Publications by authors named "Sarah M Horwitz"

76 Publications

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

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

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

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

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

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

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

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

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

Using machine learning and surface reconstruction to accurately differentiate different trajectories of mood and energy dysregulation in youth.

PLoS One 2017 6;12(7):e0180221. Epub 2017 Jul 6.

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

Difficulty regulating positive mood and energy is a feature that cuts across different pediatric psychiatric disorders. Yet, little is known regarding the neural mechanisms underlying different developmental trajectories of positive mood and energy regulation in youth. Recent studies indicate that machine learning techniques can help elucidate the role of neuroimaging measures in classifying individual subjects by specific symptom trajectory. Cortical thickness measures were extracted in sixty-eight anatomical regions covering the entire brain in 115 participants from the Longitudinal Assessment of Manic Symptoms (LAMS) study and 31 healthy comparison youth (12.5 y/o;-Male/Female = 15/16;-IQ = 104;-Right/Left handedness = 24/5). Using a combination of trajectories analyses, surface reconstruction, and machine learning techniques, the present study aims to identify the extent to which measures of cortical thickness can accurately distinguish youth with higher (n = 18) from those with lower (n = 34) trajectories of manic-like behaviors in a large sample of LAMS youth (n = 115; 13.6 y/o; M/F = 68/47, IQ = 100.1, R/L = 108/7). Machine learning analyses revealed that widespread cortical thickening in portions of the left dorsolateral prefrontal cortex, right inferior and middle temporal gyrus, bilateral precuneus, and bilateral paracentral gyri and cortical thinning in portions of the right dorsolateral prefrontal cortex, left ventrolateral prefrontal cortex, and right parahippocampal gyrus accurately differentiate (Area Under Curve = 0.89;p = 0.03) youth with different (higher vs lower) trajectories of positive mood and energy dysregulation over a period up to 5years, as measured by the Parent General Behavior Inventory-10 Item Mania Scale. Our findings suggest that specific patterns of cortical thickness may reflect transdiagnostic neural mechanisms associated with different temporal trajectories of positive mood and energy dysregulation in youth. This approach has potential to identify patterns of neural markers of future clinical course.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0180221PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5500381PMC
September 2017

Longitudinal relationships among activity in attention redirection neural circuitry and symptom severity in youth.

Biol Psychiatry Cogn Neurosci Neuroimaging 2017 May;2(4):336-345

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

Background: Changes in neural circuitry function may be associated with longitudinal changes in psychiatric symptom severity. Identification of these relationships may aid in elucidating the neural basis of psychiatric symptom evolution over time. We aimed to distinguish these relationships using data from the Longitudinal Assessment of Manic Symptoms (LAMS) cohort.

Methods: Forty-one youth completed two study visits (mean=21.3 months). Elastic-net regression (Multiple response Gaussian family) identified emotional regulation neural circuitry that changed in association with changes in depression, mania, anxiety, affect lability, and positive mood and energy dysregulation, accounting for clinical and demographic variables.

Results: Non-zero coefficients between change in the above symptom measures and change in activity over the inter-scan interval were identified in right amygdala and left ventrolateral prefrontal cortex. Differing patterns of neural activity change were associated with changes in each of the above symptoms over time. Specifically, from Scan1 to Scan2, worsening affective lability and depression severity were associated with increased right amygdala and left ventrolateral prefrontal cortical activity. Worsening anxiety and positive mood and energy dysregulation were associated with decreased right amygdala and increased left ventrolateral prefrontal cortical activity. Worsening mania was associated with increased right amygdala and decreased left ventrolateral prefrontal cortical activity. These changes in neural activity between scans accounted for 13.6% of the variance; that is 25% of the total explained variance (39.6%) in these measures.

Conclusions: Distinct neural mechanisms underlie changes in different mood and anxiety symptoms overtime.
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http://dx.doi.org/10.1016/j.bpsc.2016.06.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5416876PMC
May 2017

Beyond Screening: A Stepped Care Pathway for Managing Postpartum Depression in Pediatric Settings.

J Womens Health (Larchmt) 2017 09 14;26(9):966-975. Epub 2017 Apr 14.

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

The negative consequences of untreated postpartum depression (PD) for both the woman and her infant are well established. The impact of maternal depression has led to recommendations on systematic perinatal depression screening. Unfortunately, large-scale initiatives on PD screening have found no benefit unless systems are in place to facilitate appropriate interventions for women who screen positive. Pediatric primary care has been a focus of efforts to support screening and management of PD because pediatric providers, unlike adult healthcare providers, have the most frequent contact with postpartum women through well-child visits. Well-child visits thus present an unparalleled opportunity to detect and intervene with PD. Literature reviews suggest that specific strategies are feasible within pediatric settings and could benefit both the woman and her child. In this article, we present a stepped care approach for screening and managing PD, integrating common elements found in existing pediatric-based models. A stepped care approach is ideal because PD is a heterogeneous condition, with a range of presentations and hence responsiveness to various interventions. This care pathway begins with systematic screening for depression symptoms, followed by a systematic risk assessment for women who screen positive and care management based on risk profiles and responsiveness. This approach allows pediatric providers to be optimally flexible and responsive in addressing the majority of women with PD within the context of the family-centered medical home to improve child well-being. Challenges to managing PD within pediatrics are discussed, including strategies for addressing them. Implications for research, policy, and practice are discussed.
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http://dx.doi.org/10.1089/jwh.2016.6089DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5749581PMC
September 2017

Longitudinal course and characteristics of cyclothymic disorder in youth.

J Affect Disord 2017 06 14;215:314-322. Epub 2017 Mar 14.

Johns Hopkins University/Kennedy Krieger Institute, USA.

Objectives: Epidemiological studies suggest that cyclothymic disorder is the most prevalent subtype of bipolar disorder (BD). However, it is rarely diagnosed, especially in youth. This may be because it can be difficult to ascertain whether a youth meets diagnostic criteria. Clearer, easy-to-apply criteria could reduce misdiagnosis. The objective oftable this study was to determine whether proposed research diagnostic criteria for cyclothymic disorder (RDCyc), based on DSM-5 criteria, could be quantified and validated in youth.

Methods: Participants from the Longitudinal Assessment of Manic Symptoms (LAMS) study were recruited based on symptoms of mania and followed prospectively. RDCyc criteria were: 1) At least one core symptom each of mania and depression; 2) one additional symptom of mania and of depression; 3) persistence over two consecutive six-month periods, and 4) impairment. Exclusionary criteria were having a [hypo]manic or depressive episode. Outcomes at the two-year follow-up were compared between RDCyc youth and other diagnostic groups (BD I/II, BD NOS/non-RDCyc cyclothymic disorder, disruptive behavior disorders [DBD], depression).

Results: Thirty-seven youth met RDCyc criteria. There were no consistent differences between the RDCyc youth and youth with other BD subtypes (ps=0.001-0.960, with all-but-one p value >0.02). RDCyc youth had higher depression (p<0.0005) and mania scores (p=0.001), lower functioning (p=0.012), and higher suicide risk than DBD youth (p=0.001). They had higher mania scores than depressed youth (p.018).

Limitations: The majority of youth in the sample were recruited due to elevated symptoms of mania, which may limit the generalizability of the results. Youth were followed for two years, which may not be long enough to determine whether or not they will eventually develop a manic or depressive episode.

Conclusions: Applying RDCyc criteria identified youth who were similar to others with BD and were more impaired than those with DBD. Using these criteria could reduce misdiagnosis and increase our understanding of this prevalent, but largely ignored, diagnosis.
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http://dx.doi.org/10.1016/j.jad.2017.03.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5512510PMC
June 2017

Adoption of innovative and evidence-based practices for children and adolescents in state-supported mental health clinics: a qualitative study.

Health Res Policy Syst 2017 Mar 29;15(1):27. Epub 2017 Mar 29.

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

Background: This study examined how mental health clinic administrators decided whether or not to adopt evidence-based and other innovative practices by exploring their views of implementation barriers and facilitators and operation of these views in assessment of implementation costs and benefits.

Methods: Semi-structured interviews were conducted with 75 agency chief executive officers and program directors of 34 New York State-licensed mental health clinics serving children and adolescents.

Results: Three interconnected themes relating to barriers and facilitators were identified, namely costs and benefits associated with adoption, capacity for adoption, and acceptability of new practices. The highest percentage of participants (86.7%) mentioned costs as a barrier, followed by limited capacity (55.9%) and lack of acceptability (52.9%). The highest percentage (82.3%) of participants identified available capacity as a facilitator, followed by acceptability (41.2%) and benefits or limited costs (24.0%). Assessment of costs and benefits exhibited several principles of behavioural economics, including loss aversion, temporal discounting use of heuristics, sensitivity to monetary incentives, decision fatigue, framing, and environmental influences.

Conclusions: The results point to opportunities for using agency leader models to develop strategies to facilitate implementation of evidence-based and innovative practices for children and adolescents.
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http://dx.doi.org/10.1186/s12961-017-0190-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5372256PMC
March 2017

Which Pediatricians Comanage Mental Health Conditions?

Acad Pediatr 2017 07 6;17(5):479-486. Epub 2017 Mar 6.

Department of General Pediatrics, New York University School of Medicine, New York, NY.

Objective: Given the prevalence of mental health (MH) conditions (MHC) in children, pediatricians should initiate treatment alone or in collaboration with a specialist for children with MHC. However, the majority of pediatricians do not manage or comanage common MHC even with an on-site MH provider. We examined which physician, practice, and training characteristics are associated with pediatricians' comanaging at least half of their patients with MHC.

Methods: We analyzed responses of general pediatricians (n = 305) from the American Academy of Pediatrics 2013 Periodic Survey. Practice characteristics include presence of an on-site MH provider and perceived access to services. Independent variables included sociodemographics, training experiences, and interest in further training. The outcome was comanagement of ≥50% of patients with MHC. Weighted univariate, bivariate, and multivariable analyses were performed.

Results: Of the pediatricians who reported comanaging ≥50% of their patients with MHC, logistic regression analysis showed that pediatricians who completed ≥4 weeks of developmental behavioral pediatrics training had 1.8 increased odds (95% confidence interval 1.06, 3.08, P = .03) of comanagement, those very interested in further education in managing/treating MHC had 2.75 increased odds (95% confidence interval 1.63, 3.08, P < .001), and those with more training in MH treatment with medications had 1.4 increased odds (95% confidence interval 1.12, 1.75, P = .004) of comanaging children with MHC.

Conclusions: Specific educational experiences and interest in further education in managing or treating MHC were significantly associated with comanaging ≥50% of patients, suggesting that enhanced MH training among pediatricians could increase the comanagement of children with MHC.
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http://dx.doi.org/10.1016/j.acap.2016.10.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5495624PMC
July 2017

Diagnostic Efficiency of the Child and Adolescent Symptom Inventory (CASI-4R) Depression Subscale for Identifying Youth Mood Disorders.

J Clin Child Adolesc Psychol 2018 Sep-Oct;47(5):832-846. Epub 2017 Mar 2.

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

This study examined the diagnostic and clinical utility of the Child and Adolescent Symptom Inventory-4 R (CASI-4 R) Depressive and Dysthymia subscale for detecting mood disorders in youth (ages 6-12; M = 9.37) visiting outpatient mental health clinics. Secondary analyses (N = 700) utilized baseline data from the Longitudinal Assessment of Manic Symptoms study. Semistructured interviews with youth participants and their parents/caregivers determined psychiatric diagnoses. Caregivers and teachers completed the CASI-4 R. CASI-4 R depressive symptom severity and symptom count scores each predicted mood disorder diagnoses. Both caregiver scores (symptom severity and symptom count) of the CASI-4 R subscale significantly identified youth mood disorders (areas under the curve [AUCs] = .78-.79, ps < .001). The symptom severity version showed a small but significant advantage. Teacher symptom severity report did not significantly predict mood disorder diagnosis (AUC = .56, p > .05), whereas the teacher symptom count report corresponded to a small effect size (AUC = .61, p < .05). The CASI-4 R Depression scale showed strong incrememental validity even controlling for the other CASI-4 R scales. Caregiver subscale cutoff scores were calculated to assist in ruling in (diagnostic likelihood ratio [DLR] = 3.73) or ruling out (DLR = 0.18) presence of a mood disorder. The CASI-4 R Depressive subscale caregiver report can help identify youth mood disorders, and using DLRs may help improve diagnostic accuracy.
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http://dx.doi.org/10.1080/15374416.2017.1280807DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5801256PMC
August 2019

Amygdala-prefrontal cortical functional connectivity during implicit emotion processing differentiates youth with bipolar spectrum from youth with externalizing disorders.

J Affect Disord 2017 Jan 11;208:94-100. Epub 2016 Oct 11.

Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh, USA; Psychological Medicine, Cardiff University, United Kingdom.

Objective: Both bipolar spectrum disorders (BPSD) and attention deficit hyperactivity disorder (ADHD) present with emotion-regulation deficits, but require different clinical management. We examined how the neurobiological underpinnings of emotion regulation might differentiate youth with BPSD versus ADHD (and healthy controls, HCs), specifically assessing functional connectivity (FxC) of amygdala-prefrontal circuitry during an implicit emotion processing task.

Methods: We scanned a subset of the Longitudinal Assessment of Manic Symptoms (LAMS) sample, a clinically recruited cohort with elevated behavioral and emotional dysregulation, and age/sex-ratio matched HCs. Our sample consisted of 22 youth with BPSD, 30 youth with ADHD/no BPSD, and 26 HCs. We used generalized psychophysiological interaction (gPPI) to calculate group differences to emerging emotional faces vs. morphing shapes in FxC between bilateral amygdala and ventral prefrontal cortex/anterior cingulate cortex.

Results: FxC between amygdala and left ventrolateral prefrontal cortex (VLPFC) in response to emotions vs. shapes differed by group (p=.05): while BPSD showed positive FxC (emotions>shapes), HC and ADHD showed inverse FxC (emotions
Limitations: Co-morbidity and relatively small sample size.

Conclusions: Youth with BPSD showed abnormally positive FxC between amygdala and regions in the ventral prefrontal cortex during emotion processing. In particular, the amygdala-VLPFC finding was specific to BPSD, and not influenced by other diagnoses or medications.
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http://dx.doi.org/10.1016/j.jad.2016.09.064DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5154789PMC
January 2017

Diagnostic Efficiency of Caregiver Report on the SCARED for Identifying Youth Anxiety Disorders in Outpatient Settings.

J Clin Child Adolesc Psychol 2018 2;47(sup1):S161-S175. Epub 2016 Aug 2.

k Bethesda , Maryland.

This study investigated the diagnostic and clinical utility of the parent-rated Screen for Child Anxiety Related Emotional Disorders (SCARED-P) for detecting youth anxiety disorders. Youth ages 6 to 12 years, 11 months were recruited from 9 outpatient mental health clinics (N = 707). Consensus diagnoses were based on semistructured interviews (Schedule for Affective Disorders and Schizophrenia for School-Age Children) with youth and caregivers; 31% were diagnosed with at least one anxiety disorder. Caregivers completed the SCARED-P to describe youth anxiety levels. SCARED-P scores were not considered during the consensus diagnoses. Areas under the curve (AUCs) from receiver operating characteristic analyses and diagnostic likelihood ratios (DLRs) quantified performance of the SCARED-P total score and subscale scores (generalized anxiety disorder and separation anxiety disorder). SCARED-P total scores had variable efficiency (AUCs = .69-.88), and Generalized Anxiety Disorder and Separation Anxiety subscale scores were excellent (AUCs = .86-.89) for identifying specific anxiety disorders. Optimal subscale cutoff scores were computed to help rule in (DLRs = 2.7-5.4) or rule out (DLRs < 1.0) anxiety disorders among youth. Results suggest that the Generalized Anxiety Disorder and Separation Anxiety SCARED-P subscales accurately identify their respective matched diagnoses. DLRs may aid clinicians in screening for youth anxiety disorders and improve accuracy of diagnosis.
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http://dx.doi.org/10.1080/15374416.2016.1188698DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5729056PMC
September 2019

Comparing the CASI-4R and the PGBI-10 M for Differentiating Bipolar Spectrum Disorders from Other Outpatient Diagnoses in Youth.

J Abnorm Child Psychol 2017 04;45(3):611-623

Department of Psychiatry, Kennedy Krieger Institute, John Hopkins University, Baltimore, MD, 21218, USA.

We compared 2 rating scales with different manic symptom items on diagnostic accuracy for detecting pediatric bipolar spectrum disorder (BPSDs) in outpatient mental health clinics. Participants were 681 parents/guardians of eligible children (465 male, mean age = 9.34) who completed the Parent General Behavior Inventory-10-item Mania (PGBI-10 M) and mania subscale of the Child and Adolescent Symptom Inventory-Revised (CASI-4R). Diagnoses were based on KSADS interviews with parent and youth. Receiver operating characteristic (ROC) analyses and diagnostic likelihood ratios (DLRs) determined discriminative validity and provided clinical utility, respectively. Logistic regressions tested for incremental validity in the CASI-4R mania subscale and PGBI-10 M in predicting youth BPSD status above and beyond demographic and common diagnostic comorbidities. Both CASI-4R and PGBI-10 M scales significantly distinguished BPSD (N = 160) from other disorders (CASI-4R: Area under curve (AUC) = .80, p < 0.0005; PGBI-10 M: AUC = 0.79, p < 0.0005) even though scale items differed. Both scales performed equally well in differentiating BPSDs (Venkatraman test p > 0.05). Diagnostic likelihood ratios indicated low scores on either scale (CASI: 0-5; PGBI-10 M: 0-6) cut BPSD odds to 1/5 of those with high scores (CASI DLR- = 0.17; PGBI-10 M DLR- = 0.18). High scores on either scale (CASI: 14+; PGBI-10 M: 20+) increased BPSD odds about fourfold (CASI DLR+ = 4.53; PGBI-10 M DLR+ = 3.97). Logistic regressions indicated the CASI-4R mania subscale and PGBI-10 M each provided incremental validity in predicting youth BPSD status. The CASI-4R is at least as valid as the PGBI-10 M to help identify BPSDs, and can be considered as part of an assessment battery to screen for pediatric BPSDs.
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http://dx.doi.org/10.1007/s10802-016-0182-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5685560PMC
April 2017

Using a Theory-Guided Learning Collaborative Model to Improve Implementation of EBPs in a State Children's Mental Health System: A Pilot Study.

Adm Policy Ment Health 2016 11;43(6):978-990

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

Learning collaboratives (LCs) are used widely to promote implementation of evidence-based practices. However, there has been limited research on the effectiveness of LCs and models vary widely in their structure, focus and components. The goal of the present study was to develop and field test a theory-based LC model to augment a state-led, evidence-based training program for clinicians providing mental health services to children. Analysis of implementation outcomes contrasted LC sites to matched comparison sites that participated in the clinical training program alone. Results suggested that clinicians from sites participating in the LC were more highly engaged in the state-led clinical training program and were more likely to complete program requirements.
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http://dx.doi.org/10.1007/s10488-016-0735-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5465642PMC
November 2016

Can Emotional and Behavioral Dysregulation in Youth Be Decoded from Functional Neuroimaging?

PLoS One 2016 5;11(1):e0117603. Epub 2016 Jan 5.

Department of Computer Science, Centre for Computational Statistics and Machine Learning, University College London, London, United Kingdom.

Introduction: High comorbidity among pediatric disorders characterized by behavioral and emotional dysregulation poses problems for diagnosis and treatment, and suggests that these disorders may be better conceptualized as dimensions of abnormal behaviors. Furthermore, identifying neuroimaging biomarkers related to dimensional measures of behavior may provide targets to guide individualized treatment. We aimed to use functional neuroimaging and pattern regression techniques to determine whether patterns of brain activity could accurately decode individual-level severity on a dimensional scale measuring behavioural and emotional dysregulation at two different time points.

Methods: A sample of fifty-seven youth (mean age: 14.5 years; 32 males) was selected from a multi-site study of youth with parent-reported behavioral and emotional dysregulation. Participants performed a block-design reward paradigm during functional Magnetic Resonance Imaging (fMRI). Pattern regression analyses consisted of Relevance Vector Regression (RVR) and two cross-validation strategies implemented in the Pattern Recognition for Neuroimaging toolbox (PRoNTo). Medication was treated as a binary confounding variable. Decoded and actual clinical scores were compared using Pearson's correlation coefficient (r) and mean squared error (MSE) to evaluate the models. Permutation test was applied to estimate significance levels.

Results: Relevance Vector Regression identified patterns of neural activity associated with symptoms of behavioral and emotional dysregulation at the initial study screen and close to the fMRI scanning session. The correlation and the mean squared error between actual and decoded symptoms were significant at the initial study screen and close to the fMRI scanning session. However, after controlling for potential medication effects, results remained significant only for decoding symptoms at the initial study screen. Neural regions with the highest contribution to the pattern regression model included cerebellum, sensory-motor and fronto-limbic areas.

Conclusions: The combination of pattern regression models and neuroimaging can help to determine the severity of behavioral and emotional dysregulation in youth at different time points.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0117603PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4701457PMC
July 2016

Can Postpartum Depression Be Managed in Pediatric Primary Care?

J Womens Health (Larchmt) 2016 Apr 18;25(4):381-90. Epub 2015 Nov 18.

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

Background: Postpartum depression is prevalent among women who have had a baby within the last 12 months. Depression can compromise parenting practices, child development, and family stability. Effective treatments are available, but access to mental healthcare is challenging. Routine infant healthcare visits represent the most regular contact mothers have with the healthcare system, making pediatric primary care (PPC) an ideal venue for managing postpartum depression.

Methods: We conducted a review of the published literature on postpartum depression programs. This was augmented with a Google search of major organizations' websites to identify relevant programs. Programs were included if they focused on clinical care practices, for at-risk or depressed women during the first year postpartum, which were delivered within the primary care setting.

Results: We found that 18 programs focused on depression care for mothers of infants; 12 were developed for PPC. All programs used a screening tool. Psychosocial risk assessments were commonly used to guide care strategies, which included brief counseling, motivating help seeking, engaging social supports, and facilitating referrals. Available outcome data suggest the importance of addressing postpartum depression within primary care and providing staff training and support. The evidence is strongest in family practices and community-based health settings. More outcome data are needed in pediatric practices.

Conclusion: Postpartum depression can be managed within PPC. Psychosocial strategies can be integrated as part of anticipatory guidance. Critical supports for primary care clinicians, especially in pediatric practices, are needed to improve access to timely nonstigmatizing care.
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http://dx.doi.org/10.1089/jwh.2015.5438DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4834523PMC
April 2016

Do Pediatricians Ask About Adverse Childhood Experiences in Pediatric Primary Care?

Acad Pediatr 2016 Mar 31;16(2):154-60. Epub 2015 Oct 31.

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

Objective: The stress associated with adverse childhood experiences (ACEs) has immediate and long-lasting effects. The objectives of this study were to examine 1) how often pediatricians ask patients' families about ACEs, 2) how familiar pediatricians are with the original ACE study, and 3) physician/practice characteristics, physicians' mental health training, and physicians' attitudes/beliefs that are associated with asking about ACEs.

Methods: Data were collected from 302 nontrainee pediatricians exclusively practicing general pediatrics who completed the 2013 American Academy of Pediatrics Periodic Survey. Pediatricians indicated whether they usually, sometimes, or never inquired about or screened for 7 ACEs. Sample weights were used to reduce nonresponse bias. Weighted descriptive and logistic regression analyses were conducted.

Results: Only 4% of pediatricians usually asked about all 7 ACEs; 32% did not usually ask about any. Less than 11% of pediatricians reported being very or somewhat familiar with the ACE study. Pediatricians who screened/inquired about ACEs usually asked about maternal depression (46%) and parental separation/divorce (42%). Multivariable analyses showed that pediatricians had more than twice the odds of usually asking about ACEs if they disagreed that they have little effect on influencing positive parenting skills, disagreed that screening for social emotional risk factors within the family is beyond the scope of pediatricians, or were very interested in receiving further education on managing/treating mental health problems in children and adolescents.

Conclusions: Few pediatricians ask about all ACEs. Pediatric training that emphasizes the importance of social/emotional risk factors may increase the identification of ACEs in pediatric primary care.
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http://dx.doi.org/10.1016/j.acap.2015.08.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4779699PMC
March 2016

Cognitive flexibility and performance in children and adolescents with threshold and sub-threshold bipolar disorder.

Eur Child Adolesc Psychiatry 2016 Jun 5;25(6):625-38. Epub 2015 Oct 5.

Butler Hospital, Providence, RI, USA.

Greater understanding of cognitive function in children and adolescents with bipolar disorder (BD) is of critical importance to improve our ability to design targeted treatments to help with real-world impairment, including academic performance. We sought to evaluate cognitive performance among children with either BD type I, II, or "not otherwise specified" (NOS) participating in multi-site Course and Outcome of Bipolar Youth study compared to typically developing controls (TDC) without psychopathology. In particular, we sought to test the hypothesis that BD-I and BD-II youths with full threshold episodes of mania or hypomania would have cognitive deficits, including in reversal learning, vs. those BD-NOS participants with sub-threshold episodes and TDCs. N = 175 participants (BD-I = 81, BD-II = 11, BD-NOS = 28, TDC = 55) completed Cambridge Neuropsychological Automated Testing Battery (CANTAB) tasks. A priori analyses of the simple reversal stage of the CANTAB intra-/extra-dimensional shift task showed that aggregated BD-I/II participants required significantly more trials to complete the task than either BD-NOS participants with sub-syndromal manic/hypomanic symptoms or than TDCs. BD participants across sub-types had impairments in sustained attention and information processing for emotionally valenced words. Our results align with prior findings showing that BD-I/II youths with distinct episodes have specific alterations in reversal learning. More broadly, our study suggests that further work is necessary to see the interaction between neurocognitive performance and longitudinal illness course. Additional work is required to identify the neural underpinnings of these differences as targets for potential novel treatments, such as cognitive remediation.
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http://dx.doi.org/10.1007/s00787-015-0769-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5040213PMC
June 2016

Detection and treatment of mental health issues by pediatric PCPs in New York State: an evaluation of Project TEACH.

Psychiatr Serv 2015 Apr 15;66(4):430-3. Epub 2014 Dec 15.

Dr. Kerker, Dr. Hoagwood, Dr. Olin, and Dr. Horwitz are with the Department of Child and Adolescent Psychiatry, New York University School of Medicine, New York City (e-mail: ). Dr. Kerker is also with the Nathan S. Kline Institute for Psychiatric Research, Orangeburg, New York. Dr. Chor is with the Health and Social Development Program, American Institutes of Research, Chicago. Dr. Hoagwood is also with the New York State Office of Mental Health, Albany, where Dr. Radigan, Mr. Setias, and Ms. Wang are with the Office of Performance Measurement and Evaluation and Dr. Perkins is with the Division of Children and Family Services. The data in this report were presented at the National Institute of Mental Health's Mental Health Services Research meeting, Bethesda, Maryland, April 25, 2014.

Objective: The authors evaluated Project TEACH (PT), a statewide training and consultation program for pediatric primary care providers (PCPs) on identification and treatment of mental health conditions.

Methods: An intervention group of 176 PCPs who volunteered for PT training was compared with a stratified random sample of 200 PCPs who did not receive PT training. Data on prescription practices, diagnoses, and follow-up care were from New York State Medicaid files (2009-2013) for youths seen by the trained (N=21,784) and untrained (N=46,607) PCPs.

Results: The percentage of children prescribed psychotropic medication increased after PT training (9% to 12%, p<.001), a larger increase than in the untrained group (4% to 5%, p<.001) (comparison, p<.001). Fewer differences were noted in diagnoses and in medication use and follow-up care among children with depression.

Conclusions: This intervention may have an impact on providers' behaviors, but further research is needed to clarify its effectiveness.
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http://dx.doi.org/10.1176/appi.ps.201400079DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4384126PMC
April 2015

White matter structure in youth with behavioral and emotional dysregulation disorders: a probabilistic tractographic study.

JAMA Psychiatry 2015 Apr;72(4):367-76

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

Importance: Psychiatric disorders in youth characterized by behavioral and emotional dysregulation are often comorbid and difficult to distinguish. An alternative approach to conceptualizing these disorders is to move toward a diagnostic system based on underlying pathophysiologic processes that may cut across conventionally defined diagnoses. Neuroimaging techniques have potentials for the identification of these processes.

Objective: To determine whether diffusion imaging, a neuroimaging technique examining white matter (WM) structure, can identify neural correlates of emotional dysregulation in a sample of youth with different psychiatric disorders characterized by behavioral and emotional dysregulation.

Design, Setting, And Participants: Using global probabilistic tractography, we examined relationships between WM structure in key tracts in emotional regulation circuitry (ie, cingulum, uncinate fasciculus, and forceps minor) and (1) broader diagnostic categories of behavioral and emotional dysregulation disorders (DDs) and (2) symptom dimensions cutting across conventional diagnoses in 120 youth with behavioral and/or emotional DDs, a referred sample of the Longitudinal Assessment of Manic Symptoms (LAM) study. Thirty age- and sex-matched typically developing youth (control participants) were included. Multivariate multiple regression models were used. The study was conducted from July 1, 2010, to February 28, 2014.

Main Outcomes And Measures: Fractional anisotropy as well as axial and radial diffusivity were estimated and imported into a well-established statistical package. We hypothesized that (1) youth with emotional DDs and those with both behavioral and emotional DDs would show significantly lower fractional anisotropy compared with youth with behavioral DDs in these WM tracts and (2) that there would be significant inverse relationships between dimensional measures of affective symptom severity and fractional anisotropy in these tracts across all participants.

Results: Multivariate multiple regression analyses revealed decreased fractional anisotropy and decreased axial diffusivity within the uncinate fasciculus in youth with emotional DDs vs those with behavioral DDs, those with both DDs, and the controls (F6,160 = 2.4; P = .032; all pairwise comparisons, P < .002). In the same model, greater severity of manic symptoms was positively associated with higher fractional anisotropy across all affected youth (F3,85 = 2.8; P = .044).

Conclusions And Relevance: These findings suggest that abnormal uncinate fasciculus and cingulum WM structure may underlie emotional, but not behavioral, dysregulation in pediatric psychiatric disorders and that a different neural mechanism may exist for comorbid emotional and behavioral DDs.
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http://dx.doi.org/10.1001/jamapsychiatry.2014.2170DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4415624PMC
April 2015

Educating health care professionals on human trafficking.

Pediatr Emerg Care 2014 Dec;30(12):856-61

From the *Department of General and Community Pediatrics, Children's National Health System, Washington, DC; †Department of Emergency Medicine, Stanford University School of Medicine, Stanford; ‡Department of Pediatrics, Northern Inyo Hospital, Bishop; §Stanford University School of Medicine, Stanford, CA; ∥Weill Cornell Medical College, New York, NY; ¶Department of Pediatrics, Stanford University School of Medicine, Stanford; #Department of Child Development, California State University, Sacramento; **San Jose Police Department, San Jose, CA; ††Statistical Research Consultants, LLC, Schaumburg, IL; and ‡‡Department of Child and Adolescent Psychiatry, New York University Langone Medical Center, New York, NY.

Background: The US Department of State estimates that there are between 4 and 27 million individuals worldwide in some form of modern slavery. Recent studies have demonstrated that 28% to 50% of trafficking victims in the United States encountered health care professionals while in captivity, but were not identified and recognized. This study aimed to determine whether an educational presentation increased emergency department (ED) providers' recognition of human trafficking (HT) victims and knowledge of resources to manage cases of HT.

Methods: The 20 largest San Francisco Bay Area EDs were randomized into intervention (10 EDs) or delayed intervention comparison groups (10 EDs) to receive a standardized educational presentation containing the following: background about HT, relevance of HT to health care, clinical signs in potential victims, and referral options for potential victims. Participants in the delayed intervention group completed a pretest in the period the immediate intervention group received the educational presentation, and all participants were assessed immediately before (pretest) and after (posttest) the intervention. The intervention effect was tested by comparing the pre-post change in the intervention group to the change in 2 pretests in the delayed intervention group adjusted for the effect of clustering within EDs. The 4 primary outcomes were importance of knowledge of HT to the participant's profession (5-point Likert scale), self-rated knowledge of HT (5-point Likert scale), knowledge of who to call for potential HT victims (yes/no), and suspecting that a patient was a victim of HT (yes/no).

Findings: There were 258 study participants from 14 EDs; 141 from 8 EDs in the intervention group and 117 from 7 EDs in the delayed intervention comparison group, of which 20 served as the delayed intervention comparison group. Participants in the intervention group reported greater increases in their level of knowledge about HT versus those in the delayed intervention comparison group (1.42 vs -0.15; adjusted difference = 1.57 [95% confidence interval, 1.02-2.12]; P < 0.001). Pretest ratings of the importance of knowledge about HT to the participant's profession were high in both groups and there was no intervention effect (0.31 vs 0.55; -0.24 [-0.90-0.42], P = 0.49). Knowing who to call for potential HT victims increased from 7.2% to 59% in the intervention group and was unchanged (15%) in the delayed intervention comparison group (61.4% [28.5%-94.4%]; P < 0.01). The proportion of participants who suspected their patient was a victim of HT increased from 17% to 38% in the intervention group and remained unchanged (10%) in the delayed intervention comparison group (20.9 [8.6%-33.1%]; P < 0.01).

Interpretation: A brief educational intervention increased ED provider knowledge and self-reported recognition of HT victims.
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http://dx.doi.org/10.1097/PEC.0000000000000287DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4392380PMC
December 2014