Journal of Developmental and Behavioral Pediatrics最新文献

Atypical antipsychotics are high-risk medications with serious side effects including weight gain, hyperlipidemia, and insulin resistance. Safe use in youth with autism spectrum disorder and other neurodevelopmental disorders is especially important due to inherent risks of high obesity rates and barriers to a healthy lifestyle. Metabolic monitoring rates are low in this population in part due to difficulties with obtaining labs and other vitals. In our Developmental and Behavioral Pediatrics clinic, 31% of patients had once-yearly metabolic monitoring parameters completed. We aimed to increase metabolic monitoring rates through multi-disciplinary interventions. A pharmacist provided educational presentations to staff, the pharmacist identified patients needing monitoring and provided recommendations to the medical provider, nursing staff notified families by phone if labs were needed, and child life support services were offered. Average once-yearly metabolic monitoring rates increased from 31% to 64% 1 year after beginning interventions. Three educational presentations were provided, 183 recommendations for monitoring were made on 141 patients, and nursing made 38 phone calls to families. Of the 141 patients identified as needing monitoring at the time of clinic visit, 72 (51%) obtained the monitoring parameters within 3 months. Abnormal metabolic labs requiring additional action were found in 31/72 (43%) patients. Patients with in-person visits were more likely to obtain labs overall and on the day of clinic visit than those with telehealth appointments. Using a multidisciplinary approach within a Developmental and Behavioral Pediatrics clinic, metabolic monitoring rates in patients taking atypical antipsychotics greatly improved.

Objectives: To examine recent trends and patterns in school-aged children's mental health and health care-related measures.

Methods: Data came from the 2016 to 2021 National Survey of Children's Health (n = 155,178). Adjusted logistic regression models were used to test for significant time trends and between-group differences. Measures included mental, emotional, behavioral conditions (MEB; depression, anxiety, behavioral/conduct problems), positive indicators of mental/emotional well-being, and mental health care access/utilization.

Results: In 2021, 20.4% of children aged 6 to 17 years (over 10 million) had at least 1 current MEB, up from 18.1% in 2016 (+13%; trend p < 0.001). Two-thirds (68.8%) of children with an MEB received treatment/counseling in the past year. Over half (53.6%) of children had difficulty getting mental health care, up from 44.0% in 2018 trend p < 0.001; 6.4% had unmet mental health care needs, up from 4.3% in 2016 (trend p = 0.01). Four of 5 positive indicators significantly decreased over time (range: -8% to -14%; trend p < 0.001). Across 2016 to 2021, access to mental health treatment was lower for publicly insured, uninsured, lower income, and racial/ethnic minority children.

Conclusion: An increasing burden of MEB conditions in children aged 6 to 17 years has been accompanied by stagnant rates of mental health treatment and increasing challenges in accessing services. Access to treatment varied across population subgroups, indicating gaps in access to prevention, diagnosis, and treatment.

Case: Marcus is a 4-year-old African-American boy with cerebral palsy, Gross Motor Function Classification System level 1, and attention-deficit hyperactivity disorder (ADHD), Combined Presentation who presents to Developmental-Behavioral Pediatrics clinic for evaluation because of preschool difficulties. He is very active, jumping up and down at circle time, bumping into classmates, and impulsively hitting other children when they take his toys. As a toddler, his cognitive and social-emotional skills were on track, and he received early intervention for language and motor delays. He qualified for an IEP and transitioned to a district-based inclusive preschool setting with speech therapy and adaptive physical education. Marcus spends the week with his grandparents, and they live in a school district that is well-resourced and has inclusive school and therapy settings. The teachers call parents or grandparents frequently to pick him up. In response to misbehavior, they also put him in a separate timeout area, away from the other children, with a 1:1 aide for the rest of the day. On 2 occasions, he was strapped into a therapy chair for nonambulatory children after biting or hitting another child. Because he does well with 1:1 support, the school has switched him to a special day class with smaller class size, comprised primarily of autistic preschoolers who are minimally verbal. Marcus' parents have just started parent training in behavior management for ADHD after struggling to find a therapist that was covered by their insurance. His mother noticed while volunteering in his original class that other children with similar behavior were not sent home or transferred to a special education class. They are upset with the transfer to the more restrictive environment, but they are worried if they speak up that the district will send him to a less resourced school in the district where the family, rather than grandparents, reside. How would you advise the family to proceed?

Objective: The introduction to complementary food is an important stage, particularly for preterm infants and their parents as they navigate a changing feeding relationship. Parental feeding strategies during this period can influence long-term feeding outcomes, but the influence of specific strategies on later feeding skills and feeding problem symptoms is unknown.

Method: Parents of preterm infants completed surveys about their infant's feeding at regular intervals from 1 to 12 months of age. At each time point, parents reported on their use of feeding strategies and their infants' feeding skills (Child Oral and Motor Proficiency Scale) and feeding problem symptoms (Pediatric Eating Assessment Tool). Patterns of parental strategy use across the early complementary feeding period were examined and associations with feeding skills and problems at 12 months corrected age was assessed.

Results: Seventy-four parents completed the surveys. Frequency and type of strategies used changed over time. Four patterns of parental strategy use emerged: low-moderate, schedule dominant, dual dominant, and modification dominant. Parental use of 2 or more types of strategies at relatively high levels was associated with more feeding problem symptoms at 12 months but not feeding skills.

Conclusion: Parents of preterm infants use different strategies during the complementary feeding period to navigate their infant's feeding, with potential implications for later feeding problems. Future research should explore causal mechanism behind parental strategy use and feeding problem symptoms through longitudinal analyses and investigate how parental perceptions and decision-making regarding mealtime strategy use evolve over the first year of life.

Objective: Maternal 15q11-q13 duplication syndrome (Dup15q) has been associated with 0.5% of all cases of autism spectrum disorder (ASD). There is no established protocol for the neuropsychiatric evaluation of individuals with this syndrome. This study aims to define a protocol incorporating gold standard assessments.

Methods: Six individuals with Dup15q underwent assessment of cognitive and adaptive functioning (Leiter-3, Adaptive Behavior Assessment System-Second Edition), autistic traits (Autism Diagnostic Observation Schedule-2 [ADOS-2], Autism Diagnostic Interview-Revised [ADI-R], Social Communication Questionnaire, Social Responsiveness Scale, Repetitive Behaviors Scale-R), co-occurring psychopathology (Kiddie Schedule for Affective Disorders and Schizophrenia, Child Behavior Checklist, Swanson, Nolan, and Pelham-Forth Edition, Sleep Disturbance Scale for Children), and family functioning (Parenting Stress Index-Short Form, PedsQL). Parents were required to fill the Symptom Checklist 90 (SCL-90) and Autism-Spectrum Quotient (AQ) to gather information about their psychiatric co-occurrences and autistic traits. A molecular analysis was performed to confirm the genetic alteration.

Results: Two siblings inherited the duplication through maternal transmission, whereas 4 individuals had a de novo maternal duplication. No participant exhibited preserved cognitive abilities; 4 of 5 showed below average adaptive functioning and 2 of 6 received a diagnosis of ASD. ADOS-2 revealed greater difficulties in the Social Affect domain compared with the Repetitive and Restricted Behaviors domain (p < 0.05), findings confirmed by ADI-R (p < 0.05). K-SADS indicated clinical scores in 5 individuals, with anxiety disorder in 3 participants. High levels of parental stress and a poor quality of life were reported. The mother carrier of the duplication showed clinical scores on the "Positive Symptom Total" of the SCL-90 and on the AQ.

Conclusion: Individuals with an in tandem 15q-11q13 duplication seems to exhibit cognitive and adaptive difficulties along with psychiatric co-occurrences and autistic traits. Parents, with or without the duplication, may experience psychopathological difficulties and impaired family functioning.

Objective: The primary objective of this pilot trial was to determine to what extent hunger provocation, via rapid weaning from enteral feedings, was acceptable and feasible and to evaluate the effect of this intervention when used during intensive multidisciplinary feeding intervention for children dependent on enteral feedings.

Method: The study was conducted at an Intensive Multidisciplinary Program located in the Southeastern United States from May 2021 to October 2023. Children were randomly assigned 1:1 to standard wean or rapid wean using permuted blocks of 2 and 4 with allocation pattern concealed to investigators resulting in respective cohort sizes of 8 (N = 16 participants, total) for 8 weeks. Feasibility benchmarks and data completeness were summarized using percentages and means. The study also evaluated the effect of intervention on treatment outcomes including weight-for-age z-score, percentage of daily caloric needs met by mouth, percent of patients achieving ≥1 day where 100% of caloric needs were met via oral feeding, and time to effect.

Results: Feasibility and acceptability benchmarks were achieved. Preliminary outcome data suggest rapid tube weaning did not influence reaching 100% oral intake or fully weaning from a feeding tube when used as an adjunct to behavioral intervention.

Conclusion: This study was a prerequisite to support a future efficacy randomized clinical trial to further study how to optimize outcomes to achieve full weaning from tube feeding.

Case: Andrew is a 12-year-old boy living in Southeast Asia with autism spectrum disorder (minimally verbal), who first presented with new symptoms of low mood and anhedonia during the COVID pandemic. This was associated with loss of appetite, which culminated in him eventually refusing to eat any food or swallow any liquids (including saliva). He would hold his saliva in his mouth in the daytime and refused to swallow. He would spit out the saliva when instructed to do so. Because of his worries about swallowing his saliva involuntarily during sleep, he also experienced insomnia. If he managed to fall asleep, he would involuntarily swallow his saliva.Three months from his initial symptoms, he was relocated by his family, to another southeast Asian country for specialty care. At this time, he also refused to speak. He went from intermittently accepting some foods, to being completely averse to any food or fluid intake. He was diagnosed with avoidant restrictive food intake disorder. Because of his acute refusal to eat or drink, a nasogastric tube was inserted and subsequently a gastrostomy tube for enteral nutrition. With this intervention, he was able to maintain good weight and nutrition.Simultaneously, he began treatment in a multidisciplinary feeding and nutrition program. Genetic testing done for concerns of neurological regression yielded a variant of unknown significance. He also began an anti-depressant and sleep medication.During this period, he returned to his country of origin and was no longer able to receive direct in-person specialty feeding support, but did have a dedicated caregiver. He was seen once every few months either in-person or by telehealth by the multidisciplinary feeding and nutrition clinic in the second country. His caregiver was taught to implement behavior strategies with a goal of him resuming oral food intake eventually.What factors should be considered when evaluating a child with co-existing neurodevelopmental and psychiatric conditions, who completely stops eating or drinking in the midst of a global pandemic? What feeding approach would be helpful in managing a complex case like this? What feeding interventions can be actualized at home to reintroduce solids? How did the pandemic impact access to services?

Objective: Suicide is the second leading cause of death for adolescents. Children in surgical clinics have diagnoses that may predispose mental health challenges. This study explored associations between demographics, diagnoses, and suicide risk screenings in the outpatient pediatric surgical setting.

Methods: A database of suicide risk screenings administered across a pediatric surgical health care system from 2019 to 2023 was analyzed. Demographic variables and diagnoses were collected, and multilevel logistic regression models calculated odds ratio (OR) and 95% confidence interval (CI) for the relationships.

Results: In total, 79,384 suicide risk screenings were collected for 50,796 patients. 5.6% (n = 4476) were positive for suicidal thoughts. Asians were less likely to screen positive (OR, 0.65; 95% CI, 0.56-0.76), and females were more likely (OR, 1.92; CI, 1.80-2.05). Patients with Medicaid or uninsured were more likely to screen positive (OR, 1.47; CI, 1.38-1.57 and OR, 1.17, CI, 1.002-1.36, respectively). As affluence increased, there was decreased likelihood of positive screens (OR, 0.93; CI, 0.91-0.96). The diagnosis most associated with increased risk was mental, behavioral, and neurodevelopmental disorders (OR, 3.41; CI, 2.92-3.97), followed by pain (OR, 1.88; CI, 1.71-2.05), burns (OR, 1.43; CI, 1.21-1.69), and scoliosis (OR, 1.10; CI, 1.02-1.17).

Conclusion: When screening for suicide risk in outpatient pediatric surgical subspecialty clinics, females and patients with Medicaid or uninsured have increased risk of screening positive for suicidal ideations. Youth with mental, behavioral, and neurodevelopmental disorders were most at risk, followed by pain, burns, and scoliosis. It is important to understand how these factors influence mental health to aid in providing resources for at-risk patients.