Pediatric Mental Health Presentations and Boarding: First Year of the COVID-19 Pandemic

OBJECTIVES

Psychiatric boarding occurs when patients remain in emergency departments or are admitted to inpatient medical/surgical units to await placement at psychiatric treatment programs. Boarding was already increasing in the United States over the past decade, and the coronavirus disease 2019 pandemic has only further profoundly affected the mental health of youth. The current study aims to describe psychiatric diagnoses and boarding among pediatric patients presenting to the hospital after the pandemic onset.

METHODS

We performed a retrospective chart review from March 2019 to February 2021 of all youth aged ≤18 years with emergency department or inpatient medical/surgical admissions related to mental health complaints at a large United States Northeast pediatric hospital and compared psychiatric diagnoses and boarding during the 12 months before and after the pandemic onset. Inferential statistics included χ2 and t-tests. Interrupted time series analyses evaluated trends during the study period.

RESULTS

Proportion of hospital presentations of pediatric patients with suicidal ideation/suicide attempts (P < .001), depression (P < .001), anxiety (P = .006), eating disorders (P < .001), substance use disorders (P = .005), and obsessive compulsive and related disorders (P < .001), all increased during the first pandemic year, compared with the previous year. Average length of psychiatric boarding more than doubled (2.1 vs 4.6 days, P < .001) and 50.4% of patients experienced extended boarding periods ≥2 days during the first pandemic year.

CONCLUSIONS

This study highlights the vulnerability of a United States health care system that has been chronically inadequate at meeting the mental health needs of children and adolescents, and raises an urgent call to reform pediatric mental health care.

Developing a Clinical Pathway for Somatic Symptom and Related Disorders in Pediatric Hospital Settings

Somatic symptom and related disorders (SSRDs) are commonly encountered in pediatric hospital settings. There is, however, a lack of standardization of care across institutions for youth with these disorders. These patients are diagnostically and psychosocially complex, posing significant challenges for medical and behavioral health care providers. SSRDs are associated with significant health care use, cost to families and hospitals, and risk for iatrogenic interventions and missed diagnoses. With sponsorship from the American Academy of Child and Adolescent Psychiatry and input from multidisciplinary stakeholders, we describe the first attempt to develop a clinical pathway and standardize the care of patients with SSRDs in pediatric hospital settings by a working group of pediatric consultation-liaison psychiatrists from multiple institutions across North America. The authors of the SSRD clinical pathway outline 5 key steps from admission to discharge and include practical, evidence-informed approaches to the assessment and management of children and adolescents who are medically hospitalized with SSRDs.

Effect of timing of psychiatry consultation on length of pediatric hospitalization and hospital charges

OBJECTIVES

The purpose of this study was to evaluate the impact of timing of a psychiatry consultation during pediatric hospitalization on length of hospital stay and total hospitalization charges.

METHODS

The charts of 279 pediatric patients (totaling 308 consultations) referred to the psychiatry consultation liaison service at a freestanding tertiary pediatric hospital between January 1, 2010, and June 30, 2010 were retrospectively analyzed. The variables analyzed included the following: patient demographic characteristics; dates of admission, psychiatric consultation, and discharge; psychiatric diagnoses based on the psychiatric diagnostic evaluation; psychiatric treatment disposition; and illness severity and total charges associated with the medical stay.

RESULTS

Earlier psychiatry consultation was associated with shorter length of stay and lower hospitalization charges after adjusting for psychiatric functioning, physical illness severity, and psychiatric disposition. Poorer psychiatric functioning and milder physical illness were associated with shorter referral time.

CONCLUSIONS

Timely involvement of psychiatry consultation services during a medical or surgical hospitalization was associated with reductions in length of stay and total hospital charges in pediatric settings. These findings have important effects on quality of care via decreasing burden on the patient and family and on the medical system resources. Educating pediatric health care providers about the importance of early psychiatry consultation regardless of physical illness severity or psychiatric acuity will likely improve resource management for patients and hospitals.

Psychiatric Boarding in the Pediatric Inpatient Medical Setting: A Retrospective Analysis

BACKGROUND AND OBJECTIVES

Psychiatric concerns are a common presenting problem for pediatric providers across many settings, particularly on inpatient medical services. The volume of youth requiring intensive psychiatric treatment outnumbers the availability of psychiatric placements, and as a result many youth must board on pediatric medical units while awaiting placement. As the phenomenon of boarding in the inpatient pediatric setting increases, it is important to understand trends in boarding volume and characteristics of pediatric psychiatric boarders (PBs) and understand the supports they receive while boarding.

METHODS

A retrospective chart review of patients admitted as PBs to a medical inpatient unit at a large northeastern US pediatric hospital during 2013.

RESULTS

Four hundred thirty-seven PBs were admitted to the medical service from January to December 2013, representing a more than 50% increase from PB admissions in 2011 and 2012. Most PBs were admitted for suicidal attempt and/or ideation. Average length of boarding was 3.11 ± 3.34 days. PBs received a wide range of mental health supports throughout their admissions. PBs demonstrated modest but statistically significant clinical improvements over the course of their stay, with only a small proportion demonstrating clinical deterioration.

CONCLUSIONS

Psychiatric boarding presents many challenges for families, providers, and the health care system, and PBs have complex psychiatric histories and needs. However, boarding may offer a valuable opportunity for psychiatric intervention and stabilization among psychiatrically vulnerable youth.

Characteristics of medically hospitalized pediatric patients with somatoform diagnoses

OBJECTIVES

To describe demographic, diagnostic, and psychosocial characteristics of medically admitted patients diagnosed with somatoform disorders.

METHODS

Retrospective chart reviews were performed for pediatric patients (ages 3-18 years) seen by the Psychiatry Consultation Service in 2010 and 2011 on inpatient medical/surgical units and diagnosed with somatoform disorders. Data included demographic information; patient medical history, physical symptom characteristics, and service utilization; psychiatric diagnoses, history, and comorbidities, patient temperament, and coping style; family characteristics; and academic and social characteristics.

RESULTS

Mean age for the 161 identified patients was 14.4 years. The majority of patients were female (75%) and white (73%). Chief physical symptoms were pain (58%) and neurologic symptoms (40%); 73% of patients had medical diagnoses, and 66% had a history of prior psychiatric treatment. The most common somatoform diagnoses, using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, were pain (50%) and conversion disorders (28%). Psychiatric comorbidities were predominantly mood and anxiety disorders (42% and 29%, respectively). Mean hospitalization length was 4.9 days, with 14% of patients readmitted with psychiatric reinvolvement during the study period. Patients had sensitive temperaments (80%) and internalizing coping styles (76%) and were described as "good children" (72%). School absences (55%), academic pressures (51%), and learning difficulties (36%) were reported.

CONCLUSIONS

Clarifying the prevalence and nature of such characteristics can help pediatric providers improve patient care and minimize unnecessary medical interventions with early detection of risk for somatoform processes, provision of psychoeducation for patients and families, and early referral to mental health clinicians.

Self-Harm in Children and Adolescents Who Presented at Emergency Units During the COVID-19 Pandemic: An International Retrospective Cohort Study

OBJECTIVE

To compare psychiatric emergencies and self-harm at emergency departments (EDs) 1 year into the pandemic, to early pandemic and pre-pandemic, and to examine the changes in the characteristics of self-harm presentations.

METHOD

This retrospective cohort study expanded on the Pandemic-Related Emergency Psychiatric Presentations (PREP-kids) study. Routine record data in March to April of 2019, 2020, and 2021 from 62 EDs in 25 countries were included. ED presentations made by children and adolescents for any mental health reasons were analyzed.

RESULTS

Altogether, 8,174 psychiatric presentations were recorded (63.5% female; mean [SD] age, 14.3 [2.6] years), 3,742 of which were self-harm presentations. Rate of psychiatric ED presentations in March to April 2021 was twice as high as in March to April 2020 (incidence rate ratio [IRR], 1.93; 95% CI, 1.60-2.33), and 50% higher than in March to April 2019 (IRR, 1.51; 95% CI, 1.25-1.81). Rate of self-harm presentations doubled between March to April 2020 and March to April 2021 (IRR, 1.98; 95% CI, 1.68-2.34), and was overall 1.7 times higher than in March to April 2019 (IRR, 1.70; 95% CI, 1.44-2.00). Comparing self-harm characteristics in March to April 2021 with March to April 2019, self-harm contributed to a higher proportion of all psychiatric presentations (odds ratio [OR], 1.30; 95% CI, 1.05-1.62), whereas female representation in self-harm presentations doubled (OR, 1.98; 95% CI, 1.45-2.72) and follow-up appointments were offered 4 times as often (OR, 4.46; 95% CI, 2.32-8.58).

CONCLUSION

Increased pediatric ED visits for both self-harm and psychiatric reasons were observed, suggesting potential deterioration in child mental health. Self-harm in girls possibly increased and needs to be prioritized. Clinical services should continue using follow-up appointments to support discharge from EDs.

DIVERSITY & INCLUSION STATEMENT

One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group. While citing references scientifically relevant for this work, we also actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our reference list. The author list of this paper includes contributors from the location and/or community where the research was conducted who participated in the data collection, design, analysis, and/or interpretation of the work.

Integrated Behavioral Health Care in Pediatric Subspecialty Clinics

Comorbid behavioral and physical health conditions are accompanied by troubling symptom burden, functional impairment, and treatment complexity. Pediatric subspecialty care clinics offer an opportunity for the implementation of integrated behavioral health (BH) care models that promote resiliency. This article reviews integrated BH care in oncology, palliative care, pain, neuropsychiatry, cystic fibrosis, and transplantation. Examples include integrated care mandates, standards of care, research, and quality improvement by child and adolescent psychiatrists (CAPs) and allied BH clinicians. The role of CAPs in integrated BH care in subspecialty care is explored, focusing on cost, resource use, financial support, and patient and provider satisfaction.

Bullying Victimization in Medically Hospitalized Patients With Somatic Symptom and Related Disorders: Prevalence and Associated Factors

OBJECTIVES

The purpose of this study is to describe the prevalence of bullying victimization among medically admitted patients with somatic symptom and related disorders (SSDs) and to compare demographic, diagnostic, and psychosocial characteristics of bullied versus nonbullied patients.

METHODS

Medically admitted patients at a tertiary pediatric facility referred to the Psychiatry Consultation Service with somatic concerns were assessed via a quality improvement (QI) initiative, the SSD Standardized Clinical Assessment and Management Plan (SSD-SCAMP). Retrospective chart and QI data on adolescent and young adult patients assessed via SSD-SCAMP from May 2012 - December 2014 were reviewed.

RESULTS

Medical records of 282 patients (aged 12-22 years) diagnosed with SSDs were reviewed. Approximately 37% had a history of bullying victimization. Compared with nonbullied patients, bullied patients had higher somatization scores, more functional neurologic symptoms, and longer admissions. Bullied patients also had higher rates of comorbid anxiety, suicidal histories, and family psychiatric histories. Furthermore, bullied patients also had higher rates of learning disabilities and school accommodations and endorsed more significant life events within the year before hospitalization.

CONCLUSIONS

This study describes the unique health and psychosocial challenges experienced by medically hospitalized bullied adolescents and young adults with SSDs. The findings highlight the importance of a multidisciplinary approach to assessment and management. By implementing QI initiatives such as the SSD-SCAMP, providers can bridge the gap between the clinical needs and long-term management of patients with SSDs.

Medically Hospitalized Patients With Eating Disorders and Somatoform Disorders in Pediatrics: What Are Their Similarities and Differences and How Can We Improve Their Care?

OBJECTIVES

The purpose of the current study is to describe the demographic and clinical characteristics and health care use of medically hospitalized patients with eating disorders (ED) and somatoform disorders (SFD) in a pediatric setting and to use the findings to explore opportunities for improved care.

METHODS

Retrospective chart reviews of 125 patients with SFD and 125 patients with ED (N = 250) seen at a tertiary pediatric facility over a 12- and 19-month period, respectively.

RESULTS

Patients in both groups were predominantly girls, white, came from households with above average incomes, and had academic pressures, internalizing coping styles, and high rates of anxiety disorders. Compared with SFD patients, ED patients had longer medical admissions (P < .001), more depressive disorders (P < .01), higher lifetime rates of suicidal ideation and self-injurious behaviors (P < .05), and were more frequently discharged to intensive psychiatric treatment programs (P < .001). SFD patients were referred later to psychiatry (P < .001), had more emergency department visits (P < .001) and more visits to other hospitals (P < .05) and also had higher rates of learning difficulties (P < .001), bullying (P < .05), and trauma (P < .01) compared with ED patients.

CONCLUSIONS

Identifying overlapping features and key differences in the clinical characteristics and health care use of patients with primary psychiatric disorders like ED and SFD, who are frequent users of medical services, is the first step toward developing innovative, integrated hospital-based care approaches and clinical pathways that can reduce service utilization and improve patient outcomes.

Psychiatric concerns in pediatric epilepsy

Pediatric epilepsy is a common, chronic, and challenging physical illness for children and their families. This article provides a medical overview and discusses the cognitive functioning and psychosocial adjustment as well as the psychiatric management for children and adolescents with pediatric epilepsy. The management of these children involves establishing a collaborative health care approach, evaluating academic functioning, considering psychotherapy, and managing psychopharmacologic treatment. A thorough understanding of the biopsychosocial concerns in pediatric epilepsy can enable medical providers and mental health clinicians to promote resiliency and adaptation in children and their families facing troubling seizure disorders.

Psychotropic medication use trends in a large pediatric and young adult solid organ transplant population

INTRODUCTION

This study describes psychotropic medication use in a pediatric and young adult solid organ transplant population.

METHODS

We conducted a retrospective review of the lifetime incidence of psychotropic medication use and associated characteristics in patients seen over a 6-year period at a large pediatric transplant center utilizing univariate and multivariate statistical analyses.

RESULTS

The lifetime incidence of psychotropic medication use was 36.5% in 393 patients. Transplant psychiatry provided psychopharmacological consultation to 21.9% of patients. Controlling for age and sex, there were significant associations between psychotropic use and thoracic organ disease (heart/lung) (AOR = 2.14; 95% CI: 1.2-3.8; P = 0.01), White race (P = 0.0002), histories of depressive/mood disorders (AOR = 3.68; 95% CI: 1.8-7.7; P = 0.0005), attention/learning disorders (AOR = 3.30; 95% CI: 1.6-6.9; P = 0.001), acute and post-traumatic stress disorders (AOR = 10.54; 95% CI: 2.6-42.8; P = 0.001), and experiencing bullying (AOR = 2.16; 95% CI: 1.03-4.55; P = 0.04). In unadjusted tests, significant associations were found between lifetime psychotropic usage and patient anxiety history (OR = 2.26; 95% CI: 1.5-3.5; P = 0.0002), end-of-life disease progression (OR = 3.04; 95% CI: 1.7-5.4; P = 0.0002), family psychiatric history (OR = 2.17; 95% CI: 1.4-3.4; P = 0.0007), and adherence concerns (OR = 2.67; 95% CI: 1.7-4.1; P < 0.0001).

DISCUSSION

The lifetime incidence of psychotropic medication use among pediatric and young adult transplant patients is substantial. Patients with thoracic organ disease, end-of-life illness, individual/family psychiatric histories, trauma, and bullying histories have particularly high rates. Integrating child psychiatry as part of pediatric transplant teams should be an important consideration for the care of these patients.

Behavioral health care in solid organ transplantation in a pediatric setting

This study examined the demographic, medical, and psychiatric characteristics of transplant patients across organ groups seen by transplant psychology/psychiatry clinicians at a pediatric institution between 2008 and 2014. Chart reviews were conducted to better understand the behavioral health care provided to SOT patients and the role of transplant-dedicated psychology and psychiatry clinicians. Transplant psychology/psychiatry was consulted a total of 1060 times on 399 unique SOT patients over a 6-year period. There were no significant differences in the distribution of age, sex, or ethnicity across organ groups. Common reasons for a consultation included pretransplant evaluation, anxiety, depression, agitation, and general coping. Rates varied by organ groups. Twenty percent of consults also received a psychopharmacological evaluation, with differences in rates between organ groups. Roughly one-third of patients required high frequency of transplant psychology/psychiatry involvement. Lung and heart patients had the highest utilization. Psychiatric diagnosis rates were identified, with adjustment (41.0%) and anxiety disorders (30.1%) being the most common. Pediatric psychology and psychiatry clinicians offer developmentally informed biopsychosocial approaches to treatment for SOT patients. Clarifying the prevalence and nature of behavioral health care provided by organ group can help pediatric providers better understand appropriate psychosocial interventions and resources utilized by this patient population and ultimately guide centers toward a more unified approach to care.

Adaptations Made to Pediatric Consultation-Liaison Psychiatry Service Delivery During the Early Months of the COVID-19 Pandemic: A North American Multisite Survey

BACKGROUND

The COVID-19 pandemic led to rapid changes in clinical service delivery across hospital systems nationally. Local realities and resources were key driving factors impacting workflow changes, including for pediatric consultation-liaison psychiatry service (PCLPS) providers.

OBJECTIVE

This study aims to describe the early changes implemented by 22 PCLPSs from the United States and Canada during the COVID-19 pandemic. Understanding similarities and differences in adaptations made to PCLPS care delivery can inform best practices and future models of care.

METHODS

A 20-point survey relating to PCLPS changes during the COVID-19 pandemic was sent to professional listservs. Baseline hospital demographics, hospital and PCLPS workflow changes, and PCLPS experience were collected from March 20 to April 28, 2020, and from August 18 to September 10, 2020. Qualitative data were collected from responding sites. An exploratory thematic analysis approach was used to analyze the qualitative data that were not dependent on predetermined coding themes. Descriptive statistics were calculated using Microsoft Excel.

RESULTS

Twenty-two academic hospitals in the United States and Canada responded to the survey, with an average of 303 beds/hospital. Most respondents (18/22) were children's hospitals. Despite differences in regional impact of COVID-19 and resource availability, there was significant overlap in respondent experiences. Restricted visitation to one caregiver, use of virtual rounding, ongoing trainee involvement, and an overall low number of COVID-positive pediatric patients were common. While there was variability in PCLPS care delivery occurring virtually versus in person, all respondents maintained some level of on-site presence. Technological limitations and pediatric provider preference led to increased on-site presence.

CONCLUSIONS

To our knowledge, this is the first multicenter study exploring pandemic-related PCLPS changes in North America. Findings of this study demonstrate that PCLPSs rapidly adapted to COVID-19 realities. Common themes emerged that may serve as a model for future practice. However, important gaps in understanding their effectiveness and acceptability need to be addressed. This multisite survey highlights the importance of establishing consensus through national professional organizations to inform provider and hospital practices.

Psychological Outcomes and Interventions for Individuals With Congenital Heart Disease: A Scientific Statement From the American Heart Association

Although resilience and high quality of life are demonstrated by many individuals with congenital heart disease, a range of significant psychological challenges exists across the life span for this growing patient population. Psychiatric disorders represent the most common comorbidity among people with congenital heart disease. Clinicians are becoming increasingly aware of the magnitude of this problem and its interplay with patients’ physical health, and many seek guidance and resources to improve emotional, behavioral‚ and social outcomes. This American Heart Association scientific statement summarizes the psychological outcomes of patients with congenital heart disease across the life span and reviews age-appropriate mental health interventions, including psychotherapy and pharmacotherapy. Data from studies on psychotherapeutic, educational‚ and pharmacological interventions for this population are scarce but promising. Models for the integration of mental health professionals within both pediatric and adult congenital heart disease care teams exist and have shown benefit. Despite strong advocacy by patients, families‚ and health care professionals, however, initiatives have been slow to move forward in the clinical setting. It is the goal of this scientific statement to serve as a catalyst to spur efforts for large-scale research studies examining psychological experiences, outcomes, and interventions tailored to this population and for integrating mental health professionals within congenital heart disease interdisciplinary teams to implement a care model that offers patients the best possible quality of life.

Psychiatric concerns in pediatric epilepsy

Pediatric epilepsy is a common, chronic, and challenging physical illness for children and their families. This article provides a medical overview and discusses the cognitive functioning and psychosocial adjustment as well as the psychiatric management for children and adolescents with pediatric epilepsy. The management of these children involves establishing a collaborative health care approach, evaluating academic functioning, considering psychotherapy, and managing psychopharmacologic treatment. A thorough understanding of the biopsychosocial concerns in pediatric epilepsy can enable medical providers and mental health clinicians to promote resiliency and adaptation in children and their families facing troubling seizure disorders.

Somatic symptom and related disorders in pediatric patients: Associations with parent psychiatric and substance use histories

Parental response to pediatric patients with somatic symptom and related disorders (SSRDs) can impact symptom presentation. However, little is known about the impact of parent psychiatric and substance use disorder (SUD) history on the functional status and medical healthcare utilization of patients with SSRDs. The current study explored the associations between parent psychiatric & SUD history and patient somatic symptoms, functional disability, and hospital course in a medically hospitalized sample of pediatric patients with SSRDs. The electronic medical records of 375 pediatric patients with SSRDs, ages 5 to 18, admitted at a tertiary pediatric hospital were retrospectively reviewed. Parent psychiatric histories were identified in 45.1% of the sample. Parent SUD history and maternal psychiatric history were associated with more patient reported somatization. Parent psychiatric and SUD history were not associated with pediatric patients' level of functional disability or healthcare utilization during admission, including admission length, number of tests, and number of consultations obtained. This study has implications regarding reduction of potential stigma towards parents with psychiatric or SUD histories whose children are hospitalized with SSRDs. While such histories may provide insights regarding somatization presentation of pediatric patients with these disorders, it may not necessarily impact level of functional disability or hospital course.

Feasibility and impact of multidisciplinary training of an evidence-based intervention within a pediatric psychiatry consultation service

OBJECTIVE

To train clinicians on a multidisciplinary pediatric consultation-liaison (CL) psychiatry service to administer an evidence-based intervention, biofeedback-assisted relaxation training (BART), in the inpatient medical setting and obtain their opinions about BART's utility and feasibility in the CL setting.

METHODS

Attendings and trainees on a multidisciplinary pediatric CL service received 3 h of BART training and completed a 10-item questionnaire designed to assess opinions about BART at two time points: after training but prior to using the intervention with patients and again 3 months after implementing the intervention in their clinical practice.

RESULTS

Nineteen clinicians administered BART with 28 patients across the study period, and clinicians rated BART positively after training and significantly more positively after utilizing BART in the clinical setting. From post-training to post-implementation, trainees reported significant increases in their opinions that BART increased parent and patient receptiveness to psychiatric consultation (p<0.05) and attendings reported significant increases in their opinions that BART enhanced clinical intervention (p<0.05).

CONCLUSIONS

BART training on a multidisciplinary CL service was well received by clinicians and patients and may enhance psychiatry trainees' repertoire of cognitive-behavioral and evidence-based interventions.

Impact of a Global Child Mental Health Observership Program: Participant Evaluation, Perceptions, and Outcomes

OBJECTIVE

The authors describe the participant outcomes and global impact of a structured international observership program in child and adolescent mental health (CAMH) at a United States (US) pediatric academic center.

METHODS

The quality improvement phase of the observership program was conducted for 2 years and included 12 participants from 9 different countries. Observers utilized a question guide to describe their clinical and academic experiences in the US in relation to their countries. Each observer completed a program evaluation at the end of the observership, and provided progress reports ranging 6-20 months following completion of the program.

RESULTS

Observers valued their experience in the program with overall high evaluation ratings. Observers described major differences and similarities as well as strengths and weaknesses of the US system of care in comparison with their countries' system of care, with perspectives provided on available therapies (pharmacological and non-pharmacological), multidisciplinary treatment, and the role of culture. All observers returned to their countries upon completion of the program and demonstrated significant CAMH clinical and academic productivity with publications, leadership roles, training, education, clinical care, and advocacy in their countries after participation in the observership.

CONCLUSION

The outcomes of this program demonstrate that the development and implementation of an onsite educational observership experience in an academic setting have significant potential to build international collaboration and partnerships, in order to meet the underserved mental health needs of children and adolescents globally. Such experiences promote professional growth for all involved and advance CAMH care and advocacy worldwide.

Implementing patient-reported outcome measures on an adolescent inpatient psychiatry unit: A feasibility study

This article examines the feasibility of implementing patient-reported outcome (PRO) measures with adolescents on an inpatient psychiatry service. During the study period (March 8, 2021, to June 7, 2022), a total of 154 patient encounters were recorded for adolescents between 12 and 17 years of age. PROs were piloted during the first 3 months of the study period, with a focus on technical implementation. In the 12 months from June 8, 2021, through June 7, 2022, the PRO project moved to full implementation across all patient encounters. Fisher's exact test and independent t tests were conducted to examine the differences between patients who completed the PROs and patients who did not complete them to determine the representativeness of the sample receiving them. During the 3-month pilot period, 31.8% of patients completed the PROs at admission and discharge, while during the 12-month full implementation, 74.5% of patients completed them at both time points. Statistical tests showed no significant diagnostic, sex, or race/ethnicity differences between patients who received and did not receive the outcome measures. Even without funding, small inpatient psychiatry services for adolescents can feasibly implement PROs with completion rates similar to other published studies and capture the majority of the patients served. (PsycInfo Database Record (c) 2025 APA, all rights reserved).