Faculty Bibliography

Objective: A series of studies report elevated rates of autism and autistic characteristics among gender-diverse youth seeking gender services. Although youth with the co-occurrence present with complex care needs, existing studies have focused on co-occurrence rates. Further, clinical commentaries have emphasized provider-centered interpretations of clinical needs rather than key stakeholder-driven clinical approaches. This study aimed to employ community-based participatory research methodologies to develop a key stakeholder-driven clinical group program.Method: Autistic/neurodiverse gender-diverse (A/ND-GD) youth (N = 31), parents of A/ND-GD youth (N = 46), A/ND-GD self-advocates (N = 10), and expert clinical providers (N = 10) participated in a multi-stage community-based participatory procedure. Needs assessment data were collected repeatedly over time from A/ND-GD youth and their parents as the youth interacted with one another through ongoing clinical groups, the curriculum of which was developed progressively through the iterative needs assessments.Results: Separate adolescent and parent needs assessments revealed key priorities for youth (e.g., the importance of connecting with other A/ND-GD youth and the benefit of experiencing a range of gender-diverse role models to make gender exploration and/or gender affirmation more concrete) and parents (e.g., the need for A/ND-related supports for their children as well as provision of an A/ND-friendly environment that fosters exploration of a range of gender expressions/options). Integration and translation of youth and parent priorities resulted in 11 novel clinical techniques for this population.Conclusions: With generally high acceptability ratings for each component of the group program, this study presents a community-driven clinical model to support broad care needs and preferences of A/ND-GD adolescents.

The emergence of mental health (MH) problems during a pandemic is extremely common, though difficult to address due to the complexities of pandemics and the scarcity of evidence about the epidemiology of pandemic-related MH problems and the potential interventions to tackle them. Little attention has been devoted so far to this topic from policymakers, stakeholders and researchers, resulting in a lack of replicable, scalable and applicable frameworks to help plan, develop and deliver MH care during pandemics. As a response, we have attempted to develop a conceptual framework (CF) that could guide the development, implementation, and evaluation of MH interventions during the ongoing COVID-19 pandemic. This CF was developed by early career psychiatrists from 16 countries that cover all the WHO regions. Their opinions were elicited via a semi-structured questionnaire. They were asked to provide their views about the current MH situation in their countries and to elaborate on existing 'myths' and misinformation. They were also asked to name the resources available and to propose solutions and approaches to provide accessible and affordable care. The CF was prepared based on the extant literature and the views discussed in this group; it illustrates the epidemiology of MH problems, preparedness plans, stage-specific plans or innovative solutions, opportunities to integrate those plans and possible outcomes at policy level. This CF can serve as a technical guide for future research regarding pandemics. It can be used to monitor trends and to optimize efforts, and to develop evidence based MH interventions. Still, further research focusing on the individual components of this framework is needed.

Neuroimaging studies have uncovered the neural roots of individual differences in human general fluid intelligence (Gf). Gf is characterized by the function of specific neural circuits in brain gray-matter; however, the association between Gf and neural function in brain white-matter (WM) remains unclear. Given reliable detection of blood-oxygen-level-dependent functional magnetic resonance imaging (BOLD-fMRI) signals in WM, we used a functional, rather than an anatomical, neuromarker in WM to identify individual Gf. We collected longitudinal BOLD-fMRI data (in total three times, ~11 months between time 1 and time 2, and ~29 months between time 1 and time 3) in normal volunteers at rest, and identified WM functional connectomes that predicted the individual Gf at time 1 (n = 326). From internal validation analyses, we demonstrated that the constructed predictive model at time 1 predicted an individual's Gf from WM functional connectomes at time 2 (time 1 ∩ time 2: n = 105) and further at time 3 (time 1 ∩ time 3: n = 83). From external validation analyses, we demonstrated that the predictive model from time 1 was generalized to unseen individuals from another center (n = 53). From anatomical aspects, WM functional connectivity showing high predictive power predominantly included the superior longitudinal fasciculus system, deep frontal WM, and ventral frontoparietal tracts. These results thus demonstrated that WM functional connectomes offer a novel applicable neuromarker of Gf and supplement the gray-matter connectomes to explore brain-behavior relationships.

BACKGROUND:Emotional dysregulation (ED) and callous unemotional (CU) traits can be associated with ADHD in youth, influencing its natural history and outcome, but their effect on medication efficacy is unexplored. We examined whether two measures of baseline ED and CU traits, the Child Behavior Checklist-Dysregulation Profile (CBCL-DP) and the Antisocial Process Screening Device (APSD), respectively, were predictors of change of ADHD-Rating Scale (ADHD-RS) after a 4-week methylphenidate (MPH) monotherapy. METHODS:43 patients (37 males, 8-16 years, mean 9.9 ± 2.7 years) were included. Hierarchical linear regression models were used to explore whether CBCL-DP and APSD might predict ADHD-RS score, controlling for baseline severity. RESULTS:Baseline CBCL-DP predicted higher post-treatment ADHD-RS scores in total and hyperactivity-impulsivity, but not in inattention subscale. Baseline APSD was not significantly related to ADHD-RS scores at the follow-up. LIMITATIONS/CONCLUSIONS:Small sample size, lack of gender diversity, non-blind design and short period of observation. CONCLUSION/CONCLUSIONS:ED, assessed with that CBCL-DP, might be a negative predictor of change of hyperactive-impulsive symptoms after MPH treatment and should be systematically assessed at baseline.

This piece addresses a prominent question that arose from the author"™s presentation of her paper, "Turning Points in Adolescent Analysis". Specifically, the adolescent patient who was the subject of the paper was unable to work within the transference relationship, despite the author/analyst"™s pursuit of this feature of their exchange. Reasons for the patient"™s inability to do this are discussed, including the patient"™s neuropsychological challenges and ADHD and their impact on psychic structure formation and her concrete-ism. More useful to the patient were mirroring transference interventions as well as those which capitalized on assisting the development of inchoate ego structures and functions; and aiding the transformational pull forward into young adulthood. A child and adolescent analyst (as well as an analyst of adult patients) must choose arrows from her quiver of therapeutic action based upon which ones the patient is capable of using, and which ones target the nature and symptoms of the patient"™s disturbance which prevent her from using the transference relationship. The author draws from Anna Freud as well as contemporary thinkers on this topic.

A 32-year-old child and adolescent psychiatry resident with a history of presenting an abstract at a local psychiatric conference during residency and fourth authorship on an immunotherapy paper from a summer internship during medical school presents with a new-onset desire to write a case report. She has just come off her consultation liaison rotation, during which she consulted on a 12-year-old boy with attention-deficit/hyperactivity disorder, oppositional defiant disorder, disruptive mood dysregulation disorder, and low depressive state hospitalized for pseudoseizures, a new-onset inability to walk, and aggressive outbursts. He had a negative magnetic resonance imaging scan, negative computed tomography scan, negative laboratory test results, and an unremarkable lumbar puncture. Based on an equivocal electroencephalogram, a neurology resident decided to prescribe a mood stabilizer, obtained it himself from the pharmacy, and administered it to the patient intravenously, only then realizing that it was six times the intended loading dose. Before anybody could stop him, the resident erased all documentation about the medication and fled the city. Nevertheless, that afternoon, before the error and fraud were caught by a pharmacist and before the child and his family were notified, the child's symptoms appeared to resolve and the child walked comfortably for the first time in months. The child and adolescent psychiatry resident is tentatively titling the case report, "Resolution of Conversion Disorder With a Megadose of Unknown Mood Stabilizer."

Pediatric neuropsychologists are increasingly recognizing the importance of performance validity testing during evaluations. The use of such measures to detect insufficient effort is of particular importance in pediatric epilepsy evaluations, where test results are often used to guide surgical decisions and failure to detect poor task engagement can result in postsurgical cognitive decline. The present investigation assesses the utility of the Medical Symptom Validity Test (MSVT) in 104 clinically referred children and adolescents with epilepsy. Though the overall failure rate was 15.4% of the total group, children with 2nd grade or higher reading skills (a requirement of the task) passed at a very high rate (96.6%). Of the three failures, two were unequivocally deemed true positives, while the third failed due to extreme somnolence during testing. Notably, for those with ≥2nd grade reading levels, MSVT validity indices were unrelated to patient age, intellectual functioning, or age of epilepsy onset, while modest relations were seen with specific memory measures, number of epilepsy medications, and seizure frequency. Despite these associations, however, this did not result in more failures in this population of children and adolescents with substantial neurologic involvement, as pass rates exceeded 92% for those with intellectual disability, high seizure frequency, high medication burden, and even prior surgical resection of critical memory structures.

Drawing on data from the Clinical Practice Research Datalink, Price et al reported UK regional variations in primary care prescribing and referral rates to adult mental health services for young people with attention-deficit hyperactivity disorder (ADHD) in transition from child and adolescent mental health services. Overall, considering that around 65% of young adults with childhood ADHD present with impairing ADHD symptoms and up to 90% of individuals with ADHD may benefit from ADHD medications, the study by Price et al shows that the rate of appropriate treatment for youngsters in the transition period varies from low to very low across the UK. As such, there is a continuous need for education and training for patients, their families, mental health professionals and commissioners, to eradicate the misconception that, in the majority of the cases, ADHD remits during adolescence and to support the devolvement of appropriate services for the evidence-based management of adult ADHD across the UK.