Faculty Bibliography

Evidence-Based Treatments (EBTs) with a single-disorder focus have improved the potential for youth mental health care, yet may be an imperfect fit to clinical care settings where diagnostic comorbidity and co-occurring problems are commonplace. Most EBTs were developed to treat one diagnosis or problem (or a small homogenous cluster), but most clinically referred youths present with multiple disorders and problems. Three emerging approaches may help address the comorbidity that is so common in treated youths. Conceptually unified treatments target presumed causal and maintaining factors that are shared among more than one disorder or problem area; preliminary open trials and case studies show promising results. Modular protocols combine the 'practice elements' that commonly appear in separate single-disorder EBTs and repackage them into coordinated delivery systems; one modular protocol, MATCH, has produced positive findings in a randomized effectiveness trial. Monitoring and Feedback Systems (MFSs) provide real-time data on client progress to inform clinical decision-making, encompassing comorbid and co-occurring problems; one study shows beneficial effects in everyday practice with diverse youth problems. All three approaches-conceptually unified, modular, and MFS-can be strengthened by increased research attention to treatment integrity, clinician user-appeal, design simplicity, and the infrastructure necessary for successful implementation.

Functional connectivity between two brain regions, measured using functional MRI (fMRI), has been shown to be modulated by other regions even in a resting state, i.e., without performing specific tasks. We aimed to characterize large-scale modulatory interactions by performing region-of-interest (ROI)-based physiophysiological interaction analysis on resting-state fMRI data. Modulatory interactions were calculated for every possible combination of three ROIs among 160 ROIs sampling the whole brain. Firstly, among all of the significant modulatory interactions, there were considerably more negative than positive effects; i.e., in more cases, an increase of activity in one region was associated with decreased functional connectivity between two other regions. Next, modulatory interactions were categorized as to whether the three ROIs were from one single network module, two modules, or three different modules (defined by a modularity analysis on their functional connectivity). Positive modulatory interactions were more represented than expected in cases in which the three ROIs were from a single module, suggesting an increase within module processing efficiency through positive modulatory interactions. In contrast, negative modulatory interactions were more represented than expected in cases in which the three ROIs were from two modules, suggesting a tendency of between-module segregation through negative modulatory interactions. Regions that were more likely to have modulatory interactions were then identified. The numbers of significant modulatory interactions for different regions were correlated with the regions' connectivity strengths and connection degrees. These results demonstrate whole-brain characteristics of modulatory interactions and may provide guidance for future studies of connectivity dynamics in both resting state and task state.

Studying task modulations of brain connectivity using functional magnetic resonance imaging (fMRI) is critical to understand brain functions that support cognitive and affective processes. Existing methods such as psychophysiological interaction (PPI) and dynamic causal modeling (DCM) usually implicitly assume that the connectivity patterns are stable over a block-designed task with identical stimuli. However, this assumption lacks empirical verification on high-temporal resolution fMRI data with reliable data-driven analysis methods. The present study performed a detailed examination of dynamic changes of functional connectivity (FC) in a simple block-designed visual checkerboard experiment with a sub-second sampling rate (TR = 0.645 s) by estimating time-varying correlation coefficient (TVCC) between BOLD responses of different brain regions. We observed reliable task-related FC changes (i.e., FCs were transiently decreased after task onset and went back to the baseline afterward) among several visual regions of the bilateral middle occipital gyrus (MOG) and the bilateral fusiform gyrus (FuG). Importantly, only the FCs between higher visual regions (MOG) and lower visual regions (FuG) exhibited such dynamic patterns. The results suggested that simply assuming a sustained FC during a task block may be insufficient to capture distinct task-related FC changes. The investigation of FC dynamics in tasks could improve our understanding of condition shifts and the coordination between different activated brain regions.

We investigated associations between implicit and explicit self-perceptions of rejection with interpersonal functioning in close relationships. Adolescents (N=124) reported their explicit rejection self-perceptions on a questionnaire and completed the Implicit Association Test to assess their implicit rejection self-perceptions. After controlling for implicit self-perceptions, adolescents' explicit rejection self-perceptions were associated with the adolescents self-reporting more negative relationship quality with close friends and self-reporting more negative behaviors with romantic partners. After controlling for explicit self-perceptions, adolescents' implicit rejection self-perceptions were associated with their romantic partners reporting more negative relationship quality with them, and observations of adolescents displaying more negative behaviors with romantic partners. Implicit and explicit rejection self-perceptions uniquely explain individual differences in interpersonal behaviors.

BACKGROUND: Axis I comorbidity complicates diagnosing axis II personality disorders (PDs). PDs might influence Axis I outcome. No research has examined psychotherapy effects on PDs of treating Axis I comorbidity. Secondary analysis of a randomized controlled trial examined PD diagnostic stability after brief psychotherapy of chronic posttraumatic stress disorder (PTSD). METHODS: Patients with chronic PTSD were randomly assigned to 14 weeks of prolonged exposure, interpersonal psychotherapy, or relaxation therapy. Assessments included the Structured Clinical Interview for DSM-IV, Patient Version (SCID-P) and Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II) at baseline, week 14, and for treatment responders (>/=30% clinician-administered PTSD scale improvement, defined a priori) at week 26 follow-up. We hypothesized patients whose PTSD improved would retain fewer baseline PD diagnoses posttreatment, particularly with personality traits PTSD mimics, e.g. paranoid and avoidant. RESULTS: Forty-seven (47%) of 99 SCID-II patients evaluated at baseline received a SCID-II diagnosis: paranoid (28%), obsessive-compulsive (27%), and avoidant (23%) PDs were most prevalent. Among 78 patients who repeated SCID-II evaluations posttreatment, 45% (N = 35) had baseline PD diagnoses, of which 43% (N = 15/35) lost at week 14. Three (7%) patients without baseline PDs acquired diagnoses at week 14; 10 others shifted diagnoses. Treatment modality and PTSD response were unrelated to PD improvement. Of treatment responders reevaluated at follow-up (N = 44), 56% with any baseline Axis II diagnosis had none at week 26. CONCLUSION: This first evaluation of Axis I psychotherapy effects on personality disorder stability found that acutely treating a chronic state decreased apparent trait-across most PDs observed. These exploratory findings suggest personality diagnoses may have limited prognostic meaning in treating chronic PTSD.

BACKGROUND: Mental health disorders are common and disabling for young people because of the potential to disrupt key developmental tasks. Implementation of evidence-based psychosocial therapies in New Zealand is limited, owing to the inaccessibility, length, and cost of training in these therapies. Furthermore, most therapies address one problem area at a time, although comorbidity and changing clinical needs commonly occur in practice. A more flexible approach is needed. The Modular Approach to Therapy for Children with Anxiety, Depression, Trauma, or Conduct Problems (MATCH-ADTC) is designed to overcome these challenges; it provides a range of treatment modules addressing different problems, within a single training program. A clinical trial of MATCH-ADTC in the USA showed that MATCH-ADTC outperformed usual care and standard evidence-based treatment on several clinical measures. We aim to replicate these findings and evaluate the impact of providing training and supervision in MATCH-ADTC to: (1) improve clinical outcomes for youth attending mental health services; (2) increase the amount of evidence-based therapy content; (3) increase the efficiency of service delivery. METHODS: This is an assessor-blinded multi-site effectiveness randomized controlled trial. Randomization occurs at two levels: (1) clinicians (>/=60) are randomized to intervention or usual care; (2) youth participants (7-14 years old) accepted for treatment in child and adolescent mental health services (with a primary disorder that includes anxiety, depression, trauma-related symptoms, or disruptive behavior) are randomly allocated to receive MATCH-ADTC or usual care. Youth participants are recruited from 'mainstream', Maori-specific, and Pacific-specific child and adolescent mental health services. We originally planned to recruit 400 youth participants, but this has been revised to 200 participants. Centralized computer randomization ensures allocation concealment. The primary outcome measures are: (i) the difference in trajectory of change of clinical severity between groups (using the parent-rated Brief Problem Monitor); (ii) clinicians' use of evidence-based treatment procedures during therapy sessions; (iii) total time spent by clinicians delivering therapy. DISCUSSION: If MATCH-ADTC demonstrates effectiveness it could offer a practical efficient method to increase access to evidence-based therapies, and improve outcomes for youth attending secondary care services. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTRN12614000297628 .

Emotional dysregulation in daily life is very common in children with attention deficit hyperactivity disorder (ADHD). It is however not clear whether this reflects a specific deficit or that it may be the result of generic executive function (EF) deficits. The current study addresses this question by means of an emotional working memory (WM) task with 2 memory load conditions and four possible backgrounds (blank screen, neutral, positive or negative picture), which was administered to 38 typically developing children and 29 children with ADHD. Children responded slower on trials when negative pictures were presented at the background versus when neutral pictures were presented, indicating an emotional interference effect; however crucially, groups did not differ in this respect. Reaction times were also slower on trials with a neutral picture as background versus trials without a picture, with children with ADHD showing an enhanced interference effect. There was a main effect of WM load on performance, but it did not interact with interference or group effects. To summarize, the findings indicate a generic interference control deficit in the children with ADHD in the current sample, while they could not provide support for an emotional interference deficit.

Brains reveal amplified plasticity as they recover from an injury. We aimed to define time dependent plasticity changes in patients recovering from mild traumatic brain injury (mTBI). Twenty-five subjects with mild head injury were longitudinally evaluated within 36 h, 3 and 6 months using resting state functional connectivity (RSFC). Region of interest (ROI) based connectivity differences over time within the patient group and in comparison with a healthy control group were analyzed at p < 0.005. We found 33 distinct ROI pairs that revealed significant changes in their connectivity strength with time. Within 3 months, the majority of the ROI pairs had decreased connectivity in mTBI population, which increased and became comparable to healthy controls at 6 months. Within this diffuse decreased connectivity in the first 3 months, there were also few regions with increased connections. This hyper connectivity involved the salience network and default mode network within 36 h, and lingual, inferior frontal and fronto-parietal networks at 3 months. Our findings in a fairly homogenous group of patients with mTBI evaluated during the 6 month window of recovery defines time varying brain connectivity changes as the brain recovers from an injury. A majority of these changes were seen in the frontal and parietal lobes between 3 and 6 months after injury. Hyper connectivity of several networks supported normal recovery in the first 6 months and it remains to be seen in future studies whether this can predict an early and efficient recovery of brain function.

AIM: To determine the prevalence of bipolar disorder (BD) and sub-threshold symptoms in children with attention deficit hyperactivity disorder (ADHD) through 14 years' follow-up, when participants were between 21-24 years old. METHODS: First, we examined rates of BD type I and II diagnoses in youth participating in the NIMH-funded Multimodal Treatment Study of ADHD (MTA). We used the diagnostic interview schedule for children (DISC), administered to both parents (DISC-P) and youth (DISCY). We compared the MTA study subjects with ADHD (n = 579) to a local normative comparison group (LNCG, n = 289) at 4 different assessment points: 6, 8, 12, and 14 years of follow-ups. To evaluate the bipolar variants, we compared total symptom counts (TSC) of DSM manic and hypomanic symptoms that were generated by DISC in ADHD and LNCG subjects. Then we sub-divided the TSC into pathognomonic manic (PM) and non-specific manic (NSM) symptoms. We compared the PM and NSM in ADHD and LNCG at each assessment point and over time. We also evaluated the irritability as category A2 manic symptom in both groups and over time. Finally, we studied the irritability symptom in correlation with PM and NSM in ADHD and LNCG subjects. RESULTS: DISC-generated BD diagnosis did not differ significantly in rates between ADHD (1.89%) and LNCG 1.38%). Interestingly, no participant met BD diagnosis more than once in the 4 assessment points in 14 years. However, on the symptom level, ADHD subjects reported significantly higher mean TSC scores: ADHD 3.0; LNCG 1.7; P < 0.001. ADHD status was associated with higher mean NSM: ADHD 2.0 vs LNCG 1.1; P < 0.0001. Also, ADHD subjects had higher PM symptoms than LNCG, with PM means over all time points of 1.3 ADHD; 0.9 LNCG; P = 0.0001. Examining both NSM and PM, ADHD status associated with greater NSM than PM. However, Over 14 years, the NSM symptoms declined and changed to PM over time (df 3, 2523; F = 20.1; P < 0.0001). Finally, Irritability (BD DSM criterion-A2) rates were significantly higher in ADHD than LNCG (chi(2) = 122.2, P < 0.0001), but irritability was associated more strongly with NSM than PM (df 3, 2538; F = 43.2; P < 0.0001). CONCLUSION: Individuals with ADHD do not appear to be at significantly greater risk for developing BD, but do show higher rates of BD symptoms, especially NSM. The greater linkage of irritability to NSM than to PM suggests caution when making BD diagnoses based on irritability alone as one of 2 (A-level) symptoms for BD diagnosis, particularly in view of its frequent presentation with other psychopathologies.

Reviews the book, Life, Animated: A Story of Sidekicks, Heroes, and Autism by Ron Suskind (2014). The book is not about autism and it is not even a story of a boy with autism. At times while experiencing Life, Animated, the reviewer thought that it was the story of a parent and family coming to understand and cope with a child with autism. The book, in fact, could be read with that idea in mind and still be an immensely rewarding experience for anyone who treats or works with children with autism and their families. In the end, however, the story is much more universal than that. It is the story of a father coming to know his son. It is the story of members of a family coming to know themselves. It is the story of a child's unique experience of his internal and external worlds. Beyond showing us the experience families have in dealing with difficult mental illness and disability or suggesting unique ways of engaging with children who might communicate in a different way, the book expands what one thinks of as the human experience. It suggests that experiencing life in a way that is considered more normative in the spectrum of human experience is not necessarily a better or right way to see things.