both substance use disorders and psychosis will translate into better long-term outcomes in schizophrenia patients.

No study has analyzed the relative occurrence of a broad range of symptoms reported by mothers of children with autism, ADHD-Combined, and ADHD-Inattentive and typical controls. Mothers rated 1436 children with autism, 1056 with ADHD without autism, and 186 controls, 2-17 years, on 41 internalizing, externalizing, neurodevelopmental, and somatic problems. Most children with autism had symptoms of ADHD, oppositional defiant disorder, disruptive mood dysregulation disorder, and expressive language disorder and almost half had dysgraphia and receptive language disorder. Symptom overlap between autism and ADHD-Combined was high. Clinicians specializing in autism and ADHD must have expertise in evaluating and treating these comorbidities identified as most problematic by mothers in order to relieve family concerns and develop treatment plans relevant to families.

Emotional dysregulation (ED) manifesting as irritability or aggression produces appreciable impairment in children with attention deficit hyperactivity disorder and a main reason why they present for treatment. Central nervous system (CNS) stimulants seem to be a safe and tolerable treatment of most youth with these presentations. Optimization of CNS stimulants dose in combination with psychosocial interventions led to reductions in ED. Randomized controlled trials support that addition of risperidone further reduces aggression when these treatments are not sufficient. There is evidence for the efficacy of divalproex, molindone and selective serotonin reuptake inhibitor improve these outcomes when used as adjunct to CNS stimulants.

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.

Affective traits, including irritability and limited prosocial emotions/callous-unemotional traits (LPE/CU), each explain significant variance in youth conduct problems but few studies have examined these constructs simultaneously. This study examined whether irritability, LPE/CU, or their combination explained significant variance in measures of internalizing or externalizing psychopathology, aggression, peer problems, impairment, or parenting. Participants were 219 elementary-school-age children, including 178 with attention-deficit/hyperactivity disorder, oppositional defiant disorder, and/or conduct disorder and 41 typically developing children. Results of analyses showed that irritability and LPE/CU had significant and sometimes unique associations with measures of child behavior, impairment, and parenting. There was also evidence that the interaction between irritability and LPE/CU was significantly associated with aggression and impairment. These findings suggest that irritability and LPE/CU should be examined together when assessing and treating conduct problems in youth.

There is a lower incidence of suicide in the Philippines compared to other developed/developing countries, but the trend has been increasing. This study aims to identify the correlates of suicide attempts in Filipino youth using the World Health Organization's 2015 Global School-Based Health Survey. All schools in the Philippines with grades 7-10 were included. A stratified sampling design was used, and participants were randomly sampled. Of the 8,761 students who participated in the survey, 16.2% have attempted suicide at least once in the past 12 months. The factors that increased the risk of suicide attempts include female gender, being physically attacked, getting bullied, feeling lonely, poor sleep, having few close friends, smoking, alcohol use, less physical activity, use of amphetamine/methamphetamine, and less parental supervision. The use of methamphetamine/amphetamine is the single best risk factor of suicide attempts among Filipino youth with OR= 4.6; 95% CI [3.8, 5.6].

Background and objectives Recent observations indicate that cannabis use can result in cardiovascular complications including arrhythmias. We studied the relationship between cannabis use disorder (CUD) and arrhythmia hospitalization. Methods We conducted a retrospective analysis of the Nationwide Inpatient Sample (2010-2014). Patients (age 15-54) with a primary diagnosis for arrhythmia (N = 570,556) were compared with non-arrhythmia (N = 67,662,082) inpatients for odds ratio (OR) of CUD by the logistic regression model, adjusted for demographics and comorbid risk factors. Results The incidence of CUD in arrhythmia inpatients was 2.6%. Among cannabis users, the most prevalent arrhythmia was atrial fibrillation (42%), followed by other arrhythmias (24%) and atrial flutter (8%). Patients with CUD were younger (15-24 years, OR: 4.23), male (OR: 1.70), and African American (OR: 2.70). CUD was associated with higher odds of arrhythmia hospitalization in the young population, 1.28 times in 15-24 years (95% confidence interval [CI]: 1.229-1.346) and 1.52 times in 25-34 years (95% CI: 1.469-1.578). Conclusion and scientific significance With the growing legalization in the United States, there is an increased use of medicinal/recreational cannabis. This is the first national study to our knowledge that found that CUD is associated with a 47%-52% increased likelihood of arrhythmia hospitalization in the younger population and the risk of association was controlled for potential confounders including other substances. The fact that atrial fibrillation is the most prevalent arrhythmia is of special concern since it can result in stroke and other embolic events. Physicians need to familiarize themselves with cannabis abuse or dependence as a risk factor for arrhythmia.

This meta-analysis examined the efficacy of available pharmacological and non-pharmacological interventions for irritability among youth with autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD), disruptive behavior disorders (DBD), disruptive mood dysregulation disorder (DMDD), and/or severe mood dysregulation (SMD).Literature searches were conducted in October 2020, resulting in 564 abstracts being reviewed to identify relevant papers, with 387 articles being reviewed in full. A random effects model was used for the meta-analysis, with subgroup meta-regressions run to assess effects of study design, intervention type, medication class, and clinical population.A total of 101 studies were included (80 pharmacological, 13 non-pharmacological, 8 combined). Despite high heterogeneity in effects (IThis meta-analysis provides a comprehensive review of interventions targeting persistent non-episodic irritability among youth with various psychiatric disorders. Strong evidence was found for medium-to-large effects across study design, intervention type, and clinical populations, with the largest effects for pharmacological interventions, particularly antipsychotic medications and combined pharmacological interventions, and interventions for youth with ASD.

Central nervous system stimulants are established treatments for pediatric attention-deficit/hyperactivity disorder with robust efficacy data. Reductions in appetite, weight, and growth velocity are some of the most common concerns regarding the long-term use of central nervous system stimulants in developing children. They are associated with suppression of weight and body mass index in childhood. However, both weight and body mass index often progressively increase over adolescence at rates faster than those seen in non-attention-deficit/hyperactivity disorder youth to the degree that attention-deficit/hyperactivity disorder is associated with elevated body mass index by the end of adolescence regardless of medication use. The capacity of central nervous system stimulants to slow growth was identified 50 years ago. Recent work has established that the growth deficits accumulate during the first 2 years of use and may persist provided medication is used. Early initiation coupled with persistent use through adolescence is most likely to be associated with clinical impactful growth suppression. There has been limited formal investigation of treatments for stimulant-associated reductions in weight and height. The most robust evidence exists for drug holidays improving weight gain. Observational studies suggest that limiting lifetime exposure or discontinuing medication is associated with greater adult height. Additional research is needed to identify the causal mechanisms driving the observed slowing in growth as well as the identification of predictors of clinically impactful growth suppression.

Depression and anxiety are the most common mental health diagnoses in primary care. In this article, we discuss changes in Diagnostic and Statistical Manual of Mental Disorders (DSM) with respect to depressive and anxiety disorders. We also provide a brief overview of assessment of these disorders and associated safety concerns, while maintaining focus on the pharmacologic and non-pharmacologic interventions for the management of depression and anxiety in primary care.

The COVID-19 infectious disease pandemic has caused significant fear and uncertainty around the world and had significant adverse psychological impact. Children, adolescents and adults with autism spectrum disorder (ASD) are a particularly vulnerable population, impacted by stay-at-home orders, closures at nonessential services, and social distancing standards. This commentary describes various challenges faced by individuals with ASD in the United States including disruptions caused by educational and vocational changes, challenges to home and leisure routines, limited access to behavioral health services and changes in health services delivery due to the pandemic. We highlight the need for ongoing skills development for individuals and development within systems to better respond to needs of the ASD population in future emergencies.

The coronavirus disease 2019 (COVID-19) pandemic prevented a group-based partial hospitalization program (PHP) from running in-person care due to social distancing guidelines. However, the crisis also simultaneously increased stress on families while decreasing their desire to hospitalize youth for a nonmedical issue. Hence, the need for a PHP remained high. Health care organizations worked diligently to create a secure telehealth platform (tele-PHP) to be delivered to patients in their home environments. This article describes the development and implementation of child and adolescent tele-PHPs in response to the COVID-19 pandemic. These new programs were started in mid-March 2020, and changes were implemented over the next 3 to 4 weeks. Overall, patients and families have been receptive to behavioral health services delivered through telemedicine. While tele-PHPs are the most plausible solution to continue behavioral health care for these patients, some challenges were observed during this process. Besides procedural and technological challenges associated with creating a virtual setup, other difficulties include variable patient engagement, specific treatment-related challenges, and system-related changes. These challenges are addressed through psychoeducation, provision of online measures to assess treatment outcomes, and efforts to optimize parent engagement prior to treatment initiation for better treatment adherence. Initial experiences during a time of crisis suggest that tele-PHP services 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. Long-term effectiveness of these interventions still needs to be explored.

Bupropion hydrochloride is a norepinephrine-dopamine reuptake inhibitor approved for the treatment of depression and smoking cessation. Although cardiovascular and hematological side effects are common with bupropion along with weight loss and headache, hematological side effects are rarely reported other than few post marketing studies. Here we present the case of a 47-year-old white female who presented with significant leukocytosis after bupropion overdose.

Sleep and eating behavior are complimentary homeostatic functions and adequate sleep is fundamental for the nutritional balance of the body. Short sleep duration has been linked to development of obesity and abnormal eating patterns in children and adults. Individuals with eating disorders report significantly higher sleep disturbances of sleep apnea, insomnia, circadian rhythm disorders, and impairment of daytime functioning, as compared to controls. Sleep disturbances have been implicated in suicidal behaviors in patients with eating disorders. This chapters outline the current evidence examining the pathophysiology and comorbidity of sleep disturbance in daytime eating disorders and focus on clinical assessment and management of nocturnal eating disorders including night eating syndrome and particularly sleep-related eating disorder, which is a combination of parasomnia and eating disorder. There is an imminent need to develop evidence-based pharmacological and psychological treatments for management of nocturnal eating disorders and the sleep disturbances associated with daytime eating disorders.

Numerous studies have found that attention-deficit/hyperactivity disorder (ADHD) significantly impairs academic functioning. Observed impairments span diverse outcomes, from grade point average (GPA) and standardized test scores to grade retention and dropout. The impact of treating ADHD on academic functioning has received appreciable attention but remains a topic of debate because of the mixed and somewhat underwhelming results to date. The best evidence for effect is the capacity of central nervous system (CNS) stimulants to decrease problematic behaviors in the classroom.1 However, it is not clear whether improved behavior translates into better academic functioning. In fact, there is evidence that parents might be less likely to follow through on behavioral interventions after medication has been initiated, even when parents report persistent impairment from ADHD.2.

Objective To identify predictors of changes in height, weight, and body mass index (BMI) in children with attention deficit hyperactivity disorder (ADHD) starting central nervous system (CNS) stimulants. Study design There were 230 medication-naive children aged 5-12 years with ADHD who participated in a randomized trial evaluating the impact of CNS stimulants on growth over 30 months. This observational analysis focused on the 141 participants using study medication for 65 or more days in the first 6-months after starting medication. Biometric variables, ADHD, and oppositional defiant disorder symptom scores at medication initiation, and medication use over the study were examined as predictors of changes in standardized (z) height, weight, and BMI. Results Mean changes in z-BMI, z-weight. and z-height were negative throughout the study. The most consistent predictors of change in z-BMI, z-weight, and z-height were percent days medicated and total medication exposure. Children with lower z-height and z-weight at medication initiation experienced greater z-BMI and z-weight decreases over the first 6 months on medication. Greater appetite suppression during dose optimization predicted greater decreases in z-weight over the entire study and a greater decrease in z-height over the first 6 months on medication. z-weight change correlated with z-height change. Behavioral symptoms did not predict changes in z-BMI, z-weight, or z-height. Conclusions How much and how often CNS stimulants are used predicts changes in z-BMI, z-weight, and z-height in children. Even smaller and lighter children may be at risk for decreases in z-weight and z-BMI. Parent ratings of appetite during dose titration may serve as feasible indicators of future weight and height change in children using CNS stimulants. Trial registration Clinicialtrials.gov: NCT01109849.

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

Little is known about the persistence of bullying and victimization from childhood through adolescence and the emergence of new cases, which we investigated in a general population sample. Mothers rated the degree to which their child was a bully and a victim on the Pediatric Behavior Scale in a population-based sample of 376 children. The children were rated at 6-12 years of age ( M 9) and again an average of 8 years later ( M 16). Bullying was a problem for 14% at baseline, 9% at follow-up, and 4% at both baseline and follow-up. Victimization was a problem for 28% at baseline, 14% at follow-up, and 7% at both baseline and follow-up. Child victims were three times more likely to be adolescent victims than children who were not victims in childhood, and child bullies were five times more likely to be adolescent bullies. Only 26% of children who were victims at baseline continued to be victims at follow-up, and 30% who were bullies at baseline continued to be a bully at follow-up. For children who were neither a bully nor a victim at baseline, 87% remained neither at follow-up. Approximately half of adolescents who were bullies and half who were victims at follow-up were new cases. Although bullying and victimization decreased with time overall, the findings that 30% and 26% were still bullies and still victims and that half were new cases support the need for intervention to eliminate bullying, relieve current suffering, reduce chronicity, and prevent bullying from developing.