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Rashmi Parmar, MD, gives an overview on autism. Examples of signs and symptoms in children include trouble having a back-and-forth conversation, difficulty establishing eye contact, and difficulty reading facial expressions.

is a double board-certified adult and child psychiatrist with Community Psychiatry based in Newark, CA. She earned her medical degree at Terna Medical College & Hospital in Mumbai, India.

More than 3.5 million Americans have Autism Spectrum Disorder. How can you recognize the signs in children? 

Common Signs and Symptoms of Autism Spectrum Disorder in Children

Christine Moutier, MD, discusses the Centers for Disease Control and Prevention (CDC) report, 

Emergency Department Visits for Suspected Suicide Attempts Among Persons Aged 12–25 Years Before and During the COVID-19 Pandemic — United States, January 2019–May 2021

If you are interested in more 2020 suicide data from the CDC, 

The Leading Causes of Death in the US for 2020.

Dr Moutier recommends these resources for learning more about suicide prevention:

Training for clinicians and health systems in suicide prevention

Clinical handbook on Suicide Prevention released June 2021

Suicide Prevention in the COVID-19 Era: Transforming Threat Into Opportunity

 by the Congressional Black Caucus Task Force on Black Youth Suicide

 is Chief Medical Officer, American Foundation for Suicide Prevention, New York, NY.

Recent data from the CDC shows a rise in suicide attempts in girls aged 12-17. What can psychiatrists do? 

Concerning Trends in Suicide

SPECIAL REPORT: SEXUAL AND GENDER MINORITIES PART 2

Sexual and gender minority (SGM) youth experience the same types of traumas as their non-SGM peers, including child maltreatment, domestic and community violence, accidents, traumatic death, and separation. SGM youth are also at elevated risk for stressors common among minorities. Furthermore, these youth experience distinct ongoing stress related to discriminatory societal, medical, educational, housing, employment and/or legal attitudes, norms and/or practices, among others. In addition, 

 are at increased risk for traumas that are specifically related to their sexual orientation, gender identity ,and/or expression. They may be bullied, sexually or physically assaulted, or rejected by their parents. Thus, these youth are at significantly greater risk for cumulative trauma exposure, and for developing the negative mental health and medical problems related to stigma, minority stress, and trauma.

Trauma-Focused Cognitive Behavioral Therapy

Trauma-focused cognitive behavioral therapy (TF-CBT) is an evidence-based treatment for trauma-impacted youth, aged 3 to 17 years, and their nonoffending parents or primary caregivers.

 With 23 randomized controlled trials assessing efficacy, TF-CBT has the strongest evidence for improving youth posttraumatic stress disorder (PTSD) diagnosis or symptoms, as well as trauma-related depressive, anxiety, behavioral, or cognitive difficulties.

The TF-CBT model consists of 9 components summarized by the acronym PRACTICE; they compose 3 treatment phases (

). Typically, TF-CBT treatment includes 12 to 15 sessions, with each phase lasting 4 to 5 sessions. For youth who develop complex PTSD reactions to multiple or interpersonal traumas, the enhancing safety component is typically provided first, and the stabilization/safety phase may be longer relative to the other 2 phases, taking up to half of the treatment sessions. Parent participation is an important part of TF-CBT, with youth and parent(s) seen individually for half of each treatment session; several conjoint youth-parent sessions are also included. Abusive or rejecting parents have not usually been included in TF-CBT treatment. These sessions typically use gradual exposure, ie, increasingly calibrated direct discussion about the youth’s trauma reminders or personal trauma experiences and use of skills to cope with these. Evidence-based psychotherapies such as TF-CBT are the 

 with PTSD symptoms or other trauma-related difficulties.

During a year-long learning community sponsored by the National Child Traumatic Stress Network (NCTSN), TF-CBT was implemented with trauma-impacted 

 in order to modify the model for this population, collect data, and develop an implementation manual to describe these modifications. Family Acceptance Project (FAP) data so convincingly documented the impact of specific family rejecting and accepting behaviors on risk and well-being for SGM youth and provided an evidence-informed family intervention framework that TF-CBT developers made the decision to include rejecting parents of SGM youth in TF-CBT treatment. FAP developer, Caitlin Ryan, PhD, ACSW, helped incorporate core FAP principles and strategies into the modified TF-CBT SGM implementation manual.

 This manual describes an integrated TF-CBT-FAP framework for SGM youth recovery from trauma, and it is now available at no cost to clinicians.

For 1 year, -long program, 32 clinicians from 12 NCTSN sites used TF-CBT for trauma-impacted SGM youth in order to modify the model for this population, collect data, and develop an implementation manual to describe these modifications.

 The 24 youth—aged 8 to 12 years, with diverse gender identities and sexual orientations—experienced significant improvement on the University of California, Los Angeles PTSD Reaction Index for DSM-5 from pre- to post-treatment (mean scores of 44.0 [severe] to 17.89 [normal]; t = 5.59; P < .0001). In a subsequent 

, 19 youth aged 10 to17 years who self-identified as SGM and received TF-CBT with these modifications experienced improvement in the Child PTSD Symptom Scale for DSM-5 from pre-to post-treatment (mean scores of 50.05 [severe] to 26.21 [mild]; t = 7.65; P < .001).

The FAP is a research, education, intervention, and policy initiative that was developed in 2002 by Ryan and colleague Rafael Diaz, PhD. The goal was to help families support their SGM children to reduce health risks and promote well-being in the context of their families, cultures, and faith communities. FAP conducted the first comprehensive research on SGM youth and families and developed the first evidence-informed family support model for use in family guidance and treatment approaches for prevention, wellness, and care for SGM children and adolescents.

FAP’s family support model is grounded in participatory mixed methods research with diverse SGM youth and families. FAP’s research identified more than 100 specific behaviors that parents and caregivers use to express rejection and acceptance of their SGM children and measured these behaviors to show how they contribute to health risks and decreased well-being. FAP worked with racially, religiously, and linguistically diverse families and SGM youth to develop intervention strategies and multilingual research-based resources that can help families decrease rejection and increase support and acceptance for their SGM children.

FAP’s family support model can be implemented to reduce risk for suicidality, depression, illegal drug use, ejection and removal from the home; to decrease family rejection; and to promote well-being. FAP strategies and resources can be used in any setting and by families. Moreover, core FAP intervention components can be integrated into other models of treatment, prevention, and care—as was done to integrate FAP and TF-CBT to support recovery and promote well-being for SGM children and youth, whether or not 

 is related to the child or youth’s SGM identity.

FAP’s family support model uses a strengths-based and harm reduction framework to help parents, families, and caregivers understand sexual orientation and gender identity as components of child development. It teaches them how specific reactions to their SGM child affects the child’s well-being and impacts their child’s risk for suicide, depression, illegal drug use, and HIV (

FAP has developed a series of research-based education materials to help parents understand the importance of family support, to guide behavioral change, and to educate extended family members as well as cultural and religious leaders. These resources include: family intervention videos that portray how diverse families move from struggle to support of their SGM children; family education booklets that are best practice resources for 

; assessment scales to measure growth and change; and a multilingual 

 series that tells the story of family acceptance and rejection, suitable for use in homes, congregations, and any other public, institutional and clinical settings (

Family Rejecting Behaviors That Are Traumatic

A critical element of FAP’s approach is helping parents and clinicians understand that family behaviors that reject a child’s core identity are traumatic and, combined with other trauma experiences, can contribute to complex mental health issues. Like Adverse Childhood Experiences (ACEs), the family rejecting (and accepting behaviors) identified and measured in FAP’s research are predictive of risk for suicidal behavior, depression, illegal drug use, risky sexual behavior and decreased well-being in adulthood. But unlike ACEs, these specific family rejecting behaviors are screened by few practitioners in 

 for these specific family rejecting behaviors. FAP’s family support model aligns these research findings with the parent’s underlying cultural and religious values to support positive behavioral change.

Parents are typically surprised to learn that these “well-meaning” behaviors to help their child fit in, have a good life, and be accepted by others are actually contributing to high levels of depression, suicidality, substance use, and other adverse outcomes. Yet, all of the specific family rejecting behaviors studied by FAP focus on trying to change, prevent, deny, and minimize a child’s SGM identity. Caregivers who believe that being gay or 

 is wrong routinely engage in rejecting behavior at early ages that undermine their child’s self-worth, increase isolation and hopelessness, erode the parent-child bond, and significantly increase the likelihood of suicidal and self-harming behaviors.

In aligning the FAP and TF-CBT models, the significant benefits of integrating them became obvious. Applying core FAP strategies and resources in TF-CBT enables clinicians to help parents understand the 

harmful impact of specific rejecting behaviors

, such as preventing the youth from having an SGM friend or making them pray or attend religious services to try to change their SGM identity (

). FAP’s behavioral approach motivates parents to change harmful rejecting behaviors and to engage in affirming behaviors that increase connectedness and reduce risk—even when they continue to believe that being gay or transgender is wrong.

While the focus of treatment in TF-CBT remains on the child or youth, FAP is expanding the focus on the critical role of family support. Efforts to change a child’s sexual orientation and gender identity expression are reinforced by social, cultural, and religious norms and are transmitted intergenerationally as a cultural default position. Helping the parent understand, take responsibility for, and ask the child’s forgiveness for behaviors that have denigrated the child’s SGM identity becomes part of the transformative narrative of TF-CBT for both the child and the parent.

TF-CBT and FAP’s integrated framework provides a pathway to healing and recovery that strengthens families and engages parents and caregivers as allies, not adversaries, for their SGM children.

TF-CBT and FAP help the parent and child to create meaning out of traumatic and harmful experiences and empower parents to nurture their SGM child. The COVID-19 pandemic has heightened vulnerability for SGM children and youth in numerous ways by confining them with rejecting and abusive family members, separating them from supportive peers and adults outside the home, and resulting in the sudden death of family members and cultural leaders. This combined treatment approach can play a crucial part of our national recovery.

is the medical director of the Center for Traumatic Stress in Children & Adolescents at Allegheny General Hospital in Pittsburgh, and professor of Psychiatry at Drexel University College of Medicine in Philadelphia.

 is the director of the Family Acceptance Project at San Francisco State University. A clinician and researcher with more than 40 years of experience working on LGBTQ health issues, she and her colleagues conducted the first research on LGBTQ youth and families and developed the first evidence-informed family support model to help diverse families to support their LGBTQ children. Dr Cohen receives grant funding from the Substance Abuse and Mental Health Services Administration and the National Institute of Mental Health, and royalties from Guilford Press, Up To Date, and the Medical University of South Carolina.

Treating Trauma and Traumatic Grief in Children and Adolescents, 2nd ed

2. Cohen JA, Mannarino AP, Deblinger E, eds. 

Trauma-Focused CBT for Children and Adolescents: Treatment Applications

3. Cohen JA, Bukstein O, Walter H, et al; AACAP Work Group on Quality Issues. 

Practice parameter for the assessment and treatment of children and adolescents with posttraumatic stress disorder.

4. Cohen JA, Mannarino AP, Wilson K, Zinny A. 

Trauma‐Focused Cognitive Behavioral Therapy LGBTQ Implementation Manual

5. Cohen JA. Trauma-focused cognitive behavioral therapy (TF-CBT) for LGBTQ youth. 

6. Cohen JA. Trauma-Focused-CBT for LGBTQ youth across systems of care. Paper presented at: American Academy of Child and Adolescent Psychiatry; October 19-24, 2020; virtual meeting. Accessed April 12, 2021. 

https://aacap.confex.com/aacap/2020/meetingapp.cgi/Paper/35840

7. Ryan C. Generating a revolution in prevention, wellness, and care for LGBT children and youth. 

Temple Political & Civil Rights Law Review

 Implementing the Family Acceptance Project’s family support model: practice guidance

. San Francisco; Family Acceptance Project, Marian Wright Edelman Institute, San Francisco State University.

9. Ryan C. Supportive Families, Healthy Children: Helping Families With Lesbian, Gay, Bisexual, and Transgender ChildrenFamily Acceptance Project at San Francisco State University; 2009. Accessed April 12, 2021. 

https://familyproject.sfsu.edu/sites/default/files/FAP_English%20Booklet_pst.pdf

10. Ryan C. Poster guidance and Healthy Futures poster series. Marian Wright Edelman Institute. 2019. Accessed April 12, 2021. 

11. Ryan C. The family acceptance project’s model for LGBTQ youth. 

12. Glassgold J, Ryan C. The role of families in efforts to change, support, and affirm sexual orientation, gender identity and expression in children and youth. In: Haldeman DC, ed. 

Change Efforts in Sexual Orientation and Gender Identity: From Clinical Implications to Contemporary Public Policy

"Well-meaning" behavior by parents or guardians could be contributing to high levels of depression, suicidality, substance use, and other adverse outcomes in their child.

The Trauma-Focused CBT and Family Acceptance Project: An Integrated Framework for Children and Youth

 and the importance of its approval by the US Food and Drug Administration. 

is a practicing psychiatrist with a subspecialty in child and adolescent psychiatry, clinical researcher, and president of the Center for Psychiatry and Behavioral Medicine, Inc. in Las Vegas.

This new medication is a huge leap forward for treating attention-deficit/hyperactivity disorder. 

A Welcome Addition to the Child and Adolescent ADHD Armamentarium

Children’s Mental Health Response to COVID-19

What impact has the pandemic had on children's mental health? 

False allegations of abuse in child custody cases are an all-too-common phenomenon. Typically, one parent accuses the other parent of physical and/or sexual abuse of their child to gain leverage in their court proceeding. Nothing can befuddle or sidetrack a custody case more than an allegation of abuse. This is particularly important because judges tend to award primary physical custody to the parent who made the allegation, even if the accused parent’s actions are not substantiated. Thus, false allegations can be a powerful weapon to limit or deny custody and/or visitation in a vindictive manner.

Handling an allegation of abuse is a sensitive and thorny problem for attorneys and judges. All allegations of abuse must be taken seriously. While a strong visceral reaction to an abuse allegation is expected, it can be counterproductive. A rushed response can make the situation worse. In contrast, a wait-and-see attitude leaves the door open for a thorough evaluation before a disposition is decided upon. In essence, evaluation needs to occur before disposition.

Let us be clear: false allegations of abuse are a form of parental alienation. Alienation involves the concerted effort of one parent to undermine the other parent’s relationship with their child. Nothing could be worse than a custody decision that is based on a false allegation. And once a custody decision has been issued, modification of it is burdensome and an uphill challenge.

Clinical psychologists, psychiatrists, and other mental health professionals are often turned to in cases of abuse allegations. The court appoints them to evaluate the parties involved and to make recommendations. Allegations of abuse call for a coordinated effort between the judge, the attorneys, and the court-appointed evaluator.

A clinical approach to evaluating allegations of abuse presented here is based on years of experience with hundreds of cases of abuse allegations. This approach consists of sequential steps that should be taken. The evaluation process is aimed at determining whether an allegation of abuse has occurred or not—in other words, whether the allegation has been fabricated by a parent with the intent of sabotaging and harming the other parent.

The evaluation of possible abuse must include both parents and the child. Seeing just the child, just the accused parent, or just the accusing parent is not sufficient to understanding the entire narrative. All 3 individuals must be a part of the evaluation process. After all, we want our conclusions and recommendations to be based on full and accurate information. This can only be accomplished with the participation of all 3 individuals

The accused parent is often advised by his/her attorney not to participate in the evaluation process with the psychologist or psychiatrist. This is ill-conceived advice. By doing so, the mental health professional will be deprived of critical information that can shine a light on the falsity of the claim. Otherwise, all the information will be coming from the accusing parent, whose allegation will gain weight if it is not disputed.

It is always a good idea for the child in such a case to be seen for an independent forensic evaluation. This would be in addition to the child’s involvement with the court-appointed evaluator.

If this is the first allegation of abuse, and it is occurring during a child custody case, its validity must be questioned. In fact, there is a significant probability that the allegation is false. It is unlikely that a parent’s first abuse of a child will occur after a child custody case has been opened. Thus, if a parent does not have a history of abusing the child, it is not likely that the first abuse is occurring during the legal proceeding.

A series of allegations against a parent during a child custody proceeding is also a major red flag. An accusing parent often believes that multiple allegations against the other parent are more convincing to a judge than a single allegation. But repeated abuse of a child during a circumscribed time period—during a child custody case, for example—is quite improbable.

Detecting a false allegation is easier with the use of a timeline. Marking the major occurrences in a child custody case can show the specific sequence of events. A false allegation of abuse may occur during the custody case and not before. It may also occur in response to legal action taken by the other parent. For example, if a mother files for full custody of her child, this sets the stage for the father to report a false allegation of abuse against the mother, with the hopes that the allegation will derail the mother’s quest for custody. The motive of the false allegation can be detected by examining its place on the timeline of events.

Children between the ages of 3 and 7 years are easily coached by one parent against the other. False allegations of abuse often include unwitting help from the children. Children want to please their primary parent. They are easily swayed, cajoled, convinced, and brainwashed. It is difficult for them to know the truth once a parent has coached them extensively. False allegations can involve older children and teenagers as well, but their coaching is more easily transparent and even admitted to by the adolescent in question.

There are 5 common reasons why a parent will lodge a false allegation of abuse against the other parent. There are certain powerful beliefs that an accusing parent will have that lead to the promulgation of false allegations (

If any of these beliefs are discovered, the allegation of abuse is likely to be false. Detecting these beliefs in a parent requires careful interviews over several sessions. A parent will never admit to fabricating a false allegation. The clinician must be skilled enough to see through the typical defensiveness, deceitfulness, and/or distractions of an offending parent.

Harmful and false beliefs by the accusing parent can also be detected through interviews with the child and the accused parent. Usually, the child or the accused parent will provide critical clues as to the accusing parent’s belief system. These clues can be pieced together to provide a full understanding of the destructive dynamics at play. Bits and pieces of information will fit together into a detailed narrative that exposes the falseness of the allegation at hand. But, again, the accusing parent will never recant and will never apologize for his/her underhanded attempt at relationship interference.

Critical Points to Keep in Mind During the Evaluation

Once an allegation of abuse has been declared by a parent, the following process should ensue:

1. The Judge should appoint a clinical psychologist or a psychiatrist to evaluate the child and both parents. This evaluation must include interviews, psychological testing, and a review of collateral data (emails, texts, recordings, pictures, and others). The evaluator should have access to other independent assessments of the allegation, such as DHR investigations or a forensic evaluation of the child.

2. The clinical psychologist or psychiatrist must be experienced in child custody evaluations.

3. There should be a wait-and-see attitude about the allegation until the evaluation process has been fully completed.

4. Attorneys should not respond to an allegation of abuse by filing motions for dramatic or extreme action, such as obtaining full custody of the child.

5. Giving a parent temporary custody until the matter is settled may make sense, especially if the child’s physical safety is of acute concern.

6. The evaluation by the mental health professional should be aimed at determining the validity of the stated allegation of abuse.

7. The attorneys must not try to sabotage the evaluator in order to win their case. The evaluator’s conclusions and recommendations should be given strong weight.

A false allegation of abuse by a parent should be met with firm consequences, such as a fine, supervised parenting time, court-ordered counseling, and/or loss of primary custody. Swift and decisive consequences will stop future false allegations of abuse.

A false allegation must be considered a form of parental alienation. By being involved in one way or another, the child learns to be dishonest, deceitful, manipulative, conflictual, and blaming. The love the child should have for both parents is compromised and even destroyed by the process of a false allegation. False allegations of abuse must not be tolerated in the court system.

The accusing parent may not be appropriate for primary custody. Even shared custody may not be a good idea. A parent’s willingness to fabricate an allegation of abuse against the other parent is a poor prognostic indicator. It is not simply an accident or a mistake. A false allegation is an intentional and purposeful attempt to undermine the child custody proceeding.

A false allegation of abuse is serious business. It represents a psychiatric emergency. As such, it must be handled and dealt with in a direct and timely manner. A child’s mental health and well-being depend upon it.

is a licensed clinical psychologist in private practice in Birmingham, Alabama. His forensic practice focuses on child custody and alienation cases. He is also a clinical associate professor in the Department of Psychology at the University of Alabama at Birmingham.

A clinical approach to detecting false allegations of abuse in child custody cases.

Finding the Difficult Truth 

Elysa Marco, MD, talks about positive play—how using digital media can enhance specific abilities for kids, especially those with attention-deficit/hyperactivity disorder. 

is a board-certified cognitive and behavioral pediatric neurologist, neuroscience researcher, and author. She specializes in the evaluation and treatment of children with sensory processing disorder, autism, and other neurodevelopmental conditions at Cortica in San Rafael, California.

Kids will find the screens. Health care providers should join them in order to supply the most helpful digital treatments. 

You Can't Beat the Screens

LGBTQ COMMITTEE OF THE GROUP FOR THE ADVANCEMENT OF PSYCHIATRY

As the number of COVID-19 cases in the United States hits 30 million and continues to cause widespread pain in lives lost and economic devastation, sexual and gender minority youth face particular hardships threatening their lives, mental health, and social development.

In particular, social isolation may be especially challenging. These youths may be quarantining with rejecting family-members and losing contact with supportive social networks. The nature of quarantining means these problems are invisible to the public.

“Aiden,” a 16-year-old boy who is transgender, lives in a community particularly hard-hit by COVID-19. Aiden’s parents refuse to accept his gender identity or call him by his male name or use male pronouns. They frequently yell at Aiden to dress and act like a girl, assigning dishwashing and laundry chores to him alone, and not to his brother, to get him “used to doing girl stuff like you are supposed to.”

Serial COVID-19 outbreaks at Aiden’s school forced him into remote learning. His family has only 1 computer, shared by Aiden and his brother for schoolwork and Aiden’s mother for church meetings. Aiden’s parents banned him from using social media or communicating with friends because his parents believe “that’s where she picked up all this nonsense.” Aiden became completely disconnected from his friends. He was also cut off from affirming and supportive teachers. As tensions in Aiden’s family escalated, fighting became the only interaction between him and his parents.

One evening during a fierce argument, Aiden’s mother pushed him, and he pushed her back. As a result, she fell and had a small laceration on her shoulder. Aiden’s father became angry and punched Aiden in the face. Aiden’s brother called 911. The police arrested Aiden and his father. Aiden was released from jail to a Child Protective Services emergency residence. Because of COVID-19, he was required to spend 14 days isolated in his room, including mealtimes, and was unable to receive visitors. He also faced misdemeanor charges for assaulting his mother. His father also faced charges. Aiden was afraid of returning home because he was petrified of what his father might do to him.

Administration for Children’s Services (ACS) attempted to reunify Aiden with his parents, but over a period of several months, each attempt resulted in further physical altercations between Aiden and his father. Aiden moved into a group home where peers bullied him because of his gender identity. ACS was unable to address the problem because several staff members were hospitalized with COVID-19, and no other group homes were available for transfer. After a bully hit him, Aiden ran away from the group home, and the police could not locate him.

Even before COVID-19, lesbian, gay, bisexual, transgender, questioning (LGBTQ) youth were at 

 of depression, suicidality, and tobacco, alcohol, and other drug use.

 These increased risks stem from elevated rates of rejection, discrimination, and victimization. During the pandemic, risks were further compounded by the loss of relationships in schools, clubs, or other community venues where LGBTQ youth found support and affirmation. Laura Erickson-Schroth, MD, a psychiatrist at the Hetrick-Martin Institute, a New York City-based LGBTQ youth organization, reported that youth members of the institute are looking for more frequent counseling sessions. According to her, there were at least one-third more requests for initial psychiatry visits during 2020 than during the same period in 2019.

 found one-third of the city’s youth in foster care identifies as LGBTQ, an order of magnitude greater than the general population.

 Nearly three-quarters of these youth are Black, and one-third identify as Hispanic/Latino. LGBTQ youth are placed in group homes and other campus settings rather than foster families more often than their non-LGBTQ peers, and they are more likely to be dissatisfied with their placement. The study also found these youth experience a greater burden of depression.

According to Dylan Waguespack, director of public policy and external affairs of 

, 20% to 40% of homeless youth identify as LGBTQ. True Colors United is a national organization dedicated to ending LGBTQ youth homelessness. Although family conflict, involvement in the foster care system, and involvement in the criminal justice system are among the factors that contribute to homelessness among these youth, poverty is often the root cause. Not only are these youth at risk for adverse mental health outcomes because of rejection and discriminatory behaviors, they often face traumatic experiences through conflict with their families, involvement in overwhelmed and poorly informed state programs.

Agencies that previously made efforts to address racial, social, gender, or sexuality based inequities before the pandemic have become even more overwhelmed with the increase in housing and food insecurity, increased unemployment, instability in the agency’s own staff, and the need to rapidly implement physical distancing and other public health measures in routine work. Overwhelmed and encumbered agencies are increasingly unable to provide critical services for LGBTQ youth, leaving them powerless in impeding a downward spiral into homelessness and associated negative ramifications.

Even as the pandemic ends, there may be continual struggles and support needs. Fortunately, there are ways psychiatrists and other mental health care professions can help.

Some of these methods include the following:

Financially donate to organizations that support or serve LGBTQ youth.

Advocate for programs that decrease income inequality and promote housing and food security.

Enable rapid interventions to prevent LGBTQ youth from entering the foster care and criminal justice systems.

Use clinical, teaching, institutional, and forensic roles to speak out and advocate for this vulnerable group of young people.

Share resources and references for supportive organizations with patients who are LGBTQ (

LGBTQ youth have long experienced marginalization and significantly increased risk of poor mental health outcomes. The COVID-19 pandemic sharpened the crisis and brought clarity to the precariousness of social service agencies that address those needs. Strengthening the support system for these youth and their allies and making agencies more inclusive of their voices is critical to help these young people achieve a healthy and fulfilling life.

is the director of the Youth Equity Science/YES Project and senior visiting fellow at Yale Law School. He is also an assistant clinical professor at Columbia University and an adjunct clinical assistant professor at Cornell Weill Medical College.

the medical director emeritus at Weill Cornell Center for Human Rights. Dr Barberis the past president and journal editor for the Association of LGBTQ Psychiatrists and is an MDiv candidate at Union Theological Seminary.

is a community and public psychiatrist in New York City.Dr Drescher is a clinical professor of psychiatry at Columbia University and an adjunct professor at New York University. He is also a distinguished life fellow of the American Psychological Association and the past president of the Group for Advancement of Psychiatry

is an assistant professor of psychiatry at Columbia University Medical Center and a consulting psychiatrist at Hetrick-Martin Institute for LGBTQ youth.

. 2020;18(3):268-276. doi:10.1176.appi.focus.20200018
2. Sandfort TGM. Experiences and well-being of sexual and gender diverse youth in foster care in New York City: disproportionality and disparities. November 2020. Accessed January 5, 2020. 

https://www1.nyc.gov/assets/acs/pdf/about/2020/WellBeingStudyLGBTQ.pdf

Overwhelmed and encumbered agencies are increasingly unable to provide critical services for LGBTQ youth, leaving them powerless in impeding a downward spiral into homelessness and associated negative ramifications. There are 5 ways psychiatrists can help.

Helping LGBTQ Youth During the Pandemic

Attention-deficit/hyperactivity disorder (ADHD) is frequently 

 other psychiatric conditions, including psychotic disorders. There is 

 for shared genetic susceptibility to both conditions,

 and first-degree relatives of people with ADHD have twice the risk of having schizophrenia compared with healthy controls.

There is also an added risk of psychosis in patients with comorbid cannabis use. There are overlapping environmental 

 for both disorders, including obstetric complications, preterm birth, and low birth weight.

 There are also abnormalities in overlapping dopaminergic brain circuits in schizophrenia and ADHD.4 However, epidemiologic evidence for the association between psychotic disorders and ADHD remains inconsistent.

 performed a systematic review and meta-analysis of the association between ADHD during childhood and the subsequent risk of developing a psychotic disorder. The authors searched MEDLINE, Scopus, PsycInfo, and Web of Science from inception through November 2015. They included peer-reviewed case-control and cohort studies of children younger than 18 with ADHD (using any recognized diagnostic criteria) with a comparison group.

The primary outcome was occurrence of any psychotic disorder (also using any recognized diagnostic criteria; including schizophrenia, schizophreniform disorder, brief psychotic disorder, schizoaffective disorder, delusional disorder, psychotic disorder not otherwise specified, or schizotypal personality disorder) at or after aged 18 years following a diagnosis of ADHD. They excluded studies with attention deficits or impulsivity without any ADHD diagnosis or adult ADHD diagnosis, or psychotic disorders that were diagnosed before or concurrently with ADHD. 

Relevant data—including relative risks (RR), odds ratios (OR), hazard ratios (HR), and 95% confidence intervals—were extracted for each study. An assessment of risk of bias and study quality was performed for each included study. Pooled measures of relative effects (eg, RR, OR, HR) were calculated using random-effects meta-analysis. Egger’s test and funnel plots were used to assess for potential publication bias. Subgroup and meta-regression analyses were performed for study design, sex, treatment, relevant psychiatric comorbidities, and type of outcome, but data were not available regarding substance use comorbidity.

The authors screened 3782 records and assessed 45 full-text articles for eligibility. After review, 15 studies (1 case-control and 14 cohorts) were included in the systematic review and 12 studies (1.85 million unique participants) were included in the meta-analysis. The median prevalence of 

 in the cohort studies was 0.5% for controls and 2.7% for the ADHD population, corresponding to an approximately 5-fold increased risk of subsequent psychotic disorder in children with ADHD (relative effect = 4.74, 95% CI 4.11-5.46).

Findings were similar in subgroup analyses (including schizophrenia versus other psychotic disorders, as well as the presence or absence of follow-up after aged 18 years). In meta-regression analyses, sex, and study quality did not moderate the association. There was no evidence of publication bias.

The authors performed the first meta-analysis of observational studies on the association between ADHD and psychotic disorders. They note that substance use disorder comorbidity is common to both conditions, and that the effects of 

 are also an important consideration, as there is inconsistent evidence on the possible association between chronic psychostimulant treatment and subsequent risk of psychotic disorder. 

There was inadequate data to consider effects of either substance use or psychostimulants in the present meta-analysis, and thus this information is relevant to future studies. They also note that psychotic symptoms and ADHD symptoms may overlap and can be confused and misdiagnosed (

). Strengths of the study included the large sample size and absence of publication bias. Limitations include clinical heterogeneity in the study populations, diagnostic criteria, and outcomes.

“Mr D” is a 21-year-old African American male outpatient at the community mental health center. He has a diagnosis of ADHD, combined type, and as a child, he received remote treatment with an unknown stimulant medication. His sister has depression, but his family history is otherwise unremarkable. At age 19, he was admitted for 1 week to the state psychiatric hospital because he had command auditory hallucinations for self-harm and began banging his head against the wall. He subsequently received a diagnosis of schizophrenia and cannabis use disorder. For the past year, he has been clinically stable on antipsychotic medication without additional psychiatric hospitalizations.

A childhood diagnosis of ADHD increased the risk of subsequent psychotic disorder almost 5-fold, independent of sex and diagnostic outcome (schizophrenia versus other psychotic disorder). Early detection (and management) of psychotic disorders in children with an ADHD diagnosis is essential.

1. Hamshere ML, Stergiakouli E, Langley K, et al. 

Shared polygenic contribution between childhood attention-deficit hyperactivity disorder and adult schizophrenia

Risk of bipolar disorder and schizophrenia in relatives of people with attention-deficit hyperactivity disorder

3. Linnet KM, Dalsgaard S, Obel C, et al. 

Maternal lifestyle factors in pregnancy risk of attention deficit hyperactivity disorder and associated behaviors: review of the current evidence

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Association of attention-deficit/hyperactivity disorder in childhood and adolescence with the risk of subsequent psychotic disorder: a systematic review and meta-analysis

There is evidence for overlapping risk factors and symptomatology between ADHD and psychotic disorders. New research investigates the association between ADHD during childhood and the subsequent risk of developing a psychotic disorder.









Examining the Relationship Between ADHD and Psychotic Disorders

A classification system to identify communication between brain regions brings us closer to predicting and diagnosing attention deficit hyperactivity disorder (ADHD) with better precision than ever before, according to a 

In this Q&A, we speak with lead author of the study, Chris McNorgan, PhD. Dr McNorgan is assistant professor, Department of Psychology at the University at Buffalo, State University of New York, and director of Computational Cognitive Neuroscience Laboratory, in the Department of Psychology at the University at Buffalo — SUNY.

Psychiatric Times (PT): You talk about task-based functional connectivity as a biomarker of ADHD. Can you tell us more about that?

 The challenge with using behavior to diagnose cognitive disorders is that behavior is extremely variable, even within individual patients. Behavioral indicators commonly used to identify ADHD might meet a subjective threshold on one day, but not during a follow-up test, leading to diagnostic instability.

 detects or confirms the presence of a condition of interest by virtue of covarying with the condition: If the biomarker is present, then so is the condition. ADHD is associated with atypical activity patterns, and because the brain does not rewire itself every day, we expected to find persistent differences between ADHD and controls in the connectivity that governs those activity patterns. 

Although a computer is required to represent the complex connectivity patterns that distinguished between controls and ADHD, the high classification accuracy for these machine-learning models establishes that these connectivity patterns provide sufficient evidence to reliably identify ADHD.

PT: What new information does the study provide?

 Ours was not the first study that assumed ADHD can be identified by characteristic functional connectivity. However, the substantial improvement in prediction accuracy over previous studies tells us a few things. First, that task-based functional connectivity within a brain network involved in a task that taxes inhibitory control appears to be more predictive of ADHD than resting state connectivity collected while individuals let their minds wander.

The second finding is more of an analytic innovation, explicitly tying diagnostic accuracy to performance on a relevant behavioral task. The 

 (IGT) was developed under a particular theory about the role of inhibitory processing in ADHD. However, just because it is theoretically tied to ADHD does not make it so. 

Because the classifiers had to identify both IGT performance and ADHD diagnosis from the same set of functional connections, it had to find which connections, if any, were predictive of both. Successfully solving the problem established that performance on the IGT is relevant to ADHD by virtue of the fact that the same functional connections predict both. The study provides a template for similarly linking other diagnostic measures to outcomes.

PT: What can you tell us about the future of machine learning in predicting ADHD with diagnostic accuracy?

 Although task-based connectivity was more diagnostic than resting-state, running an experimental task in an MRI scanner will not be a practical diagnostic tool anytime soon. However, by explicitly linking neuroimaging results to easily administered behavioral tasks, models like this might be used in the future. They may translate a particular behavioral performance profile into a likely connectivity profile confirmed by MRI if need be. These results might inform the choice of intervention. 

ADHD diagnoses have been described as unstable: The same individual may fall above or below threshold at different times. So the fact that childhood ADHD diagnoses were 

 in fMRI scans taken from young adults is remarkable, and I think points to the disorder as something that is deeply ingrained at the neurological level, although it may appear much more transitory at the behavioral level. We do not have information about severity in the participants at the time of the scan, but even if we assumed all of them were symptom-free, their brains are clearly doing something identifiably different.

Finally, these models are remarkably accurate because they make use of many different data points. The optimal precision was calculated based on 4 individual fMRI scans per participant. There may be different subtypes that could be identified by an extension of this paradigm using new tasks. All this points to the general idea that having more information on-hand leads to better evaluations, though the information required to achieve very high accuracy may take a computer to process it.

PT: Did you find anything in your research that was unexpected?

 In hindsight, finding subgroups seems obvious, but we were not looking for different connectivity profiles for high- and low-scorers on the IGT. This was purely for a proof-of-concept, and to make it easier to argue that the classifier had identified activity that was related to inhibitory control. This got us thinking about how this sort of approach might be useful for identifying subpopulations.

PT: Can you tell us about future directions in this research?

New research brings us closer to linking diagnostically predictive connectivity patterns in patients with ADHD.

Child & Adolescent Psychiatry