Leah Kuntz

The American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, and Children’s Hospital Association have declared a national emergency for children and adolescent mental health. Children and families in the United States have experienced “enormous adversity and disruption,” which was only exacerbated by the COVID-19 pandemic.

worsening crisis in child and adolescent mental health

 is inextricably tied to the stress brought on by COVID-19 and the ongoing struggle for racial justice and represents an acceleration of trends observed prior to 2020. Rates of childhood mental health concerns and suicide rose steadily between 2010 and 2020 and by 2018 suicide was the second leading cause of death for youth ages 10-24. The pandemic has intensified this crisis,” the groups wrote.

The groups went on to call for government and advocate intervention for the following 10 items:

1. Increased federal funding for evidence-based mental health screening, diagnosis, and treatment, particularly for underprivileged populations.

2. Improved access to technology to maintain availability of telemedicine.

3. Sustained funding for effective school-based mental health care.

4. Adoption of effective and financially sustainable integrated mental health care in primary care pediatrics.

5. Strengthened suicide prevention programs in schools, primary care, and community response teams.

6. Address challenges of acute care needs for children and young adults, like the shortage of beds and emergency room boarding.

7. Creation of fully funded community-based systems of care that can connect families with the programs they need.

8.Support family resilience through trauma-informed care services.

9. Address longstanding workforce challenges, including intensified efforts to recruit and support underrepresented populations into mental health professions.

10. Enforce mental health parity laws through advanced policies.

“We are caring for young people with soaring rates of depression, anxiety, trauma, loneliness, and 

 that will have lasting impacts on them, their families, and their communities. We must identify strategies to meet these challenges through innovation and action, using state, local and national approaches to improve the access to and quality of care across the continuum of mental health promotion, prevention, and treatment,” wrote the groups.

, many youth have been socially isolated. They have been attending school virtually, have not been able to see their friends, and have not been able to participate in extracurricular activities. Most of my patients have struggled academically with the changes and are having difficulty catching up. Although the majority of my patients have returned to in-person school, many have fewer social opportunities,” said Ann Childress, MD, a psychiatrist with a subspecialty in child and adolescent psychiatry, and president of the Center for Psychiatry and Behavioral Medicine in Las Vegas.

Childress also recommends encouraging patients to get the vaccine: “In addition to providing usual care, I have found that a short discussion of the vaccine science in a supportive way has been helpful. Several of my hesitant patients have gotten the vaccine after an appointment or allowed their teens to get vaccinated.”

What measures have you taken to support child and adolescent mental health during the pandemic? Write us at 

1. American Academy of Pediatrics. AAP-AACAP-CHA declaration of a national emergency in child and adolescent mental health. October 19, 2021. Accessed October 21, 2021. 

https://www.aap.org/en/advocacy/child-and-adolescent-healthy-mental-development/aap-aacap-cha-declaration-of-a-national-emergency-in-child-and-adolescent-mental-health/

Articles

Three leading groups in child and adolescent mental health have declared a state of emergency for the nation’s youth. 

Child and Adolescent Mental Health: A National Emergency 

“Are you okay? Is something wrong? Can I help you? These were quite literally the only words I desperately needed to hear the day I found myself standing atop the Golden Gate Bridge walkway, believing beyond a shadow of a doubt that I had not one other course of action to take but to die by these 2 hands,” said Kevin Hines, author, public speaker, documentary filmmaker, and keynote presenter at the American Psychiatric Nurses Association (APNA) 35th Annual Conference.

In his presentation, “Cracked Not Broken...Surviving and Thriving After a Suicide Attempt,” Hines shared thoughts on suicide prevention and recovery, steps for building mental health, and the importance of establishing relationships that heal, all informed by his lived experience.

A Life and Death Measure: Eating Disorder Treatment

At age 19, after a tumultuous childhood, Hines seriously began contemplating suicide, and even wrote a note to loved ones. He was having auditory hallucinations, voices “screaming in his head, telling him what to do.” Hines felt unable to share his pain with his family. On September 25, 2000, Hines walked up the Golden Gate Bridge. As he tells it, Hines believed he “had no other course of action”—that he had to die.

Hines told the audience of the horrifying statistics: Of the Golden Gate Bridge jumpers, 99% do not survive. Of the 1% that survive the 220 feet fall, a majority of them have admitted to having instantaneous regret. “They call us the most exclusive survivors club in the world,” Hines said. “I get to be here. And getting to be here is a privilege and a gift.”

With the second chance he was given, Hines is determined to help others. He shared the steps he takes every day to keep mentally well, in the hopes it may help other patients:

 Hines participates in regular cognitive behavioral therapy, talk therapy, music therapy, blue wave light box therapy, breath therapy.

 On a regular basis, Hines meditates using the Headspace app. By clearing his mind and destressing, Hines lives more well-rounded and builds wellness patterns.

 Approximately 3 days a week, 23 minutes a day, Hines engages in rigorous exercise.

 Keeping a consistent sleep schedule, 7-9 hours every night, with no caffeine past 2PM, helps keep Hines’s mind clear.

 Proper nutrients keeps him physically and mentally healthy, and ready for the day.

 He keeps up to date on the latest in mental health news, and helps educate his friends and family.

Hines stressed the importance of volunteering for a cause—when you give back, you feel better.

He takes his meds every day at the same time every day, and it helps him feel better. “It could change your life,” he said.

 Hines made a binder that he gave to his personal protectors, so they knew what to do if he seemed mentally unstable. It includes his story, his medications, his symptoms, and his triggers. This plan helps him stay positive, well, safe, and self-aware.

“If you are going to learn 1 thing from me today, and 1 thing alone, may I please ask that is be this: Never again silence your pain. Your pain is worthy of my time and others. Your pain is important. Your pain is valid. Your pain matters, simply because all of you do,” Hines shared.

One man shares his suicide survival story, and what he does to aid suicide prevention. 

“Never Silence Your Pain”: Life After a Suicide Attempt

“In the United States, there are roughly 28.8 million people with an eating disorder, which is about 9% of our population. Globally, that jumps up to 70 million,” said Rebecca Owens, DNP, MBA, MSN, RN-BC, to the audience of the 

American Psychiatric Nurses Association (APNA) 35th Annual Conference

Owens explained that up to 80% of eating disorders go undetected or never receive treatment. She felt it was important to start with a review of the 4 big ED classifications: anorexia nervosa, bulimia nervosa, avoidant/restrictive food intake disorder, and binge eating disorder.

With 92% of frontline clinicians admitting in hindsight to potentially missing an eating disorder (ED) diagnosis, Owens suggested 2 screening tools for consideration that might help clinicians catch more patients that need care: the SCOFF Questionnaire and the EDA-5.

The SCOFF Questionnaire is a UK-developed, straightforward, 5 question screener for EDs that can be used in almost any setting. Studies show it is highly effective for potential or actual ED identification, particularly high mortality disorders (anorexia or bulimia), with good psychometric properties.

S- Do you make yourself SICK because you feel uncomfortably full?

C- Do you worry you have lost CONTROL over how much you eat?
O- Have you recently lost more than ONE stone (a couple pounds) in a 3-month period?

F- Do you believe yourself to be FAT when others say you are too thin?

F- Would you say that FOOD dominates your life?

EDA-5 is an electronic, semi structured, interview-based, diagnostic tool that is available online at: 

. It facilitates ED diagnoses in general medicine and psychiatric settings and reduces patient-clinician burden in ED determination. Owens shared a few sample screens and told the APNA audience she finds it to be a “very practical, very easy tool to use.”

“The more of us that are understanding the complexities of eating disorders, the better it will be for our patients and communities,” said Owens.

Owens also emphasized the urgent need for improved ED treatment outcomes, and more availability of specialized ED services. “We want to be prepared to capture and help these patients get into timely treatment. It quite literally could be a life and death measure, as we’ve heard through the statistics.”

In a psychiatric setting, step 1 may be an identification of the ED itself, as patients may be coming in for other psychiatric comorbidities, such as an anxiety disorder, a mood disorder, or substance use disorder.

“There’s a lot to learn,” Owens said. “Early screening, diagnosis, and treatment are crucial to prevent long term, life threatening EDs.”

Nearly 80% of eating disorders go undetected. What screening tools can help identify them? 

A Life and Death Measure: Eating Disorder Treatment 

VistaGen Therapeutics announced new mechanism of action data from a study in laboratory rats that demonstrated a single intranasal dose of PH94B was largely confined to the nasal passages and minimal or undetectable in most other tissues, including the central nervous system (CNS). This supports the proposed mechanism of action of PH94B: binding to receptors of peripheral neurons in the nasal passages, not to neuronal receptors in the CNS, and limiting molecule movement to the circulatory system.

“In this study, the absence of radiolabeled PH94B in the rodent brain is an encouraging sign that PH94B may have limited circulatory systemic exposure when administered intranasally,” stated Mark Smith, MD, PhD, Chief Medical Officer of VistaGen. “Furthermore, the tissue distribution of radiolabeled carbon-14 PH94B was minimal in the tested lab animals, with the highest concentration primarily in the nasal turbinates. These findings strongly support a local disposition of PH94B in the olfactory receptor neurons and an absence of binding of PH94B in the central nervous system. We believe that this is another positive indication supporting the clinical development of PH94B.”

PH94B is an investigational, odorless, CNS pherine nasal spray with a rapid onset of approximately 15 minutes. The investigation agent is intended for the treatment of social anxiety disorder (SAD), with therapeutic potential in multiple additional anxiety disorders. The investigation agent is intended for the treatment of social anxiety disorder (SAD), with therapeutic potential in multiple additional anxiety disorders. PH94B is administered intranasally in microgram doses, and it activates peripheral nasal chemosensory neurons that trigger neural circuits in the brain to suppress fear and anxiety.

“We are very excited about these new study results, which further highlight how the mechanism of action of PH94B is fundamentally differentiated from all current anti-anxiety therapies,” said Shawn K. Singh, Chief Executive Officer of VistaGen. “When combined with previously announced preclinical electrophysiology data demonstrating that the mechanism of action of PH94B does not involve direct activation of GABA-A receptors, which is in distinct contrast to the mechanism of action of benzodiazepines, we see a growing body of evidence suggesting that PH94B has potential to achieve anti-anxiety effects without requiring systemic uptake or causing benzodiazepine-like side effects and safety concerns.”

VistaGen has initiated 2 ongoing phase 3 clinical trials of PH94B—PALISADE-1 and PALISADE-2—for potential acute treatment of anxiety in adults with SAD; the US Food and Drug Administration has granted it fast track designation.

“At a time when the current drug treatment paradigm for social anxiety disorder, or SAD, is falling far short of delivering necessary relief without worrisome potential consequences, an innovative treatment alternative is imperative. If successfully developed in our ongoing PALISADE Phase 3 Program, PH94B has the potential to fill that void as the first fast-acting, on demand acute treatment of anxiety for more than 23 million Americans who suffer from SAD,” Singh said further.

1. VistaGen Therapeutics. VistaGen Therapeutics reports new preclinical mechanism of action data supporting PH94B’s potential anti-anxiety activity via peripheral nasal neurons without entry into the brain. October 5, 2021. 

https://www.globenewswire.com/news-release/2021/10/05/2308651/0/en/VistaGen-Therapeutics-Reports-New-Preclinical-Mechanism-of-Action-Data-Supporting-PH94B-s-Potential-Anti-Anxiety-Activity-via-Peripheral-Nasal-Neurons-without-Entry-into-the-Brain.html

PH94B for the treatment of social anxiety disorder further differentiates its mechanism of action from benzodiazepines in a new lab rat preclinical study. 

New Investigational Social Anxiety Disorder Drug Differentiates Mechanism of Action

As Larry Merkel, MD, PhD, professor of psychiatry and neurobehavioral sciences and Director of Outreach at the University of Virginia, told 2021 Annual 

 World CME Conference attendees, working with culturally different patients can be challenging and rewarding, but rarely avoided in current day psychiatry.

“Everyone’s backgrounds are very complicated, multi-layered, and dynamic,” said Merkel. “No person has influences these days from just 1 culture—we live in multiple cultures.”

Cultural distance is essentially qualitatively thinking about the difference between doctor and patient—how many things in your background are similar to their background, or not?

“There’s been research showing that the greater the cultural difference between the psychiatrist and the patient, the more likely there are to be mistakes of all sorts,” Merkel said.

Merkel also covered models for managing cultural differences, including the Cultural Formulation Interview (CFI) from DSM-5, which patients seem to value over traditional interactions.

 Field trials in a variety of locations (ie, United States, Canada, Netherlands, India, Kenya, and Peru) showed CFI is feasible, acceptable, useful, and sensitizes clinicians to cultural issues.

 An implementation study in an outpatient psychiatric clinic demonstrated CFI is an integral part of cultural competence training; there was a 50% reduction in discontinuation rate vs treatment as usual after one training session.

CFI does have some potential problems, Merkel noted. CFI can help with direction of therapy, but not diagnosis. Additionally, it is not able to be used with cognitive disability or with severe symptoms such as acute psychosis, suicidal behavior, or aggression.

We're fathers, mothers, children, physicians, barbers, Protestants, Catholics, Jews—all sorts of identities.

Further, the concept of identity may be difficult to translate work with, according to Merkel. “We all have multiple identities. We’re fathers, mothers, children, physicians, barbers, Protestants, Catholics, Jews—all sorts of identities. We use those identities in different ways at different times. Sometimes, if you ask a person what their identity is, they may have no idea what you’re talking about.”

Merkel has a few recommendations for physicians working with culturally different patients:

-Know something about the main populations with whom you are likely to work.

-Adapt to include more culturally relevant data.

-Take time and effort to work with interpreters.

-Be brief and succinct in your questions if you are using an interpreter.

-Understand that it may be difficult, and be patient.

Qualitative analysis of Cultural Formulation Interview: findings and complications for revising the outline for cultural formulation. 

2. Jarvis GE, Kirmayer LJ, Gómez-Carillo A, et al. 

Update on the Cultural Formulation Interview. 

3. Lewis-Fernández R, Aggarwal NK, Kirmayer LJ. 

The Cultural Formulation Interview: progress to date and future directions.

Cultural differences between patients and physician are hard to avoid. How can you best work with diverse patients? 

The Challenges and Rewards of Working With Culturally Different Patients

“You can imagine if you're regularly hearing in the media that trans people are risks to other people in bathrooms, that you're a risk to your peers on sports teams, that really you're just confused about your gender identity—over time, you may internalize these ideas and start to have self-hatred or low self-esteem,” said Jack L. Turban, MD, MHS, a Fellow in Child & Adolescent Psychiatry at Stanford University School of Medicine and 

In his session, “Evolving Treatment Paradigms for Transgender Youth,” Turban discussed the evolution of prepubertal transgender youth treatment over the past 2 decades, the current evidence base for pubertal suppression for transgender adolescents, and the rationale for gender-affirming hormone treatment for transgender adolescents.

Transgender youth, Turban explained, have an array of psychiatric morbidities, including mood disorders (12.4 to 64%), anxiety disorders (16.3 to 55%), and prior suicide attempts (9.3 to 30%). Additionally, about 80% have been a victim of bullying.

Another topic Turban found important to approach is the dangers of gender identity conversion therapy. In his research published in 

, Turban took a sample size of more than 27,000 American transgender adults who had spoken to a therapist about their gender identity, and compared those whose therapy involved trying to make them cisgender with those whose therapy did not have any conversion efforts.

 The results showed exposure to conversion efforts before age 10 led to increased suicidal ideation, increased lifetime cigarette use, increased lifetime illicit drug use, as well as more suicide attempts.

“We had a ton of data that trying to change sexual orientation was dangerous, but this is the first study to look at trying to change someone's gender identity and the mental health outcomes,” said Turban.

Furthermore, Turban noted it seems like childhood is particularly vulnerable time period for being exposed to conversion efforts. Conversion therapy is still legal in 29 states and 4 territories,

 and approximately 13.5% of transgender individuals report lifetime exposure to gender identity conversion efforts.

Instead, Turban believes a social transition might be a good idea for a prepubertal child. In a social transition, transgender children or adolescents adopt the name, pronouns, and gender expression (like clothing or haircuts) that match their gender identity.

“Banning social transition is likely dangerous and can send a message to a child that being transgender is bad. This can essentially instill shame and damage relationships between the child and the therapist, and the child in the family,” Turban said.

Research review: gender identity in youth: treatment paradigms and controversies.

2. Turban JL, Beckwith N, Reisner SL, Keuroghlian AS. 

Association between recalled exposure to gender identity conversion efforts and psychological distress and suicide attempts among transgender adults.

3. Movement Advancement Project. Updated 2021. Accessed October 2, 2021. 

https://www.lgbtmap.org/equality-maps/conversion_therapy

4. Turban JL, King D, Reisner SL, Keuroghlian AS. 

Psychological attempts to change a person's gender identity from transgender to cisgender: estimated prevalence across US states, 2015.

Transgender youth are at increased risk for a number of psychiatric morbidities. Gender identity conversion therapy can make them worse. 

Leah Kuntz

Articles

Child and Adolescent Mental Health: A National Emergency

“Never Silence Your Pain”: Life After a Suicide Attempt

A Life and Death Measure: Eating Disorder Treatment

New Investigational Social Anxiety Disorder Drug Differentiates Mechanism of Action

The Challenges and Rewards of Working With Culturally Different Patients

Treating Transgender Youth: The Danger of Gender Identity Conversion Therapy