CASE: Thomas is a 13-year-old boy with autism spectrum disorder, attention deficit hyperactivity disorder (ADHD), generalized anxiety disorder, separation anxiety disorder, and major depressive disorder who presented for a follow-up to his developmental and behavioral pediatrician (DBP). His mother describes an increase in symptoms of anxiety and depression for the last 6 weeks, accompanied by suicidal ideation and thoughts of self-mutilation. Before this increase in symptoms, he had been doing well for the last several months with the exception of increasing weight gain, and Abilify was decreased from 5 mg to 2.5 mg at his last visit. Other medications at that time included Zoloft 100 mg twice daily, Focalin XR 40 mg every morning, and Focalin 5 mg every night. Without seeking the guidance of our developmental and behavioral pediatrics clinic, his mother increased his intake of Zoloft to 150 mg each morning and continued 100 mg each evening because of worsening anxiety and depression. Religion is very important to Thomas and his family. He acknowledges that he does not want to die and feels badly because “suicide is against our religion.” Helping Thomas receive appropriate care has been a challenge. He was diagnosed with ADHD and Asperger disorder at the age of 5. Thomas is homeschooled and is very attached to his mother. His parents have very different parenting styles, with his mother being more permissive and his father more authoritarian. At the time of initial diagnosis, the behavioral health services (BHS) in Thomas' community, which is about an hour away from the DBP, were limited to older children, and he was followed by a DBP for ADHD medication management. At the age of 11, he expressed passive suicidal ideation and described that he imagined his mother as “the devil with fire coming out of her eyes” when she corrected him. He was evaluated by BHS, diagnosed with anxiety disorder, and started on Lexapro. BHS linked to the DBP were out of network for his insurance. The family was unable to pay out of pocket, so care was subsequently transferred to a DBP clinic that was in network. Soon after, Thomas developed auditory hallucinations, and Abilify was added after consultation with BHS. Over the last few years, Thomas' symptoms have waxed and waned. He did well for a short time and then again developed auditory hallucinations, worsening symptoms of anxiety and depression, and increasing somatic symptoms including vomiting and penile pain. Medications were adjusted with input from BHS, and further attempts were made to link him to local BHS but were unsuccessful. With his current concerns of suicidal ideation and self-mutilation, what would be your next steps?

CASE: Billy is a 2.6-year-old boy who presented for evaluation in the developmental-behavioral pediatrics (DBP) clinic 2 weeks before the onset of pandemic-related clinic restrictions. Billy had received early intervention for the past year because of speech and fine motor delays. Billy's parents requested the evaluation in the DBP clinic because his delayed speech and disruptive behaviors had raised concern that he may have autism spectrum disorder. Owing to the onset of the pandemic, subsequent visits were completed through telehealth with a developmental-behavioral pediatrician, psychologist, behavioral clinician, and social workers who developed a collaborative plan of care. Billy was diagnosed with global developmental delay, significant tantrums, and impulsivity but did not meet the criteria for autism spectrum disorder.Billy lives with his parents and 2 sisters in a rural area, 3 hours from the DBP clinic. Both of his parents have been treated for depression in the past and reported that school was difficult for them. His sisters, ages 5 and 6 years, receive speech/language therapy but have not required additional special education services. His family has endured recent stressors including a flooding event that caused significant damage to their home, financial difficulties, and the recent unexpected death of a close family member. Billy's disruptive behaviors have resulted in difficulty finding and maintaining child care, further contributing to parental stress and dysfunction in the home.Despite assistance from the social worker, additional developmental and behavioral support services near the family's home were not identified. Therefore, services were offered to Billy and his parents through telehealth. Billy's parents began behavioral parent training with a clinician embedded within the DBP clinic and, with direct support from his parents, Billy began receiving supplemental speech/language and occupational therapies through telehealth. Through recurrent engagement with Billy's parents and frequent communication among the behavioral clinician, developmental-behavioral pediatrician, psychologist, and social worker, Billy was able to make significant developmental progress, and his parents reported improved ability to manage his difficult behaviors.How can telehealth be used to help families navigate complex systems and obtain optimal care and support?

Context Nationwide Children’s Hospital (NCH) has a large pediatric residency program with 43 residents in the categorical pediatric program and 10 residents in the Internal Medicine-Pediatrics (IM-Peds) program per class. Of the 43 categorical pediatric residents, four are in the osteopathic recognition track (ORT) and continue their osteopathic education throughout residency. There is currently a lack of data examining the effect of an ORT, and specifically a pediatric ORT, on a residency program. Objective To evaluate the impact of an ORT osteopathic recognition track on an overall residency program’s perceptions of osteopathic manipulative treatment (OMT) and to evaluate allopathic (MD) resident perception of osteopathic educational sessions. Methods An anonymous survey was conducted in June 2017 and distributed to 141 residents (both categorical and IM-Peds) to gather baseline information regarding perceptions and knowledge of OMT. Based on the initial results, a four-part case-based educational series was implemented during the 2018–2019 academic year to teach osteopathic principles to MD residents. A second survey was distributed following each session. Results For the initial survey, 59 (41.8%) residents responded. Survey results demonstrated that resident perceptions of OMT as an efficacious treatment option increased after starting their residency at NCH (p=0.04), and 25 of 43 (58.1%) MD residents stated an interest in learning OMT skills. A total of 140 attendees were present at the four educational sessions. One hundred and thirty-eight residents (98.5%) found the educational sessions beneficial and 132 (94.2%) stated they would refer a patient for OMT. Conclusion ORT residents make a significant impact on their colleagues’ perceptions and knowledge of OMT. This study suggests that further efforts to highlight the clinical applications of OMT in pediatric patients would be welcomed by residents.

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