Faculty Bibliography

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.

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: Temper outbursts are frequently considered symptoms of irritability within the context of ODD, mood disorder, and anxiety disorder. However, even when chronic irritability is not present, they are associated with significant functional impairments. We will provide an overview of our research program that takes a multimodal approach to understanding severe temper outbursts in young children. Methods: We evaluated 216 boys and girls (ages 5-9 years; 73% boys) from diverse socioeconomic backgrounds who comprised three groups: 1) children with severe temper outbursts (STO; n = 80); 2) children with ADHD without outbursts (ADHD; n = 79); and 3) typically developing children (TDC; n = 57). Severe temper outbursts were defined as follows: 1) occurring at least three times per week; 2) lasting >10 minutes; 3) excessive for developmental level; and 4) causing significant impairment. Parents completed a semistructured diagnostic interview about their child and questionnaires about their child's behavior and emotion regulation skills. Children completed brief IQ and language screeners, questionnaires about their emotions and behavior, and tasks assessing frustration tolerance and emotion regulation. A number of these children (64 percent) successfully completed an MRI session that included resting-state, structural, and diffusion tension imaging scans. Results: Approximately 84 percent of the STO group received an ADHD diagnosis, 67 percent were diagnosed with ODD, 28 percent were diagnosed with an anxiety disorder, and 12 percent were diagnosed with a mood disorder. Few exhibited chronic irritabilities based on parent report. On an emotion regulation task, the STO group demonstrated deficits in regulating negative affect in response to frustration. Findings from the resting-state fMRI analyses suggest disruptions in dorsal anterior cingulate cortex (dACC) circuitry associated with tantrum severity. Tantrum severity was also related to cortical thickness of the dACC. Conclusions: Children with severe temper outbursts represent a highly impaired group, even when chronic irritability is not present. Evidence suggests an association between these outbursts and disruptions in dACC circuitry, a region implicated in the expression and regulation of frustration. Such findings have important implications for future conceptualization and treatment of young children with severe temper outbursts

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.

Objectives: The application of mindfulness-based practices in psychiatry is indeed real and patient-level outcomes include symptom reduction and enhanced sense of well-being. Perhaps as importantly, the provider also experiences gains such as enhanced attention, empathy, compassion, and resilience. Methods: This hands-on workshop led by experienced mindfulness-based researchers, practitioners, and authors will consider the evidence for mindfulness in clinical psychiatry and teach the audience several simple mindfulness exercises for themselves and their patients. Results: Upon workshop completion, participants will have considered the application of mindfulness in several common practice-based cases in child psychiatry. Conclusions: The clinician will be able to define mindfulness, understand its applications, refine mindfulness techniques as part of their toolkit, and access mindfulness resources for themselves and their child and adolescent patients

Objectives: The five presenters and discussant in this Clinical Perspectives highlight the challenges associated with pediatric psychiatric crises in standard emergency care settings. Each presenter will focus on a crisis care model that can address urgent patient needs, improve access to mental health care, and decrease unnecessary time or treatments in hospitals Methods: A literature review of pediatric mental health emergencies and crisis care systems will be provided. Each presenter will share her experience in creating, implementing, and/or practicing a particular crisis care model, including phone triage systems, mobile crisis clinics, and crisis stabilization and residential units. Presenters will discuss funding and community resources that have made such projects feasible and highlight key components of program development. Results: Communities and agencies are responding to increased emergent pediatric mental health needs by shifting treatment from standard emergency department settings to a continuum of team-based and nonhospital services. Each of the crisis care models included here has improved community access to behavioral health providers and helped triage children to more appropriate locations/programs of care. Data collected from individual sites indicate improved quality of care and interagency relationships, decreased length of stay or need for emergency department visits, increased outpatient follow-up, and decreased need for inpatient hospitalizations. Conclusions: Providing quality care to youth in mental health crises has become a challenge in our current health care system, with the decline of inpatient beds, lack of providers with mental health training, and limited access to community mental health services. A continuum of psychiatric crisis care services can better meet community and patient needs, thereby relieving burden on emergency departments and linking children and families to the services they need. More research on additional outcomes, as well as establishment of national standards of pediatric psychiatric crisis care, is needed

We review recent findings related to the neurobiology of infant attachment, emphasizing the role of parenting quality in attachment formation and emotional development. Current findings suggest that the development of brain structures important for emotional expression and regulation (amygdala, prefrontal cortex, hippocampus) is deeply associated with the quality of care received in infancy, with sensitive caregiving providing regulation vital for programming these structures, ultimately shaping the development of emotion into adulthood. Evidence indicates that without sensitive caregiving, infants fail to develop mechanisms needed for later-life emotion and emotion regulation. Research suggests that a sensitive period exists in early life for parental shaping of emotional development, although further cross-species research is needed to discern its age limits, and thus inform interventions.