Faculty Bibliography

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

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.

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

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: We aim to present four integrated care models across the continuum of care in subspecialty pediatrics. We will share case examples and pilot data of clinical programs that incorporate unique and shared elements. Methods: A brief review of the need for integrated care within subspecialty pediatrics will be conducted followed by an overview of a multidisciplinary program for enhancing resilience in children dealing with the stress of medical illness in inpatient settings. We will discuss a quality improvement initiative that systematically assesses family stress and coordinates matched interventions within pediatric intensive care. Systematic screening in outpatient settings will be discussed by the next two presenters who will describe assessment of family stress, quality of life, and mental health in patients with medical illnesses, such as cystic fibrosis and epilepsy, amongst others. Finally, our discussant will review the opportunities and challenges in program implementation and evaluation. Results: Mounting evidence suggests that chronic illness management and hospitalizations can have significant psychological and health repercussions for both children and their family caregivers. Evidence-based models of pediatric specialty care for the systematic identification of stress and risk, as well as the deployment of coordinated, matched supports, remain scant. Integrated family-engaged care refers broadly to models of care in which multidisciplinary teams work in partnership with youth and families to plan, deliver, manage, and continuously improve the integration of health and behavioral health services, systems, and outcomes. New York University and the University of California, San Francisco have implemented four models for increasing integration and family engagement across the pediatric specialty care continuum. Key drivers of success and challenges in implementation have been analyzed through in-depth case studies. Teams evaluated both process and outcomes measures, such as treatment engagement, family stress/coping, and healthcare utilization. Conclusions: Outcome-driven engagement of families and teams toward greater levels of integration has the potential to both improve the lives of youth and families we serve and help transform our health care system toward the quadruple aim of better culture, better health, and better care at lower costs

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.

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.

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