Faculty Bibliography

Objectives: This talk will review the clinical significance of symptoms of mood (emotional) dysregulation versus frank co-occurring mood disorders in adults with ADHD and examine evidence for the potential treatment of co-occurring mood disorders or symptoms of emotional dysregulation in adults with ADHD. Methods: Studies on co-occurring mood disorders and emotional dysregulation symptoms in adults with ADHD were surveyed and reviewed via PubMed search and cross-referencing from review articles/chapters. Results: Mood dysregulation has been shown to be a commonly occurring symptom in adults with ADHD and exists as a separate, unique factor compared with symptoms of inattention, hyperactivity/impulsivity, and executive dysfunction. The same factor analysis found that emotional dysregulation symptoms loaded highly on the combined subtype of ADHD or in cases that did not meet full ADHD criteria. Treatment studies have found that emotional dysregulation symptoms do generally respond to treatment with stimulants or with the nonstimulant, atomoxetine, but at approximately half the effect size of stimulants. Studies have shown high rates of mood disorders of bipolar disorder (10-15%), major depression (15-20%), and dysthymia (20%) in adults with ADHD. Furthermore, rates of ADHD are quite high in individuals with mood disorders. The available literature on treating ADHD and comorbid mood disorders is surprisingly scant. Bupropion has an extensive history of use as an antidepressant, and several studies have shown it to be an effective nonstimulant in ADHD, but studies have not systematically assessed its use when mood disorders or mood dysregulation co-occur with ADHD. A handful of studies have examined the addition of stimulant medications to patients with major depression treated with antidepressants. Conclusions: Clinicians should be aware of high rates of co-occurring mood disorders in adults with ADHD, and the reverse, as not identifying one of the comorbidities may result in incomplete treatment or negative outcomes. High rates of mood dysregulation symptoms have been reported in adults with ADHD, even though they are not part of the core ADHD symptoms in DSM-5

Purpose The African American church has long been recognized as a valuable partner for health interventions in the community. While an extensive literature exists documenting the potential efficacy of diabetes education programs in church settings, there has yet to be an effort to leverage spiritual beliefs and practices to promote diabetes self-management and shared decision making within a faith-based framework that is culturally tailored to the African American church. The purpose of this article is to describe the translation of a clinic-based diabetes education program into faith-based education curriculum tailored for use in the African American church. Conclusions Themes extracted from focus groups and input from a faith-based community partner provided a methodical and patient-informed foundation for culturally tailoring and piloting a diabetes self-management curriculum for the African American church setting. This study illustrates how spirituality can be incorporated into interventions to enhance health promotion and behavioral change among African Americans with diabetes. Participants in our study described how religious beliefs play an active role in many aspects of diabetes care, including self-management behaviors, coping strategies, and patient/provider communication. In addition, this intervention can serve as a model for the development of patient-centered health interventions.

Objectives: This clinical perspectives session presents preliminary data on the outcomes of a clinical pathway (CP) for children and adolescents with autism spectrum disorder (ASD) or intellectual disability (ID) who were hospitalized in a general child psychiatric unit at a public hospital. Methods: Children with ASD are at greater risk of psychiatric hospitalization than their neurotypical peers. Although care in specialized psychiatry units has preliminary evidence for positive outcomes, the vast majority of children in the United States are treated in general units that are not designed for this challenging population. Review of best practices and expert consensus was used to design and implement a CP in three child and adolescent inpatient units at Bellevue Hospital Center. Fidelity to the CP was examined by use of a checklist. Retrospective chart review was used to identify patients eligible for the CP in the 18 months before implementation and compare outcomes (mean length of stay, use of intramuscular medications, and use of restraint) of patients exposed to the CP in the first 18 months of implementation. Results: Treatment fidelity to the CP was acceptable based on checklist review. Record review identified over 70 patients with ASD who were admitted in the 18 months before implementation. Of these patients, approximately 50 percent met CP eligibility criteria. Outcomes for these admissions were compared with outcomes for 30 admissions to the CP. Preliminary analysis indicated improved outcomes post-CP implementation. Conclusions: Expert consensus has indicated that expanded, targeted admission assessment; basic supports for functional communication; predictable routines; developmentally appropriate milieu of activities, including physical activities; and increased density of positive reinforcement are critical elements for effective inpatient care of children with ASD or ID. The design and pilot implementation of a clinical pathway using these elements at Bellevue Hospital Center over 18 months showed that it is feasible to incorporate these principles in a general inpatient child psychiatry unit and may improve outcomes

OBJECTIVE: The Child and Adolescent Mental Health Studies (CAMS) program is housed in a Liberal Arts undergraduate college of a large research university. Psychiatrists, clinical psychologists, and social workers at the university's medical center teach the courses. The purpose of this study is to evaluate the extent to which CAMS encourages graduates of the program to pursue a career in child and adolescent mental health (CAMH). METHODS: In 2015-2016, graduates of the CAMS program were invited to participate in a mixed methods study. In addition to statistical analyses, qualitative thematic analyses were performed to interpret free-text responses. RESULTS: Forty-five percent (314/702) of invited graduates completed the online survey. Interviews were conducted with 11% (34/314) of participants by study staff over the phone. Quantitative results suggested that 81% (149/185) of participants enrolled in educational programs after graduation due to an interest in CAMH. A significantly higher proportion of the total sample (t = 3.661, p < .001) reported that they changed their career goals while undergraduate students compared to those who did so after graduation. Results of qualitative interviews with 34 participants uncovered five key themes unique to CAMS that may explain the program's influence on graduates' career choices and career development: practitioners-as-instructors, instructor mentorship, novel course content, experiential learning opportunities, and career training and skills. CONCLUSIONS: Quantitative and qualitative results indicated that teaching college undergraduate students about CAMH encourages them to set career goals within the field. These findings suggest the utility of implementing similar programs at other undergraduate colleges.

Objectives: Youths increasingly present to emergency departments (EDs) with agitated behavior or aggression attributed to psychosis, anxiety, mania, or intoxication or related to underlying behavioral disorder. They 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 effectiveness of PRN medications to treat or prevent acute agitation. Further work is needed to understand PRN usage and identify efficacy of different PRN medications to guide clinical practice. Methods: This report describes the use of PRN medications during restraint events in a specialized child psychiatric emergency program between the program's opening in 2011 until December 2016. During this period, 8,800 youth (ages 2-17 years) were seen, and 185 experienced restraint. Chart review examined patient demographics, diagnosis, medication utilization, and efficacy. Results: The youth who experienced restraint ranged in age from six to 17 years. Diagnoses included internalizing, externalizing, and developmental disorders, as well as substance intoxication. The medications used predominantly included most commonly diphenhydramine, chlorpromazine, haloperidol, lorazepam, and risperidone, among others, at a range of doses. Documented efficacy of medication varied significantly as we will report. Conclusions: There are currently no published consensus guidelines for the psychopharmacological management of agitation and little published literature comparing effectiveness of different PRN medications or comparing those medications to placebo. A review of PRN prescribing practices in a specialized child psychiatric emergency program, where all patients are treated by child and adolescent psychiatrists, illustrates the range of medication usage and the varying degree of efficacy of these medications. Further research is needed into the effectiveness of PRN medications, as is professional guidance for choice of medication and dose

Objectives: Schools have long been recognized as major centers for provision of almost universally available health education and services. Seventy to 80 percent of children and adolescents who do receive mental healthcare do so in the school setting. School-based telepsychiatry is an underutilized modality to mitigate the limited access to mental health services for many youth, especially in rural communities. Methods: During the presentation, we will provide a review of the literature regarding use of school-based telepsychiatry. We will then review the design and implementation of the New York University (NYU) school-based telepsychiatry program in partnership with the New York State Office of Mental Health, highlighting key features. Results: We will report on the characteristics of the schools and patients participating in the NYU school-based telepsychiatry program. We will describe the experience of patients and trainees with school-based telepsychiatry, including impediments and successeswithassessment and treatment.Data will beprovided for school-based telepsychiatry services completed since the program was piloted. We will discuss demographics, diagnostic composition, and treatments conducted, as well as clinician and patient/family satisfaction with the modality. Conclusions: Schools are an ideal location for healthcare education and provision. Follow-up for mental health services in schools is much higher than in traditional community mental health facilities. School-based telepsychiatry is a modality that can be successfully implemented in underserved areas to significantly enhance the availability of needed mental health services for children and adolescents. Focus on education for psychiatric trainees in the modality and development of formal curricula is of outmost importance as the modality continues to gain increased utilization

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.

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