Faculty Bibliography

BACKGROUND:Children in Sub-Saharan Africa (SSA) comprise half of the total regional population, yet existing mental health services are severely under-equipped to meet their needs. Although effective interventions for the treatment of disruptive behavioral disorders (DBDs) in youth have been tested in high-poverty and high-stress communities in developed countries, and are relevant for widespread dissemination in low- and middle-income countries (LMICs), most of these evidence-based practices (EBPs) have not been utilized in SSA, a region heavily impacted by poverty, diseases including HIV/AIDS, and violence. Thus, this paper presents a protocol for a scale-up longitudinal experimental study that uses a mixed-methods, hybrid type II, effectiveness implementation design to test the effectiveness of an EBP, called Multiple Family Group (MFG) aimed at improving child behavioral challenges in Uganda while concurrently examining the multi-level factors that influence uptake, implementation, sustainment, and youth outcomes. METHODS:The MFG intervention will be implemented and tested via a longitudinal experimental study conducted across 30 public primary schools located in both semi-urban and rural communities. The schools will be randomly assigned to three study conditions (n = 10 per study condition): (1) MFG delivered by trained family peers; (2) MFG delivered by community health workers; or; (3) comparison: usual care comprising mental health care support materials, bolstered with school support materials. A total of 3000 children (ages 8 to 13 years; grades 2 to 7) and their caregivers (N = 3000 dyads); 60 parent peers, and 60 community health workers will be recruited. Each study condition will comprise of 1000 child-caregiver dyads. Data will be collected at baseline, 8 and 16 weeks, and 6-month follow-up. DISCUSSION/CONCLUSIONS:This project is the first to test the effectiveness of the MFG intervention while concurrently examining multi-level factors that influence overall implementation of a family-based intervention provided in schools and aimed at reaching the large child population with mental health service needs in Uganda. Moreover, the study draws upon an EBP that has already been tested for delivery by parent peers and community facilitators, and hence will take advantage of the advancing science behind task-shifting. If successful, the project has great potential to address global child mental health needs. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov, ID: NCT03081195 . Registered on 16 March 2017.

Background It remains unclear if naltrexone combined with psychotherapy is superior to naltrexone alone in treating alcohol use disorders (AUD). The current meta-analysis examined the hypothesis that psychotherapy is a significant moderator that influences AUD-related outcomes and that naltrexone combined with psychotherapy is associated with significantly better AUD-related outcomes than naltrexone alone. Methods A total of 30 studies (N_naltrexone = 2317; N_placebo = 2056) were included. Random effects model meta-analyses were carried out for each of the studied outcomes. Subsequently, the random effects model pooled estimates from studies with and without psychotherapy were compared using a Wald test. A mixed-effect model, incorporating psychotherapy as a moderator, was used to examine the impact of psychotherapy on treatment outcomes. Results Naltrexone had a significant treatment effect on abstinence relapse and Gamma-Glutamyl Transferase levels, but not cravings. The pooled estimates for studies with and without psychotherapy were not significantly different for any of the studied outcomes. Psychotherapy was not a significant moderator in the mixed effects models for any of the studied outcomes. Conclusions Naltrexone treatment is efficacious in reducing alcohol consumption, but not reducing cravings. Adding psychotherapy on top naltrexone did not result in any significant additional benefit for AUD patients.

BACKGROUND:Prefrontal-limbic circuits that form the neural architecture for emotion to influence behavior have been implicated in the pathophysiology of attention-deficit/hyperactivity disorder (ADHD) and represent a potentially important target of medication treatment that has not been substantively evaluated. This study tested the effect of the psychostimulant prodrug lisdexamfetamine dimesylate on amygdala activation and connectivity during the emotional bias of response execution and inhibition. METHODS:Twenty-five adults with ADHD were scanned twice with event-related functional magnetic resonance imaging while performing an emotional go/no-go task after 3 to 4 weeks of lisdexamfetamine treatment and 3 weeks off medication in a randomized, counterbalanced, hybrid crossover design. Drug, trial type, and face emotion (happy, sad, or neutral) were included as within-subjects factors in repeated measures analyses of activation and connectivity. RESULTS:Lisdexamfetamine was associated with increased right amygdala activation and reduced psychophysiological interactions with the orbital aspect of the left inferior frontal gyrus specifically for responses to sad faces compared with placebo, but there was no effect on the accuracy of response execution or inhibition. The relative gain in right amygdala activation in response to sad faces for lisdexamfetamine was correlated with a reduction in symptoms of ADHD. CONCLUSIONS:Treatment with lisdexamfetamine potentiates affective encoding in amygdala, purportedly via catecholaminergic mechanisms, but functionally disconnects the amygdala from inferior frontal regions that encode behavioral significance-resulting in reduced emotional bias of cognitive control. Pinpointing the neurophysiologic underpinnings of therapeutic improvement with lisdexamfetamine represents a first step in developing targeted approaches to treatment of ADHD.

BACKGROUND:Experimental research supports delay aversion as a motivational feature of attention deficit/hyperactivity disorder (ADHD). To investigate the neurobiology of delay aversion in ADHD, this study examined whether adolescents with ADHD display an unusually strong activation in affective brain regions in response to cues predicting forthcoming delay and whether these effects are (a) delay-dose dependent and (b) statistically mediate the association between ADHD and self-reported delay aversion. METHODS:Twenty-nine right-handed male adolescents with combined type ADHD and 32 typically developing controls (ages 10-18 years) performed a reaction time task in an MRI scanner. Pretarget cues indicated delay-related response consequences. One indicated that delay would follow the response irrespective of response speed (CERTAIN DELAY), a second that delay would only follow if the response was too slow (CONDITIONAL DELAY), and a third that no delay would follow the response whatever its speed (NO DELAY). Delay levels were 2, 6, or 14 s. Participants also rated their own delay aversion in everyday life. RESULTS:Individuals with ADHD rated themselves as more delay averse than controls. Significantly greater activation to CERTAIN DELAY cues relative to NO DELAY cues was found in participants with ADHD compared to controls (bilaterally) in amygdala, anterior insula, temporal pole, dorsolateral prefrontal cortex (DLPFC), and ventromedial prefrontal cortex. Amygdala and DLPFC activation strength were strongly and delay-dose dependently correlated with delay aversion ratings, and statistically mediated the relationship between ADHD status and delay aversion. CONCLUSIONS:When presented with cues predicting impending delay, adolescents with ADHD, relative to controls, displayed a delay-related increase in activation in amygdala and DLPFC, regions known to be implicated in the processing of aversive events. Future studies should examine the specificity of these effects to delay aversion compared to aversive events in general.

OBJECTIVE:Children with ADHD overestimate their own social and behavioral competence when using explicit self-report measures, a phenomenon known as Positive Illusory Bias (PIB). This study examined whether children with ADHD show PIB when self-perceptions are measured implicitly, reflecting associations that are relatively difficult to consciously control. METHOD/METHODS:Participants were 23 children (ages 6.8-9.8) with ADHD and 55 typically developing (TD) children. Children's explicit self-perceptions of competence were measured via self-report on the Self-Perception Profile for Children; their implicit associations were assessed using an Implicit Association Test. Parent and teacher ratings formed an adult-reported composite indicator of children's competence, to which children's self-perceptions were compared. RESULTS:Children with ADHD overestimated their competence as compared with adult-informant reports on both explicit and implicit measures, whereas TD children tended to be accurate. CONCLUSION/CONCLUSIONS:Inflated self-perceptions in children with ADHD may exist on an implicit level outside of conscious awareness.

This study examined the diagnostic and clinical utility of the Child and Adolescent Symptom Inventory-4 R (CASI-4 R) Depressive and Dysthymia subscale for detecting mood disorders in youth (ages 6-12; M = 9.37) visiting outpatient mental health clinics. Secondary analyses (N = 700) utilized baseline data from the Longitudinal Assessment of Manic Symptoms study. Semistructured interviews with youth participants and their parents/caregivers determined psychiatric diagnoses. Caregivers and teachers completed the CASI-4 R. CASI-4 R depressive symptom severity and symptom count scores each predicted mood disorder diagnoses. Both caregiver scores (symptom severity and symptom count) of the CASI-4 R subscale significantly identified youth mood disorders (areas under the curve [AUCs] = .78-.79, ps < .001). The symptom severity version showed a small but significant advantage. Teacher symptom severity report did not significantly predict mood disorder diagnosis (AUC = .56, p > .05), whereas the teacher symptom count report corresponded to a small effect size (AUC = .61, p < .05). The CASI-4 R Depression scale showed strong incrememental validity even controlling for the other CASI-4 R scales. Caregiver subscale cutoff scores were calculated to assist in ruling in (diagnostic likelihood ratio [DLR] = 3.73) or ruling out (DLR = 0.18) presence of a mood disorder. The CASI-4 R Depressive subscale caregiver report can help identify youth mood disorders, and using DLRs may help improve diagnostic accuracy.

Encoding and retrieval difficulties, and avoidance of both traumatic and positive memories, are associated with posttraumatic stress disorder (PTSD) symptoms. However, most PTSD research and clinical work has solely examined the role of traumatic memories in the maintenance/resolution of PTSD symptoms. This review provides a comprehensive discussion of the literature on positive memories and PTSD. First, we review theories and evidence on the relations between trauma, PTSD, and memory processes (particularly positive memories). Next, we propose a conceptual model that integrates evidence from experimental and positive/memory-based intervention research and highlights hypothesized mechanisms underlying the potential effectiveness of targeting positive memories in PTSD interventions. Specifically, we discuss how targeting positive memories could (1) increase positive affect and reduce negative affect, (2) correct negative cognitions, (3) increase specificity of retrieving autobiographical memories, and (4) be effectively integrated/sequenced with and enhance the effects of trauma-focused interventions. Lastly, we suggest clinical research avenues for investigating the relations between positive memories and PTSD, to possibly alter the current PTSD intervention paradigm focused only on traumatic memories. Overall, our proposed model drawing from experimental and intervention research, and outlining potential effects of targeting positive memories to reduce PTSD severity, needs further empirical investigation.

Is covert visuospatial attention-selective processing of information in the absence of eye movements-preserved in adults with attention-deficit/hyperactivity disorder (ADHD)? Previous findings are inconclusive due to inconsistent terminology and suboptimal methodology. To settle this question, we used well-established spatial cueing protocols to investigate the perceptual effects of voluntary and involuntary attention on an orientation discrimination task for a group of adults with ADHD and their neurotypical age-matched and gender-matched controls. In both groups, voluntary attention significantly improved accuracy and decreased reaction times at the relevant location, but impaired accuracy and slowed reaction times at irrelevant locations, relative to a distributed attention condition. Likewise, involuntary attention improved accuracy and speeded responses. Critically, the magnitudes of all these orienting and reorienting attention effects were indistinguishable between groups. Thus, these counterintuitive findings indicate that spatial covert attention remains functionally intact in adults with ADHD.

PURPOSE OF REVIEW:This review summarizes the recent literature examining nonsuicidal self-injury (NSSI) in adolescents, with a particular focus on how primary care pediatricians (PCPs) might assess and intervene as a common first point of contact. This NSSI review is timely and relevant, given the prevalence rates among adolescents, as well as its link to suicidal behaviors. RECENT FINDINGS:NSSI is most prevalent among adolescents, with lifetime prevalence rates between 17 and 60%. With evidence that the most common age of onset is between 12 and 14 years, evaluating NSSI is a challenging yet necessary aspect of a comprehensive adolescent medical examination. The function of NSSI behaviors may have implications for effective treatment and should be included in assessment. The majority of research has indicated that NSSI serves an emotion regulation function, in that the behavior results in a decrease in intensity of adverse emotional states in the absence of more effective coping strategies. SUMMARY:Considering the prevalence of self-injury among adolescents, the likelihood that PCPs will encounter NSSI in their practice is quite high. Given that more than 50% of youth do not receive needed mental health services, it is critical that PCPs assess for NSSI and intervene accordingly.