Faculty Bibliography

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.

The impact of evidence-based parenting health promotion programs is threatened by limited enrollment and attendance. We used a discrete choice experiment (DCE) to examine how Early Head Start and Head Start parents prioritized key attributes of parenting programs when considering potential participation. Utility values and importance scores indicate that parents placed the highest priority on a program that optimized child academic outcomes, and after that, on a program that offered incentives and logistical supports, and maximized potential effects on friendship skills, behavioral skills, and the parent-child relationship. Next, we used simulations or forecasting tools to estimate parents' preferences for types of programs. Sixty-five percent of parents preferred Outcome-focused Programs that fostered parents' understanding and practice of skills, whereas 23% prioritized Enhanced Support Programs offering logistic support, such as incentives, followed by child outcomes. The remaining 12% of parents preferred Format-focused Programs that targeted positive outcomes via one 30-min meeting. Parents preferring Outcome-focused Programs reported higher child prosocial behaviors compared to parents preferring Enhanced Support and Format-focused Programs. Parents preferring Outcome-focused Programs were more likely to be those of 3- and 4-year-old children than of 2-year-olds. Findings challenge the one-size-fits-all approach to offering parenting programs and suggest ways to enhance accessibility and program reach.

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
Copyright

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
Copyright

Objectives: Participants in this Workshop will learn methods by which to overcome common pitfalls and obstacles to scholarly writing and publication and will establish skills essential to getting papers published. Relatively few students, trainees, and clinicians publish scientific or other educational manuscripts because of limitations of time, experience, and access to mentorship. However, facilitating publishing opportunities for these groups is important because the process of authoring and publishing scientific manuscripts can increase competency in research literacy, engagement in evidence-based practices, and other skills needed to increase mastery in child and adolescent psychiatry.
Method(s): We provide attendees a "backstage pass" experience, combining practical instruction with individualized, hands-on training and consultation to build an early foundation for getting published. Topics covered include how to choose a publishable topic of interest and how to utilize and maintain mentorship relationships. Attendees also will receive personalized consultation and mentorship around their individual goals and their works in progress from peers and our presenters, who have significant and diverse experiences with authorship and publication-particularly with JAACAP and JAACAP Connect.
Result(s): Attendees will learn practical steps toward getting published in scholarly journals and strategies to overcome current limitations and obstacles. Participants also will have the opportunity to get started with mentored authorship and publishing experiences available through JAACAP Connect.
Conclusion(s): This Workshop provides medical students, residents, fellows, early-career psychiatrists, and other clinicians with limited scholarly experience both practical knowledge and foundational skills essential to writing and getting published. AC, ADV, R
Copyright

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.

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.

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
Copyright