Faculty Bibliography

Adolescents are an important population to represent in biobanks. Inclusion of biospecimens from adolescents advances our understanding of the long-term consequences of pediatric disease and allows the discovery of methods to prevent adult diseases during childhood. Consent for biobanking is complex, especially when considering adolescent participation, as it brings up issues that are not present with general clinical research. The development and successful implementation of an adolescent capacity assessment tool applied specifically to biobanking can potentially provide researchers and clinicians with contextualized information on participants' understanding, appreciation, reasoning, and voluntary choice for biobanks. This tool would enhance current studies looking at the role of shared decision-making in biobanking, as well as provide a formal measurement when considering decisions around pediatric and adolescent biobanking participation. This study adapted the MacCAT-CR for use with a hypothetical adolescent biobank study and examines predictors of MacCAT-CR scores on healthy and chronically ill adolescents.

Attachment-related learning (that is, forming preferences for cues associated with the parent) defies the traditional rules of learning in that it seems to occur independently of apparent reinforcement¹-young children prefer cues associated with their parent, regardless of valence (rewarding or aversive), despite the diversity of parenting styles². This obligatory attraction for parental cues keeps the child nearby and safe to explore the environment; thus, it is critical for survival and sets the foundation for normal human cognitive-emotional behaviour. Here we examined the learning underlying this attraction in preschool-age children. Young children underwent an aversive conditioning procedure either in the parent's presence or alone. We showed that despite disliking the aversive unconditioned stimulus, children exhibited a behavioural approach for conditioned stimuli that were acquired in the parent's presence and an avoidance for stimuli acquired in the parent's absence, an effect that was strongest among those with the lowest cortisol levels. The results suggest that learning systems during early childhood are constructed to permit modification by parental presence.

We investigated the real-time cascade of postural, visual, and manual actions for object prehension in 38 6- to 12-month-old infants (all independent sitters) and eight adults. Participants' task was to retrieve a target as they spun past it at different speeds on a motorized chair. A head-mounted eye tracker recorded visual actions and video captured postural and manual actions. Prehension played out in a coordinated sequence of postural-visual-manual behaviors starting with turning the head and trunk to bring the toy into view, which in turn instigated the start of the reach. Visually fixating the toy to locate its position guided the hand for toy contact and retrieval. Prehension performance decreased at faster speeds, but quick planning and implementation of actions predicted better performance.

This article presents an integrative approach to the special challenges of therapy with couples on the brink of dissolution or divorce-who often describe this therapy as their "last chance." In some, one partner is considering ending the relationship, and in others, both partners are considering ending it. Often, these couples have had prior dissatisfying experiences in couple therapy. Four types of last chance couples are described: high-conflict couples; couples in which partners have differing goals for their lives or different timelines for reaching shared goals; couples in which one or both partners have acted in a manner that violates the values, expectations, emotional comfort, or safety of the other; and couples in which there has been a gradual loss of intimacy. The Therapeutic Palette, a multiperspectival, theoretically eclectic integrative approach, is enlisted as a general framework for selecting and sequencing use of particular theories and their associated practices, based on the three "primary colors" of couple therapy: time frame/focus, level of directiveness, and change entry point. An additional complementary framework, the creative relational movement approach, is proposed to provide an integrative frame encompassing both language-based and action-based practices, suggesting that meaning is held and expressed as much through interaction or "relational motion" as it is through language. Principles of change are described. Due to the couple's level of crisis and desire for immediate evidence of possible improvement, priority is given to action-based interventions in early stages of therapy, by engaging couples in "experiments in possibility." Typical action approaches are described. An extended vignette follows.

Objective: This study examined adult attention-deficit/hyperactivity disorder (ADHD) screening and management patterns among healthcare provider (HCP) subgroups. Methods: An online survey of US-based HCPs (neurologists, n=200; nurse practitioners [NPs], n=100; psychiatrists, n=201; primary care physicians [PCPs], n=201) was conducted from May to June 2017. The survey assessed issues relating to adult ADHD screening and management and HCP perceptions of factors influencing patient choice of pharmacotherapy. Participants were required to be experienced in diagnosing and/or treating ADHD in adults (≥5 patients/month for neurologists and NPs; ≥10 patients/month for psychiatrists and PCPs). Results: Significantly greater percentages of psychiatrists than non-psychiatrists were confident in diagnosing ADHD (P<0.001) and screened/evaluated for ADHD in patients with depression/anxiety disorders (P<0.001). Significantly greater percentages of psychiatrists versus non-psychiatrists prescribed once-daily long-acting (LA) stimulants (71.6% vs 62.2%; P=0.023) or short-acting (SA) stimulants more than once daily (40.3% vs 29.7%; P=0.009) as first-line therapy. In contrast, a significantly greater percentage of non-psychiatrists than psychiatrists prescribed once-daily SA stimulants (32.9% vs 17.4%; P<0.001). Psychiatrist and non-psychiatrist HCPs viewed insurance coverage/treatment costs (79.9%), perceived duration of effect (72.2%), and side effects (66.5%) as important factors to patients when choosing treatment. HCPs reported that the greatest mean ± SD percentages of patients changed their treatment regimen in the past 6 months because of perceptions of insufficient duration of effect (35.4%±22.1%) and lack of efficacy (30.3%±21.0%). Conclusion: Compared with psychiatrists, non-psychiatrists exhibited less confidence in diagnosing adult ADHD and experienced greater difficulty determining optimal treatment regimens.

Over the past two decades, a low frequency variant (rs1800012) within the first intron of the type I collagen alpha 1 (COLIA1) gene has been implicated in lower areal BMD (aBMD) and increased risk of osteoporotic fracture. This association is particularly strong in postmenopausal women, in whom net bone loss arises in the context of high bone turnover. High bone turnover also accompanies childhood linear growth; however, the role of rs1800012 in this stage of net bone accretion is less well understood. Thus, we assessed the association between rs1800012 and aBMD and bone mineral content (BMC) Z-scores for the 1/3 distal radius, lumbar spine, total hip, and femoral neck total body less head in the Bone Mineral Density in Childhood Study, a mixed-longitudinal cohort of children and adolescents (total n = 804 girls and 771 boys; n = 19 girls and 22 boys with the TT genotype). Mixed effects modeling, stratified by sex, was used to test for associations between rs1800012 and aBMD or BMC Z-scores and for pubertal stage interactions. Separately, SITAR growth modeling of aBMD and BMC in subjects with longitudinal data reduced the complex longitudinal bone accrual curves into three parameters representing a-size, b-timing, and c-velocity. We tested for differences in these three parameters by rs1800012 genotype using t-tests. Girls with the TT genotype had significantly lower aBMD and BMC Z-scores prior to puberty completion (e.g. spine aBMD-Z P-interaction = 1.0 × 10^-6), but this association was attenuated post-puberty. SITAR models revealed that TT girls began pubertal bone accrual later (b-timing; e.g. total hip BMC, P = 0.03). BMC and aBMD Z-scores also increased across puberty in TT homozygous boys. Our data, along with previous findings in post-menopausal women, suggest that rs1800012 principally affects female bone density during periods of high turnover. Insights into the genetics of bone gain and loss may be masked during the relatively quiescent state in mid-adulthood, and discovery efforts should focus on early and late life.

CONTEXT/BACKGROUND:Dual-energy X-ray absorptiometry (DXA) is a cornerstone of pediatric bone health assessment, yet differences in height-for-age confound the interpretation of areal bone mineral density (aBMD) measures. To reduce the confounding of short stature on spine bone density, use of bone mineral apparent density (BMAD) and height-for-age Z-score (HAZ)‒adjusted aBMD (aBMDHAZ) are recommended. However, spine BMAD reference data are sparse, and the degree to which BMAD and aBMDHAZ account for height-related artifacts in bone density remains unclear. OBJECTIVE:We developed age-, sex-, and population ancestry‒specific spine BMAD reference ranges; compared height-adjustment methods in accounting for shorter stature; and assessed the stability of these measures over time. DESIGN/METHODS:Secondary analysis of data from a previous longitudinal study. PARTICIPANTS/METHODS:Children and adolescents aged 5 to 19 years at baseline (n = 2014; 922 males; 22% black) from the Bone Mineral Density in Childhood Study. MAIN OUTCOME MEASURES/METHODS:Lumbar spine BMAD and aBMDHAZ from DXA. RESULTS:Spine BMAD increased nonlinearly with age and was greater in blacks and females (all P < 0.001). Age-specific spine BMAD z-score reference curves were constructed for black and non‒black males and females. Overall, both BMAD and aBMDHAZz scores reduced the confounding influence of shorter stature, but neither was consistently unbiased across all age ranges. Both BMAD and aBMDHAZz scores tracked strongly over 6 years (r = 0.70 to 0.80; all P < 0.001). CONCLUSION/CONCLUSIONS:This study provided robust spine BMAD reference ranges and demonstrated that BMAD and aBMDHAZ partially reduced the confounding influence of shorter stature on bone density.

Annual gains in BMC and areal bone mineral density (aBMD) in children vary with age, pubertal status, height-velocity, and lean body mass accrual (LBM velocity). Evaluating bone accrual in children with bone health-threatening conditions requires consideration of these determinants. The objective of this study was to develop prediction equations for calculating BMC/aBMD velocity SD scores (velocity-Z) and to evaluate bone accrual in youth with health conditions. Bone and body compositions via DXA were obtained for up to six annual intervals in healthy youth (n = 2014) enrolled in the Bone Mineral Density in Childhood Study (BMDCS) . Longitudinal statistical methods were used to develop sex- and pubertal-status-specific reference equations for calculating velocity-Z for total body less head-BMC and lumbar spine (LS), total hip (TotHip), femoral neck, and 1/3-radius aBMD. Equations accounted for (1) height velocity, (2) height velocity and weight velocity, or (3) height velocity and LBM velocity. These equations were then applied to observational, single-center, 12-month longitudinal data from youth with cystic fibrosis (CF; n = 65), acute lymphoblastic leukemia (ALL) survivors (n = 45), or Crohn disease (CD) initiating infliximab (n = 72). Associations between BMC/aBMD-Z change (conventional pediatric bone health monitoring method) and BMC/aBMD velocity-Z were assessed. The BMC/aBMD velocity-Z for CF, ALL, and CD was compared with BMDCS. Annual changes in the BMC/aBMD-Z and the BMC/aBMD velocity-Z were strongly correlated, but not equivalent; LS aBMD-Z = 1 equated with LS aBMD velocity-Z = -3. In CF, BMC/aBMD velocity-Z was normal. In posttherapy ALL, BMC/aBMD velocity-Z was increased, particularly at TotHip (1.01 [-.047; 1.7], p < 0.0001). In CD, BMC/aBMD velocity-Z was increased at all skeletal sites. LBM-velocity adjustment attenuated these increases (eg, TotHip aBMD velocity-Z: 1.13 [0.004; 2.34] versus 1.52 [0.3; 2.85], p < 0.0001). Methods for quantifying the BMC/aBMD velocity that account for maturation and body composition changes provide a framework for evaluating childhood bone accretion and may provide insight into mechanisms contributing to altered accrual in chronic childhood conditions. © 2018 American Society for Bone and Mineral Research.