Faculty Bibliography

Objectives: Digital innovation has the potential to transform both the science and practice of child mental health. Creation of pediatric digital health tools requires that bioethics, human-centered design, and clinical and scientific expertise are integrated with digital tool development, digital data collection, and data analytics. In this talk, we will describe the opportunities for innovations in pediatric digital mental health and the concurrent ethical and security risks. We will then present a framework and design methodology for creating ethical, human-centered, clinically informed, and evidence-based digital tools for children's mental health.
Method(s): The data presented will come from our experience founding and leading the New York University Langone Department of Child and Adolescent Psychiatry's WonderLab, which creates pediatric digital mental health tools that are evidence based, scalable, and ethical, as well as beautiful and fun so that parents and children would want to use them. The WonderLab brings clinical, scientific, digital engineering, digital design, data science, and bioethics expertise together with user engagement and a "build, measure, learn" agile development culture and methodology. We will use the WonderLab team's development and launch of our first app-based study, "When to Wonder: Picky Eating," to illustrate our framework and methodology.
Result(s): We will describe the innovation opportunities in pediatric digital mental health, including innovation in measurement, engagement, access, and collaborative methodologies. We will then present the ethical, privacy, security, and safety risks related to digital health applications and app-based data collection with children and their families. Finally, we will describe how the WonderLab team, methodology, and products innovate across multiple domains within an explicit ethical and clinically informed framework.
Conclusion(s): Digital innovation and data science have great potential to address the challenges facing our patients and our field. To build ethical and useful digital health tools for children's mental health requires multidisciplinary teams, user engagement, collaborative agile methodology, and a framework that ensures that innovations are integrated with and reflect our ethics and commitment to children. R, COMP, DAM
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Objectives: We will: 1) describe the WonderLab, a digital health initiative within the New York University Langone Health Department of Child and Adolescent Psychiatry; 2) introduce When to Wonder: Picky Eating, which is the WonderLab's first early childhood mental health digital study; and 3) present preliminary data from this study. Our first objective is to demonstrate how smartphone-based tools developed to assess children in their homes and the use of advanced data analytics can transform how, when, and where we assess young children's development and mental health. Our second objective is to share how our multidisciplinary team and agile development methodology enable us to build and launch a consumer-facing pediatric health app within an academic medical center.
Method(s): The WonderLab creates scalable mobile digital health tools to collect multimodal data in children's homes at the individual, family, and population levels. In December 2018, we released When to Wonder: Picky Eating, a national study with consent, enrollment, study activities, and feedback fully integrated in iOS and Android apps that parents download from the app stores. When to Wonder: Picky Eating focuses on the emotions and behaviors related to picky eating in children under the age of 7 years. Data sources include parent-report, video, audio, and an active task that children and parents play independently to quantify children's food preferences.
Result(s): We will present preliminary data from When to Wonder: Picky Eating to characterize normative and clinically significant emotions and behaviors related to picky eating. We will also share data on recruitment and engagement using social media, app performance, and "lessons learned" about digital pediatric health.
Conclusion(s): We create clinically and scientifically valid digital tools that parents and children want to use. We integrate clinical, scientific, engineering, design, data science, and bioethics expertise with collaborative user engagement and a "build, measure, learn" agile development culture. Our app-based study demonstrates how to build digital health tools that collect and analyze population-level and individual-level, multimodal data about children and families in the home. These new tools and approaches have the potential to transform our engagement with families and our delivery of care. EA, EC, MED
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Objectives: The risk for psychopathology increases with the number of adverse childhood experiences. Summing a number of experiences, however, assumes that all adversity equitably confers risk and operates through complementary mechanisms. To disentangle neurobiological pathways between disparate events and mental health, we examined how threat and deprivation-2 common dimensions of adversity-relate to early childhood psychopathology. Threat or the presence of experiences involving harm or threat of harm affects emotional control. Deprivation or absence of expected environmental inputs affects higher-order cognitive function. If threat and deprivation differentially affect brain development, then they may differentially relate to psychopathology, especially among young children.
Method(s): To examine these patterns, we used the Duke Preschool Anxiety Study, a cross-sectional study of youth ages 2-6 years enrolled through primary care from 2007 to 2011, weighted to reflect a screened population of 3433. Threat and deprivation were operationalized using questions from the Conflict Tactics Scale-2, Conflict Tactics Scale for Parent and Child, and Preschool Age Psychiatric Assessment. Threat measured physical or sexual abuse, domestic violence, and violent neighborhood. Deprivation measured neglect and lack of cognitive stimulation. Poisson regression with robust standard errors estimated adjusted prevalence ratios (PR) jointly for deprivation and threat in relation to counts for total symptoms and symptoms for specific disorders, such as anxiety, depression, and ADHD, in 760 children.
Result(s): Threat (47%) and deprivation (18%) were common; 36 percent of children had at least one disorder, and the total number of symptoms ranged from 0 to 46. Threat-exposed children had 40 percent more total symptoms (95% CI 1.2-1.6) than unexposed children after adjusting for deprivation and demographic covariates. Deprivation was not meaningfully associated with total symptom count (PR 1.1, 95% CI 0.9-1.5) after adjusting for threat and demographic covariates.
Conclusion(s): These disparate associations among threat, deprivation, and mental health symptomatology may reflect the young age of these children or our approach designed to distinguish the unique contributions of deprivation and threat, lending support to the dimensional model of adversity and psychopathology. CAN, PSP, PSC
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INTRODUCTION AND OBJECTIVE/OBJECTIVE:Systematic review tools that provide guidance on evaluating epidemiology studies are receiving increasing attention and support because their application facilitates improved quality of the review, consistency across reviewers, and transparency for readers. The U.S. Environmental Protection Agency's Integrated Risk Information System (IRIS) Program has developed an approach for systematic review of evidence of health effects from chemical exposures that includes structured approaches for literature search and screening, study evaluation, data extraction, and evidence synthesis and integration. This approach recognizes the need for developing outcome-specific criteria for study evaluation. Because studies are assessed at the outcome level, a study could be considered high quality for one investigated outcome, and low quality for another, due to differences in the outcome measures, analytic strategies, how relevant a certain bias is to the outcome, and how the exposure measure relates to the outcome. The objective of this paper is to illustrate the need for outcome-specific criteria in study evaluation or risk of bias evaluation, describe the process we used to develop the criteria, and summarize the resulting criteria. METHODS:We used a process of expert consultation to develop several sets of outcome-specific criteria to guide study reviewers, improve consistency, and ensure consideration of critical issues specific to the outcomes. The criteria were developed using the following domains: outcome assessment, exposure measurement (specifically timing of exposure in relation to outcome; other exposure measurement issues would be addressed in exposure-specific criteria), participant selection, confounding, analysis, and sensitivity (the study's ability to detect a true effect or hazard). RESULTS:We discuss the application of this process to pregnancy-related outcomes (preterm birth, spontaneous abortion), other reproductive-related outcomes (male reproductive hormones, sperm parameters, time to pregnancy, pubertal development), chronic disease (diabetes, insulin resistance), and acute or episodic conditions (asthma, allergies), and provide examples of the criteria developed. For each outcome the most influential methodological considerations are highlighted including biological sample collection and quality control, sensitivity and specificity of ascertainment tools, optimal timing for recruitment into the study (e.g., preconception, specific trimesters), the etiologically relevant window for exposure assessments, and important potential confounders. CONCLUSIONS:Outcome-specific criteria are an important part of a systematic review and will facilitate study evaluations by epidemiologists with experience in evaluating studies using systematic review methods who may not have extensive discipline-specific experience in the outcomes being reviewed.

BACKGROUND:Asthma, gastroesophageal reflux disease (GERD), posttraumatic stress disorder (PTSD) and depression have each been linked to exposure to the September 11, 2001 World Trade Center (WTC) terrorist attacks (9/11). We described the prevalence and patterns of these conditions and associated health-related quality of life (HRQOL) fifteen years after the attacks. METHODS:We studied 36,897 participants in the WTC Health Registry, a cohort of exposed rescue/recovery workers and community members, who completed baseline (2003-2004) and follow-up (2015-16) questionnaires. Lower respiratory symptoms (LRS; cough, dyspnea, or wheeze), gastroesophageal reflux symptoms (GERS) and self-reported clinician-diagnosed asthma and GERD history were obtained from surveys. PTSD was defined as a score > 44 on the PTSD checklist, and depression as a score > 10 on the Patient Health Questionnaire (PHQ). Poor HRQOL was defined as reporting limited usual daily activities for > 14 days during the month preceding the survey. RESULTS:In 2015-16, 47.8% of participants had ≥1 of the conditions studied. Among participants without pre-existing asthma, 15.4% reported asthma diagnosed after 9/11; of these, 76.5% had LRS at follow up. Among those without pre-9/11 GERD, 22.3% reported being diagnosed with GERD after 9/11; 72.2% had GERS at follow-up. The prevalence of PTSD was 14.2%, and of depression was 15.3%. HRQOL declined as the number of comorbidities increased, and was particularly low among participants with mental health conditions. Over one quarter of participants with PTSD or depression reported unmet need for mental health care in the preceding year. CONCLUSIONS:Nearly half of participants reported having developed at least one of the physical or mental health conditions studied by 2015-2016; comorbidity among conditions was common. Poor HRQOL and unmet need for health were frequently reported, particularly among those with post-9/11 PTSD or depression. Comprehensive physical and mental health care are essential for survivors of complex environmental disasters, and continued efforts to connect 9/11-exposed persons to needed resources are critical.

BACKGROUND:Multiple chronic health conditions have been associated with exposure to the September 11, 2001 World Trade Center (WTC) terrorist attacks (9/11). We assessed whether excess deaths occurred during 2003-2014 among persons directly exposed to 9/11, and examined associations of 9/11-related exposures with mortality risk. MATERIALS AND METHODS/METHODS:Deaths occurring in 2003-2014 among members of the World Trade Center Health Registry, a cohort of rescue/recovery workers and lower Manhattan community members who were exposed to 9/11, were identified via linkage to the National Death Index. Participants' overall levels of 9/11-related exposure were categorized as high, intermediate, or low. We calculated standardized mortality ratios (SMR) using New York City reference rates from 2003 to 2012. Proportional hazards were used to assess associations of 9/11-related exposures with mortality, accounting for age, sex, race/ethnicity and other potential confounders. RESULTS:We identified 877 deaths among 29,280 rescue/recovery workers (3.0%) and 1694 deaths among 39,643 community members (4.3%) during 308,340 and 416,448 person-years of observation, respectively. The SMR for all causes of death was 0.69 [95% confidence interval (CI) 0.65-0.74] for rescue/recovery workers and 0.86 (95% CI 0.82-0.90) for community members. SMRs for diseases of the cardiovascular and respiratory systems were significantly lower than expected in both groups. SMRs for several other causes of death were significantly elevated, including suicide among rescue recovery workers (SMR 1.82, 95% CI 1.35-2.39), and brain malignancies (SMR 2.25, 95% CI 1.48-3.28) and non-Hodgkin's lymphoma (SMR 1.79, 95% CI 1.24-2.50) among community members. Compared to low exposure, both intermediate [adjusted hazard ratio (AHR) 1.36, 95% CI 1.10-1.67] and high (AHR 1.41, 95% CI 1.06-1.88) levels of 9/11-related exposure were significantly associated with all-cause mortality among rescue/recovery workers (p-value for trend 0.01). For community members, intermediate (AHR 1.13, 95% CI 1.01-1.27), but not high (AHR 1.14, 95% CI 0.94-1.39) exposure was significantly associated with all-cause mortality (p-value for trend 0.03). AHRs for associations of overall 9/11-related exposure with heart disease- and cancer-related mortality were similar in magnitude to those for all-cause mortality, but with 95% CIs crossing the null value. CONCLUSIONS:Overall mortality was not elevated. Among specific causes of death that were significantly elevated, suicide among rescue/recovery workers is a plausible long-term consequence of 9/11 exposure, and is potentially preventable. Elevated mortality due to other causes, including non-Hodgkin's lymphoma and brain cancer, and small but statistically significant associations of 9/11-related exposures with all-cause mortality hazard warrant additional surveillance.

Biomarkers of environmental metal exposure in children are important for elucidating exposure and health risk. While exposure biomarkers for As, Cd, and Pb are relatively well defined, there are not yet well-validated biomarkers of Mn exposure. Here, we measured hair Mn, Pb, Cd, and As levels in children from the Mid-Ohio Valley to determine within and between-subject predictors of hair metal levels. Occipital scalp hair was collected in 2009-2010 from 222 children aged 6-12 years (169 female, 53 male) participating in a study of chemical exposure and neurodevelopment in an industrial region of the Mid-Ohio Valley. Hair samples from females were divided into three two centimeter segments, while males provided a single segment. Hair was cleaned and processed in a trace metal clean laboratory, and analyzed for As, Cd, Mn, and Pb by magnetic sector inductively coupled plasma mass spectrometry. Hair Mn and Pb levels were comparable (median 0.11 and 0.15 µg/g, respectively) and were ~10-fold higher than hair Cd and As levels (0.007 and 0.018 µg/g, respectively). Hair metal levels were higher in males compared to females, and varied by ~100-1000-fold between all subjects, and substantially less (<40-70%) between segments within female subjects. Hair Mn, Pb, and Cd, but not As levels systematically increased by ~40-70% from the proximal to distal hair segments of females. There was a significant effect of season of hair sample collection on hair Mn, Pb, and Cd, but not As levels. Finally, hair metal levels reported here are ~2 to >10-fold lower than levels reported in other studies in children, most likely because of more rigorous hair cleaning methodology used in the present study, leading to lower levels of unresolved exogenous metal contamination of hair.

OBJECTIVE:To examine the association between 9/11-related exposures and self-reported hearing problems among 16,579 rescue/recovery workers in the World Trade Center (WTC) Health Registry. METHODS:Using Registry Waves 1 (2003 to 2004) and 2 (2006 to 2007), we modeled the association between two metrics of 9/11-related exposures and hearing difficulties. RESULTS:The prevalence of incident, persistent hearing problems was 4.4%. In a fully adjusted model, workers with higher environmental hazards scores were twice as likely (interquartile range OR 2.1; 95% confidence interval [CI] 1.8, 2.5) to report hearing problems. Based on the same fully adjusted model, workers unable to hear in the dust cloud were 2.3 (95% CI 1.8, 3.0) times more likely to report hearing problems as compared with workers not in the dust cloud. CONCLUSIONS:We observed a consistent association between WTC-related exposures and self-reported hearing problems among rescue/recovery workers.

Perfluoroalkyl substances (PFAS) were shown to be immunotoxic in laboratory animals. There is some epidemiological evidence that PFAS exposure is inversely associated with vaccine-induced antibody concentration. We examined immune response to vaccination with FluMist intranasal live attenuated influenza vaccine in relation to four PFAS (perfluorooctanoate, perfluorononanoate, perfluorooctane sulfonate, perfluorohexane sulfonate) serum concentrations among 78 healthy adults vaccinated during the 2010-2011 influenza season. We measured anti-A H1N1 antibody response and cytokine and chemokine concentrations in serum pre-vaccination, 3 days post-vaccination, and 30 days post-vaccination. We measured cytokine, chemokine, and mucosal IgA concentration in nasal secretions 3 days post-vaccination and 30 days post-vaccination. Adults with higher PFAS concentrations were more likely to seroconvert after FluMist vaccination as compared to adults with lower PFAS concentrations. The associations, however, were imprecise and few participants seroconverted as measured either by hemagglutination inhibition (9%) or immunohistochemical staining (25%). We observed no readily discernable or consistent pattern between PFAS concentration and baseline cytokine, chemokine, or mucosal IgA concentration, or between PFAS concentration and change in these immune markers between baseline and FluMist-response states. The results of this study do not support a reduced immune response to FluMist vaccination among healthy adults in relation to serum PFAS concentration. Given the study's many limitations, however, it does not rule out impaired vaccine response to other vaccines or vaccine components in either children or adults.