Journal of Child and Adolescent Psychopharmacology

The objective of this review is to review existing evidence on the management and prevention of agitation and aggression in the pediatric psychiatric inpatient setting with emphasis on general unit structure, organization, and milieu programming when discussing prevention. For management of agitation and aggression, the review focuses on de-escalation, as-needed medication, and restraint and seclusion.

The existing literature search was conducted, yielding 1836 English language citations. An additional 109 studies were identified by citation search. Among them, 287 full-text studies were assessed for eligibility, and 107 studies were included for review. Studies were included if the contents of studies were shown to prevent agitation or aggression in pediatric psychiatric inpatient units, with focuses on staffing, staff training, milieu programming, and environmental changes. Studies were also included if the contents of studies discussed management of agitation and aggression with focuses on de-escalation, restraint and seclusion, and as-needed medication use.

We recognized multiple challenges while summarizing existing evidence in our field, including lack of definition, knowledge, and standardized measurement of agitation and aggression. Challenges further extend to heterogeneity and a constellation of small studies that are not controlled. However, existing evidence supports that management and prevention of agitation and aggression start with attention to staffing, staff training, and milieu programming. Evidence for the use of as-needed (pro re nata) medication for the management of agitation and aggression in pediatric populations is limited.

Rett syndrome (RTT) is a severe neurodevelopmental disorder affecting predominantly females and associated with variants in the MECP2 gene. Recent success in clinical trials have resulted in an expanded use of the Rett Syndrome Behaviour Questionnaire (RSBQ) for clinical and research purposes. Implementation of the RSBQ as a global clinical severity scale has raised concerns about its construct validity considering its content, structure, and psychometric features. To further understand RSBQ data, we analyzed RSBQ scores available in the literature with a focus on variability and influencing factors.

We identified publications reporting RSBQ total and/or subscale scores and summarized relevant study information, such as type of investigation, administration method, and descriptive data. We then analyzed means and standard deviations, calculating variance-to-mean ratios (VMR), as a measure of variability, when raw score descriptive statistics were available. Where appropriate, we compared means and VMRs by Welch t-tests.

Of the 14 publications identified, raw total scores from 5 observational studies and 4 clinical trials (baseline) were available. Raw subscale scores from four of the five observational studies were also available. We found a wide but comparable range of mean total scores for observational studies and clinical trials. However, VMRs were significantly higher in observational studies. Subscale scores showed either high (i.e., General Mood, Breathing Problems) or low (e.g., Hand Behaviours, Body Rocking and Expressionless Face) variability. Available data demonstrated greater variability in pediatric than adult groups and less variability when using interviews or electronic RSBQ administration compared with paper forms. Total score changes over time did not affect variability. Although certain studies offered insight into the relationship between the RSBQ and other measures, overall, data were insufficient for characterizing how RSBQ variability relates to other factors.

Our findings on score variability support the need for more comprehensive reporting of RSBQ data, cohort characterization, and methodology; and the deployment of standardized RSBQ administration methods, such as advanced data capture systems. There is potential for use of subscales as outcome measures, subject to further psychometric validation studies, including prospective investigations testing the stability of RSBQ scores and influencing factors. Further examining the relationship between RSBQ scores and other instruments will aid in its interpretation as a clinical outcome measure.

The current intense period of drug development for fragile X syndrome (FXS) and other neurodevelopmental disorders (NDDs) indications has highlighted the importance of behavioral outcome measures with strong psychometric properties and specifically content validity. The Aberrant Behavior Checklist—Community Edition (ABC-C), which has successfully been applied to autism spectrum disorder drug trials, has been revised for FXS (ABC_FX) and is widely used for both clinical and research purposes. Despite its strong psychometric validation, the ABC_FX and its parent measure have not been subjected to qualitative content validity evaluations. The present study intended to fill this gap.

Using two surveys administered sequentially and developed with guidance and review from the Food and Drug Administration (FDA), we asked 10 clinicians experienced in FXS and related NDDs to determine the adequacy of the ABC_FX for assessing its behavioral constructs, its relevance to FXS, and its potential for detecting response to interventions. Various descriptive statistic parameters and ad hoc metrics were used to analyze categorical and Likert-like scale responses.

Experts considered that most items and all six ABC_FX subscales indeed evaluated their explicit or implicit behavioral constructs. However, item and subscale specificity were relatively low (∼25%–30%). Relevance of items of the Hyperactivity subscale was relatively high while low for many items of the Socially Unresponsive/Lethargic subscale. These items were also considered of low responsiveness potential. Irritability, Hyperactivity, Stereotypy, and Social Avoidance were the subscales with the strongest profiles, although the experts estimated that Stereotypy items may not be that responsive to treatment. A novel Anxiety construct, representing mainly recently reported observable behaviors, contributed mainly by Irritability items, emerged as a potential measure.

The present study demonstrated the overall adequacy of the ABC_FX for its behavioral constructs, its relevance to FXS, and its potential for detecting response to treatment. It also showed that anxiety, a distinctive feature of FXS and other genetic NDDs, can also be measured by the ABC_FX. These findings can help with the implementation and interpretation of the ABC_FX, as well as with potential improvements to the measure in FXS and other NDDs.

The Vineland Adaptive Behavior Scales—3rd Edition (Vineland-3) is one of the most used measures of adaptive behavior among those with sodium channel protein type 2 subunit alpha related disorders (SCN2A-RDs). Several disease-modifying treatments are in early trials for SCN2A-RDs, and as such, clinical outcome assessments (COAs) are necessary. The Vineland-3 introduced growth scale values (GSVs), which are useful for measuring within-person change and thus may be useful in future clinical trials. The purpose of this study was to evaluate the psychometric properties of the Vineland-3 GSVs in SCN2A-RDs in preparation for future clinical trials.

A sample of 65 individuals with SCN2A-RDs (mean = 108, SD = 76.0 months) was recruited for a clinical trial readiness study. The Vineland-3 Comprehensive Interview was administered by trained raters at regular intervals. Multiple psychometric properties were evaluated, including floor and ceiling effects, split-half internal consistency, test-retest reliability, and inter-rater reliability (on approximately 20% of all completions).

Floor effects were relatively infrequent on the GSV metric but occurred on all subdomains using the norm-referenced v-scale metric. Split-half and test-retest reliability were excellent for all subdomains (r_xx >0.95 and inter-class correlation coefficient [ICC] >0.90, respectively), except for coping, which still maintained adequate reliability (r_xx = 0.87, ICC = 0.65). Inter-rater reliability was also very strong, though it was more variable (α_kripp range 0.78–1.00).

The Vineland-3 holds great potential as a COA in SCN2A-RDs; it exhibited very strong psychometric properties in this sample. This is a prerequisite level of evidence needed to demonstrate that a measure is fit-for-purpose for future clinical trials. While some reliability was high, some domains (e.g., domestic) still exhibited problems related to floor effects, which may suggest that they are less relevant to this population. Future studies should expand on this with mixed-methods research for prioritizing concepts of interest on the Vineland-3.

Catatonia is a highly morbid psychomotor disorder that impacts autistic adults and children. There is very little literature that describes outpatient catatonia management practices, none of which discusses the use of the electronic health record (EHR). Thus, we conducted this study to analyze patient messages in a specialized catatonia clinic.

We conducted a retrospective analysis of messaging practices in the EHR for patients in a specialized clinic with autism and catatonia from July 1, 2021, to May 31, 2024. Catatonic symptom severity was recorded via the Bush Francis Catatonia Rating Scale (BFCRS), Kanner Catatonia Severity Scale (KCS), and Kanner Catatonia Examination (KCE). We conducted Spearman and Pearson correlation coefficients to determine whether a relationship exists between the frequency of patient messages, catatonic symptoms, and length of follow-up.

A total of 12,972 messages were sent to the health system or received by the patient or their family. Of those, 6375 (49.1%) messages were sent from the family to the health system. Relationships between message frequency to the health system and all baseline catatonia severity scores (BFCRS, KCS, KCE) were not statistically significant, although message frequency was strongly associated with length of follow-up (r = 0.65, p < 0.001). A total of 5555 (42.8%) messages were sent directly to or received from providers in the catatonia specialty clinic. The rate of messages to providers in the catatonia clinic was 2.9 messages/day.

The frequency of patient messaging was high in this catatonia specialty clinic. Health systems should consider this possibility when planning for similar service lines.

Electroconvulsive therapy (ECT) is an effective treatment for severe and treatment-resistant psychiatric disorders, particularly depression and catatonia. ECT requires intravenous (IV) access, which can pose a barrier for pediatric patients and those with neurodevelopmental disorders who may have difficulty tolerating IV placement. This case series highlights individualized pharmacologic and nonpharmacologic strategies that facilitate IV placement in pediatric and neurodivergent patients receiving ECT.

We reviewed the medical records of five patients aged 14–27 who required ECT but experienced barriers to tolerating IV placement and described strategies used to overcome these limitations.

We describe five strategies: (1) oral anxiolytic premedication, (2) planned physical restraint, (3) intramuscular (IM) ketamine induction, (4) inhalational sevoflurane anesthesia, and (5) placement of an implanted venous access device. Using these strategies, all patients were able to tolerate IV placement and ECT treatment. Consistent treatment protocols, multidisciplinary planning, and engagement of outpatient care teams facilitated the success of these interventions.

Pediatric and neurodivergent patients face unique barriers to ECT, particularly related to IV placement. Our case series demonstrates that individualized, multidisciplinary approaches can enable successful ECT treatment. These findings underscore the importance of adaptive strategies to promote health equity and ensure access to effective psychiatric interventions in special needs populations.