Publications by authors named "Amy Roy"

46 Publications

A Quality Improvement Project to Delay Umbilical Cord Clamping Time.

Pediatr Qual Saf 2021 Sep-Oct;6(5):e452. Epub 2021 Sep 24.

Department of Pediatrics, Joan C Edwards School of Medicine, Marshall University, Huntington, W.Va.

Delayed cord clamping (DCC) has numerous benefits to the neonate, including increased hemoglobin levels, decreased need for red blood cell transfusions, and decreased incidence of necrotizing enterocolitis and intraventricular hemorrhage. A preliminary observational study at our institution demonstrated 12% of the observed deliveries met the DCC standard, defined as umbilical cord clamping at least 30-60 seconds after birth. Therefore, we designed a quality improvement project to increase the percentage of deliveries using DCC.

Methods: We planned a quality improvement project aiming to increase DCC rates on the university obstetrics service. Our interventions included provider education, installation of timers in the delivery suites, and modification to documentation in the electronic health record. We measured our results through the documented status of cord clamping, either: (1) greater than or equal to 30 seconds or (2) less than 30 seconds. We analyzed the DCC rates weekly and compared those results to the DCC goal of 80% of all deliveries.

Results: Postintervention DCC rates were 96% overall. Rates of DCC met our aim of 80% or greater each of the 6 weeks we collected data.

Conclusion: Simple and inexpensive interventions quickly led to improvements in DCC rates on our university obstetrics service. Our interventions including, provider education, installation of timers in delivery suites, and modification to cord clamping documentation in the electronic health record can be easily instituted at other hospitals. Additionally, the simplicity of this system can produce long-term sustainability of DCC.
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http://dx.doi.org/10.1097/pq9.0000000000000452DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8741268PMC
September 2021

An Integrated Mobile Acute Care Service Enhances Value.

Popul Health Manag 2021 08 9;24(4):442-447. Epub 2020 Dec 9.

DispatchHealth, Denver, Colorado, USA.

Reducing the cost of care while enhancing its quality and experience are essential components to success in value-based care. Because emergency department (ED) and hospital settings represent high-cost environments, the authors sought to reduce their unnecessary use by deploying a novel care delivery service that offers mobile, on-demand care for high-acuity conditions in patient homes. This study is a retrospective quality improvement evaluation of the initial year of the mobile acute care model in a health system with a substantial penetration of value-based care. Although all patients were eligible for mobile services as clinically indicated, those in accountable care organizations were prioritized by the care management teams. A variety of operational, clinical, and financial metrics were assessed to determine the program's performance and value. There were 3436 patient encounters during the study period, a utilization rate of 71% that trended upward throughout the year. Of these visits, 44% involved patients in value-based payment models; 80% of these represented patients in Medicare risk agreements. Throughout the year, progressively improving operational and clinical performance were observed, as were consistently high patient satisfaction scores. An estimated 63.8% of total mobile visits resulted in ED avoidance; 21.6% were emergency medical transport avoidant; 14.1% led to avoided hospital observation or inpatient stays. Patients were highly satisfied with the service. In-home mobile care for high-acuity illness can prevent unnecessary ED and hospital use for some patients and is associated with high patient satisfaction. Acute mobile care is a useful component of a value-based care strategy.
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http://dx.doi.org/10.1089/pop.2020.0289DOI Listing
August 2021

Decomposing complex links between the childhood environment and brain structure in school-aged youth.

Dev Cogn Neurosci 2021 04 22;48:100919. Epub 2021 Jan 22.

Department of Psychology, Yale University, New Haven, CT, USA. Electronic address:

Childhood experiences play a profound role in conferring risk and resilience for brain and behavioral development. However, how different facets of the environment shape neurodevelopment remains largely unknown. Here we sought to decompose heterogeneous relationships between environmental factors and brain structure in 989 school-aged children from the Adolescent Brain Cognitive Development Study. We applied a cross-modal integration and clustering approach called 'Similarity Network Fusion', which combined two brain morphometrics (i.e., cortical thickness and myelin-surrogate markers), and key environmental factors (i.e., trauma exposure, neighborhood safety, school environment, and family environment) to identify homogeneous subtypes. Depending on the subtyping resolution, results identified two or five subgroups, each characterized by distinct brain structure-environment profiles. Notably, more supportive caregiving and school environments were associated with greater myelination, whereas less supportive caregiving, higher family conflict and psychopathology, and higher perceived neighborhood safety were observed with greater cortical thickness. These subtypes were highly reproducible and predicted externalizing symptoms and overall mental health problems. Our findings support the theory that distinct environmental exposures are differentially associated with alterations in structural neurodevelopment. Delineating more precise associations between risk factors, protective factors, and brain development may inform approaches to enhance risk identification and optimize interventions targeting specific experiences.
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http://dx.doi.org/10.1016/j.dcn.2021.100919DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7868609PMC
April 2021

Understanding Phasic Irritability: Anger and Distress in Children's Temper Outbursts.

Child Psychiatry Hum Dev 2021 Feb 6. Epub 2021 Feb 6.

Psychology Department, Fordham University, 441 East Fordham Road, Dealy Hall, Bronx, NY, 10458, USA.

Pediatric irritability can be highly impairing and is implicated in adverse outcomes. The phasic component, characterized by temper outbursts, is a frequent impetus to seek treatment. This study tested whether a previously described anger-distress model of tantrums applies to an outpatient sample of school-age children with clinically impairing temper outbursts (TO; 5.0-9.9 years; N = 86), and examined the clinical relevance of resulting factors through associations with measures of psychopathology, and differences between children with TO and two groups without: children with ADHD (n = 60) and healthy controls (n = 45). Factor analyses established a three-factor model: High Anger, Low Anger, Distress. These factors had unique associations with measures of irritability, externalizing problems, and internalizing problems in the TO group. Additionally, an interaction between groups and outburst factors emerged. Results provide evidence for the presence and clinical utility of the anger-distress model in children's outbursts and suggest avenues for future pediatric irritability research.
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http://dx.doi.org/10.1007/s10578-021-01126-5DOI Listing
February 2021

Mesothelioma and Radical Surgery 2 (MARS 2): protocol for a multicentre randomised trial comparing (extended) pleurectomy decortication versus no (extended) pleurectomy decortication for patients with malignant pleural mesothelioma.

BMJ Open 2020 09 1;10(9):e038892. Epub 2020 Sep 1.

Bristol Trials Centre (CTEU), University of Bristol, Bristol, UK.

Introduction: Mesothelioma remains a lethal cancer. To date, systemic therapy with pemetrexed and a platinum drug remains the only licensed standard of care. As the median survival for patients with mesothelioma is 12.1 months, surgery is an important consideration to improve survival and/or quality of life. Currently, only two surgical trials have been performed which found that neither extensive (extra-pleural pneumonectomy) or limited (partial pleurectomy) surgery improved survival (although there was some evidence of improved quality of life). Therefore, clinicians are now looking to evaluate pleurectomy decortication, the only radical treatment option left.

Methods And Analysis: The MARS 2 study is a UK multicentre open parallel group randomised controlled trial comparing the effectiveness and cost-effectiveness of surgery-(extended) pleurectomy decortication-versus no surgery for the treatment of pleural mesothelioma. The study will test the hypothesis that surgery and chemotherapy is superior to chemotherapy alone with respect to overall survival. Secondary outcomes include health-related quality of life, progression-free survival, measures of safety (adverse events) and resource use to 2 years. The QuinteT Recruitment Intervention is integrated into the trial to optimise recruitment.

Ethics And Dissemination: Research ethics approval was granted by London - Camberwell St. Giles Research Ethics Committee (reference 13/LO/1481) on 7 November 2013. We will submit the results for publication in a peer-reviewed journal.

Trial Registration Numbers: ISRCTN-ISRCTN44351742 and ClinicalTrials.gov-NCT02040272.
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http://dx.doi.org/10.1136/bmjopen-2020-038892DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7467531PMC
September 2020

Editorial: A Call for Developmental Psychopathology Approaches to Diagnostic Nosology.

Authors:
Amy Krain Roy

J Am Acad Child Adolesc Psychiatry 2021 03 23;60(3):343-345. Epub 2020 Jul 23.

Fordham University, The Bronx, New York; and NYU Grossman School of Medicine, New York. Electronic address:

The publication of DSM-5 came with a number of significant advances, including shifts in disorder classifications and a new focus on dimensional assessment. It also introduced disruptive mood dysregulation disorder (DMDD), which was met with some criticism and concern. Although there was research to support the establishment of this new diagnosis aimed at improving classification of children and adolescents with persistent and impairing irritability, specific symptoms and definitions of frequency and impairment were not as empirically supported, and concerns arose regarding validity and reliability. The introduction of new diagnoses is a complex endeavor, particularly for disorders affecting children and adolescents, which require consideration of the immense neural, cognitive, and emotional changes occurring during this developmental period. Rigorous approaches grounded in developmental psychopathology are needed to establish a meaningful and clinically useful set of symptoms and associated characteristics. This is the approach that Wiggins et al. take to address the applicability of the DMDD diagnosis for children below the age of 6 years. Although this minimum age was included in DSM-5 to prevent unwarranted labeling of young children for whom temper outbursts are common, it fails to consider growing evidence of impairing irritability in preschoolers and limits identification of children who would benefit from early interventions. In response to this, these authors take a comprehensive bottom-up approach to empirically identify symptoms and to define limits of clinical severity, tailored specifically to preschool-aged children. As such, this study serves as a model of how to develop and to refine the diagnostic nosology of child psychiatric disorders.
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http://dx.doi.org/10.1016/j.jaac.2020.07.008DOI Listing
March 2021

A Preliminary Investigation of the Effects of a Western Diet on Hippocampal Volume in Children.

Front Pediatr 2020 3;8:58. Epub 2020 Mar 3.

Pediatric Emotion Regulation Lab, Department of Psychology, Fordham University, The Bronx, NY, United States.

Over the course of the 20th century, there has been a sharp increase in the consumption of saturated fat and refined sugars. This so-called "western diet" (WD) has been extensively linked to biological alterations and associated functional deficits in the hippocampus of animals. However, the effects of a WD on the human hippocampus are less well-characterized. This preliminary study aimed to extend prior animal work by investigating the effects of a WD on hippocampal volume in children. Twenty-one healthy children (ages 5-9) completed a structural T1-weighted magnetic resonance imaging scan. Bilateral hippocampal volumes (as regions-of-interest) and bilateral amygdala volumes (as medial temporal lobe control regions-of-interest) were calculated. WD variables were derived from the parent-completed Youth/Adolescent Food Frequency Questionnaire. Specifically, variables were calculated as percent of daily calories consumed from sugars, fats, or a combination of these (WD). While the relationships between overall WD consumption and bilateral hippocampal volumes were not significant, increased fat consumption was significantly related to decreased left hippocampal volume. Sugar consumption was not related to hippocampal size. Control region volumes were not related to any diet variables. This study is the first to directly link diet-specifically fat consumption-to decreased left hippocampal volume in children. This extends previous work showing smaller left hippocampal volume related to obesity in pediatric samples. Though preliminary, findings represent an important step toward understanding the impact of diet on child brain development.
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http://dx.doi.org/10.3389/fped.2020.00058DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7062798PMC
March 2020

Advances in the Conceptualization, Assessment, and Treatment of Pediatric Irritability.

Behav Ther 2020 03 26;51(2):207-210. Epub 2019 Nov 26.

Florida International University.

Pediatric irritability is a functionally impairing transdiagnostic symptom underlying a substantial proportion of child mental health referrals. The past 20 years have witnessed a striking uptick in empirical work focused on pediatric irritability, with increasing recognition of its role across multiple internalizing and externalizing disorders. That said, it has only been in recent years that research has begun to make advances in understanding the natural course and neurobiological underpinnings of irritability across development; research directly informing effective clinical management of pediatric irritability has been limited. At this critical stage in the study of pediatric irritability, this special series brings together the latest work from leading experts across three interrelated domains: (a) progress in understanding the phenomenology and course of pediatric irritability; (b) advances in the assessment of pediatric irritability; and (c) innovations in the treatment of pediatric irritability. The papers in this special series collectively offer critical steps forward for better understanding pediatric irritability and improving proper assessment, classification, and clinical management.
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http://dx.doi.org/10.1016/j.beth.2019.10.010DOI Listing
March 2020

Functional connectivity of the anterior insula associated with intolerance of uncertainty in youth.

Cogn Affect Behav Neurosci 2020 06;20(3):493-502

Fordham University, Dealy Hall 436, 441 East Fordham Road, Bronx, NY, 10458, USA.

Intolerance of uncertainty (IU) is a trait characteristic marked by distress in the face of insufficient information. Elevated IU has been implicated in the development and maintenance of anxiety disorders, particularly during adolescence, which is characterized by dramatic neural maturation and the onset of anxiety disorders. Previous task-based work implicates the bilateral anterior insula in IU. However, the association between anterior insula intrinsic functional connectivity (iFC) and IU has not been examined in adolescents. Fifty-eight healthy youth (mean age = 12.56; 55% boys) completed the Intolerance of Uncertainty Scale for Children (IUSC-12) and a 6-minute resting state fMRI scan. Group-level analyses were conducted using a random-effects, ordinary least-squares model, including IUSC-12 scores (Total, Inhibitory subscale, Prospective subscale), and three nuisance covariates (age, sex, and mean framewise displacement). IUSC-12 Inhibitory subscale scores were predictive of iFC between the left and right anterior insula and right prefrontal regions. IUSC-12 Prospective subscale scores significantly predicted iFC between the anterior insula and the anterior cingulate cortex. IUSC-12 total scores did not predict significant iFC of the bilateral anterior insula. Follow-up analyses, including anxiety (MASC Total Score) in the models, failed to find significant results. This could suggest that the associations found between IUSC-12 scores and anterior insula iFC are not unique to IU and, rather, reflect a broader anxiety-related connectivity pattern. Further studies with larger samples are needed to tease apart unique associations. These findings bear significance in contributing to the literature evaluating the neural correlates of risk factors for anxiety in youth.
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http://dx.doi.org/10.3758/s13415-020-00780-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7272284PMC
June 2020

Heterogeneity of the Anxiety-Related Attention Bias: A Review and Working Model for Future Research.

Clin Psychol Sci 2019 Sep 14;7(5):879-899. Epub 2019 May 14.

Hunter College, The City University of New York, Department of Psychology, New York, NY.

The anxiety-related attention bias (AB) has been studied for several decades as a clinically-relevant output of the dynamic and complex threat detection-response system. Despite research enthusiasm for the construct of AB, current theories and measurement approaches cannot adequately account for the growing body of mixed, contradictory, and null findings. Drawing on clinical, neuroscience, and animal models, we argue that the apparent complexity and contradictions in the empirical literature can be attributed to the field's failure to clearly conceptualize AB heterogeneity and the dearth of studies in AB that consider additional cognitive mechanisms in anxiety, particularly disruptions in threat-safety discrimination and cognitive control. We review existing research and propose a working model of AB heterogeneity positing that AB may be best conceptualized as multiple subtypes of dysregulated processing of and attention to threat anchored in individual differences in threat-safety discrimination and cognitive control. We review evidence for this working model and discuss how it can be used to advance knowledge of AB mechanisms and inform personalized prevention and intervention approaches.
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http://dx.doi.org/10.1177/2167702619838474DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7983558PMC
September 2019

The Contribution of Sensory Sensitivity to Emotional Lability in Children with ADHD Symptoms.

Evid Based Pract Child Adolesc Ment Health 2019 2;4(4):319-327. Epub 2019 Aug 2.

Department of Psychology, Fordham University, Bronx, N.Y., USA.

Emotional lability and sensory sensitivity have been shown to contribute to the overall clinical picture in children with attention deficit hyperactivity disorder (ADHD; Dunn & Bennett, 2002; Sobanski et al., 2010). Further, both of these characteristics have been individually demonstrated to contribute to poorer quality of life, increased functional impairment, and poorer treatment response (Anastopoulos et al., 2010; Boterberg & Warreyn, 2016). However, to date, no study has evaluated the relationship among all three of these factors. The current study hypothesized that increased sensory sensitivity would moderate the relationship between hyperactive/impulsive symptoms of ADHD and emotional lability in youth. Results indicate that heightened sensory sensitivity strengthens the relationship between hyperactive/impulsive symptoms of ADHD and emotional lability in children with three or more clinically impairing ADHD symptoms. This dimensional approach was taken in accordance with growing evidence that even children with sub-threshold ADHD experience significant functional impairment and high rates of sensory sensitivity (Hong et al., 2014). These findings suggest that clinicians treating children with ADHD symptoms and emotional lability should consider assessing for sensory sensitivity as integration of multi-sensory techniques or referral to concurrent occupational therapy may significantly improve treatment outcomes and quality of life for these children and their families.
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http://dx.doi.org/10.1080/23794925.2019.1647122DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7540722PMC
August 2019

Parental Responses to Temper Outbursts in Children With ADHD: The Role of Psychological Factors.

J Atten Disord 2020 12 9;24(14):2054-2063. Epub 2017 Dec 9.

Fordham University, Bronx, NY, USA.

Children with ADHD frequently exhibit temper outbursts (TO). One related factor may be parental responses, such as harsh discipline and accommodation. This study tests the hypotheses that these responses will be associated with greater TO, and parental characteristics of higher anger and lower sense of competence, in children with ADHD. : Participants included 79 5- to 9-year-old children with ADHD (77.22% boys). Regressions were used to determine the association between parental psychological factors and responses to TO while covarying for TO frequency, severity, and duration. : Parental anger and sense of competence were not significantly related to any discipline responses after covarying for TO characteristics, although sense of competence predicted spanking at trend-level significance. Both parental anger and sense of competence significantly predicted accommodation over and above TO characteristics. : Results underscore the importance of parental anger and sense of competency in predicting parental behavior, specifically parental accommodation.
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http://dx.doi.org/10.1177/1087054717745595DOI Listing
December 2020

Altered intrinsic functional connectivity of the cingulate cortex in children with severe temper outbursts.

Dev Psychopathol 2018 05 14;30(2):571-579. Epub 2017 Aug 14.

New York University Langone School of Medicine.

Severe temper outbursts (STO) in children are associated with impaired school and family functioning and may contribute to negative outcomes. These outbursts can be conceptualized as excessive frustration responses reflecting reduced emotion regulation capacity. The anterior cingulate cortex (ACC) has been implicated in negative affect as well as emotional control, and exhibits disrupted function in children with elevated irritability and outbursts. This study examined the intrinsic functional connectivity (iFC) of a region of the ACC, the anterior midcingulate cortex (aMCC), in 5- to 9-year-old children with STO (n = 20), comparing them to children with attention-deficit/hyperactivity disorder (ADHD) without outbursts (ADHD; n = 18). Additional analyses compared results to a sample of healthy children (HC; n = 18) and examined specific associations with behavioral and emotional dysregulation. Compared to the ADHD group, STO children exhibited reduced iFC between the aMCC and surrounding regions of the ACC, and increased iFC between the aMCC and precuneus. These differences were also seen between the STO and HC groups; ADHD and HC groups did not differ. Specificity analyses found associations between aMCC-ACC connectivity and hyperactivity, and between aMCC-precuneus iFC and emotion dysregulation. Disruption in aMCC networks may underlie the behavioral and emotional dysregulation characteristic of children with STO.
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http://dx.doi.org/10.1017/S0954579417001080DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5812860PMC
May 2018

Factor structure of the intolerance of uncertainty scale for children.

J Anxiety Disord 2018 01 31;53:100-107. Epub 2017 Jul 31.

Department of Psychology, Mental Health Interventions and Technology (MINT) Program, Florida International University, Miami, FL, United States.

Intolerance of uncertainty (IU), a dispositional negative orientation toward uncertainty and its consequences, has been studied in adults, but research has only recently examined IU in youth. Despite some advances, little is known about the factor structure of measures of IU in youth. The present study used confirmatory factor analysis to examine the structure of IU as measured by the Intolerance of Uncertainty Scale for Children (IUSC; Comer et al., 2009) in a sample of youth (N=368) 9-18 years of age (M=12.47) with and without anxiety disorders and their mothers. Findings demonstrated multiple acceptable factor structures: a correlated factors 2-factor structure and a bifactor model where a general factor underlies all items. While the bifactor model provides better fit and reliability to the data, multivariate analyses indicated that the 2-factor structure distinguishes apprehensive anxiety regarding future events (prospective IU) from present-focused inhibition of behavior due to uncertainty and negative reactions to the presence of uncertainty (inhibitory IU); a total IU score predicted all anxiety domains for self- and parent-reports except for parent-report harm avoidance. Findings are discussed in terms of consistency of IU across adult and youth samples, and how results can inform treatment efforts and etiologic models of IU and anxiety.
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http://dx.doi.org/10.1016/j.janxdis.2017.07.003DOI Listing
January 2018

The Neural Correlates of Emotional Lability in Children with Autism Spectrum Disorder.

Brain Connect 2017 06;7(5):281-288

2 Department of Child and Adolescent Psychiatry, NYU Child Study Center of the Langone Medical Center , New York, New York.

Autism spectrum disorder (ASD) is exceptionally heterogeneous in both clinical and physiopathological presentations. Clinical variability applies to ASD-specific symptoms and frequent comorbid psychopathology such as emotional lability (EL). To date, the physiopathological underpinnings of the co-occurrence of EL and ASD are unknown. As a first step, we examined within-ASD inter-individual variability of EL and its neuronal correlates using resting-state functional magnetic resonance imaging (R-fMRI). We analyzed R-fMRI data from 58 children diagnosed with ASD (5-12 years) in relation to the Conners' Parent Rating Scale EL index. We performed both an a priori amygdala region-of-interest (ROI) analysis, and a multivariate unbiased whole-brain data-driven approach. While no significant brain-behavior relationships were identified regarding amygdala intrinsic functional connectivity (iFC), multivariate whole-brain analyses revealed an extended functional circuitry centered on two regions: middle frontal gyrus (MFG) and posterior insula (PI). Follow-up parametric and nonparametric ROI-analyses of these regions revealed relationships between EL and MFG- and PI-iFC with default, salience, and visual networks suggesting that higher-order cognitive and somatosensory processes are critical for emotion regulation in ASD. We did not detect evidence of amygdala iFC underpinning EL in ASD. However, exploratory whole-brain analyses identified large-scale networks that have been previously reported abnormal in ASD. Future studies should consider EL as a potential source of neuronal heterogeneity in ASD and focus on multinetwork interactions.
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http://dx.doi.org/10.1089/brain.2016.0472DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5510050PMC
June 2017

Distinct Functional Connectivities Predict Clinical Response with Emotion Regulation Therapy.

Front Hum Neurosci 2017 3;11:86. Epub 2017 Mar 3.

The Graduate Center, City University of New YorkNew York, NY, USA; Hunter College, City University of New YorkNew York, NY, USA.

Despite the success of available medical and psychosocial treatments, a sizable subgroup of individuals with commonly co-occurring disorders, generalized anxiety disorder (GAD) and major depressive disorder (MDD), fail to make sufficient treatment gains thereby prolonging their deficits in life functioning and satisfaction. Clinically, these patients often display temperamental features reflecting heightened sensitivity to underlying motivational systems related to threat/safety and reward/loss (e.g., somatic anxiety) as well as inordinate negative self-referential processing (e.g., worry, rumination). This profile may reflect disruption in two important neural networks associated with emotional/motivational salience (e.g., salience network) and self-referentiality (e.g., default network, DN). Emotion Regulation Therapy (ERT) was developed to target this hypothesized profile and its neurobehavioral markers. In the present study, 22 GAD patients (with and without MDD) completed resting state MRI scans before receiving 16 sessions of ERT. To test study these hypotheses, we examined the associations between baseline patterns of intrinsic functional connectivity (iFC) of the insula and of hubs within the DN (anterior and dorsal medial prefrontal cortex [MPFC] and posterior cingulate cortex [PCC]) and treatment-related changes in worry, somatic anxiety symptoms and decentering. Results suggest that greater treatment linked reductions in worry were associated with iFC clusters in both the insular and parietal cortices. Greater treatment linked gains in decentering, a metacognitive process that involves the capacity to observe items that arise in the mind with healthy psychological distance that is targeted by ERT, was associated with iFC clusters in the anterior and posterior DN. The current study adds to the growing body of research implicating disruptions in the default and salience networks as promising targets of treatment for GAD with and without co-occurring MDD.
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http://dx.doi.org/10.3389/fnhum.2017.00086DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5334508PMC
March 2017

Disruptive Mood Dysregulation Disorder (DMDD): An RDoC perspective.

J Affect Disord 2017 07 13;216:117-122. Epub 2016 Aug 13.

Fordham University, Bronx, NY, United States. Electronic address:

In recent years, there has been much debate regarding the most appropriate diagnostic classification of children exhibiting emotion dysregulation in the form of irritability and severe temper outbursts. Most recently, this has resulted in the addition of a new diagnosis, Disruptive Mood Dysregulation Disorder (DMDD) in the DSM 5. The impetus for including this new disorder was to reduce the number of diagnoses that these children would typically receive; however, there is concern that it has only complicated matters rather than simplifying them. For example, a recent epidemiologic study shows that DMDD cannot be differentiated from oppositional defiant disorder (ODD) based on symptoms alone. Thus, these children are an ideal population in which to apply RDoC constructs in order to obtain greater clarity in terms of underlying processes and ultimately, inform nosology and appropriate interventions. The aim of this article is to provide a foundation for future research by examining extant theoretical and empirical evidence for the role of four key RDoC constructs in DMDD.
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http://dx.doi.org/10.1016/j.jad.2016.08.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5305694PMC
July 2017

Disruptive Mood Dysregulation Disorder: A New Diagnostic Approach to Chronic Irritability in Youth.

Focus (Am Psychiatr Publ) 2016 Jan 24;14(1):145-151. Epub 2015 Dec 24.

(Reprinted from the 2014; 171:918-924 with permission from American Psychiatric Association Publishing).
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http://dx.doi.org/10.1176/appi.focus.140104DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6524431PMC
January 2016

Neural Correlates of Aggression in Medication-Naive Children with ADHD: Multivariate Analysis of Morphometry and Tractography.

Neuropsychopharmacology 2015 Jun 3;40(7):1717-25. Epub 2015 Feb 3.

Department of Psychiatry, Columbia University College of Physicians and Surgeons and New York State Psychiatric Institute, New York, NY, USA.

Aggression is widely observed in children with attention deficit/hyperactivity disorder (ADHD) and has been frequently linked to frustration or the unsatisfied anticipation of reward. Although animal studies and human functional neuroimaging implicate altered reward processing in aggressive behaviors, no previous studies have documented the relationship between fronto-accumbal circuitry-a critical cortical pathway to subcortical limbic regions-and aggression in medication-naive children with ADHD. To address this, we collected behavioral measures and parental reports of aggression and impulsivity, as well as structural and diffusion MRI, from 30 children with ADHD and 31 healthy controls (HC) (mean age, 10±2.1 SD). Using grey matter morphometry and probabilistic tractography combined with multivariate statistical modeling (partial least squares regression and support vector regression), we identified anomalies within the fronto-accumbal circuit in childhood ADHD, which were associated with increased aggression. More specifically, children with ADHD showed reduced right accumbal volumes and frontal-accumbal white matter connectivity compared with HC. The magnitude of the accumbal volume reductions within the ADHD group was significantly correlated with increased aggression, an effect mediated by the relationship between the accumbal volume and impulsivity. Furthermore, aggression, but not impulsivity, was significantly explained by multivariate measures of fronto-accumbal white matter connectivity and cortical thickness within the orbitofrontal cortex. Our multi-modal imaging, combined with multivariate statistical modeling, indicates that the fronto-accumbal circuit is an important substrate of aggression in children with ADHD. These findings suggest that strategies aimed at probing the fronto-accumbal circuit may be beneficial for the treatment of aggressive behaviors in childhood ADHD.
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http://dx.doi.org/10.1038/npp.2015.18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4915254PMC
June 2015

A Critical Review of Attentional Threat Bias and Its Role in the Treatment of Pediatric Anxiety Disorders.

J Cogn Psychother 2015 1;29(3):171-184. Epub 2015 Jan 1.

Nathan S. Kline Institute for Psychiatric Research, Orangeburg, New York.

Threat bias, or exaggerated selective attention to threat, is considered a key neurocognitive factor in the etiology and maintenance of pediatric anxiety disorders. However, upon closer examination of the literature, there is greater heterogeneity in threat-related attentional biases than typically acknowledged. This is likely impacting progress that can be made in terms of interventions focused on modifying this bias and reducing anxiety, namely attention bias modification training. We suggest that the field may need to "take a step back" from developing interventions and focus research efforts on improving the methodology of studying attention bias itself, particularly in a developmental context. We summarize a neurocognitive model that addresses the issue of heterogeneity by broadly incorporating biases toward and away from threat, linking this variation to key neurodevelopmental factors, and providing a basis for future research aimed at improving the utility of threat bias measures and interventions in clinical practice.
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http://dx.doi.org/10.1891/0889-8391.29.3.171DOI Listing
January 2015

Alterations in amygdala functional connectivity reflect early temperament.

Biol Psychol 2014 Dec 26;103:248-54. Epub 2014 Sep 26.

Section on Development and Affective Neuroscience, National Institute of Mental Health, Bethesda, MD, USA.

Behavioral inhibition (BI) is a temperament identified early in life that is associated with increased risk for anxiety disorders. Amygdala hyperresponsivity, found both in behaviorally inhibited and anxious individuals, suggests that amygdala dysfunction may represent a marker of anxiety risk. However, broader amygdala networks have not been examined in individuals with a history of childhood BI. This study uses resting state fMRI to assess amygdala intrinsic functional connectivity (iFC) in 38 healthy young adults (19 with a history of BI, 19 with no history of BI) selected from a longitudinal study. Centromedial, basolateral, and superficial amygdala iFCs were compared between groups and examined in relation to self-report measures of anxiety. Group differences were observed in amygdala iFC with prefrontal cortex, striatum, anterior insula, and cerebellum. Adults characterized with BI in childhood endorsed greater state anxiety prior to entering the scanner, which was associated with several of the group differences. Findings support enduring effects of BI on amygdala circuitry, even in the absence of current psychopathology.
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http://dx.doi.org/10.1016/j.biopsycho.2014.09.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4356650PMC
December 2014

Age-related changes in the intrinsic functional connectivity of the human ventral vs. dorsal striatum from childhood to middle age.

Dev Cogn Neurosci 2015 Feb 30;11:83-95. Epub 2014 Aug 30.

Section on Development and Affective Neuroscience, National Institute of Mental Health, National Institutes of Health, USA. Electronic address:

The striatum codes motivated behavior. Delineating age-related differences within striatal circuitry can provide insights into neural mechanisms underlying ontogenic behavioral changes and vulnerabilities to mental disorders. To this end, a dual ventral/dorsal model of striatal function was examined using resting state intrinsic functional connectivity (iFC) imaging in 106 healthy individuals, ages 9-44. Broadly, the dorsal striatum (DS) is connected to prefrontal and parietal cortices and contributes to cognitive processes; the ventral striatum (VS) is connected to medial orbitofrontal and anterior cingulate cortices, and contributes to affective valuation and motivation. Findings revealed patterns of age-related changes that differed between VS and DS iFCs. We found an age-related increase in DS iFC with posterior cingulate cortex (pCC) that stabilized after the mid-twenties, but a decrease in VS iFC with anterior insula (aIns) and dorsal anterior cingulate cortex (dACC) that persisted into mid-adulthood. These distinct developmental trajectories of VS vs. DS iFC might underlie adolescents' unique behavioral patterns and vulnerabilities to psychopathology, and also speaks to changes in motivational networks that extend well past 25 years old.
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http://dx.doi.org/10.1016/j.dcn.2014.08.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6310902PMC
February 2015

Pain and Anxiety Experienced by Patients Following Placement of a Percutaneous Endoscopic Gastrostomy.

JPEN J Parenter Enteral Nutr 2015 Sep 23;39(7):823-7. Epub 2014 Sep 23.

Department of Gastroenterology, Derriford Hospital, Plymouth, UK

Background: Abdominal pain following percutaneous endoscopic gastrostomy (PEG) placement is a recognized complication. However, the prevalence and degree of severity of pain are poorly characterized. We assessed abdominal pain and anxiety levels associated with PEG placement in communicative and noncommunicative patients.

Methods: A prospective questionnaire assessed patients' anxiety and abdominal pain 1 hour before, 1 hour after, and 24 hours after PEG placement using 11-point Likert-type scales. Patients were followed up until pain had resolved. Procedural data, analgesia requirements, and complications were recorded. For analysis, patients were divided into 2 groups: communicative (able to self-assess) and noncommunicative (clinician assessed).

Results: Seventy consecutive patients were assessed. Of the 49 self-assessed patients, 11 (22%) reported immediate pain, 32 (65%) reported pain at 1 hour (24 mild, 5 moderate, 3 severe), and 40 (82%) reported pain at 24 hours. Pain most commonly lasted between 24 and 48 hours (25 patients). Of the 21 clinician-assessed patients, only 1 was deemed to have pain, and this was at 24 hours. Four (6%) patients were admitted with pain. There was no relationship between preplacement anxiety scores and postplacement pain scores.

Discussion: Abdominal pain after PEG placement pain is common but resolved by 48 hours in most patients. In patients able to communicate, clinicians scored pain lower compared with patients' scores. It is likely that pain is not identified in patients unable to communicate. Patients need to be better informed about the possibility of postprocedural pain and routinely offered access to appropriate analgesia.
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http://dx.doi.org/10.1177/0148607114551798DOI Listing
September 2015

Disruptive mood dysregulation disorder: a new diagnostic approach to chronic irritability in youth.

Am J Psychiatry 2014 Sep;171(9):918-24

Disruptive mood dysregulation disorder (DMDD), a newcomer to psychiatric nosology, addresses the need for improved classification and treatment of children exhibiting chronic nonepisodic irritability and severe temper outbursts. In recent years, many of these children have been diagnosed with bipolar disorder, despite the lack of distinct mood episodes. This diagnostic practice has raised concerns, in part because of the escalating prescription of atypical antipsychotics. This article provides an overview of the limited literature on DMDD, including its history and relevant studies of assessment and treatment. A case study is included to illustrate key points, including diagnostic issues that clinicians may encounter when considering a diagnosis of DMDD.
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http://dx.doi.org/10.1176/appi.ajp.2014.13101301DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4390118PMC
September 2014

Abnormal amygdala functional connectivity associated with emotional lability in children with attention-deficit/hyperactivity disorder.

J Am Acad Child Adolesc Psychiatry 2014 Mar 14;53(3):351-61.e1. Epub 2013 Dec 14.

Phyllis Green and Randolph Cowen Institute for Pediatric Neuroscience, New York University Child Study Center; Fordham University.

Objective: A substantial proportion of children with attention-deficit/hyperactivity disorder (ADHD) also display emotion regulation deficits manifesting as chronic irritability, severe temper outbursts, and aggression. The amygdala is implicated in emotion regulation, but its connectivity and relation to emotion regulation in ADHD has yet to be explored. The purpose of this study was to examine the relationship between intrinsic functional connectivity (iFC) of amygdala circuits and emotion regulation deficits in youth with ADHD.

Method: Bilateral amygdala iFC was examined using functional magnetic resonance imaging in 63 children with ADHD, aged 6 to 13 years. First, we examined the relationship between amygdala IFC and parent ratings of emotional lability (EL) in children with ADHD. Second, we compared amygdala iFC across subgroups of children with ADHD and high EL (n = 18), ADHD and low EL (n = 20), and typically developing children (TDC), all with low EL (n = 19).

Results: Higher EL ratings were associated with greater positive iFC between the amygdala and rostral anterior cingulate cortex in youth with ADHD. EL scores were also negatively associated with iFC between bilateral amygdala and posterior insula/superior temporal gyrus. Patterns of amygdala-cortical iFC in ADHD participants with low EL were not different from the comparison group, and the effect sizes for these comparisons were smaller than those for the trend-level differences observed between the high-EL and TDC groups.

Conclusions: In children with ADHD and a range of EL, deficits in emotion regulation were associated with altered amygdala-cortical iFC. When comparing groups that differed on ADHD status but not EL, differences in amygdala iFC were small and nonsignificant, highlighting the specificity of this finding to emotional deficits, independent of other ADHD symptoms.
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http://dx.doi.org/10.1016/j.jaac.2013.11.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3961844PMC
March 2014

Resveratrol attenuates cisplatin renal cortical cytotoxicity by modifying oxidative stress.

Toxicol In Vitro 2014 Mar 12;28(2):248-57. Epub 2013 Nov 12.

Department of Pharmacology, Physiology and Toxicology, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV 25755, United States.

Cisplatin, a cancer chemotherapy drug, is nephrotoxic. The aim of this study was to investigate whether resveratrol (RES) reduced cisplatin cytotoxicity and oxidative stress. Rat renal cortical slices were pre-incubated 30min with 0 (VEH, ethanol) or 30μg/ml RES followed by 60, 90 or 120min co-incubation with 0, 75, or 150μg/ml cisplatin. Lactate dehydrogenase (LDH) leakage was unchanged at 60 and 90min by cisplatin. Cisplatin increased (p<0.05) LDH leakage at 120min which was protected by RES. Cisplatin induced oxidative stress prior to LDH leakage as cisplatin depressed glutathione peroxidase and superoxide dismutase (SOD) activity, increased lipid peroxidation, protein carbonyls and 4-hydroxynonenal (4-HNE) adducted proteins within 60min. RES failed to reverse glutathione (GSH) depression by cisplatin. In order to eliminated an extracellular interaction between RES and cisplatin, additional studies (RINSE studies) allowed a 30min RES uptake into slices, transfer of slices to buffer lacking RES, followed by 120min cisplatin incubation. RES in the RINSE studies prevented LDH leakage by cisplatin indicating that RES protection was not via a physical interaction with cisplatin in the media. These findings indicate that RES diminished cisplatin in vitro renal toxicity and prevented the development of oxidative stress.
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http://dx.doi.org/10.1016/j.tiv.2013.11.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3924893PMC
March 2014

Clinical features of young children referred for impairing temper outbursts.

J Child Adolesc Psychopharmacol 2013 Nov 29;23(9):588-96. Epub 2013 Oct 29.

1 Department of Psychology, Fordham University , Bronx, New York.

Objective: In light of the current controversy about whether severe temper outbursts are diagnostic of mania in young children, we conducted a study to characterize such children, focusing on mania and other mood disorders, emotion regulation, and parental psychiatric history.

Methods: Study participants included 51 5-9-year-old children with frequent, impairing outbursts (probands) and 24 non-referred controls without outbursts. Parents completed a lifetime clinical interview about their child, and rated their child's current mood and behavior. Teachers completed a behavior rating scale. To assess emotion regulation, children were administered the Balloons Game, which assesses emotion expressivity in response to frustration, under demands of high and low regulation. Parental lifetime diagnoses were ascertained in blind clinical interviews.

Results: No child had bipolar disorder, bipolar disorder not otherwise specified (NOS), or major depression (MDD). The most prevalent disorder was oppositional defiant disorder (88.2%), followed by attention-deficit/hyperactivity disorder (74.5%), anxiety disorders (49.0%), and non-MDD depressive disorders (33.3%). Eleven probands (21.6%) met criteria for severe mood dysregulation. During the Balloons Game, when there were no demands for self-regulation, children with severe outbursts showed reduced positive expressivity, and also showed significant deficits in controlling negative facial expressions when asked to do so. Anxiety disorders were the only diagnoses significantly elevated in probands' mothers.

Conclusions: Overall, young children with severe temper outbursts do not present with bipolar disorder. Rather, disruptive behavior disorders with anxiety and depressive mood are common. In children with severe outbursts, deficits in regulating emotional facial expressions may reflect deficits controlling negative affect. This work represents a first step towards elucidating mechanisms underlying severe outbursts in young children.
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http://dx.doi.org/10.1089/cap.2013.0005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3842879PMC
November 2013

Intrinsic functional connectivity of amygdala-based networks in adolescent generalized anxiety disorder.

J Am Acad Child Adolesc Psychiatry 2013 Mar 7;52(3):290-299.e2. Epub 2013 Feb 7.

Department of Psychology, Fordham University, Bronx, NY 10458, USA.

Objective: Generalized anxiety disorder (GAD) typically begins during adolescence and can persist into adulthood. The pathophysiological mechanisms underlying this disorder remain unclear. Recent evidence from resting state functional magnetic resonance imaging (R-fMRI) studies in adults suggests disruptions in amygdala-based circuitry; the present study examines this issue in adolescents with GAD.

Method: Resting state fMRI scans were obtained from 15 adolescents with GAD and 20 adolescents without anxiety who were group matched on age, sex, scanner, and intelligence. Functional connectivity of the centromedial, basolateral, and superficial amygdala subdivisions was compared between groups. We also assessed the relationship between amygdala network dysfunction and anxiety severity.

Results: Adolescents with GAD exhibited disruptions in amygdala-based intrinsic functional connectivity networks that included regions in medial prefrontal cortex, insula, and cerebellum. Positive correlations between anxiety severity scores and amygdala functional connectivity with insula and superior temporal gyrus were also observed within the GAD group. There was some evidence of greater overlap (less differentiation of connectivity patterns) of the right basolateral and centromedial amygdala networks in the adolescents with, relative to those without, GAD.

Conclusions: These findings suggest that adolescents with GAD manifest alterations in amygdala circuits involved in emotion processing, similar to findings in adults. In addition, disruptions were observed in amygdala-based networks involved in fear processing and the coding of interoceptive states.
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http://dx.doi.org/10.1016/j.jaac.2012.12.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3760686PMC
March 2013

Adolescents' risk-taking behavior is driven by tolerance to ambiguity.

Proc Natl Acad Sci U S A 2012 Oct 1;109(42):17135-40. Epub 2012 Oct 1.

Center for Neural Science, New York University, New York, NY 10003, USA.

Adolescents engage in a wide range of risky behaviors that their older peers shun, and at an enormous cost. Despite being older, stronger, and healthier than children, adolescents face twice the risk of mortality and morbidity faced by their younger peers. Are adolescents really risk-seekers or does some richer underlying preference drive their love of the uncertain? To answer that question, we used standard experimental economic methods to assess the attitudes of 65 individuals ranging in age from 12 to 50 toward risk and ambiguity. Perhaps surprisingly, we found that adolescents were, if anything, more averse to clearly stated risks than their older peers. What distinguished adolescents was their willingness to accept ambiguous conditions--situations in which the likelihood of winning and losing is unknown. Though adults find ambiguous monetary lotteries undesirable, adolescents find them tolerable. This finding suggests that the higher level of risk-taking observed among adolescents may reflect a higher tolerance for the unknown. Biologically, such a tolerance may make sense, because it would allow young organisms to take better advantage of learning opportunities; it also suggests that policies that seek to inform adolescents of the risks, costs, and benefits of unexperienced dangerous behaviors may be effective and, when appropriate, could be used to complement policies that limit their experiences.
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http://dx.doi.org/10.1073/pnas.1207144109DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3479478PMC
October 2012

Durable effects of cognitive restructuring on conditioned fear.

Emotion 2012 Dec 9;12(6):1393-7. Epub 2012 Jul 9.

Department of Psychology, Stanford University, USA.

Studies of cognitive reappraisal have demonstrated that reinterpreting a stimulus can alter emotional responding, yet few studies have examined the durable effects associated with reinterpretation-based emotion regulation strategies. Evidence for the enduring effects of emotion regulation may be found in clinical studies that use cognitive restructuring (CR) techniques in cognitive-behavioral therapy (CBT) to alleviate anxiety. These techniques are based on cognitive theories of anxiety that suggest these disorders arise from biased cognitions; therefore, changing a person's thoughts will elicit durable changes in an individual's emotional responses. Despite the considerable success of CBT for anxiety disorders, durable effects associated with emotion regulation have not been thoroughly examined in the context of a laboratory paradigm. The goal of this study was to determine whether CR, a technique used in CBT and similar to cognitive reappraisal, could attenuate conditioned fear responses, and whether the effect would persist over time (24 hr). We conditioned participants using images of snakes or spiders that were occasionally paired with a mild shock to the wrist while we obtained subjective fear reports and electrodermal activity (EDA). After conditioning, half of the participants were randomly assigned to CR training aimed at decreasing their emotional response to the shock and the conditioned stimuli, while the other half received no such training. All participants returned 24 hr later to repeat the conditioning session. Compared with control participants, CR participants demonstrated a reduction in fear and EDA across sessions. These findings suggest that CR has durable effects on fear responding.
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http://dx.doi.org/10.1037/a0029143DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3971472PMC
December 2012
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