Faculty Bibliography

Cognitive-behavioral therapy (CBT), consisting of exposure and response prevention (EX/RP), is both efficacious and preferred by patients with obsessive-compulsive disorder (OCD), yet few receive this treatment in practice. This study describes the implementation of an Internet-based CBT program (ICBT) developed in Sweden in individuals seeking OCD treatment in New York. After translating and adapting the Swedish ICBT for OCD, we conducted an open trial with 40 adults with OCD. Using the RE-AIM implementation science framework, we assessed the acceptability, feasibility, and effectiveness of ICBT. The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) was the primary outcome measure. Of 40 enrolled, 28 participants completed the 10-week ICBT. In the intent-to-treat sample (N = 40), Y-BOCS scores decreased significantly over time (F = 28.12, df = 2, 49, p < . 001). Depressive severity (F = 5.87, df = 2, 48, p < . 001), and quality of life (F = 12.34, df = 2, 48, p < . 001) also improved. Sensitivity analyses among treatment completers (N = 28) confirmed the intent-to-treat results, with a large effect size for Y-BOCS change (Cohen's d = 1.38). ICBT took less time to implement than face-to face EX/RP and participants were very to mostly satisfied with ICBT. On a par with results in Sweden, the adapted ICBT program reduced OCD and depressive symptoms and improved quality of life among individuals with moderate to severe OCD. Given its acceptability and feasibility, ICBT deserves further study as a way to increase access to CBT for OCD in the United States.

Acute agitation in children and adolescents in the emergency department carries significant risks to patients and staff and requires skillful management, using both nonpharmacologic and pharmacologic strategies. Effective management of agitation requires understanding and addressing the multifactorial cause of the agitation. Careful observation and multidisciplinary collaboration is important. Medical work-up of agitated patients is also critical. Nonpharmacologic deescalation strategies should be first line for preventing and managing agitation and should continue during and after medication administration. Choice of medication should focus on addressing the cause of the agitation and any underlying psychiatric syndromes.

Healthy parenting may be protective against the development of emotional psychopathology, particularly for children reared in stressful environments. Little is known, however, about the brain and behavioral mechanisms underlying this association, particularly during childhood and adolescence, when emotional disorders frequently emerge. Here, we demonstrate that psychological control, a parenting strategy known to limit socioemotional development in children, is associated with altered brain and behavioral responses to emotional conflict in 27 at-risk (urban, lower income) youth, ages 9-16. In particular, youth reporting higher parental psychological control demonstrated lower activity in the left anterior insula, a brain area involved in emotion conflict processing, and submitted faster but less accurate behavioral responses-possibly reflecting an avoidant pattern. Effects were not replicated for parental care, and did not generalize to an analogous nonemotional conflict task. We also find evidence that behavioral responses to emotional conflict bridge the previously reported link between parental overcontrol and anxiety in children. Effects of psychological control may reflect a parenting style that limits opportunities to practice self-regulation when faced with emotionally charged situations. Results support the notion that parenting strategies that facilitate appropriate amounts of socioemotional competence and autonomy in children may be protective against social and emotional difficulties.

Face-to-face interaction between infants and their caregivers is a mainstay of developmental research. However, common laboratory paradigms for studying dyadic interaction oversimplify the act of looking at the partner's face by seating infants and caregivers face to face in stationary positions. In less constrained conditions when both partners are freely mobile, infants and caregivers must move their heads and bodies to look at each other. We hypothesized that face looking and mutual gaze for each member of the dyad would decrease with increased motor costs of looking. To test this hypothesis, 12-month-old crawling and walking infants and their parents wore head-mounted eye trackers to record eye movements of each member of the dyad during locomotor free play in a large toy-filled playroom. Findings revealed that increased motor costs decreased face looking and mutual gaze: Each partner looked less at the other's face when their own posture or the other's posture required more motor effort to gain visual access to the other's face. Caregivers mirrored infants' posture by spending more time down on the ground when infants were prone, perhaps to facilitate face looking. Infants looked more at toys than at their caregiver's face, but caregivers looked at their infant's face and at toys in equal amounts. Furthermore, infants looked less at toys and faces compared to studies that used stationary tasks, suggesting that the attentional demands differ in an unconstrained locomotor task. Taken together, findings indicate that ever-changing motor constraints affect real-life social looking.

Pediatric psychiatric emergency care is delivered in different settings with vastly different resources around the country. Training programs lack guidance on developing optimal curricula for this highly variable but crucial setting. A model curriculum for child and adolescent psychiatry trainees may be helpful to provide such guidance; its components include recommendations for assessing baseline knowledge, identifying and teaching core subject content, encouraging development of essential skills, and building in supervision for learners. Future directions include further study in current pediatric emergency psychiatry education and expanding the scope of curricula to include different learners and delivery models.

BACKGROUND:Little is known about the impact of prenatal maternal stress (PNMS) on the developmental trajectory of temperament and few studies have been able to incorporate a natural disaster as a quasi-experimental stressor. The current study investigated PNMS related to Superstorm Sandy ('Sandy'), a hurricane that struck the New York metropolitan area in October 2012, in terms of objective exposure during pregnancy, subjective stress reaction as assessed by maternal symptoms of post-traumatic stress, and their impact on the developmental changes in temperament during early childhood. METHOD:A subsample of 318 mother-child dyads was drawn from the Stress in Pregnancy Study. Temperament was measured at 6, 12, 18, and 24 months of age. RESULTS:Objective exposure was associated with greater High-Intensity Pleasure, Approach, Perceptual Sensitivity and Fearfulness, but lower Cuddliness and Duration of Orientation at 6 months. Objective exposure and its interaction with subjective stress reaction predicted developmental changes in temperament. In particular, objective exposure was linked to greater increases in Activity Level but decreases in High-Intensity Pleasure, Approach, and Fearfulness. The combination of objective exposure and subjective stress reaction was also associated with greater increases in Activity Level. LIMITATIONS:Temperament was measured solely via maternal report. Trimester-specific effects of Sandy on temperament were not examined. CONCLUSION:This is the first study to examine the effects of prenatal maternal exposure to a natural disaster on trajectories of early childhood temperament. Findings suggest that both objective stress exposure and subjective stress reaction in-utero predict developmental trajectories of temperament in early childhood.

BACKGROUND:There is substantial evidence that bipolar disorder (BD) manifests on a spectrum rather than as a categorical condition. Detection of people with subthreshold manifestations of BD is therefore important. The Hypomania Checklist-32 (HCL-32) was developed as a tool to identify such people. PURPOSE:The aims of this paper were to: (1) investigate the factor structure of HCL-32; (2) determine whether the HCL-32 can discriminate between mood disorder subtypes; and (3) assess the familial aggregation and cross-aggregation of hypomanic symptoms assessed on the HCL with BD. PROCEDURES:Ninety-six probands recruited from the community and 154 of their adult first-degree relatives completed the HCL-32. Diagnosis was based on semi-structured interviews and family history reports. Explanatory factor analysis and mixed effects linear regression models were used. FINDINGS:A four-factor ("Activity/Increased energy," "Distractibility/Irritability", "Novelty seeking/Disinhibition, "Substance use") solution fit the HCL-32, explaining 11.1% of the total variance. The Distractibility/Irritability score was elevated among those with BP-I and BP-II, compared to those with depression and no mood disorders. Higher HCL-32 scores were associated with increased risk of BD-I (OR = 1.22, 95%CI 1.14-1.30). The "Distractibility/Irritability" score was transmitted within families (β = 0.15, p = 0.040). However, there was no familial cross-aggregation between mood disorders and the 4 HCL factors. CONCLUSIONS:Our findings suggest that the HCL-32 discriminates the mood disorder subtypes, is familial and may provide a dimensional index of propensity to BD. Future studies should explore the heritability of symptoms, rather than focusing on diagnoses.

CONTEXT:Polytraumatization classes based on trauma endorsement patterns relate to distinct clinical outcomes. Person-centered approaches robustly evaluate the nature, and construct validity of polytraumatization classes. OBJECTIVE:Our review examined evidence for the nature and construct validity of lifespan polytraumatization typologies. DATA SOURCES:In September 2016, we searched Pubmed, PSYCINFO, PSYC ARTICLES, Academic Search Complete, PILPTS, Web of Science, CINAHL, Medline, PsycEXTRA, and PBSC. Search terms included "latent profile," "latent class," "latent analysis," "person-centered," "polytrauma," "polyvictimization," "traumatization," "lifetime," "cooccurring," "complex," "typology," "multidimensional," "sequential," "multiple," "subtype," "(re)victimization," "cumulative," "maltreatment," "abuse," and "stressor." Inclusionary criteria included: peer-reviewed; latent class/latent profile analyses (LCA/LPA) of lifespan polytrauma classes; adult samples of size greater than 200; only trauma types as LCA/LPA indicators; mental health correlates of typologies; and individual-level trauma assessment. Of 1,397 articles, nine met inclusion criteria. DATA EXTRACTION:Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, research assistants completed a secondary reference search, and independently extracted data with standardized coding forms. RESULTS:Three-class (n = 5) or four-class (n = 4) solutions were found. Seven studies found a class characterized by higher trauma endorsement (high-trauma). All studies found a class characterized by lower trauma endorsement (low-trauma), and predominance of specific traumas (specific-trauma; e.g., childhood maltreatment). High-trauma versus low-trauma classes and specific-trauma versus low-trauma classes differed on mental health correlates. CONCLUSION:Evidence supports the prevalence of a high-trauma class experiencing poorer mental health, and the detrimental impact of aggregated interpersonal and other traumas. We highlight the clinical importance of addressing polytraumatization classes, and comprehensively assessing the impact of all traumas.

BACKGROUND:Attention-deficit/hyperactivity disorder (ADHD) is proposed to be a neuropsychologically heterogeneous disorder that encompasses two distinct sub-groups, one with executive function (EF) deficits and one with delay aversion (DA). However, such claims have often been based on studies that have operationalized neuropsychological deficits using a categorical approach - using intuitive but rather arbitrary, clinical cut-offs. The current study applied an alternative empirical approach to sub-grouping in ADHD, latent profile analysis (LPA), and attempted to validate emerging subgroups through clinically relevant correlates. METHODS:One-hundred medication-naïve children with ADHD and 96 typically developing children (6-14 years) completed nine EF and three DA tasks as well as an odor identification test. Parents and teachers provided reports of the children's behavior (ADHD and EF). Models of the latent structure of scores on EF and DA tests were contrasted using confirmatory factor analysis (CFA). LPA was carried out based on factor scores from the CFA and sub-groups were compared in terms of odor identification and behavior. RESULTS:A model with one DA and two EF factors best fit the data. LPA resulted in four sub-groups that differed in terms of general level of neuropsychological performance (ranging from high to very low), odor identification, and behavior. The sub-groups did not differ in terms of the relative EF and DA performance. Results in the ADHD group were replicated in the control group. CONCLUSIONS:While EF and DA appear to be dissociable constructs; they do not yield distinct sub-groups when sub-grouping is based on a statistical approach such as LPA.

The emergency department's role in a psychiatric crisis is to assess for safety, provide crisis interventions, reach a diagnosis, make decisions about disposition and treatment, and provide linkage to the next level of care within the hospital or in the community. The evaluation of children and adolescents involved in the child welfare system brings numerous additional challenges to this already-complex environment, including familial and systemic issues and an almost ubiquitous history of trauma. This article endeavors to increase understanding of child welfare-related issues and provides insight toward using a more trauma-informed and comprehensive approach that incorporates all these factors.