Faculty Bibliography

BACKGROUND:The retention of youth living with HIV (YLHIV) in adult care after transfer from pediatric care in the United States is a challenge. A targeted comprehensive retention strategy (CRS) may improve retention among YLHIV. METHODS:A retrospective cohort study of YLHIV after transfer from pediatric to adult care for patients with at least 1 adult visit at 2 urban HIV care programs in the United States employing CRSs with internal medicine/pediatrics-trained providers, peer navigators, social workers and mental health resources. Primary outcomes were successful retention in care after transfer (≥2 provider visits in the adult clinic ≥90 days apart within 1 year of transfer) and successful transition (successful retention plus a stable HIV viral load (VL) defined as VL 1 year after transfer that was less than or equal to the VL obtained at or immediately before transfer). Logistic regression assessed factors associated with successful transition. A subgroup analysis was performed to examine rates of successful transfer and linkage from pediatric to adult clinics (attending at least 1 adult visit after transition). RESULTS:Of the 89 patients included in the study, 79 (89%) patients had successful retention and 53 (60%) had successful transition to the adult program. Factors associated with successful transition included non-African American race [adjusted odds ratio (aOR) = 11.26, 95% confidence interval (CI): 1.32-95.51], perinatal HIV (aOR = 8.00, 95% CI: 1.39-46.02) and CD4 count > 500 cells/mm (aOR = 5.22, 95% CI: 1.54-17.70). Of those who were retained, 53/79 (67%) had stable or improved virologic control at 1 year after transition. In a subgroup analysis, 54/56 (96%) patients who were targeted to transition successfully linked to adult care. CONCLUSIONS:Overall, YLHIV in the United States engaged in a CRS program appear to have high retention rates but suboptimal virologic control after transfer from pediatric HIV care.

Mild traumatic brain injury (mTBI) can affect high-level executive functioning long after somatic symptoms resolve. We tested if simple EEG responses within an oddball paradigm could capture variance relevant to this clinical problem. The P3a and P3b components reflect bottom-up and top-down processes driving engagement with exogenous stimuli. Since these features are related to primitive decision abilities, abnormal amplitudes following mTBI may account for problems in the ability to exert executive control. Sub-acute (<2 weeks) mTBI participants (N = 38) and healthy controls (N = 24) were assessed at an initial session as well as a two-month follow-up (sessions 1 and 2). We contrasted the initial assessment to a comparison group of participants with chronic symptomatology following brain injury (N = 23). There were no group differences in P3a or P3b amplitudes. Yet in the sub-acute mTBI group, higher symptomatology on the Frontal Systems Behavior scale (FrSBe), a questionnaire validated as measuring symptomatic distress related to frontal lobe injury, correlated with lower P3a in session 1. This relationship was replicated in session 2. These findings were distinct from chronic TBI participants, who instead expressed a relationship between increased FrSBe symptoms and a lower P3b component. In the sub-acute group, P3b amplitudes in the first session correlated with the degree of symptom change between sessions 1 and 2, above and beyond demographic predictors. Controls did not show any relationship between FrSBe symptoms and P3a or P3b. These findings identify symptom-specific alterations in neural systems that vary along the time course of post-concussive symptomatology.

We conducted a qualitative review (n = 15 manuscripts) and meta-analysis (n = 9 manuscripts) of the extant literature to evaluate the prevalence and morbidity of subthreshold Attention Deficit Hyperactivity Disorder (ADHD). Our qualitative review showed that a sizable minority (mean: 17.7%) of clinically referred and non-referred children met a priori definitions of subthreshold ADHD. Those affected exhibited significantly higher rates of family dysfunction, cognitive impairment, executive dysfunction, interpersonal and school deficits, temperament problems, psychiatric comorbidity, and juvenile delinquency compared to children with no ADHD symptoms. These deficits were highly consistent with those observed in children with full threshold ADHD. These findings indicate that children with subthreshold ADHD symptoms are at significantly greater risk for negative outcomes in a wide range of non-overlapping functional domains worthy of further clinical and scientific consideration.

BACKGROUND:Body dysmorphic disorder (BDD) is a common disorder which is associated with a high rate of comorbidity and functional impairment. Although research shows that cognitive-behavioral therapy can be an efficacious treatment for BDD, there is growing evidence that dysregulated emotion is a core deficit. The Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders (UP) is a transdiagnostic, emotion focused cognitive-behavioral therapy protocol that has been developed to target emotion regulation processes that play an important role in the development and maintenance of many emotional disorders METHODS: : In the present study, 128 patients meeting criteria for BDD were randomized to either the UP (n = 64) or waitlist/treatment-as-usual (WL/TAU) condition. Diagnoses were determined using semi-structural interviews and patients also completed the Brown Assessment of Beliefs Scale (BABS), the Appearance Anxiety Inventory (AAI), the Difficulties in Emotion Regulation Scale (DERS), the Beck Depression Inventory (BDI) and the Clinical Global Impression (CGI). RESULTS:Repeated measure ANOVA indicated that the UP significantly decreased depression, BDD symptoms and body-related anxiety, as well as significantly improving emotional regulation all with large effect sizes compared to the TAU/WL condition. Treatment gains as well as remission of comorbid conditions were maintained at the three-month follow-up. LIMITATIONS:Our study limitations include restricted follow-up periods and excluding participants who were actively suicidal. CONCLUSIONS:To our knowledge, this is the first examination of the UP for BDD, and results suggest that this disorder shares common mechanisms with other disorders of emotion, and that the UP may be an additional efficacious treatment for this condition.

OBJECTIVE:This study evaluated changes in positive affect within cognitive-behavioral treatments (CBT) for anxiety disorders. It was hypothesized that there would be significantly greater increases in positive affect in CBT conditions compared to the waitlist, and particularly higher in the Unified Protocol (UP) than the single disorder protocols (SDP) given the UP's focus on emotions (including positive emotions) rather than symptoms. METHOD:Patients with heterogeneous anxiety disorders (N = 223) were randomly assigned to the UP, SDP or waitlist. Linear mixed model regression (intent to treat) analyses were used to compare change in positive affect, quality of life, and savoring between patients in the treatment conditions (UP and SDP) versus waitlist conditions. Between condition effect sizes were calculated to assess the magnitude of difference within conditions at post-treatment. RESULTS:Results indicated a significant Group (treatment vs. waitlist) × Time (pre- post-treatment) interaction (F(1, 154.36) = 6.75; p = .01) for positive affect in which the treatment group showed significant improvements in positive affect pre- to post-treatment (ESsg = 0.37, SEsg = 0.09, 95% CI [0.20: 0.54]) and the waitlist condition did not. There were no differences between UP and SDP conditions in positive affect at baseline or at post-treatment. CONCLUSIONS:These results suggest CBT, which typically focuses on reductions in negative affect, may also improve positive affect. The importance of future research evaluating, targeting, and improving positive affect in CBT trials is discussed. Clinicaltrials.gov Identifier: NCT01243606.

Neurogenesis in the adult hippocampus was rediscovered in the 1990's after being reported in the 1960's. Since then, thousands upon thousands of laboratories have reported on the characteristics and presumed functional significance of new neurons in the adult brain. In 1999, we reported that mental training with effortful learning could extend the survival of these new cells and in the same year, others reported that physical training with exercise could increase their proliferation. Based on these studies and others, we developed MAP Train My Brain™, which is a brain fitness program for humans. The program combines mental and physical (MAP) training through 30-min of effortful meditation followed by 30-min of aerobic exercise. This program, when practiced twice a week for eight weeks reduced depressive symptoms and ruminative thoughts in men and women with major depressive disorder (MDD) while increasing synchronized brain activity during cognitive control. It also reduced anxiety and depression and increased oxygen consumption in young mothers who had been homeless. Moreover, engaging in the program reduced trauma-related cognitions and ruminative thoughts while increasing self-worth in adult women with a history of sexual trauma. And finally, the combination of mental and physical training together was more effective than either activity alone. Albeit effortful, this program does not require inordinate amounts of time or money to practice and can be easily adopted into everyday life. MAP Training exemplifies how we as neuroscientists can take discoveries made in the laboratory out into the world for the benefit of others.

OBJECTIVE:Parental age at birth has been shown to affect the rates of a range of neurodevelopmental disorders, but the understanding of the mechanisms through which it mediates different outcomes is still lacking. A population-based cohort was used to assess differential effects of parental age on estimates of risk across pediatric-onset neuropsychiatric disorders: autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), and Tourette's disorder/chronic tic disorder (TD/CT). METHOD:The study cohort included all singleton births in Denmark from 1980 through 2007 with full information on parental ages (N = 1,490,745) and was followed through December 31, 2013. Cases of ASD, ADHD, OCD, and TD/CT were identified in the Danish Psychiatric Central Register and the National Patient Register. Associations with parental age were modeled using a stratified Cox regression, allowing for changes in baseline diagnostic rates across time. RESULTS:Younger parental age was significantly associated with increased estimates of risk for ADHD and TD/CT, whereas older parental age was associated with ASD and OCD. Except for OCD, no evidence for differential effects of parental ages on male versus female offspring was observed. CONCLUSION:This study provides novel evidence for the association between age at parenthood and TD/CT and OCD and for the first time shows in a population-based sample that parental age confers differential risk rates for pediatric-onset psychiatric disorders. These results are consistent with a model of shared and unshared risk architecture for pediatric-onset neuropsychiatric conditions, highlighting unique contributions of maternal and paternal ages.