Faculty Bibliography

This paper describes the implementation of Behavioral Activation (BA) as the core psychotherapy treatment within a broader clinician-led effort to establish a care pathway for adolescent depression in an academic medical center that served public and private hospital systems. This quality improvement effort required a standardized yet flexible approach to psychotherapy to be used by clinicians with a range of experience and training backgrounds while serving diverse clinical populations in child psychiatry and pediatric clinics. This paper highlights implementation of BA in treating adolescent depression across these varying systems. In particular, the paper emphasizes the application of BA as a principle-driven, treatment that enables flexibility across settings while remaining rooted in scientific evidence. The paper also reviews lessons learned from this effort that may support efforts to implement BA in other clinical settings and systems.

Anxiety disorders are the most frequently diagnosed form of psychopathology in children and often result in chronic impairment that persists into adulthood. Identifying neurobehavioral correlates of anxiety that appear relatively early in life would inform etiological models of development and allow intervention and prevention strategies to be implemented more effectively. The error-related negativity (ERN), a negative deflection in the event-related potential at fronto-central sites approximately 50 ms following the commission of errors, has been consistently found to be larger among anxious adults. The current study sought to extend these findings to even younger individuals: the ERN was elicited by a Go/NoGo task in 48 six year-old children with a clinical anxiety disorder assessed by diagnostic interview and 48 age-matched controls. In addition to child anxiety disorder, the ERN was examined in relation to maternal history of anxiety disorder, which was previously related to a smaller ERN. Anxious children were characterized by a larger (i.e., more negative) ERN and maternal history of anxiety disorder was associated with a smaller ERN. Thus, the relationship between an increased ERN and clinical anxiety is evident by age 6, and this effect appears independent from an opposing influence of maternal anxiety history on the ERN. These findings support the ERN as a promising neurobehavioral marker of anxiety, and implications are discussed.

BACKGROUND: There is increasing interest in error-related brain activity in anxiety disorders. The error-related negativity (ERN) is a negative deflection in the event-related potential approximately 50 ms after errors compared to correct responses. Recent studies suggest that the ERN may be a biomarker for anxiety, as it is positively associated with anxiety disorders and traits in adults and older youth. However, it is not known if the ERN in young children is related to risk for anxiety disorders. We addressed this by examining the association of six-year olds' ERNs with two established risk factors for anxiety: parental anxiety disorder and child temperamental negative emotionality (NE). METHOD: The ERN was assessed using a Go/No-Go task in a community sample of 413 six-year olds. In a prior assessment at age 3, child temperament was evaluated using a laboratory observational measure and parental psychopathology was assessed using semi-structured diagnostic interviews. RESULTS: Children of mothers with anxiety disorders and children with greater temperamental NE (particularly fearfulness) exhibited significantly smaller ERNs than their peers. Paternal psychopathology, maternal mood and substance use disorders, and child positive emotionality were not associated with children's ERNs. CONCLUSION: Both maternal anxiety disorders and child NE (particularly fearfulness) were significantly associated with children's ERNs. However, the direction of these associations was opposite to the relations between ERNs and anxiety in older youth and adults. These results suggest that there may be a difference between risk and disorder status in the relation of error-related brain activity to anxiety between early childhood and late childhood/ early adolescence.

The dopamine active transporter 1 (DAT1) gene is implicated in psychopathology risk. Although the processes by which this gene exerts its effects on risk are poorly understood, a small body of research suggests that the DAT1 gene influences early emerging negative emotionality, a marker of children's psychopathology risk. As child negative emotionality evokes negative parenting practices, the DAT1 gene may also play a role in gene-environment correlations. To test this model, children (N = 365) were genotyped for the DAT1 gene and participated in standardized parent-child interaction tasks with their primary caregiver. The DAT1 gene 9-repeat variant was associated with child negative affect expressed toward the parent during parent-child interactions, and parents of children with a 9-repeat allele exhibited more hostility and lower guidance/engagement than parents of children without a 9-repeat allele. These gene-environment associations were partially mediated by child negative affect toward the parent. The findings implicate a specific polymorphism in eliciting negative parenting, suggesting that evocative associations play a role in elevating children's risk for emotional trajectories toward psychopathology risk.

BACKGROUND: A growing literature indicates that the Child Behavior Checklist-Dysregulation Profile (CBCL-DP) identifies youths with heightened risk for severe psychopathology, comorbidity, and impairment. However, this work has focused on school-age children and adolescents; no studies have examined whether preschool-aged children with the CBCL-DP exhibit a similar constellation of problems. METHOD: Using a community sample of preschoolers, we compared children with (N = 61) and without (N = 488) the CBCL-DP on a broad range of variables assessed using multiple methods. RESULTS: Univariate analyses revealed numerous differences between children with the CBCL-DP and their peers on psychiatric symptomatology, temperament, parenting behavior, and parental personality, psychopathology, and marital functioning. In multivariate analyses, children with the CBCL-DP exhibited greater temperamental negative affectivity and lower effortful control. They also had more depressive and oppositional defiant symptoms, as well as greater functional impairment. Parents of CBCL-DP children reported engaging in more punitive, controlling parenting behavior than parents of non-profile children. CONCLUSIONS: In a non-clinical sample of preschoolers, the CBCL-DP is associated with extensive emotional and behavioral dysregulation and maladaptive parenting.

The current study examined behavioral measures and response-locked event-related brain potentials (ERPs) derived from a Go/No-Go task in a large (N = 328) sample of 5- to 7-year-olds in order to better understand the early development of response monitoring and the impact of child age and sex. In particular, the error-related negativity (ERN, defined on both error trials alone and the difference between error and correct trials, or DeltaERN), correct response negativity (CRN), and error positivity (P(e)) were examined. Overall, the ERN, CRN, and the P(e) were spatially and temporally similar to those measured in adults and older children. Even within our narrow age range, older children were faster and more accurate; a more negative DeltaERN and a more positive P(e) were associated with: increasing age, increased accuracy, and faster reaction times on errors, suggesting these enhanced components reflected more efficient response monitoring of errors over development. Girls were slower and more accurate than boys, although both genders exhibited comparable ERPs. Younger children and girls were characterized by increased posterror slowing, although they did not demonstrate improved posterror accuracy. Posterror slowing was also related to a larger P(e) and reduced posterror accuracy. Collectively, these data suggest that posterror slowing may be unrelated to cognitive control and may, like the P(e), reflect an orienting response to errors.

BACKGROUND: The late positive potential (LPP) is an event-related potential component that indexes selective attention toward motivationally salient information and is sensitive to emotional stimuli. Few studies have examined the LPP in children. Depression has been associated with reduced reactivity to negative and positive emotional stimuli, including reduced LPPs in response to emotional faces. The current study sought to identify the time course and scalp distribution of the LPP in response to emotional faces in young children and to determine whether reduced reactivity is observed among children at risk for depression. METHODS: Electrocortical reactivity to emotional faces was examined in a large sample of young children and as a function of maternal and paternal depression. RESULTS: In the overall sample, emotional faces were associated with increased positivities compared to neutral faces at occipital sites 200-600 ms after stimulus onset and at parietal sites 600-1,000 ms after stimulus onset. Children of mothers with a history of depressive disorders exhibited reduced differentiation in the early occipital LPP for emotional compared to neutral faces. CONCLUSIONS: Results suggest that children as young as 6 years exhibit LPPs to emotional faces, and patterns of electrocortical reactivity to emotional stimuli may be associated with vulnerability to depressive disorders.

We examined the psychometric properties of the Behavioral Inhibition Questionnaire (BIQ; Bishop, Spence, & McDonald, 2003), a rating scale for children's behavioral inhibition. Parent and teacher ratings, parent interviews, and laboratory observations were obtained for 495 preschoolers. Confirmatory factor analysis yielded 6 factors, each reflecting the BIQ's subscales, and all loading onto a second-order general dimension. Model fit was acceptable for parent ratings, but only marginal for teacher ratings. The convergent and discriminant validity of the BIQ was examined by using a multitrait-multimethod approach. Results indicate that the BIQ displays evidence of reliability and validity that can complement observational paradigms.

Researchers have long been interested in whether particular temperamental traits in childhood connote risk for depressive disorders. For example, children characterized as having high negative emotionality (NE; sadness, fear, anger) and low positive emotionality (PE; anhedonia, listlessness, and lack of enthusiasm) are hypothesized to be at risk for depression. Few studies, however, have examined whether (and how) these two temperamental dimensions interact to confer risk. In a sample of 329 preschoolers, the present study addressed this question by examining the relation between PE and NE and asymmetry in resting EEG activity in frontal and posterior regions, which are putative biomarkers for depression. Using a laboratory battery to define temperament, we found an interaction of PE and NE on posterior asymmetry. Specifically, when PE was high, NE was associated with greater relative right activity. When PE was low, NE was not related to posterior asymmetry. These results were driven by differences in EEG activity in right posterior regions, an area associated with emotional processing and arousal, and were specific to girls. We found no relation between temperament and frontal asymmetry. These findings suggest that, at least for girls, PE and NE may have an interactive effect on risk for depression.

Attentional biases for negative stimuli have been observed in school-age and adolescent children of depressed mothers and may reflect a vulnerability to depression. The direction of these biases and whether they can be identified in early childhood remains unclear. The current study examined attentional biases in 5-7-year-old children of depressed and non-depressed mothers. Following a mood induction, children participated in a dot-probe task assessing biases for sad and happy faces. There was a significant interaction of group and sex: daughters of depressed mothers attended selectively to sad faces, while children of controls and sons of depressed mothers did not exhibit biases. No effects were found for happy stimuli. These findings suggest that attentional biases are discernible in early childhood and may be vulnerability markers for depression. The results also raise the possibility that sex differences in cognitive biases are evident before the emergence of sex differences in the prevalence of depression.