Faculty Bibliography

Violence-related post-traumatic stress disorder (PTSD) in the context of war and terrorism has become an increasingly pressing public health issue relevant to refugee children and families. PTSD and related psychopathology in children can adversely affect all domains of development and, in particular, interfere with learning and socialization. When the experience of violent trauma and related loss is shared with the entire family, resulting impairment and distress may prevent caregivers from being psychologically available to process their traumatized children's emotional communication and otherwise meet their children's developmental needs. When children suffer from PTSD, it may be impossible to put their experience and related thoughts and feelings into words, let alone a coherent narrative. The latter difficulty can be even more pronounced when the child displays dissociative symptoms, possibly signaling a dissociative subtype of PTSD. Thus, the narrative within the child's play during psychotherapy becomes all the more important as an indicator of the child's internal world. This case report is an example both of evaluation and of psychotherapy that is both psychodynamic and trauma-informed with a 10-year-old Afghani boy who suffered the violent loss of his father at age of 3 years, leading to his immigration to Switzerland. This paper addresses the question of how the psychotherapist can accompany the child through the elaboration of his trauma and how the therapist can contribute to the co-construction of a coherent narrative of the child's experience and to the restoration of an intersubjective connection between the traumatized child and caregiver.

Social interaction deficits seen in psychiatric disorders emerge in early-life and are most closely linked to aberrant neural circuit function. Due to technical limitations, we have limited understanding of how typical versus pathological social behavior circuits develop. Using a suite of invasive procedures in awake, behaving infant rats, including optogenetics, microdialysis, and microinfusions, we dissected the circuits controlling the gradual increase in social behavior deficits following two complementary procedures-naturalistic harsh maternal care and repeated shock alone or with an anesthetized mother. Whether the mother was the source of the adversity (naturalistic Scarcity-Adversity) or merely present during the adversity (repeated shock with mom), both conditions elevated basolateral amygdala (BLA) dopamine, which was necessary and sufficient in initiating social behavior pathology. This did not occur when pups experienced adversity alone. These data highlight the unique impact of social adversity as causal in producing mesolimbic dopamine circuit dysfunction and aberrant social behavior.

There is an increasing movement toward international collaboration and global discussion in mental health. If provided with the right opportunities, early career psychiatrists (ECPs) and researchers in mental health can contribute meaningfully to this discussion. However, they often experience multiple barriers when attempting to add their voices via academic publications. We represent a diverse group of ECPs and researchers from all six World Health Organization regions. In this piece, we discuss these barriers, grounded in our first-hand experiences, and put forth a series of recommendations. The most potentially beneficial and immediate way forward is ensuring a much-needed mentorship and support, particularly for low- and middle-income countries. In this regard, international organizations, especially those with a particular focus on education, such as the Section on Education in Psychiatry of the World Psychiatric Association, can play a pivotal role.

OBJECTIVE:This report summarizes findings from a 2020 survey of US child and adolescent psychiatry training programs that explored the impact of the COVID-19 pandemic on pediatric telepsychiatry training. The authors hypothesized that telepsychiatry training significantly increased during the pandemic, in part due to legal and regulatory waivers during the COVID-19 public health emergency. METHODS:In August 2020, an anonymous, 28-question online survey was emailed to all (138) accredited child psychiatry fellowships on the Accreditation Council for Graduate Medical Education website. Forty-nine programs responded (36%). This analysis focuses on three of the 28 questions relevant to the hypotheses: characteristics of the program's training in telepsychiatry; perceived impediments to clinical training; and perceived impediments to didactic training pre-COVID onset vs. post-COVID onset, respectively. Total scores were created to investigate differences in training programs and impediments to including telepsychiatry pre- and post-COVID onset. Paired sample t-tests were used to compare means pre- and post-COVID onset. RESULTS:Results provided support for significant differences between training components related to telepsychiatry pre- and post-COVID onset, with participants reporting more training components post-COVID onset (M = 5.69) than pre-COVID onset (M = 1.80); t(48) = 9.33, p < .001. Participants also reported significantly fewer barriers to providing clinical experiences in pediatric telepsychiatry post-COVID onset (M = 2.65) than pre-COVID onset (M = 4.90); t(48) =  - 4.20, p < .001. CONCLUSIONS:During the COVID-19 pandemic, pediatric telepsychiatry training in child psychiatry fellowships increased significantly. Perceived barriers to providing clinical, but not didactic, training decreased significantly.

Fungal infections of the central nervous system (FI-CNS) are life-threatening infections that most commonly affect immunocompromised individuals, but immunocompetent individuals may also be infected. Although FI-CNS are relatively rare, the prevalence of FI-CNS is on the rise because of the increasing number of transplant recipients, human immunodeficiency virus-infected individuals, and use of immunosuppressive therapies. Most cases of FI-CNS originate from outside the central nervous system. The etiologic fungi can be classified into 3 fungal groups: molds, dimorphic fungi, and yeasts. The clinical presentation of FI-CNS is highly variable and may be difficult to diagnose premortem. We present a case series of 3 patients, each infected by 1 representative species from each of the 3 fungal groups (Aspergillus species, Blastomyces species, Candida species) to illustrate different neuropathologic phenotypes of FI-CNS. All 3 patients had no history of immunodeficiency and were not suspected to have FI-CNS until they were diagnosed at autopsy. Fungal infections of the central nervous system are often fatal due to delayed diagnosis and diagnostic testing. Awareness of such poly-phenotypic manifestations of FI-CNS will be helpful in reducing delayed diagnosis. It is important for clinicians to include FI-CNS on the differential diagnosis when radiographic findings are nonspecific.

OBJECTIVES/OBJECTIVE:Agitation and restraint among pediatric psychiatric patients are a frequent, yet little studied, source of morbidity and, rarely, mortality in the emergency department (ED). This study examined agitation and restraint among youth patients in a specialized pediatric psychiatric ED, considering clinical and sociodemographic characteristics of those who required restraint to determine the clinical correlates of agitation and restraint in this population. METHODS:This descriptive study was a 6-year retrospective chart review of all patients restrained for acute agitation. Demographics, clinical characteristics, diagnoses, and reasons for restraint were collected. Relationships between sociodemographic and clinical variables to types of restraints used were examined, along with change over the study period in rate of and mean time in restraint. RESULTS:The average restraint rate was 1.94%, which remained fairly consistent throughout study period, although average time in restraint decreased significantly. Restraints were more common in males. Adolescents were overrepresented in the ED population, and after controlling for this, restraint rates were similar in adolescents and younger children. Physical aggression was the most frequent precipitant, although among adolescents verbal aggression was also a precipitant (more so than in younger children). Disruptive behavior disorder diagnoses were most frequently associated with restraint. CONCLUSIONS:A lower rate of restraint is reported here than has been seen in programs where youths are treated in medical or adult psychiatric EDs. Hospitals without specialized pediatric psychiatric emergency programs should invest in staff training in deescalation techniques and in access to pediatric psychiatric treatment. The finding that, of youth restrained, a significant proportion were under 12 years old and/or carried diagnoses not typically associated with aggressive behavior, indicates that crisis prevention, management, and treatment should include younger populations and diverse diagnostic groups, rather than focusing narrowly on older patients with psychotic or substance use disorders.

Determination of optimal individual treatment rules (ITR) is a rapidly growing area in precision medicine; various parametric and non-parametric methods have been proposed. Existing methods, however, focus on the mean outcome and thus are sensitive to outliers, skewed and heavy-tailed outcome distributions. In this paper, we propose an optimal ITR estimation framework using a weighted classifier with robust weights based on measures of similarity. Compared to previous methods in the literature, this two-stage nonparametric model is novel and enjoys several advantages. First, due to its non-parametric nature, it is more flexible than regression-based parametric and semi-parametric models. Second, the similarity-based confidence index is essentially a weighted sum of indicator functions depending on the sign of pairwise outcome differences; therefore, it is robust to outliers, skewed and heavy-tailed outcome distributions. The performance of the proposed approach is demonstrated via simulation studies and an analysis of data from a randomized clinical trial for depression.