Faculty Bibliography

Objectives: Youth with ASD experience complex psychiatric symptoms and medical comorbidities that often lead them and their families to seek care in the emergency department (ED). Yet EDs, including both general medical and pediatric EDs and psychiatric-specific emergency settings, are often poorly equipped to care for youth with autism. Enhanced interdisciplinary collaboration, use of care pathways to address communication and sensory needs, and more comprehensive evaluation can improve both the patient's experience in the ED and the quality of care received. Methods: Speakers will present the following three models for improving collaborative, interdisciplinary care for youth with ASD in different emergency settings: 1) a regional program to improve care for youth with ASD in a network of general hospital EDs; 2) an autism care pathway in a pediatric ED setting; and 3) an autism care pathway in a psychiatric ED setting. Finally, financial and administrative barriers to enhanced care for youth with autism in the ED will be discussed, along with the ways that these barriers can be addressed on an individual institution level and policy level. Results: Participants will gain exposure to models of enhanced care for youth with autism and strategies to implement such models of care. Conclusions: Given the rising prevalence of ASD, improving care for patients with ASD in our EDs is critical. Child psychiatrists can lead efforts to improve care to make a meaningful impact on the ED experience of youth with autism

Objectives: The goals of this study are to describe long-term clinical and functional outcomes in the New York Study of hyperactive children who were followed prospectively for 33 years and identify possible predictors that influence these outcomes. Methods: White hyperactive boys (N = 207 probands) were recruited in childhood and followed in adolescence (mean age 18 years), early adulthood (mean age 25 years), and mid-adulthood (mean age 41 years). In late adolescence, 178 comparison participants were recruited. At the final followup in mid-adulthood, a total of 135 probands and 136 comparison participants (65.2 and 76.4 percent of original cohort, respectively) were assessed. Outcome measures included occupational, economic, and educational attainment and marital history, occupational and social functioning, ongoing and lifetime psychiatric disorders, hospitalizations, obesity, risk-taking behaviors, and criminal behaviors. Results: Compared with peers without ADHD, probands showed greater persistence of ADHD, along with greater prevalence of CD/antisocial personality disorder (APD) and SUD in late adolescence. These dysfunctions continued into early adulthood, even when ADHD remitted for the majority of the sample group, and were associated with deficits in educational and occupational attainment, leading to a relative economic disadvantage. Furthermore, the disproportionally high rate of CD/APD and SUD in probands versus comparison participants translated to significantly higher rates of criminality, risk-taking behavior, and risk-related medical outcomes in adulthood. Probands also showed elevated obesity rates in relation to comparison participants but no differences in mood or anxiety disorders. Conclusions: There is heterogeneity in the clinical and functional outcomes of children with ADHD. This study's findings show that childhood ADHD does not preclude adequate functioning in various life domains. However, it does predispose to maladjustment in adolescence and adulthood in a subset of these children, particularly those who develop CD/APD, an important predictor of long-term outcome

Objectives: Human infants born prematurely experience repeated noxious medical procedures, but maternal contact can attenuate the behavioral response to these procedures. However, the mechanisms by which the mother reduces pain or the enduring impact of using the mother as an analgesic stimulus are unknown. By use of an animal model of early life pain with and without the mother, we monitored behavior at different points across the lifespan. Methods: Infant rats were given mild tail shocks (0.5 mA, 1 second every 4 minutes for 32 minutes) either with the mother present or absent for five consecutive days. Two age ranges were chosen to represent the sensitive period for pain programming (PN5-9) and the age at which maternal presence has major neurobehavioral effects, including suppression of amygdala activity (PN10-14). In infancy, neural pain responses were assessed via cFos expression in brain areas associated with pain, as well as behavioral measures related to pain response. In adulthood, pain thresholds, social behavior, and unlearned fear behavior were assessed as a function of infant pain experience. Results: Activity and ultrasonic vocalizations after treatment from PN5-9 and PN10-14 were reduced by the mother's presence during exposure to painful shock. After treatment at PN10-14 pups only, Fos expression in the periaqueductal gray and basolateral and medial amygdala was elevated by the shock alone and reduced by the mother. Adults treated at PN5-9 had reduced carrageenan-induced hyperalgesia and reduced social behavior but no changes in fear behavior if they had undergone pain-mother pairings. In contrast, when treated at PN10-14, the adult had no change in hyperalgesia and showed disruption of social behavior. Shock with or without the mother decreased unlearned fear responding only if treated at PN10-14. The social behavior deficits were normalized by 2 weeks of environmentally enriched rearing after weaning. Conclusions: Our results provide evidence that maternal presence during early life pain reduces pain responses in both infancy and adulthood, but it is also associated with long-term changes in emotionality. The results of these studies aid in our understanding of the impact of nursery procedures that are used to attenuate pain on later outcomes focused on affective behaviors and potentially provide a strategy to reduce those effects

Objectives: Closing the gap between evidence-based clinical practices and routine care for children with ADHD is an important public health goal. Methods: Medicaid enrollment, claims, and prescription drug disbursement data from the Medicaid Analytic Extract (MAX) from 20 states for 2001 to 2010 were analyzed for children with ADHD (ages 3-17 years). Treatment services were analyzed to compare rates of medication, psychotherapy, and combined treatment services. Results: The proportion of children of low income who were diagnosed with ADHD rose by 83 percent. Rates of comorbidity were high (43.3 percent in 2010), an increase of 13 percent over the study period. There was a 74 percent increase in combined treatment; psychotherapy alone increased by 52 percent, and rates of medication alone decreased by 18 percent. Conclusions: More children received treatments that appeared to conform to clinical practice standards over the decade

Objectives: Organizational Skills Training (OST), is a 10-week psychosocial intervention found effective in improving organizational, time management, and planning (OTMP) skills in children with Attention-Deficit/Hyperactivity Disorder (ADHD). Little is known about the feasibility of identifying brain markers for treatment response. Using resting state fMRI (R-fMRI), we aimed to examine neuronal correlates of post-treatment change as a first step toward larger controlled studies of objective predictors of treatment response. Methods: We examined pre- and post-OST R-fMRI data of 15 children (12 males; mean age: 9+/-1 year) with ADHD and significant impairments in OTMP skills indexed by total scores on Children's Organizational Skills Scales-Parent (COSS-P) or Teacher (COSS-T). Our primary outcome measure was the change in COSS-P scores. As secondary summary outcome measure, we used prepost Z-score differences averaged across COSS-T, Homework Problems Checklist, Academic Progress Report and Academic Performance Rating scales. We selected a priori the intrinsic functional connectivity (iFC) of the dorsal anterior cingulate cortex (dACC), based on its role on cognitive control. Multivariate distance matrix regression (MDMR) analysis additionally allowed for whole-brain explorations. Follow-up iFC analyses were conducted on regions with significant within-subject post-OST differences by MDMR analysis. Results: COSS-P decreased significantly (t=7.1, p< 0.0001). In a cluster involving striatum bilaterally, dACC iFC decreased post-OST; these decreases were positively correlated with COSS-P improvements (r=.34, NS) and to improvements in the summary outcome (r=.63; p<0.03). MDMR analyses revealed iFC changes in the right medial and lateral precentral cortex. Followup seed-based iFC analyses of this region showed significant decreases in cortico-striatal iFC post-OST. Conclusions: Results support the feasibility of identifying changes in brain iFC after OST. Two distinct analysis converged on decreased corticosubcortical iFC post-treatment which related to change in clinical measures. As decreases in striato-cortical iFC characterize typical development, results suggest regionally-specific enhanced maturational effects of OST

Objectives: We present initial empirical work examining neural markers of social communicative impairment characteristic of ASD across children with ASD and ADHD. Increasing evidence indicates that autistic traits (AT) are present in a substantial group of children with ADHD. These children do not meet diagnostic criteria for ASD, present higher functional impairment, or pose a challenge for recognition and treatment. To date, it is unknown whether AT in ADHD and ASD represent similar neurobiological dysfunctions. Methods: To address this question, we examined resting-state fMRI data from children with ADHD (mean age 9.5 +/- 1.6 years), identified as ADHD with AT (ADHD+AT; N = 45), or without ADHD (ADHD-AT; N = 57) per parent responses on the Social Responsiveness Scale. We conducted seed-based connectivity analyses of the right fusiform face area (FFA). After removal of nuisance signals (24-Friston motion parameters, cerebral spinal fluid, and white matter masks), we extracted the residual mean time series for the FFA seed. We then ran between-group analysis using random effect models [covariate: age, motion, subjects, whole-brain intrinsic functional connectivity (iFC) average]. Gaussian random field theory corrected for multiple comparisons (Z > 2.3, p < 0.05). Results: Children with ADHD+AT had weaker iFC between the right FFA and left rostral anterior cingulate cortex (ACC). Secondary analyses with agematched children with ASD (N = 57) showed a hypoconnectivity iFC pattern similar to ADHD+AT. Conclusions: These initial findings highlight a circuit involving two core hubs of the social brain: the FFA subserving face recognition and the ACC subserving "mentalizing." Weaker iFC between these nodes characterized children with AT regardless of their DSM-based diagnosis, illustrating the use of eschewing extreme comparisons for the identification of potential biomarkers specific to and shared across psychiatric conditions

Objectives: The goal of this study is to present the results of one of the largest evaluations of an intervention model for children in foster care aimed to improve care within the services system. This Bridging the Way Home program created processes by which a defined trauma-informed intervention model [trauma systems therapy (TST)] could inform the work of all those involved in the care of a foster child (i.e., clinical and nonclinical providers, foster parents). An overarching aim of this project was to determine whether such concerted care could drive improvements in outcomes. Methods: In this Clinical Perspectives session, we will detail all elements of the Bridging the Way Home program. We will begin with a presentation of the clinical model used in this program, TST, and how it was adapted for foster children. We then will detail how the Bridging the Way Home program was implemented in Kansas, including the process of training all providers and foster parents to provide this care, launching the care teams, and monitoring the quality of care. This implementation trained approximately 430 providers and 516 foster parents. We then will present the evaluation approach that aimed to insert sufficient scientific rigor without sacrificing external validity so that the results would be as generalizable as possible. Results: The evaluation revealed that implementing a trauma-informed approach within a large, complex service system can be achieved successfully, and findings indicate that doing so results in improved mental health and placement stability for the children served. Conclusions: Results indicate that improvements inmentalhealthoutcomesand placement stability were not the result of the delivery of TST by any one individual but, rather, by the concerted provision of care by all those around the child

Objectives: This presentation details the intervention model that was implemented in the Bridging the Way Home program. Trauma systems therapy (TST) is a standardized model of clinical care that includes a defined organizational process so that it can be adapted to the needs of providers and their organizations. This organizational approach, used within the Bridging the Way Home program, defines the organizational processes that must be implemented for the clinical model to be successfully implemented, sustained, and scaled across the organization. Methods: The clinical model of TST includes a defined sequence of assessment, treatment planning, treatment engagement, and treatment implementation. The information gathered within TST assessment defines a traumatized child's problems within two dimensions: 1) a child who is not able to regulate emotional and behavioral states in specific contexts; and 2) a social environment/services system that is not able to help the child regulate these emotional and behavioral states. Specific interventions are chosen based on the magnitude of the child's problems within these two dimensions. These interventions aim to build the child's regulation capacities and the capacity of those around the child to support regulation. Depending on the child's needs, a specific intervention approach is selected that may involve combinations of psychotherapy, psychopharmacology, home-based care, and legal advocacy. The TST organizational model facilitates an organization's integration of services to implement clear and specific treatment plans. Results: TST was implemented successfully within the Bridging the Way Home Program. Providers and foster parents were able to deliver TST with fidelity, and greater fidelity contributed to a greater benefit for foster children. Conclusions: TST defines a clinical and organizational model for children that can serve to improve care across a service-oriented system. This outcome was achieved for foster children within the Bridging the Way Home Program

Objectives: Dramatic changes in typical brain organization occur during the first 5 years of life. There is a critical time window for the emergence of life- long pervasive psychiatric conditions, such as autism, and possibly for the initiation of processes resulting in later onset psychopathology. This presentation aims to provide an overview of the growing abilities of pediatric imaging to comprehensively map the development of neural circuitry (i.e., the connectome) in the early years of life and during the prenatal period. Implications for efforts to delineate typical from atypical development will be discussed. Methods: Dr. Adriana Di Martino will review recent methodological advances in functional and structural imaging for the developing connectome, including natural sleep MRI (for infants and toddlers/preschoolers) and fetal imaging. She will discuss the potential translational impact of these methodologies. Examples of possible uses in the future will be provided, which can range from identifying etiologic factors contributing to the development of mental illness to informing assessments of risk and prognosis. Current gaps and obstacles that need to be addressed also will be highlighted. Results: The audience will gain insight into the impact of recent technical and methodological advances on our ability to characterize early brain development in vivo. Furthermore, participants will learn of the short-term implications for our understanding of how abnormal patterns of brain connectivity emerge and potential long-term implications for translational pursuits (e.g., inform assessment of risk and prognosis). Finally, they will learn of the gaps and obstacles that must be addressed for these visions to be realized. Conclusions: Although brain connectomics has just begun to understand normative early developmental trajectories and their interfering factors, examples of its potential for translational impact are growing. As the field continues to overcome technical challenges, the potential for brain imaging to deliver clinically useful findings will continue to increase

Objectives: This course provides an overview of the most common pediatric sleep problems in the context of psychiatric disorders. The most advanced and relevant pharmacological and behavioral treatment options will be presented. Methods: This session will consist of comprehensive literature review and case-based presentations. Results: Dr. Reut Gruber will examine the associations between insomnia and the affective and cognitive mechanisms implicated in internalizing problems in adolescents and discuss the implications of these associations to treatment. Dr. Judith Owens will review a systematic approach to the evaluation of adolescents presented to a child psychiatry practice, with a chief complaint of daytime sleepiness, including differential diagnosis, diagnostic tools, and reasons to refer to a sleep clinic. Dr. Argelinda Baroni will describe common parasomnias in children and adolescents, with an emphasis on psychological and behavioral comorbidities. Dr. Kyle Johnson will review the prevalence and characteristics of sleep disorders in children with ASD and discuss their impact on the functioning of the child and family, along with currently available treatments. Finally, Dr. Anna Ivanenko will define clinical characteristics of sleep disorders and their potential underlying neurobiological mechanisms in children with ADHD. She will review current knowledge of the treatment options for sleep disorders in children with ADHD. Conclusions: Learning how to address sleep disorders using behavioral and pharmacological treatments will provide clinicians with essential tools for their psychiatric practice