Faculty Bibliography

Functional abdominal pain (FAP) is a common childhood somatic complaint that contributes to impairment in daily functioning (e.g., school absences) and increases risk for chronic pain and psychiatric illness. Cognitive behavioral treatments for FAP target primarily older children (9 + years) and employ strategies to reduce a focus on pain. The experience of pain may be an opportunity to teach viscerally hypersensitive children to interpret the function of a variety of bodily signals (including those of hunger, emotions) thereby reducing fear of bodily sensations and facilitating emotion awareness and self-regulation. We designed and tested an interoceptive exposure treatment for younger children (5-9 years) with FAP. Assessments included diagnostic interviews, 14 days of daily pain monitoring, and questionnaires. Treatment involved 10 weekly appointments. Using cartoon characters to represent bodily sensations (e.g., Gassy Gus), children were trained to be "FBI agents" - Feeling and Body Investigators - who investigated sensations through exercises that provoked somatic experience. 24 parent-child dyads are reported. Pain (experience, distress, and interference) and negative affect demonstrated clinically meaningful and statistically significant change with effect sizes ranging from 0.48 to 71 for pain and from 0.38 to 0.61 for pain distress, total pain: X² (1, n = 24) = 13.14, p < 0.0003. An intervention that helps children adopt a curious stance and focus on somatic symptoms reduces pain and may help lessen somatic fear generally.

Objectives: More and more youth are presenting to emergency departments (EDs) in psychiatric distress. Many of these youth present with agitated behavior or aggression as a result of psychosis, anxiety, mania, intoxication, or in relation to underlying behavioral disorder. Agitated patients can be dangerous to themselves, staff, and other patients in the ED and may require restraint. Although reduction of restraint and injury is a priority of every ED, there are little published data on the use and efficacy of PRN medications to treat or prevent acute agitation. In the absence of evidence-based guidelines, expert guidance is needed to assist clinicians in choosing effective and appropriate PRN medications for acute agitation. Methods: The Delphi method for consensus guideline development was used by a team of ED-based child and adolescent psychiatrists from across the United States. By use of an iterative, blinded process to reduce bias, participants reviewed existing or published PRN medication algorithms and guidelines for acute agitation and then developed consensus guidelines with identification of areas of dissension and need for further research. Results: There were significant variations in preferred medications across geography and type of ED setting (medical vs. psychiatric ED). Participants emphasized the importance of nonpharmacologic de-escalation strategies; clinical diagnostic assessment, even in the moment of acute agitation; consideration of individual patient factors in choosing medications; and careful monitoring for efficacy and adverse effects. A range of medications, including antipsychotic drugs, antihistamine, benzodiazepine, and a-adrenergic medications, was recommended. Conclusions: There are currently no AACAP Practice Parameters for the psychopharmacological management of agitation, and there is little published literature comparing effectiveness of different PRN medications or comparing those medications to placebo. Expert consensus guidelines such as these provide much-needed guidance to ED clinicians. These guidelines also demonstrate areas where further research is needed, especially into the comparative efficacy of different PRN medications in patients of different ages, clinical presentations, and diagnostic/treatment history

Insecure attachment styles have consistently been identified as risk factors for adolescent psychopathology and, more specifically, suicidal ideation. However, much less is known about the mechanisms that account for the relationship between attachment styles and severity of suicidal ideation within clinical samples. In the current study, adolescents' expectancies for caregiver availability and responsiveness were coded from transcripts of the Suicide Narrative Interview in a clinical sample of 129 depressed and suicidal adolescents. Results indicated that negative expectancies for caregiver availability in the Suicide Narrative Interview were associated both with attachment insecurity and with the intensity of adolescents' suicidal ideation. The implications of adolescents' expectancies for caregiver availability as targets for clinical intervention are discussed.

Objectives: The goal of this session is to bring Clinical Perspectives and the eponymous JAACAP column "into life" by casting content from recent and forthcoming installments of the series into the popular "TED Talk" (Technology, Education, and Design Talk) format. Methods: Following the format first established at the 2014 Annual Meeting, this will be a 180-minute session co-moderated by JAACAP Editor-in-Chief Andres Martin and Assistant Editor for Clinical Perspectives Laura Prager. The session will start with a brief introduction providing the background, context, and "ground rules" for an effective TED Talk, including adherence to tight time limits and minimal use of audiovisual supports. The authors of five published or forthcoming Clinical Perspectives will then each present a 15-minute TED Talk of their respective articles. Each presentation will be followed by five minutes of interactive and moderated discussion. There will be a short break between speakers, allowing for a brief introduction. The session will end with overarching concluding remarks, time for discussion, and an invitation for new submissions. Results: All five presentations will discuss child psychiatric takes on topics of acute public health relevance and social concern that have been featured prominently in the lay media. Conclusions: Child and adolescent psychiatry is grounded in solid clinical practice, and it is from this clinical substrate that important research questions and hypotheses first arise. Clinical Perspectives provides a forum to consider and revisit clinical phenomena anew, a platform from which to reclaim the excitement that first drew us into our chosen field. The TED Talk format, which has been so successful in the global dissemination of Technology, Education, and Design ideas, can be successfully borrowed to reveal that child and adolescent psychiatry does indeed have (clinical) "ideas worth spreading."

BACKGROUND:Adults with bipolar disorder (BD) have higher rates of substance use disorders (SUDs) compared to the general population. SUD rates in young offspring/relatives of BD probands, as well as factors which drive those rates, are not as well-characterized. METHODS:We aimed to examine SUD prevalence among adolescent/young adult offspring and relatives of probands with and without BD. Data were collected from five sites in the US and Australia during 2006-2011. Youth offspring/relatives ("Relatives of BD probands;" n=267; mean age=16.8years; ±2.9S.D.), identified through a proband family member with DSM-IV BD (Type I or II), were compared to offspring/relatives of control probands ("relatives of control probands;" n=149; mean age=17.4years; ±2.9S.D.). Logistic regression with generalized estimating equations was used to compare the groups across a range of substance use and SUD variables. Odds ratios were calculated for lifetime prevalence of substance outcomes. RESULTS:Bivariate analyses showed DSM-IV SUDs were more prevalent among relatives of BD probands than among relatives of control probands (29% vs. 18%; p=0.01). Generalized estimating equation models showed BD mood and childhood-onset externalizing disorders in adolescent and young adult relatives to each significantly increase the odds (OR=2.80-3.17; p<0.02) for the development of several substance variables among all relatives, whereas the risk of SUDs in relatives was not increased when the relatives had no mood or externalizing disorders themselves. CONCLUSION:Relatives of BD probands with lifetime mood and externalizing disorders report more substance use/SUDs than relatives of control probands. In contrast, SUD outcomes in relatives of BD probands without mood or externalizing disorders were no different from control relatives without psychopathology. Early recognition and treatment of psychiatric disorders may lead to less substance use in this highly vulnerable population.

The health of people ever incarcerated in New York City (NYC) jails during 2001 to 2005 was characterized by matching jail, shelter, mortality, sexually transmitted infection, HIV, and tuberculosis (TB) data from the NYC Departments of Health and Mental Hygiene, Correction, and Homeless Services. Compared with nonincarcerated people and those living in the lowest income NYC neighborhoods, those ever incarcerated had higher HIV prevalence and HIV case rates. Ever-incarcerated females also had higher rates of gonorrhea and syphilis than nonincarcerated females. Ever-incarcerated people who used the single adult homeless shelter system had higher HIV, gonorrhea, and TB case rates and all-cause mortality rates than ever-incarcerated people without shelter use, when adjusting for other variables. People ever incarcerated in NYC jails are at risk for conditions of public health importance. Sex-specific jail- and community-based interventions are needed.

States are restructuring health care delivery with a focus on cost savings and care quality. Building on lessons learned from the first statewide roll-out of the NY State Managing and Adapting Practice (MAP) program, we targeted adaptations to the MAP trainings with the goal of addressing key factors related to clinician dropout. We describe these adaptations made to MAP version 2, using Damschroder et al.'s (2009) theoretical model of the consolidated Framework for Implementation Research (CFIR). our adaptations were connected with each of the five domains: intervention characteristics, outer setting (incentives and cost), inner setting (leadership/champions), characteristics of the individuals, and the process of training implementation (planning, engaging, executing, and reflecting and evaluating. Next, we compared dropout rates between MAP version 1 (v1) and MAP version 2 (v2). Because the structural adaptations aimed to increase retention rate by targeting factors hypothesized to be associated with empirically derived predictors of dropout, we expected that the dropout rate would be significantly lower in MAP v2. We then examined associations of clinician sociodemographic characteristics, clinical characteristics, and attitudes with dropout. Although older participant age was significantly associated with dropout in MAP v1, we hypothesized that participant age will not be a significant predictor of dropout in MAP v2 because MAP v2 adaptations focused on age-related factors. However, we expected clinic region, which is immutable, to remain a significant predictor of dropout.

PURPOSE: The purpose of this review was to synthesize current knowledge about anxiety among adolescent survivors of pediatric cancer and highlights areas for future research. METHODS: Systematic literature searches were conducted in five databases for articles published anytime before December 28, 2015. Manuscripts were reviewed by a team of six coders. Included manuscripts reported outcomes relevant to anxiety, worry, and post-traumatic stress in survivors of pediatric cancer (age at the time of study: 10-22 years) who were off treatment. RESULTS: Twenty-four articles met inclusion criteria. Included results were categorized into the following domains: post-traumatic stress, anxiety, cancer-related worry, and interventions. With the exception of post-traumatic stress, there was little research about anxiety in this population; however, studies generally indicated that adolescent survivors of pediatric cancer are at elevated risk for anxiety, post-traumatic stress symptoms, and cancer-related worry. CONCLUSIONS: This review provides preliminary evidence that anxiety is a relevant, but understudied, psychosocial outcome for adolescent survivors of pediatric cancer. More research is needed to better understand the presentation of anxiety in this population, its effect on survivors' quality of life, and possible areas for intervention.