Publications by authors named "Sarah Horwitz"

179 Publications

Determinants of using children's mental health research in policymaking: variation by type of research use and phase of policy process.

Implement Sci 2021 Jan 19;16(1):13. Epub 2021 Jan 19.

Department of Child and Adolescent Psychiatry, New York University School of Medicine, 1 Park Avenue, New York, NY, 10016, USA.

Background: Research use in policymaking is multi-faceted and has been the focus of extensive study. However, virtually no quantitative studies have examined whether the determinants of research use vary according to the type of research use or phase of policy process. Understanding such variation is important for selecting the targets of implementation strategies that aim to increase the frequency of research use in policymaking.

Methods: A web-based survey of US state agency officials involved with children's mental health policymaking was conducted between December 2019 and February 2020 (n = 224, response rate = 33.7%, 49 states responding (98%), median respondents per state = 4). The dependent variables were composite scores of the frequency of using children's mental health research in general, specific types of research use (i.e., conceptual, instrumental, tactical, imposed), and during different phases of the policy process (i.e., agenda setting, policy development, policy implementation). The independent variables were four composite scores of determinants of research use: agency leadership for research use, agency barriers to research use, research use skills, and dissemination barriers (e.g., lack of actionable messages/recommendations in research summaries, lack of interaction/collaboration with researchers). Separate multiple linear regression models estimated associations between determinant and frequency of research use scores.

Results: Determinants of research use varied significantly by type of research use and phase of policy process. For example, agency leadership for research use was the only determinant significantly associated with imposed research use (β = 0.31, p < 0.001). Skills for research use were the only determinant associated with tactical research use (β = 0.17, p = 0.03) and were only associated with research use in the agenda-setting phase (β = 0.16, p = 0.04). Dissemination barriers were the most universal determinants of research use, as they were significantly and inversely associated with frequency of conceptual (β = -0.21, p = 0.01) and instrumental (β = -0.22, p = 0.01) research use and during all three phases of policy process.

Conclusions: Decisions about the determinants to target with policy-focused implementation strategies-and the strategies that are selected to affect these targets-should reflect the specific types of research use that these strategies aim to influence.
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http://dx.doi.org/10.1186/s13012-021-01081-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7815190PMC
January 2021

Aligning dissemination and implementation science with health policies to improve children's mental health.

Am Psychol 2020 11;75(8):1130-1145

Department of Child and Adolescent Psychiatry, New York University Langone Health.

The prevalence of mental health problems among children (ages 0-21) in the United States remains unacceptably high and, post-COVID-19, is expected to increase dramatically. Decades of psychological knowledge about effective treatments should inform the delivery of better services. Dissemination and implementation (D&I) science has been heralded as a solution to the persistent problem of poor quality services and has, to some extent, improved our understanding of the contexts of delivery systems that implement effective practices. However, there are few studies demonstrating clear, population-level impacts of psychological interventions on children. Momentum is growing among communities, cities, states, and some federal agencies to build "health in all policies" to address broad familial, social, and economic factors known to affect children's healthy development and mental health. These health policy initiatives offer a rare opportunity to repurpose D&I science, shifting it from a primary focus on evidence-based practice implementation, to a focus on policy development and implementation to support child and family health and well-being. This shift is critical as states develop policy responses to address the health and mental health impacts of the COVID-19 pandemic on already-vulnerable families. We provide a typology for building research on D&I and children's mental health policy. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/amp0000706DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8034490PMC
November 2020

Changes in Attitudes and Knowledge after Trainings in a Clinical Care Pathway for Autism Spectrum Disorder.

J Autism Dev Disord 2020 Nov 17. Epub 2020 Nov 17.

Child Study Center, Department of Child and Adolescent Psychiatry, NYU Langone, New York, NY, 10016, USA.

Caring for individuals with autism spectrum disorder (ASD) can be complicated, especially when challenging behaviors are present. Providers may feel unprepared to work with these individuals because specialized training for medical and social service providers is limited. To increase access to specialized training, we modified an effective half-day ASD-Care Pathway training (Kuriakose et al. 2018) and disseminated it within five different settings. This short, focused training on strategies for preventing and reducing challenging behaviors of patients with ASD resulted in significant improvements in staff perceptions of challenging behaviors, increased comfort in working with the ASD population, and increased staff knowledge for evidence-informed practices. Implications, including the impact of sociodemographic characteristics on pre/post changes, and future directions are discussed.
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http://dx.doi.org/10.1007/s10803-020-04775-yDOI Listing
November 2020

Trends Over a Decade in NIH Funding for Autism Spectrum Disorder Services Research.

J Autism Dev Disord 2020 Oct 10. Epub 2020 Oct 10.

Department of Child and Adolescent Psychiatry, NYU Langone Health, New York, NY, USA.

Investments in autism spectrum disorder (ASD) research, guided by the Interagency Autism Coordinating Committee (IACC), have focused disproportionately on etiology over a well-established stakeholder priority area: research to improve accessibility and quality of community-based services. This study analyzed National Institutes of Health ASD services research funding from 2008 to 2018 to examine funding patterns, evaluate the impact of IACC objectives, and identify future directions. Approximately 9% of total funds were allocated to services research. This investment remained relatively stable across time and lacked diversity across domains (e.g., area of focus, ages sampled, implementation strategies used). While advancements were observed, including increased prevalence of projects focused on adult samples and on dissemination/implementation and prevention areas, greater investment in service research is critically needed.
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http://dx.doi.org/10.1007/s10803-020-04746-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8035332PMC
October 2020

Generalizing the Prediction of Bipolar Disorder Onset Across High-Risk Populations.

J Am Acad Child Adolesc Psychiatry 2020 Oct 8. Epub 2020 Oct 8.

Virginia Commonwealth University, Richmond, Virginia.

Objective: Risk calculators (RC) to predict clinical outcomes are gaining interest. An RC to estimate risk of bipolar spectrum disorders (BPSD) could help reduce the duration of undiagnosed BPSD and improve outcomes. Our objective was to adapt an RC previously validated in the Pittsburgh Bipolar Offspring Study (BIOS) sample to achieve adequate predictive ability in both familial high-risk and clinical high-risk youths.

Method: Participants (aged 6-12 years at baseline) from the Longitudinal Assessment of Manic Symptoms (LAMS) study (N = 473) were evaluated semi-annually. Evaluations included a Kiddie Schedule for Affective Disorders (K-SADS) interview. After testing an RC that closely approximated the original, we made modifications to improve model prediction. Models were trained in the BIOS data, which included biennial K-SADS assessments, and tested in LAMS. The final model was then trained in LAMS participants, including family history of BPSD as a predictor, and tested in the familial high-risk sample.

Results: Over follow-up, 65 youths newly met criteria for BPSD. The original RC identified youths who developed BPSD only moderately well (area under the curve [AUC] = 0.67). Eliminating predictors other than the K-SADS screening items for mania and depression improved accuracy (AUC = 0.73) and generalizability. The model trained in LAMS, including family history as a predictor, performed well in the BIOS sample (AUC = 0.74).

Conclusion: The clinical circumstances under which the assessment of symptoms occurs affects RC accuracy; focusing on symptoms related to the onset of BPSD improved generalizability. Validation of the RC under clinically realistic circumstances will be an important next step.
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http://dx.doi.org/10.1016/j.jaac.2020.09.017DOI Listing
October 2020

Predictors of Hospitalization in a Cohort of Children with Elevated Symptoms of Mania.

Adm Policy Ment Health 2021 01;48(1):171-180

Department of Psychiatry, Virginia Commonwealth University, Richmond, VA, 23298-0308, USA.

Describe hospitalization rates in children with elevated symptoms of mania and determine predictors of psychiatric hospitalizations during the 96 month follow-up. Eligible 6-12.9 year olds and their parents visiting 9 outpatient mental health clinics were invited to be screened with the Parent General Behavior Inventory 10-item Mania Scale. Of 605 children with elevated symptoms of mania eligible for follow-up, 538 (88.9%) had ≥ 1 of 16 possible follow-up interviews and are examined herein. Multivariate Cox regression indicated only four factors predicted hospitalizations: parental mental health problems (HR 1.80; 95% CI 1.21, 2.69); hospitalization prior to study entry (HR 3.03; 95% CI 1.80, 4.43); continuous outpatient mental health service use (HR 3.73; 95% CI 2.40, 5.50); and low parental assessment of how well treatment matched child's needs (HR 3.97; 95% CI 2.50, 6.31). Parental perspectives on mental health services should be gathered routinely, as they can signal treatment failures.
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http://dx.doi.org/10.1007/s10488-020-01059-6DOI Listing
January 2021

Affective Processing Biases in Relation to Past, Current, and Future Depression in Children and Adolescents.

J Affect Disord 2020 08 1;273:146-156. Epub 2020 May 1.

Department of Psychiatry, Division of Child and Adolescent Psychiatry, Case Western Reserve University, Cleveland, OH; and Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh, Pittsburgh, PA; and Division of Psychiatry, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.

Background: The affective go/no-go (AGN) task has been used to assess affective biases in attention set-shifting and deficits in inhibitory control of emotional information among depressed youth, but results have been inconsistent. We aimed to test AGN robustness and clarify temporal relationships between depressive symptoms and affective processing in youth.

Methods: We evaluated AGN performance twice (Time 1 N = 306; Time 2 N = 238) in relation to current, previous, and future depression in the same children/adolescents with depression and those without diagnoses who participated in the Longitudinal Assessment of Manic Symptoms (LAMS) study. Mixed repeated ANCOVAs were powered to detect small-medium group by valence interactions in response latency and errors. Supplemental regression analyses examined depressive symptoms as a continuous variable in relation to AGN performance.

Results: No clear pattern emerged, mirroring the broader AGN literature. In primary analyses, group by valence interactions were only observed at one AGN administration; none replicated across administrations. Similarly, in regression analyses depressive symptoms had no relation to affective processing biases/deficits at AGN Time 1, though some relationships were detected between symptoms and AGN Time 2.

Limitations: Relatively few youth met criteria for a depressive disorder, though analyses were appropriately powered and supplemental analyses examined depressive symptoms continuously. Comparison groups were not healthy controls at recruitment but were free from any Axis I disorder at AGN administration.

Conclusions: Given the inconsistency of AGN findings, attention should be focused on tasks that provide more sensitive, robust measures of emotional information processing in depressed youth.
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http://dx.doi.org/10.1016/j.jad.2020.03.150DOI Listing
August 2020

Staff Perceptions and Implementation Fidelity of an Autism Spectrum Disorder Care Pathway on a Child/Adolescent General Psychiatric Inpatient Service.

J Autism Dev Disord 2021 Jan;51(1):158-168

Department of Child and Adolescent Psychiatry, Child Study Center, Hassenfeld Children's Hospital at NYU Langone, One Park Avenue, 7th Floor, New York, NY, 10016, USA.

While youth with autism spectrum disorder (ASD) are psychiatrically hospitalized at high rates, general psychiatric settings are not designed to meet their unique needs. Previous evaluations of an ASD-Care Pathway (ASD-CP) on a general psychiatric unit revealed sustained reductions in crisis interventions (intramuscular medication use, holds/restraints; Cervantes et al. in J Autism Dev Disord 49(8):3173-3180, https://doi.org/10.1007/s10803-019-04029-6 , 2019; Kuriakose et al. in J Autism Dev Disord 48(12):4082-4089, https://doi.org/10.1007/s10803-018-3666-y , 2018). The current study investigated staff perceptions of the ASD-CP (N = 30), and examined rates of ASD-CP implementation fidelity in relation to patient outcomes (N = 28). Staff identified visual communication aids and reward strategies as most helpful. The number of days of reward identification early in the inpatient stay was associated with fewer crisis interventions later in a patient's stay.
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http://dx.doi.org/10.1007/s10803-020-04509-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8034489PMC
January 2021

Acquisition of Information About Innovative Practices in Outpatient Mental Health Clinics.

Adm Policy Ment Health 2020 09;47(5):752-763

Department of Child and Adolescent Psychiatry, New York University, New York, NY, USA.

This study uses qualitative interviews with leaders of 34 mental health clinics in the context of a statewide rollout of clinical and business innovations to explore how clinics first learn about innovations and which external sources of information they access. Clinic leaders reported accessing information about innovations mainly from government agencies, professional associations, peer organizations, and research literature. Leaders mentioned an average of two external sources of information. There was evidence of variation in how leaders accessed information and how information about innovations was communicated within clinics. Findings have implications for improving dissemination of information about innovations in mental health systems.
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http://dx.doi.org/10.1007/s10488-020-01029-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7222893PMC
September 2020

Evaluation of a Web-Based Training Model for Family Peer Advocates in Children's Mental Health.

Psychiatr Serv 2020 May 8;71(5):502-505. Epub 2020 Jan 8.

Department of Child and Adolescent Psychiatry, New York University School of Medicine, New York (Horwitz, Cervantes, Kuppinger, Hoagwood); McSilver Institute for Poverty Policy and Research, New York University Silver School of Social Work, New York (Quintero, Cleek); Families Together in New York State, Albany (Burger); Division of Integrated Community Services for Children and Families, New York State Office of Mental Health, Albany (Lane, Bradbury).

Objective: The aim of this study was to compare knowledge gains from a new online training program with gains from an existing in-person training program for family peer advocates.

Methods: Data were used from a pre-post study of individuals who enrolled in the Web-based Parent Empowerment Program training; 144 participants completed the training and pre-post tests, and 140 were admitted to the analyses. Knowledge was assessed with 34 questions, 29 of which were common to the online and in-person trainings. Pre-post knowledge scores were available from the in-person training.

Results: Statistically significant gains in knowledge were found with both the 34 questions and the 29 questions common to both trainings. Knowledge gains across the two training models did not differ.

Conclusions: Data on knowledge gains from this accessible, affordable online model show promise for training the growing and important workforce of family peer advocates.
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http://dx.doi.org/10.1176/appi.ps.201900365DOI Listing
May 2020

Clinical, cortical thickness and neural activity predictors of future affective lability in youth at risk for bipolar disorder: initial discovery and independent sample replication.

Mol Psychiatry 2019 12 19;24(12):1856-1867. Epub 2018 Oct 19.

Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA.

We aimed to identify markers of future affective lability in youth at bipolar disorder risk from the Pittsburgh Bipolar Offspring Study (BIOS) (n = 41, age = 14, SD = 2.30), and validate these predictors in an independent sample from the Longitudinal Assessment of Manic Symptoms study (LAMS) (n = 55, age = 13.7, SD = 1.9). We included factors of mixed/mania, irritability, and anxiety/depression (29 months post MRI scan) in regularized regression models. Clinical and demographic variables, along with neural activity during reward and emotion processing and gray matter structure in all cortical regions at baseline, were used to predict future affective lability factor scores, using regularized regression. Future affective lability factor scores were predicted in both samples by unique combinations of baseline neural structure, function, and clinical characteristics. Lower bilateral parietal cortical thickness, greater left ventrolateral prefrontal cortex thickness, lower right transverse temporal cortex thickness, greater self-reported depression, mania severity, and age at scan predicted greater future mixed/mania factor score. Lower bilateral parietal cortical thickness, greater right entorhinal cortical thickness, greater right fusiform gyral activity during emotional face processing, diagnosis of major depressive disorder, and greater self-reported depression severity predicted greater irritability factor score. Greater self-reported depression severity predicted greater anxiety/depression factor score. Elucidating unique clinical and neural predictors of future-specific affective lability factors is a step toward identifying objective markers of bipolar disorder risk, to provide neural targets to better guide and monitor early interventions in bipolar disorder at-risk youth.
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http://dx.doi.org/10.1038/s41380-018-0273-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6814510PMC
December 2019

Development of bipolar disorder and other comorbidity among youth with attention-deficit/hyperactivity disorder.

J Child Psychol Psychiatry 2020 02 15;61(2):175-181. Epub 2019 Sep 15.

Department of Psychology, University of New Orleans, New Orleans, LA, USA.

Objective: To examine development of bipolar spectrum disorders (BPSD) and other disorders in prospectively followed children with attention-deficit/hyperactivity disorder (ADHD).

Method: In the Longitudinal Assessment of Manic Symptoms (LAMS) study, 531 of 685 children age 6-12 (most selected for scores > 12 on General Behavior Inventory 10-item Mania scale) had ADHD, 112 with BPSD, and 419 without. With annual assessments for 8 years, retention averaged 6.2 years. Chi-square analyses compared rate of new BPSD and other comorbidity between those with versus without baseline ADHD and between retained versus resolved ADHD diagnosis. Cox regression tested factors influencing speed of BPSD onset.

Results: Of 419 with baseline ADHD but not BPSD, 52 (12.4%) developed BPSD, compared with 16 of 110 (14.5%) without either baseline diagnosis. Those who developed BPSD had more nonmood comorbidity over the follow-up than those who did not develop BPSD (p = .0001). Of 170 who still had ADHD at eight-year follow-up (and not baseline BPSD), 26 (15.3%) had developed BPSD, compared with 16 of 186 (8.6%) who had ADHD without BPSD at baseline but lost the ADHD diagnosis (χ  = 3.82, p = .051). There was no statistical difference in whether ADHD persisted or not across new BPSD subtypes (χ  = 1.62, p = .446). Of those who developed BPSD, speed of onset was not significantly related to baseline ADHD (p = .566), baseline anxiety (p = .121), baseline depression (p = .185), baseline disruptive behavior disorder (p = .184), age (B = -.11 p = .092), maternal mania (p = .389), or paternal mania (B = .73, p = .056). Those who started with both diagnoses had more severe symptoms/impairment than those with later developed BPSD and reported having ADHD first.

Conclusions: In a cohort selected for symptoms of mania at age 6-12, baseline ADHD was not a significant prospective risk factor for developing BPSD. However, persistence of ADHD may marginally mediate risk of BPSD, and early comorbidity of both diagnoses increases severity/impairment.
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http://dx.doi.org/10.1111/jcpp.13122DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6980179PMC
February 2020

Impact of a Trauma-Informed Intervention for Youth and Staff on Rates of Violence in Juvenile Detention Settings.

J Interpers Violence 2019 Jun 28:886260519857163. Epub 2019 Jun 28.

1 New York University School of Medicine, New York City, USA.

The majority of youth in the juvenile justice system have experienced multiple traumatic events in their lives, including community violence, physical abuse, neglect, and traumatic loss. These high prevalence rates, coupled with the known negative consequences of trauma in childhood and adolescence, have led to a greater emphasis on implementing trauma-informed services and practices within juvenile justice settings. However, although many stakeholders and government entities have expressed support for creating more trauma-informed juvenile justice systems, there is still limited empirical knowledge about which interventions are most effective at improving outcomes, particularly at the organizational or facility level. In an effort to fill this gap, the current study evaluated the impact of a trauma-informed milieu intervention, including skills training for youth and training for staff, on rates of violence at two secure juvenile detention facilities ( = 14,856) located in a large Northeastern city. The analyses revealed that the intervention was significantly related to a reduction of violent incidents in Facility A, with no impact on incidents in Facility B. Follow-up analyses revealed that a larger proportion of eligible youth in Facility A completed the skills group program as compared with eligible youth in Facility B (16% vs. 9%). This finding has important implications for the implementation of trauma-informed interventions for youth in juvenile detention settings, as it suggests that to impact outcomes at the facility level, a minimum threshold of youth may need to be exposed to the intervention. In addition, reductions in violence at Facility A were only realized after both staff training and youth skills components were implemented, suggesting that both components are necessary to create change at the facility level. Future research is needed to further explore the impact of organizational and implementation-level factors on trauma-informed care outcomes in juvenile justice settings.
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http://dx.doi.org/10.1177/0886260519857163DOI Listing
June 2019

Sustainability of a Care Pathway for Children and Adolescents with Autism Spectrum Disorder on an Inpatient Psychiatric Service.

J Autism Dev Disord 2019 Aug;49(8):3173-3180

Department of Child and Adolescent Psychiatry, Child Study Center, Hassenfeld Children's Hospital, NYU Langone Health, New York, NY, USA.

Children with autism spectrum disorder (ASD) are frequently hospitalized within general psychiatric settings, which are not usually designed to meet their needs. An initial evaluation of a care pathway developed for youth with ASD receiving services in a general psychiatric inpatient unit (ASD-CP) showed promise in improving outcomes while using few resources (Kuriakose et al. in J Autism Dev Disord 48:4082-4089, 2018). As sustainability of inpatient psychiatric initiatives is imperative but rarely investigated, this study examined the stability of ASD-CP outcomes during an 18-month follow-up period (n = 15) compared to the 18-month initial evaluation (n = 20) and 18-month pre-implementation (n = 17) periods. Decreased use of crisis interventions, including holds/restraints and intramuscular medication use, was sustained in the 18 months after the initial implementation period. Implications and limitations are discussed.
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http://dx.doi.org/10.1007/s10803-019-04029-6DOI Listing
August 2019

Post-traumatic stress and related symptoms among juvenile detention residents: Results from intake screening.

Child Abuse Negl 2019 06 20;92:22-31. Epub 2019 Mar 20.

New York University School of Medicine, Department of Child and Adolescent Psychiatry, New York, NY, United States.

Background: Juvenile justice-involved youth have high rates of trauma exposure, physical and sexual abuse and PTSD. Several factors have been found to be related to PTSD symptoms in youth including number and chronicity of traumatic events.

Objective: To simultaneously examine the relationships between allostatic load (defined here as number of traumatic experiences), poly-victimization (exposure to two or more forms of victimization based on 5 of the 6 categories in Ford et al.'s 2010 study), physical/sexual abuse and PTSD in justice-involved youth.

Participants And Setting: The sample consisted of 1984 youth in juvenile detention in a Northeastern city. The sample was 73.4% male and the majority of youth were either African American or Hispanic.

Methods: Clinicians collected demographic and psychosocial information, and measured symptoms of PTSD, depression, and problematic substance use.

Results: Results showed that youth with more traumas, those who experienced poly-victimization and those who experienced physical/sexual assault/abuse were not only more likely to have PTSD, but also more likely to have depression, thoughts of suicide/self-harm, and problematic substance use (as indicated by the presence of 2 or more of 6 possible indicators). Poly-victimization was a stronger correlate of PTSD than number of traumas or physical/sexual assault/abuse. However, among youth with PTSD, number of traumas was associated with co-occurring problems while poly-victimization and physical/sexual assault/abuse were not.

Conclusions: Findings can be used to help direct resources to juvenile justice-involved youth who are most in need of treatment.
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http://dx.doi.org/10.1016/j.chiabu.2019.03.011DOI Listing
June 2019

Screening for and preventing perinatal depression.

J Child Fam Stud 2018 Oct 20;27(10):3169-3175. Epub 2018 Jun 20.

New York University School of Medicine, New York, NY.

New York City (NYC) public hospitals recently mandated that all pregnant women be screened for depression, but no funds were allocated for screening or care coordination/treatment, and research suggests that unfunded mandates are not likely to be successful. To address this, we implemented an on-site depression prevention intervention (NYC ROSE) for positive depression screens among pregnant, mostly Black and Hispanic, lower-income women in one public hospital. In this paper, we used Aarons' implementation model to describe the successes and challenges of screening and intervention. Patient tracking sheets and electronic medical records were abstracted. Key informant interviews and an informal focus group were conducted, and staff observations were reviewed; common implementation themes were identified and fit into Aarons' model. We found that a lack of funding and staff training, which led to minimal psychoeducation for patients, were outer context factors that may have made depression screening difficult, screening results unreliable, and NYC ROSE enrollment challenging. Although leadership agreed to implement NYC ROSE, early involvement of all levels of staff and patients would have better informed important inner context factors, like workflow and logistical/practical challenges. There was also a mismatch between the treatment model and the population being served; patients often lived too far away to receive additional services on site, and economic issues were often a higher priority than mental health services. Screening and interventions for perinatal depression are essential for optimal family health, and a detailed, thoughtful and funded approach can help ensure effectiveness of such efforts.
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http://dx.doi.org/10.1007/s10826-018-1157-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6404764PMC
October 2018

Sustainability of an Evidence-Based Practice in Community Mental Health Agencies Serving Children.

Psychiatr Serv 2019 05 13;70(5):413-416. Epub 2019 Feb 13.

Department of Child and Adolescent Psychiatry, New York University School of Medicine, New York (Horwitz, Lewis, Gleacher, Wang, Hoagwood); Division of Integrated Community Services for Children and Families, New York State Office of Mental Health (NYS OMH), Albany (Bradbury, Ray-LaBatt).

Objective: The authors documented rates of sustained use of an evidence-based practice following training sponsored by New York State (NYS), and they identified clinician characteristics related to sustained use.

Methods: Clinicians (N=89) who were employed in licensed NYS Office of Mental Health agencies serving children and adolescents and who were trained to proficiency in Managing and Adapting Practice (MAP) in 2016 were contacted between 9 and 18 months later and asked whether they were still using (users) or had stopped using (nonusers) MAP and their reason for doing so.

Results: Responses were received from 57% of trainees and of those, 80% reported continued use of MAP. Score on the appeal subscale of the Evidence-Based Practices Attitude Scale (EBPAS) was the only significant difference between users and nonusers.

Conclusions: Most clinicians reported sustained use of MAP. The EBPAS appeal subscale can be used to identify clinicians who are likely to discontinue use.
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http://dx.doi.org/10.1176/appi.ps.201800430DOI Listing
May 2019

Associations between Parental Psychopathology and Sexual Behavior in an Outpatient Psychiatric Sample.

J Clin Child Adolesc Psychol 2020 Jan-Feb;49(1):50-59. Epub 2018 Oct 30.

Department of Psychiatry and Behavioral Health, The Ohio State University Wexner Medical Center.

Early age of sexual debut is associated with an increase in negative outcomes, including higher incidence of nonconsensual sexual experiences, higher rates of sexually transmitted infections, and risky sexual practices. Little research has examined the role of parental psychopathology as a predictor of adolescent sexual activity, however. The current study aims to close this gap by examining the relationship between parental psychopathology and sexual activity in a longitudinal sample of youth. Participants were 685 adolescents from the Longitudinal Assessment of Manic Symptoms study, the majority of whom were male (67%) and White (65%). Analyses considering likelihood of sexual initiation included the full sample, whereas analyses considering predictors of the age of sexual debut included the 162 participants who reported ever having sexual intercourse (62% male, 51% White) via the Youth Risk Behavior Surveillance-High School version. Cox regression analyses suggested that maternal generalized anxiety disorder predicted decreased likelihood of initiating sex during the 8-year follow-up period, whereas paternal conduct disorder predicted increased likelihood of initiating sex. Multivariate linear regressions also showed that maternal conduct disorder predicted earlier age of sexual debut among those who had initiated, whereas paternal antisocial personality disorder predicted later age of sexual debut. These associations were observed in both male and female adolescents. Furthermore, these effects were largely not explained by the established relationship between youth psychopathology and sexual behavior. Results have implications for interventions aimed at decreasing sexual risk taking in vulnerable youth.
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http://dx.doi.org/10.1080/15374416.2018.1514614DOI Listing
October 2020

Correlates of Perinatal Post-Traumatic Stress among Culturally Diverse Women with Depressive Symptomatology.

Issues Ment Health Nurs 2018 Oct 2;39(10):840-849. Epub 2018 Oct 2.

c Department of Child and Adolescent Psychiatry , New York University School of Medicine , New York , New York , USA.

Post-traumatic stress disorder (PTSD) is an important and often neglected comorbidity of pregnancy; left untreated, it can lead to serious health complications for the mother and developing fetus. Structured interviews were conducted to identify risk factors of PTSD among culturally diverse women with depressive symptomatology receiving perinatal services at community obstetric/gynecologic clinics. Women abused as adults, with two or more instances of trauma, greater trauma severity, insomnia, and low social support were more likely to present perinatal PTSD symptoms. Perinatal PTSD is prevalent and has the potential for chronicity. It is imperative healthcare providers recognize salient risk factors and integrate culturally sensitive screening, appropriate referral, and treatment services for perinatal PTSD.
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http://dx.doi.org/10.1080/01612840.2018.1488313DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6397067PMC
October 2018

Do Subspecialists Ask About and Refer Families with Psychosocial Concerns? A Comparison with General Pediatricians.

Matern Child Health J 2019 Jan;23(1):61-71

New York University School of Medicine, New York, NY, USA.

Objectives Calls for pediatricians to tend to children's psychosocial concerns have existed for decades because they are known to negatively impact child health. Children with chronic illnesses frequently have child- and family-level psychosocial concerns that complicate the care provided by their pediatric subspecialists. This study compares pediatricians who exclusively practice general pediatrics with subspecialists regarding their inquiring/screening and referring for psychosocial concerns. Physician and practice characteristics associated with these behaviors were examined. Methods We conducted a cross-sectional study using the 2013 American Academy of Pediatrics Periodic Survey of Fellows. Respondents included 304 pediatricians who exclusively practice general pediatrics and 147 subspecialists. The primary analysis compared the current practices of generalists vs. subspecialists with regard to inquiring/screening and referring children with 10 different psychosocial concerns. Covariates included socio-demographics, practice characteristics, and training experiences. Weighted univariate, bivariate and multivariable analyses were performed. Results Less than half of all pediatricians in the sample reported routinely inquiring/screening for most psychosocial concerns, and 2/3 of subspecialists failed to routinely inquire/screen for most of these conditions. Pediatricians who practice general pediatrics exclusively were more likely to inquire/screen (incident rate ratio (IRR) 1.41, p < .05) and refer (IRR 1.59, p < .001) for a greater number of psychosocial concerns than subspecialists, after adjusting for provider and practice characteristics. Having attended a child or adolescent mental health (MH) lecture/conference in the past 2 years was also related to inquiring/screening (IRR 1.24, p < .05). Conclusions Pediatricians infrequently inquire/screen and refer psychosocial concerns, with subspecialists addressing these concerns even less frequently.
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http://dx.doi.org/10.1007/s10995-018-2594-yDOI Listing
January 2019

Does an Autism Spectrum Disorder Care Pathway Improve Care for Children and Adolescents with ASD in Inpatient Psychiatric Units?

J Autism Dev Disord 2018 Dec;48(12):4082-4089

Department of Child and Adolescent Psychiatry, Child Study Center, Hassenfeld Children's Hospital at NYU Langone Health, 1 Park Avenue, 7th Floor, New York, NY, 10016, USA.

Youth with autism spectrum disorder (ASD) are psychiatrically hospitalized at high rates. Though specialized psychiatric units are effective, few specialized units exist. The ASD Care Pathway (ASD-CP) was developed as a scalable approach to improving care in general psychiatric units through staff training and a package of autism-specific intervention strategies. An evaluation of the effectiveness of the ASD-CP in a public hospital child psychiatric service compared 18 months (n = 17) versus 18 months (n = 20) post implementation. Average length of hospital stay decreased 40% (22.4-13.4 days) and use of crisis interventions decreased 77% (holds/restraints; 0.65/day to 0.15/day), though each result only approached statistical significance (p = 0.07; 0.057). This study provides preliminary evidence for improved outcomes after implementation of an ASD-CP.
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http://dx.doi.org/10.1007/s10803-018-3666-yDOI Listing
December 2018

Decreased functional connectivity in the fronto-parietal network in children with mood disorders compared to children with dyslexia during rest: An fMRI study.

Neuroimage Clin 2018 1;18:582-590. Epub 2018 Mar 1.

Cincinnati Children's Hospital Medical Center, University of Cincinnati, United States.

Background: The DSM-5 separates the diagnostic criteria for mood and behavioral disorders. Both types of disorders share neurocognitive deficits of executive function and reading difficulties in childhood. Children with dyslexia also have executive function deficits, revealing a role of executive function circuitry in reading. The aim of the current study is to determine whether there is a significant relationship of functional connectivity within the fronto-parietal and cingulo-opercular cognitive control networks to reading measures for children with mood disorders, behavioral disorders, dyslexia, and healthy controls (HC).

Method: Behavioral reading measures of phonological awareness, decoding, and orthography were collected. Resting state fMRI data were collected, preprocessed, and then analyzed for functional connectivity. Differences in the reading measures were tested for significance among the groups. Global efficiency (GE) measures were also tested for correlation with reading measures in 40 children with various disorders and 17 HCs.

Results: Significant differences were found between the four groups on all reading measures. Relative to HCs and children with mood disorders or behavior disorders, children with dyslexia as a primary diagnosis scored significantly lower on all three reading measures. Children with mood disorders scored significantly lower than controls on a test of phonological awareness. Phonological awareness deficits correlated with reduced resting state functional connectivity MRI (rsfcMRI) in the cingulo-opercular network for children with dyslexia. A significant difference was also found in fronto-parietal global efficiency in children with mood disorders relative to the other three groups. We also found a significant difference in cingulo-opercular global efficiency in children with mood disorders relative to the Dyslexia and Control groups. However, none of these differences correlate significantly with reading measures.

Conclusions/significance: Reading difficulties involve abnormalities in different cognitive control networks in children with dyslexia compared to children with mood disorders. Findings of the current study suggest increased functional connectivity of one cognitive control network may compensate for reduced functional connectivity in the other network in children with mood disorders. These findings provide guidance to clinical professionals for design of interventions tailored for children suffering from reading difficulties originating from different pathologies.
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http://dx.doi.org/10.1016/j.nicl.2018.02.034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5964829PMC
January 2019

Evaluation of a Train-The-Trainers Model for Family Peer Advocates in Children's Mental Health.

J Child Fam Stud 2018 1;27(4):1130-1136. Epub 2017 Dec 1.

1Department of Child and Adolescent Psychiatry, New York University Child Study Center, New York University School of Medicine, New York, NY USA.

Standardized training and credentialing is increasingly important to states and healthcare systems. Workforce shortages in children's mental health can be addressed through training and credentialing of professional peer parents (called family peer advocates or FPAs), who deliver a range of services to caregivers. A theory-based training program for FPAs targeting skills and knowledge about childhood mental health services (Parent Empowerment Program, or PEP) was developed through a partnership among a statewide family-run organization, state policy leaders, and academic researchers. Prior studies by this team using highly-experienced family peer advocates (who were also co-developers of the training program) as trainers found improvements in knowledge about mental health services and self-efficacy. In 2010, to meet demands and scale the model, a training of trainers (TOT) model was developed to build a cohort of locally-trained FPAs to deliver PEP training. A pre/post design was used to evaluate the impact of TOT model on knowledge and self-efficacy among 318 FPAs across the state. Participants showed significant pre-post (6 month) changes in knowledge about mental health services and self-efficacy. There were no significant associations between any FPA demographic characteristics and their knowledge or self-efficacy scores. A theory-based training model for professional peer parents working in the children's mental health system can be taught to local FPAs, and it improves knowledge about the mental health system and self-efficacy. Studies that evaluate the effectiveness of different training modalities are critical to ensure that high-quality trainings are maintained.
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http://dx.doi.org/10.1007/s10826-017-0961-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5854741PMC
December 2017

Differences in Medicaid Antipsychotic Medication Measures Among Children with SSI, Foster Care, and Income-Based Aid.

J Manag Care Spec Pharm 2018 Mar;24(3):238-246

5 Rutgers University, New Brunswick, New Jersey.

Background: Concerns about antipsychotic prescribing for children, particularly those enrolled in Medicaid and with Supplemental Security Income (SSI), continue despite recent calls for selective use within established guidelines.

Objectives: To (a) examine the application of 6 quality measures for antipsychotic medication prescribing in children and adolescents receiving Medicaid and (b) understand distinctive patterns across eligibility categories in order to inform ongoing quality management efforts to support judicious antipsychotic use.

Methods: Using data for 10 states from the 2008 Medicaid Analytic Extract (MAX), a cross-sectional assessment of 144,200 Medicaid beneficiaries aged < 21 years who received antipsychotics was conducted to calculate the prevalence of 6 quality measures for antipsychotic medication management, which were developed in 2012-2014 by the National Collaborative for Innovation in Quality Measurement. These measures addressed antipsychotic polypharmacy, higher-than-recommended doses of antipsychotics, use of psychosocial services before antipsychotic initiation, follow-up after initiation, baseline metabolic screening, and ongoing metabolic monitoring.

Results: Compared with children eligble for income-based Medicaid, children receiving SSI and in foster care were twice as likely to receive higher-than-recommended doses of antipsychotics (adjusted odds ratio [AOR] = 2.4, 95% CI = 2.3-2.6; AOR = 2.5, 95% CI = 2.4-2.6, respectively) and multiple concurrent antipsychotic medications (AOR = 2.2, 95% CI = 2.0-2.4; AOR = 2.2, 95% CI = 2.0-2.4, respectively). However, children receiving SSI and in foster care were more likely to have appropriate management, including psychosocial visits before initiating antipsychotic treatment and ongoing metabolic monitoring. While children in foster care were more likely to experience baseline metabolic screening, SSI children were no more likely than children eligible for income-based aid to receive baseline screening.

Conclusions: While indicators of overuse were more common in SSI and foster care groups, access to follow-up, metabolic monitoring, and psychosocial services was somewhat better for these children. However, substantial quality shortfalls existed for all groups, particularly metabolic screening and monitoring. Renewed efforts are needed to improve antipsychotic medication management for all children.

Disclosures: This project was supported by grant number U18HS020503 from the Agency for Healthcare Research and Quality (AHRQ) and Centers for Medicare & Medicaid Services (CMS). Additional support for Rutgers-based participants was provided from AHRQ grants R18 HS019937 and U19HS021112, as well as the New York State Office of Mental Health. The content of this study is solely the responsibility of the authors and does not necessarily represent the official views of AHRQ, CMS, or the New York State Office of Mental Health. Finnerty has been the principle investigator on research grants/contracts from Bristol Myers Squibb and Sunovion, but her time on these projects is fully supported by the New York State Office of Mental Health. Scholle, Byron, and Morden work for the National Committee for Quality Assurance, a not-for-profit organization that develops and maintains quality measures. Neese-Todd was at Rutgers University at the time of this study and is now employed by the National Committee for Quality Assurance. The other authors have no financial relationships relevant to this article to disclose. Study concept and design were contributed by Finnerty, Neese-Todd, and Crystal, assisted by Scholle, Leckman-Westin, Horowitz, and Hoagwood. Scholle, Byron, Morden, and Hoagwood collected the data, and data interpretation was performed by Pritam, Bilder, Leckman-Westin, and Finnerty, with assistance from Scholle, Byron, Crystal, Kealey, and Neese-Todd. The manuscript was written by Leckman-Westin, Kealey, and Horowitz and revised by Layman, Crystal, Leckman-Westin, Finnerty, Scholle, Neese-Todd, and Horowitz, along with the other authors.
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http://dx.doi.org/10.18553/jmcp.2018.24.3.238DOI Listing
March 2018

Friendly Faces: Characteristics of Children and Adolescents With Repeat Visits to a Specialized Child Psychiatric Emergency Program.

Pediatr Emerg Care 2021 Jan;37(1):4-10

Statistical Research Consultants, LLC, Schaumburg, IL.

Objectives: Pediatric mental health emergency department (ED) visits continue to rise with 19% to 62% of youth presenting to the ED ultimately returning for a mental health-related complaint. To better understand the needs of children returning to the ED, this study examines the clinical, demographic, and environmental factors associated with revisits to a dedicated child psychiatric ED.

Methods: Clinical factors, home environment, and mental health service utilization of 885 children presenting to a dedicated child psychiatric ED over a 1-year period were abstracted by retrospective chart review. Bivariate analyses comparing demographic and clinical characteristics for children with and without revisits and a multivariable logistic regression were performed.

Results: Of the children presenting to the ED, 186 (21.0%) had at least 1 revisit in the subsequent 180 days. Thirty-one percent of initial visits presented as urgent, 55% presented as emergent. Children presenting with more severe symptoms at their initial visit were more likely to return within 6 months. Female gender, suicidal and disruptive behavioral symptomatology, and a diagnosis of oppositional defiant disorder were associated with repeat visits. Children with mental health system involvement were more likely to have revisits than those who were "treatment naive."

Conclusions: Revisits to the ED are driven by both clinical factors, including severity and psychosocial complexity, and barriers to accessing services. Addressing the problem of return ED visits will require the development of a robust mental health service system that is accessible to children and families of all socioeconomic levels.
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http://dx.doi.org/10.1097/PEC.0000000000001428DOI Listing
January 2021

Diagnostic Accuracy of the CASI-4R Psychosis Subscale for Children Evaluated in Pediatric Outpatient Clinics.

J Clin Child Adolesc Psychol 2019 Jul-Aug;48(4):610-621. Epub 2018 Jan 26.

l Department of Psychiatry and Behavioral Sciences, Johns Hopkins University and Kennedy Krieger Institute.

Diagnostic accuracy of the -oriented Child and Adolescent Symptom Inventory (CASI-4R) Psychotic Symptoms scale was tested using receiver operating characteristic analyses to identify clinically significant psychotic symptoms. Participants were new outpatients (= 700), ages 6.0 to 12.9 years (= 9.7, = 1.8) at 9 child outpatient mental health clinics, who participated in the Longitudinal Assessment of Manic Symptoms (LAMS) Study baseline assessment. Because LAMS undersampled participants with low mania scores by design, present analyses weighted low scorers to produce unbiased estimates. Psychotic symptoms, operationally defined as a score of 3 or more for hallucinations or 4 or more for delusions based on the Schedule for Affective Disorders and Schizophrenia (K-SADS) psychosis items, occurred in 7% of youth. K-SADS diagnoses for those identified with psychotic symptoms above threshold included major depressive disorder, bipolar spectrum disorder, attention deficit/hyperactivity disorder, posttraumatic stress disorder, psychotic disorders, and autism spectrum disorder. The optimal psychosis screening cut score (maximizing sensitivity and specificity) was 2.75+ (corresponding diagnostic likelihood ratio [DiLR] = 4.29) for the parent version and 3.50+ (DiLR = 5.67) for the teacher version. The Area under the Curve for parent and teacher report was .83 and .74 (both < .001). Parent report performed significantly better than teacher report for identifying psychotic symptoms above threshold (= .03). The CASI-4R Psychosis subscale (J) appears clinically useful for identifying psychotic symptoms in children because of its brevity and accuracy.
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http://dx.doi.org/10.1080/15374416.2017.1410824DOI Listing
May 2020

A Response to Proposed Budget Cuts Affecting Children's Mental Health: Protecting Policies and Programs That Promote Collective Efficacy.

Psychiatr Serv 2018 03 1;69(3):268-273. Epub 2017 Nov 1.

Dr. Hoagwood, Dr. Horwitz, Dr. Olin, Ms. Kuppinger, Ms. Burton, and Ms. Shorter are with the Department of Child and Adolescent Psychiatry, New York University School of Medicine, New York. Dr. Atkins is with the Department of Psychiatry, University of Illinois, Chicago. Dr. Kutash is with the Department of Child and Family Studies, College of Behavioral and Community Sciences, University of South Florida, Tampa. Dr. Burns is with the Department of Psychiatry and Behavioral Sciences, Duke University, Durham, North Carolina. Ms. Peth-Pierce is with Public Health Communications Consulting, LLC, Cleveland. Dr. Kelleher is with the Center for Innovation in Pediatric Practice, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio.

Children stand to lose if the federal government follows through on threats to cut funding for critical safety-net programs that have long supported families and communities. Although cuts directly targeting children's mental health are a great concern, cuts to policies that support health, housing, education, and family income are equally disturbing. These less publicized proposed cuts affect children indirectly, but they have direct effects on their families and communities. The importance of these services is supported by an extensive body of social learning research that promotes collective efficacy-neighbors positively influencing each other-shown to have positive long-term effects on children's development and adult outcomes. In this article, the authors describe two federal programs that by virtue of their impact on families and communities are likely to promote collective efficacy and positively affect children's mental health; both programs are facing severe cutbacks. They suggest that states adopt a cross-system approach to promote policies and programs in general medical health, mental health, housing, education, welfare and social services, and juvenile justice systems as a viable strategy to strengthen families and communities and promote collective efficacy. The overall goal is to advance a comprehensive national mental health policy for children that enhances collaboration across systems and strengthens families and communities, which is especially critical for children living in marginalized communities.
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http://dx.doi.org/10.1176/appi.ps.201700126DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5832551PMC
March 2018

Developing a sustainable child and family service system after a community tragedy: Lessons from Sandy Hook.

J Community Psychol 2017 08 21;45(6):748-764. Epub 2017 Apr 21.

Professor, NYU Langone Medical Center.

This paper describes a systematic approach to assessing community services post-Sandy Hook shooting. An evaluation team was invited to develop a sustainability plan for community services in Newtown. Service organizations, providers and families were interviewed. Descriptive statistics were used to characterize the range of services; respondent perspectives were coded using content analysis. We found that Newtown has a broad array of community services, but respondent groups varied in their perceptions of service adequacy. Consensus existed about core components of an ideal service system, including centralizing access; coordinating care; personalizing and tailoring services for families; and providing evidence-based care. The strategic community assessment approach developed here may inform how communities examine their service capacity and develop sustainability plans post-disaster.
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http://dx.doi.org/10.1002/jcop.21890DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5536844PMC
August 2017

Reading related white matter structures in adolescents are influenced more by dysregulation of emotion than behavior.

Neuroimage Clin 2017 23;15:732-740. Epub 2017 Jun 23.

Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, University of Pittsburgh, United States.

Mood disorders and behavioral are broad psychiatric diagnostic categories that have different symptoms and neurobiological mechanisms, but share some neurocognitive similarities, one of which is an elevated risk for reading deficit. Our aim was to determine the influence of mood versus behavioral dysregulation on reading ability and neural correlates supporting these skills in youth, using diffusion tensor imaging in 11- to 17-year-old children and youths with mood disorders or behavioral disorders and age-matched healthy controls. The three groups differed only in phonological processing and passage comprehension. Youth with mood disorders scored higher on the phonological test but had lower comprehension scores than children with behavioral disorders and controls; control participants scored the highest. Correlations between fractional anisotropy and phonological processing in the left Arcuate Fasciculus showed a significant difference between groups and were strongest in behavioral disorders, intermediate in mood disorders, and lowest in controls. Correlations between these measures in the left Inferior Longitudinal Fasciculus were significantly greater than in controls for mood but not for behavioral disorders. Youth with mood disorders share a deficit in the executive-limbic pathway (Arcuate Fasciculus) with behavioral-disordered youth, suggesting reduced capacity for engaging frontal regions for phonological processing or passage comprehension tasks and increased reliance on the ventral tract (e.g., the Inferior Longitudinal Fasciculus). The low passage comprehension scores in mood disorder may result from engaging the left hemisphere. Neural pathways for reading differ mainly in executive-limbic circuitry. This new insight may aid clinicians in providing appropriate intervention for each disorder.
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http://dx.doi.org/10.1016/j.nicl.2017.06.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5491458PMC
April 2018