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Moale AC, Motter EM, Eisenhauer P, Gandhi N, Kim SP, Girard TD, Reynolds CF, Leland NE, Chang JC, Scheunemann LP. Integrating Perspectives on Family Caregiving After Critical Illness: A Qualitative Content Analysis. Am J Crit Care 2024; 33:180-189. [PMID: 38688852 DOI: 10.4037/ajcc2024309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
BACKGROUND To date, no intervention has definitively improved outcomes for families of critical illness survivors. An integrated perspective on caregivers' needs after critical illness could help identify high-priority intervention targets and improve outcomes. OBJECTIVES To obtain diverse perspectives on the needs, barriers and facilitators, and social determinants of health associated with family caregiving across the critical illness continuum and assess the extent to which successful caregiving interventions in other populations may be adapted to the critical illness context. METHODS This qualitative content analysis of 31 semistructured interviews and 10 focus groups with family caregivers, health care providers, and health care administrators explored family caregivers' needs during post- intensive care unit (ICU) transitions and the barriers and facilitators associated with addressing them. Trained coders analyzed transcripts, identified patterns and categories among the codes, and generated themes. RESULTS Caregivers have 3 instrumental needs: formal and informal support, involvement in care planning, and education and training. Only caregivers described their self-care and mental health needs. Social determinants of health are the key barriers and facilitators shaping the caregivers' journey, and caregiving as a social determinant of health was a prominent theme. CONCLUSIONS Caregivers have instrumental, self-care, and mental health needs after critical illness. Adapting hands-on and skills training interventions to the post-ICU setting, while tailoring interventions to caregivers' health-related social context, may improve caregiver outcomes.
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Affiliation(s)
- Amanda C Moale
- Amanda C. Moale is a pulmonary and critical care medicine fellow, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Erica M Motter
- Erica M. Motter is a research coordinator, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Peter Eisenhauer
- Peter Eisenhauer is an internist, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nimit Gandhi
- Nimit Gandhi is an internist, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - S Peter Kim
- S. Peter Kim is an internist, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Tim D Girard
- Tim D. Girard is a professor, Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Charles F Reynolds
- Charles F. Reynolds III is an emeritus professor, Department of Psychiatry, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center
| | - Natalie E Leland
- Natalie E. Leland is a professor, Department of Occupational Therapy, University of Pittsburgh
| | - Judy C Chang
- Judy C. Chang is a professor, Department of Obstetrics, Gynecology, and Reproductive Sciences and General Internal Medicine and Clinical and Translational Science Institute, University of Pittsburgh School of Medicine
| | - Leslie P Scheunemann
- Leslie P. Scheunemann is an assistant professor, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Pittsburgh Medical Center; and Division of Geriatric Medicine and Gerontology, University of Pittsburgh
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Carlson GA, Singh MK, Amaya-Jackson L, Benton TD, Althoff RR, Bellonci C, Bostic JQ, Chua JD, Findling RL, Galanter CA, Gerson RS, Sorter MT, Stringaris A, Waxmonsky JG, McClellan JM. Narrative Review: Impairing Emotional Outbursts: What They Are and What We Should Do About Them. J Am Acad Child Adolesc Psychiatry 2023; 62:135-150. [PMID: 35358662 DOI: 10.1016/j.jaac.2022.03.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 01/31/2022] [Accepted: 03/21/2022] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Impairing emotional outbursts, defined by extreme anger or distress in response to relatively ordinary frustrations and disappointments, impact all mental health care systems, emergency departments, schools, and juvenile justice programs. However, the prevalence, outcome, and impact of outbursts are difficult to quantify because they are transdiagnostic and not explicitly defined by current diagnostic nosology. Research variably addresses outbursts under the rubrics of tantrums, anger, irritability, aggression, rage attacks, or emotional and behavioral dysregulation. Consistent methods for identifying and assessing impairing emotional outbursts across development or systems of care are lacking. METHOD The American Academy of Child and Adolescent Psychiatry Presidential Task Force (2019-2021) conducted a narrative review addressing impairing emotional outbursts within the limitations of the existing literature and independent of diagnosis. RESULTS Extrapolating from the existing literature, best estimates suggest that outbursts occur in 4%-10% of community children (preschoolers through adolescents). Impairing emotional outbursts may respond to successful treatment of the primary disorder, especially for some children with attention-deficit/hyperactivity disorder whose medications have been optimized. However, outbursts are generally multi-determined and often represent maladaptive or deficient coping strategies and responses. CONCLUSION Evidence-based strategies are necessary to address factors that trigger, reinforce, or excuse the behaviors and to enhance problem-solving skills. Currently available interventions yield only modest effect sizes for treatment effect. More specific definitions and measures are needed to track and quantify outbursts and to design and assess the effectiveness of interventions. Better treatments are clearly needed.
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Affiliation(s)
- Gabrielle A Carlson
- Renaissance School of Medicine at Stony Brook University, Putnam Hall, South Campus, Stony Brook, New York.
| | | | | | - Tami D Benton
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | | | - Jeff Q Bostic
- MedStar Georgetown University Hospital, Washington, DC
| | - Jaclyn Datar Chua
- Perelman School of Medicine, University of Pennsylvania, Philadelphia; University of Pennsylvania, Philadelphia
| | | | - Cathryn A Galanter
- SUNY Downstate, Brooklyn, New York; Kings County Hospital Center, Brooklyn, New York
| | | | - Michael T Sorter
- Cincinnati Children's Hospital and the University of Cincinnati, Ohio
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Hinckley JD, Danielson CK. Elucidating the Neurobiologic Etiology of Comorbid PTSD and Substance Use Disorders. Brain Sci 2022; 12:brainsci12091166. [PMID: 36138902 PMCID: PMC9496654 DOI: 10.3390/brainsci12091166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 08/23/2022] [Accepted: 08/29/2022] [Indexed: 11/26/2022] Open
Abstract
Early childhood maltreatment and other traumatic event experiences ("trauma") are common among youth, including those with substance use problems including substance use disorders (SUD). Particularly, interpersonal violence is associated with high rates of comorbidity between posttraumatic stress disorder (PTSD) and SUD, and these comorbid disorders exhibit high levels of overlapping symptomatology. Theoretical models proposed to explain the bidirectional relationship between PTSD and SUD include the self-medication hypothesis and susceptibility hypothesis. In this article, we explore neurobiologic changes associated with trauma, PTSD, and SUD that underly dysregulated stress response. Examining lessons learned from recent translational and clinical research, we propose that further elucidating the neurobiologic etiology of comorbid PTSD and SUD will require a collaborative, interdisciplinary approach, including the integration of preclinical and clinical studies, exploration of biologic markers in clinical studies, and accumulation of larger studies and longitudinal studies with the power to study PTSD and SUD. Such research can transform the field and ultimately reduce high rates and costly impairment of co-occurring PTSD and SUD across the lifespan.
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Affiliation(s)
- Jesse D. Hinckley
- Division of Addiction Science, Treatment & Prevention, Department of Psychiatry, University of Colorado School of Medicine, 1890 N Revere Court, MS-F570, Aurora, CO 80045, USA
- Correspondence:
| | - Carla Kmett Danielson
- National Crime Victims Research & Treatment Center, Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, 67 President Street, MSC 861, Charleston, SC 29425, USA
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Keeshin BR, Monson E. Assessing and Responding to the Trauma of Child Maltreatment. Focus (Am Psychiatr Publ) 2022; 20:176-183. [PMID: 37153127 PMCID: PMC10153498 DOI: 10.1176/appi.focus.20210033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Child maltreatment is a significant risk factor for severe psychiatric outcomes in childhood and contributes to problematic symptoms that direct parents, teachers, or other invested parties to seek psychiatric intervention. With ongoing workforce shortages, much of the pediatric psychiatric care to this population is delivered by generalists. Child maltreatment and trauma can critically alter a child's development trajectory, affecting potential success in school and other important life pursuits. In addition, child maltreatment and resultant traumatic stress can dramatically disrupt child and adolescent development of healthy emotional regulation, distress tolerance, and the ability to form effective interpersonal relationships. Such disruption can lead to presentations within children and adolescents that mimic other symptoms of psychopathology but that typically respond poorly to traditional psychopharmacology. Ineffective treatment trials can lead to increased risk of polypharmacy and inaccurate expectations for treatment benefits. Such treatment efforts may impede addressing important environmental contributors and delay indicated therapeutic strategies. This article seeks to review child maltreatment-including core features and prevalence, overlap of child maltreatment with adverse childhood experiences, developmental impacts of exposure and resultant traumatic stress, guidance for appropriate assessment, and evidence-based interventions-and provide basic deprescribing guidelines to reduce polypharmacy burden.
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Affiliation(s)
- Brooks R Keeshin
- Department of Pediatrics (Keeshin) and Department of Psychiatry (Monson), Huntsman Mental Health Institute, University of Utah, Salt Lake City
| | - Eric Monson
- Department of Pediatrics (Keeshin) and Department of Psychiatry (Monson), Huntsman Mental Health Institute, University of Utah, Salt Lake City
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Sorter M, Chua J, Lamy M, Barzman D, Ryes L, Shekhtman JA. Management of Emotion Dysregulation and Outbursts in Children and Adolescents. Curr Psychiatry Rep 2022; 24:213-226. [PMID: 35316849 DOI: 10.1007/s11920-022-01325-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/08/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE OF REVIEW Emotion dysregulation and outbursts are very common reasons for referral to child and adolescent mental health services and a frequent cause of admission to hospitals and residential programs. Symptoms of emotion dysregulation and outburst are transdiagnostic, associated with many disorders, have the potential to cause severe impairment and their management presents a major challenge in clinical practice. RECENT FINDINGS There are an increasing number of psychosocial interventions that demonstrate promise in improving emotion dysregulation and outbursts. Acute care systems to manage the most severely ill patients have limited best practice guidelines but program advancements indicate opportunities to improve care models. Pharmacotherapy may be of assistance to psychosocial interventions but must be used with caution due to potential adverse effects. Much remains to be discovered however evidence informed, targeted treatments for specific populations show potential for future improvements in outcomes.
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Affiliation(s)
- Michael Sorter
- Cincinnati Children's Hospital, University of Cincinnati, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA. .,University of Cincinnati College of Medicine, Cincinnati, USA.
| | - Jaclyn Chua
- Children's Hospital of Philadelphia, Philadelphia, USA
| | - Martine Lamy
- Cincinnati Children's Hospital, University of Cincinnati, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.,University of Cincinnati College of Medicine, Cincinnati, USA
| | - Drew Barzman
- Cincinnati Children's Hospital, University of Cincinnati, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.,University of Cincinnati College of Medicine, Cincinnati, USA
| | - Louis Ryes
- Xavier University, Cincinnati, USA.,University of Kentucky College of Medicine, Lexington, USA
| | - Joshua Abraham Shekhtman
- The Ohio State University, Columbus, USA.,University of Cincinnati College of Medicine, Cincinnati, USA
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