Faculty Bibliography

STUDY OBJECTIVES:This study sought to examine the relationship between internet use, sleep, and internalizing disorder symptoms in adolescents with an evening circadian preference. METHODS:One hundred seventy-two adolescents aged 10-18 years with an evening circadian preference completed a week of sleep diaries and questionnaires about internet use and internalizing disorder symptoms. RESULTS:Adolescents reported internet use for 3.81 hours on weekdays and 5.44 hours on weekends, with > 90% having access to both a computer with internet and a personal cell phone. A majority of adolescents used the internet from 4-8 pm (71%) and from 9-11 pm (62%). Common online activities included listening to music (77%), watching videos (64%), communicating with others (64%), and doing homework (58%). Late-night internet use (9-11 pm) was associated with more internalizing disorder symptoms. Middle-of-the-night internet use (midnight-5 am) was associated with a later bedtime, shorter total sleep time, and more internalizing disorder symptoms. Adolescents used the internet to fulfill social needs, to avoid or combat boredom, or for maladaptive activities. Using the internet for social interaction or avoidance/boredom was associated with higher internalizing disorder symptoms. Using the internet for maladaptive reasons was associated with more late-night and middle-of-the-night use. CONCLUSIONS:Adolescent internet use late at night and in the middle of the night is common. Internet use may be motivated by desires for social connection, by boredom/avoidance, or for maladaptive behaviors. Because middle-of-the-night internet use was associated with higher internalizing disorder symptoms and worse sleep, it presents as a potential target for intervention. CITATION:2021;17(10):2019-2027.

Objectives: Cannabis use disorder (CUD) is a common comorbidity in schizophrenia and affects the disease phenomenology. Given the heterogeneity and chronic course of schizophrenia, it is important to study the impact of CUD on healthcare utilization and outcomes in children with schizophrenia spectrum disorders. This study reports the demographic differences in a sample of inpatient children with schizophrenia and CUD, and analyzes its impact on the length of hospitalization.
Method(s): We used the nationwide inpatient sample within the Healthcare Cost and Utilization Project (HCUP) from the years 2012 to 2014. We identified patients with diagnoses of schizophrenia spectrum disorder and CUD using validated ICD-9 and Clinical Modification codes. Pearson chi² test and student's t test were used to assess categorical and continuous variables, respectively.
Result(s): We analyzed 6518 inpatient children with a diagnosis of schizophrenia spectrum disorder from 2012 to 2014. The prevalence of CUD was 1.7%. There was a relatively stable trend of CUD in children from 2012 to 2014 of 1.6%, except for a spike of 2% in the year 2013. The mean age for children with schizophrenia and CUD is 15.54 +/- 2.5 years (p < 0.00). CUD was higher in males (81.3%) than females (18.8%) (p < 0.00) with predominance in African American (37%) and White (35.9%) patients. The mean length of hospitalization was 11.5 +/- 18.54 days (p = 0.36). We further categorized this sample with comorbid suicidal ideations and found that 2.2% (n = 35) of them had CUD. The mean age for children with schizophrenia having suicidal ideation and CUD is 15.71 +/- 1.8 years (p < 0.00). CUD was higher in males (60%) than females (40%) (p = 0.16) with predominance in White (53.8%) and African American (26.9%) patients. The mean length of hospitalization was 8.5 +/- 8.9 days (p = 0.679).
Conclusion(s): Our study found almost consistent trends of CUD in children with schizophrenia between 2012 and 2014, which indicates the necessity to develop interventions and programs to target CUD and resulting healthcare expenditure. There is a need to explore the biological and psychological mechanisms behind the preponderance of cannabis use in males and to identify the gender- and race-specific risk factors to mitigate the long-term adversities. SUD, SZ, S
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Background/UNASSIGNED:The Head Start treatment protocols have focused on curing young children with brain tumors while avoiding or delaying radiotherapy through using a combination of high-dose, marrow-ablative chemotherapy and autologous hematopoietic cell transplantation (AuHCT). Late effects data from treatment on the Head Start II (HS II) protocol have previously been published for short-term follow-up (STF) at a mean of 39.7 months post-diagnosis. The current study examines long-term follow-up (LTF) outcomes from the same cohort. Methods/UNASSIGNED:Eighteen HS II patients diagnosed with malignant brain tumors <10 years of age at diagnosis completed a neurocognitive battery and parents completed psychological questionnaires at a mean of 104.7 months' post-diagnosis. Results/UNASSIGNED:There was no significant change in Full Scale IQ at LTF compared to baseline or STF. Similarly, most domains had no significant change from STF, including verbal IQ, performance IQ, academics, receptive language, learning/memory, visual-motor integration, and externalizing behaviors. Internalizing behaviors increased slightly at LTF. Clinically, most domains were within the average range, except for low average mathematics and receptive language. Additionally, performance did not significantly differ by age at diagnosis or time since diagnosis. Of note, children treated with high-dose methotrexate for disseminated disease or atypical teratoid/rhabdoid tumor displayed worse neurocognitive outcomes. Conclusions/UNASSIGNED:These results extend prior findings of relative stability in intellectual functioning for a LTF period. Ultimately, this study supports that treatment strategies for avoiding or delaying radiotherapy using high-dose, marrow-ablative chemotherapy and AuHCT may decrease the risk of neurocognitive and social-emotional declines in young pediatric brain tumor survivors.

Objectives: Undergraduate college courses on well-being have proliferated in the United States, but there are few data examining whether they have an impact on student well-being or mental health. This study examined the impact of such a course on students' well-being and grade point average (GPA) compared to students who completed a psychology course on psychopathology.
Method(s): Participants were 152 undergraduates enrolled in the "Science of Happiness" (SOH), which focuses on well-being and mental health challenges (n = 64), and "Child and Adolescent Psychopathology" (CAP), a psychology course (n = 88). Well-being measures were collected using validated questionnaires (PERMA Profiler [PP], Satisfaction with Life Scale [SWLS]) at the beginning of the semester and at the completion of the semester. Both t tests and linear regression examined the effect of the courses on the outcomes.
Result(s): At baseline, there were no statistically significant differences in well-being or grades between the 2 groups. Examining the pre/post-SOH changes, we found statistically significant improvements on the SWLS (M = 1.28; SD = 4.85; t63 = 2.11; p < 0.04) and in GPA (M = 0.07; SD = 0.17; t72 = 3.47; p < 0.001). The improvement in the PP Well-being was not significant for either SOH or CAP but trended positive for SOH (M = 0.05) and negative for CAP (M = -0.05). In CAP, there was no statistically significant improvement in SWLS, but GPA change was statistically significant (M = 0.04; SD = 0.14; t96 = 2.99; p < 0.004). When we examined the pre-/postdifferences between the 2 groups, we found no statistical significance for SWLS or GPA.
Conclusion(s): Given the prevalence of mental health challenges in college students and the need for effective, large-scale prevention interventions for this population, courses on well-being are a strategy that warrant further exploration. PRE, COLST, SC
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Objectives: The United States is among the most diverse nations worldwide, boasting a majority percentage of the population comprised of ethnic minorities. Despite this, there remains a longstanding and pervasive history of racism toward several minority ethnic groups. According to a 2019 report from the Pew Research Center, race relations in America have worsened in recent times. Racism is a social determinant of health. Experiences of racism significantly impact the identity and self-perception of children and adolescents. It is therefore critical to examine how the unique racial experience of prominent ethnic minority groups shapes their developing identities and to accurately inform best practices in mental health diagnosis and treatment.
Method(s): Presenters will review the historical context of racism in the United States for the following prominent minority groups: African American, Latinx, East Asian, and South Asian. Each presenter will expand on the experience of racism specific to each ethnic group, identify unique negative biases, and review how these dynamics of discrimination impact adolescent identity development. Presenters will also share clinical pearls for how to explore topics of racial discrimination with youth in treatment.
Result(s): The experience of racism in adolescence has a significant impact on the developing adolescent identity and increases the risk of poor self-esteem, social isolation, and mental illness.
Conclusion(s): Racism is an unquestionably prevalent social issue affecting Americans of varying ethnic backgrounds. The experience of racism can be unique for differing ethnic groups. Because racism has a significant impact on the identity of developing youth and can increase the risks of mental illness, it is imperative for psychiatrists to consider race and ethnic bias in our discussions, assessments, and treatment of our patients. ETHN, ADOL, IDD
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Stimulants (methylphenidate or amphetamines) are the recommended first-line option for the pharmacological treatment of individuals with attention deficit hyperactivity disorder (ADHD). However, some patients with ADHD will not respond optimally to stimulants. Here, we discuss strategies to manage stimulant-refractory ADHD, based on the recommendations advanced in clinical guidelines, knowledge of expert practice in the field, and our own clinical recommendations, informed by a comprehensive literature search in PubMed, PsycInfo, EMBASE + EMBASE classic, OVID Medline, and Web of Science (up to 30 March 2021). We first highlight the importance of stimulant optimization as an effective strategy to increase response. We then discuss a series of factors that should be considered before using alternative pharmacological strategies for ADHD, including poor adherence, time action properties of stimulants (and wearing-off of effects), poor tolerability (that prevents the use of higher, more effective doses), excessive focus on or confounding from presence of comorbid non-ADHD symptoms, and tolerance. Finally, we consider the role of non-stimulants and combined pharmacological approaches. While the choice of medication for ADHD is still to a large extent based on a trial-and-error process, there are reasonably accepted data and guidelines to aid in clinical decision-making. It is hoped that advances in precision psychiatry in the years ahead will further guide prescribers to tailor medication choice to the specific characteristics of the patient.

Objectives: The history of racial discrimination against African American (AfAm) and Black people in the United States is deeply rooted in the history of this country. This presentation will help participants understand the intersection between racism, structural racism, and subsequent hardships as it relates to the AfAm youth's experience of discrimination. This presentation will also help participants learn practical approaches for exploring issues of discrimination with AfAm patients.
Method(s): The presenter will review the history of racial discrimination toward AfAm groups in the United States and give an overview of common experiences of discrimination for AfAm youth. Additionally, using the models of adolescent development of Erik Erikson, William Cross, James Marcia, and Beverly Tatum, the presenter will describe how racial prejudice impacts adolescent socialization and (racial) identity development, and the risk that this may confer for mental illness. Finally, the presenter will offer clinical pearls for clinicians to explore topics of racial and religious prejudice with AfAm patients.
Result(s): For AfAms, racism, segregation, and the resultant impacts on self-esteem and identity have been a constant reality and threat from the time of slavery through the present day. These brutal institutions, sanctioned and maintained by institutional racism, clearly manifest in all aspects of life for African Americans-segregated and unequal education system and housing, healthcare disparities, mental healthcare disparities, disproportionally elevated incarceration rates, and as painfully highlighted this past year, continued vulnerability to acts of violence at the hands of law enforcement. These disastrous long-term consequences have been documented and are clear. However, the experience of Black youth, introduced to these harsh realities over time, has strong implications during crucial periods of development, including physical, emotional, and identity development.
Conclusion(s): There is benefit for clinicians to incorporate exploration of the impact of racial discrimination, although it is challenging, in the evaluation and treatment of AfAm and Black youth. DEI, DEV, ADOL
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Objectives: There is a significant and urgent need across psychiatry and other academic medicine departments to design, create, and execute effective dialogues on race, while examining unconscious bias and privilege. The overarching goal of facilitated dialogue is to create a safe space for faculty, staff, and trainees of different racial backgrounds to engage in meaningful dialogue that helps all develop an antiracist approach to their work and lives.
Method(s): Based on the literature and the findings of a departmental needs assessment survey that we designed, we developed clear learning objectives, community norms, an 8-month curriculum, facilitator training and supervision, mixed-race dialogue group composition and logistics, and continuous improvement and comprehensive program evaluation. The curriculum covered topics spanning social identity, power and privilege, bias and discrimination, microaggressions, historical and structural racism, current events, cultural formulation and application to practice, allyship, and antiracism stance and action. Each facilitated dialogue session incorporated antiracist readings, videos, podcasts, immersive activities, and interactive group discussion.
Result(s): A total of 114 department faculty, staff, and trainees completed the antiracism education needs assessment survey. Ten clinical leaders were trained to serve as dialogue facilitators. Ninety-seven faculty, staff, and trainees from diverse sociodemographic backgrounds opted to participate, and 179 learner experience surveys were collected from October 2020 to January 2021. At least 94% of respondents felt engaged, safe in the dialogue environment, learned key antiracism concepts, and learned tools on how to take an antiracist stance in their work and lives.
Conclusion(s): Our curriculum, process, and facilitators have successfully addressed our goals of creating a safe space to discuss experiences with race and racism, staying open to the experiences of others, being open to new ways of viewing race, and furthermore use this new perspective to adopt an antiracist stance in their lives. Our workshop format is designed to help participants understand our process and to think through creating their own dialogues. It involves a mix of instructive and highly interactive activities, performed through breakouts and debriefings. AC, DEI, REST
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Objectives: This poster will evaluate the clinical outcomes related to implementing a collaborative care service providing therapy, mental health assessment, and medication management in an academic pediatric primary care clinic.
Method(s): A modified collaborative care model was developed and implemented in order to provide therapy and mental health services to pediatric patients while simultaneously providing education and clinical supervision to providers to increase their capacity to participate in the behavioral health care of their patients. Encounter data was collected from the start of the program in March 2018 until March 2021 using electronic medical record data on all patients utilizing collaborative care services to measure trends in referrals for and utilization of collaborative care counseling and psychiatric services.
Result(s): All measures of utilization of the program increased over time. In March 2018, the first month of implementation, 22 patient visits occurred, 169 monthly visits occurred in March 2019, 290 monthly patient visits occurred in March 2020, and 320 monthly visits occurred in March 2021. Of note, monthly patient visits dropped 25% in April 2020 (first full month of pandemic), but patient visits rebounded in May 2020 and have continued to increase. The average wait time from referral to collaborative care to scheduling the first appointment has consistently remained at 1 week. Prior to the start of the program, 2/12 (16.7%) of full-time pediatricians reported feeling confident enough with their behavioral health knowledge to manage psychiatric medications. In March 2021, 12/13 (92.3%) pediatricians were routinely managing the psychiatric medications of their patients.
Conclusion(s): The development of a modified pediatric collaborative care psychiatry program including integrated counseling and psychiatry services in combination with building behavioral health capacity among pediatric providers can provide mental health services to a substantial number of pediatric patients in the primary care setting. In addition, the time from referral to the first appointment is more rapid than the average wait time for an intake appointment in local mental health clinics. Lastly, the percentage of pediatric providers who reported feeling the confidence to provide psychiatric medication management to their pediatric patients increased significantly. CON, AC, PYI
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Decades of research have revealed numerous risk factors for mental disorders beyond genetics, but their consistency and magnitude remain uncer-tain. We conducted a "meta-umbrella" systematic synthesis of umbrella reviews, which are systematic reviews of meta-analyses of individual studies, by searching international databases from inception to January 1, 2021. We included umbrella reviews on non-purely genetic risk or protective factors for any ICD/DSM mental disorders, applying an established classification of the credibility of the evidence: class I (convincing), class II (highly suggestive), class III (suggestive), class IV (weak). Sensitivity analyses were conducted on prospective studies to test for temporality (reverse causation), TRANSD criteria were applied to test transdiagnosticity of factors, and A Measurement Tool to Assess Systematic Reviews (AMSTAR) was employed to address the quality of meta-analyses. Fourteen eligible umbrella reviews were retrieved, summarizing 390 meta-analyses and 1,180 associations between putative risk or protective factors and mental disorders. We included 176 class I to III evidence associations, relating to 142 risk/protective factors. The most robust risk factors (class I or II, from prospective designs) were 21. For dementia, they included type 2 diabetes mellitus (risk ratio, RR from 1.54 to 2.28), depression (RR from 1.65 to 1.99) and low frequency of social contacts (RR=1.57). For opioid use disorders, the most robust risk factor was tobacco smoking (odds ratio, OR=3.07). For non-organic psychotic disorders, the most robust risk factors were clinical high risk state for psychosis (OR=9.32), cannabis use (OR=3.90), and childhood adversities (OR=2.80). For depressive disorders, they were widowhood (RR=5.59), sexual dysfunction (OR=2.71), three (OR=1.99) or four-five (OR=2.06) metabolic factors, childhood physical (OR=1.98) and sexual (OR=2.42) abuse, job strain (OR=1.77), obesity (OR=1.35), and sleep disturbances (RR=1.92). For autism spectrum disorder, the most robust risk factor was maternal overweight pre/during pregnancy (RR=1.28). For attention-deficit/hyperactivity disorder (ADHD), they were maternal pre-pregnancy obesity (OR=1.63), maternal smoking during pregnancy (OR=1.60), and maternal overweight pre/during pregnancy (OR=1.28). Only one robust protective factor was detected: high physical activity (hazard ratio, HR=0.62) for Alzheimer's disease. In all, 32.9% of the associations were of high quality, 48.9% of medium quality, and 18.2% of low quality. Transdiagnostic class I-III risk/protective factors were mostly involved in the early neurodevelopmental period. The evidence-based atlas of key risk and protective factors identified in this study represents a benchmark for advancing clinical characterization and research, and for expanding early intervention and preventive strategies for mental disorders.