Faculty Bibliography

Objective: This study evaluated the efficacy and tolerability of modafinil at a range of doses, versus placebo, in alleviating symptoms of ADHD in adults. Method: Adult patients with ADHD were randomized in 1:1:1:1:1 fashion to double-blind treatment with modafinil 255, 340, 425, or 510 mg daily or placebo for 9 weeks. The primary efficacy outcome was the change from baseline at final visit in the Adult ADHD Investigator Symptom Rating Scale (AISRS) total score. Results: A total of 338 patients were enrolled, of whom 330 received at least 1 dose of study medication (modafinil or placebo). No statistically significant difference in the AISRS total score was observed at final visit between any modafinil group and placebo; however, some observations among patients who completed the trial may warrant further investigation. Conclusion: Modafinil was reasonably tolerated but did not demonstrate a benefit on ADHD symptoms in adults. (J. of Att. Dis. 2012; XX(X) 1-XX).

BACKGROUND: Violence-exposed youth rarely receive mental health services, even though exposure increases risk for academic and psychosocial problems. This study examines the association between violence exposure and mental health service contact. The 4 forms of violence exposure were peer, family, sexual, and witnessing. METHODS: Data are from 1534 Boston public high school students who participated in a 2008 self-report survey of violence exposure and its correlates. Multivariate logistic regressions estimated associations between each form of violence with service contact, then examined whether associations persisted when controlling for suicidality and self-injurious behaviors. RESULTS: In unadjusted models, violence-exposed students more often reported service contact than their peers. However, in multivariate models, only exposure to family (odds ratio [OR] = 1.69, 95% confidence interval [CI] = 1.23-2.31) and sexual violence (OR = 2.34, 95% CI = 1.29-4.20) were associated with service contact. Associations attenuated when controlling for suicidality and self-injurious behaviors, indicating they were largely explained by self-harm. Sexual violence alone remained associated with mental health service contact in fully adjusted models, but only for girls (OR=3.32, 95% CI=1.30-8.45), suggesting sex-specific pathways. CONCLUSIONS: Associations between adolescent violence exposure and mental health service contact vary by forms of exposure. Outreach to a broader set of exposed youth may reduce the impact of violence and its consequences for vulnerable students.

Despite the common co-occurrence of symptoms of attention deficit hyperactivity disorder (ADHD) in individuals with autism spectrum disorders (ASD), the underlying mechanisms are under-explored. A potential candidate for investigation is response time intra-subject variability (RT-ISV), a hypothesized marker of attentional lapses. Direct comparisons of RT-ISV in ASD versus ADHD are limited and contradictory. We aimed to examine whether distinct fluctuations in RT-ISV characterize children with ASD and with ADHD relative to typically developing children (TDC). We applied both a priori-based and data-driven strategies to RT performance of 46 children with ASD, 46 with ADHD, and 36 TDC (aged 7-11.9 years). Specifically, we contrasted groups relative to the amplitude of four preselected frequency bands as well as to 400 frequency bins from 0.006 to 0.345 Hz. In secondary analyses, we divided the ASD group into children with and without substantial ADHD symptoms (ASD+ and ASD-, respectively). Regardless of the strategy employed, RT-ISV fluctuations at frequencies between 0.20 and 0.345 Hz distinguished children with ADHD, but not children with ASD, from TDC. Children with ASD+ and those with ADHD shared elevated amplitudes of RT-ISV fluctuations in frequencies between 0.18 and 0.345 Hz relative to TDC. In contrast, the ASD- subgroup did not differ from TDC in RT-ISV frequency fluctuations. RT-ISV fluctuations in frequencies 0.18-0.345 Hz (i.e., periods between 3 and 5 s) are associated with ADHD symptoms regardless of categorical diagnosis and may represent a biomarker. These results suggest that children with ADHD and those with ASD+ share common underlying pathophysiological mechanisms of RT-ISV.

Young people with conduct disorder often experience histories of psychosocial adversity and socioeconomic insecurity. For these individuals, real-world future outcomes are not only delayed in their delivery but also highly uncertain. Under such circumstances, accentuated time preference (extreme favoring of the present over the future) is a rational response to the everyday reality of social and economic transactions. Building on this observation, the author sets out the hypothesis that the exaggerated temporal discounting displayed by individuals with conduct disorder reported by White et al. (2014) is an adaptation to chronic exposure to psychosocial insecurity during development. The author postulates that this adaptation leads to (a) a decision-making bias whereby delay and uncertainty are coded as inseparable characteristics of choice outcomes and/or (b) reprogramming of the brain networks regulating intertemporal decision making. Future research could explore the putative role of environmental exposures to adversity in the development of exaggerated temporal discounting in conduct disorder as well as the mediating role of putative cognitive and neurobiological adaptations.

The rollout of DSM-5 is both a challenge and an opportunity for psychiatrists and particularly for trainees. Psychiatric education in the wake of DSM-5 will go beyond memorizing lists of new criteria. Teachers and learners alike will seize the "teachable moment" to learn new content, model how to approach and apply new understanding, think about how new knowledge is developed, and appreciate the importance of public dialogue.We can capitalize on this moment to improve the teaching of assessment skills as a central focus of residency training.

OBJECTIVE: Psychotic symptoms are common in the population and index risk for a range of severe psychopathological outcomes. We wished to investigate functional connectivity in a community sample of adolescents who reported psychotic symptoms (the extended psychosis phenotype). METHOD: This study investigated intrinsic functional connectivity (iFC) during resting-state functional magnetic resonance imaging (fMRI; rs-fMRI). Following screening in schools, 11 non-treatment seeking, youth with psychotic symptoms (aged 11-13) and 14 community controls participated in the study. Seed regions of interest comprised brain regions previously shown to exhibit aberrant activation during inhibitory control in adolescents with psychotic symptoms. RESULTS: Relative to controls, adolescents with psychotic symptoms exhibited reduced iFC between regions supporting inhibitory control. Specifically, they showed weaker iFC between the right inferior frontal gyrus (IFG) and the cingulate, IFG and the striatum, anterior cingulate and claustrum, and precuneus and supramarginal gyrus. Conversely, the psychotic symptoms group exhibited stronger iFC between the superior frontal gyrus and claustrum and IFG and lingual gyrus. CONCLUSION: The present findings are the first to reveal aberrant functional connectivity in resting-state networks in a community sample of adolescents with psychotic symptoms and suggest that disruption in integration between distributed neural networks (particularly between prefrontal, cingulate and striatal brain regions) may be a key neurobiological feature of the extended psychosis phenotype.

Public-sector mental health care providers are at high risk for burnout, which negatively affects not only provider well-being but also the quality of services for clients and the functioning of organizations. This study examines the influence of demographics, work characteristic, and organizational variables on levels of burnout among child and adolescent mental health service providers operating within a public-sector mental health service system. Additionally, given the dearth of research examining differences in burnout levels among mental health subdisciplines (e.g., social work, psychology, marital and family therapy) and mental health programs (e.g., outpatient, day treatment, wraparound, case management), analyses were conducted to compare levels of burnout among multiple mental health disciplines and program types. Surveys were completed by 285 providers across 49 mental health programs in a large urban public mental health system. Variables representing dimensions of organizational climate and transformational leadership accounted for the greatest amount of variance in provider reported burnout. Analyses demonstrated significantly lower levels of depersonalization among wraparound providers compared to traditional case managers. Age was the only demographic variable related to burnout. Additionally, no significant effects were found for provider discipline or for agency tenure and caseload size. Results suggest the need to consider organizational development strategies aimed at creating more functional and less stressful climates and increasing levels of transformational leadership behaviors in order to reduce levels of burnout among clinicians working in public mental health settings for youth and families.

BACKGROUND: Characterization of health conditions in recent immigrant subgroups, including foreign-born whites and Asians, is limited but important for identifying emerging health disparities. Hypertension, a major modifiable risk factor for cardiovascular disease, has been shown to be associated with acculturation, but the acculturative experience varies for different racial/ethnic groups. Assessing the impact of race/ethnicity on the relationship between acculturation-related factors and hypertension is therefore of interest. METHODS: Data from the 2005-2008 waves (n = 36,550) of the NYC Community Health Survey were combined to estimate self-reported hypertension prevalence by nativity, language spoken at home, and time spent in the United States. Multivariable analyses were used to assess (i) the independent associations of acculturation-related factors and hypertension and (ii) potential effect modification by race/ethnicity. Sensitivity analysis recalibrating self-reported hypertension using measured blood pressures from a prior NYC population-based survey was performed. Prevalence was also explored by country of origin. RESULTS: Being foreign vs. US born was associated with higher self-reported hypertension in whites only. Speaking Russian vs. English at home was associated with a 2-fold adjusted odds of self-reported hypertension. Living in the United States for >/=10 years vs. less time was associated with higher self-reported hypertension prevalence in blacks and Hispanics. Hypertension prevalence in Hispanics was slightly lower when using a recalibrated definition, but other results did not change substantively. CONCLUSIONS: Race/ethnicity modifies the relationship between acculturation-related factors and hypertension. Consideration of disease prevalence in origin countries is critical to understanding health patterns in immigrant populations. Validation of self-reported hypertension in Hispanic populations is indicated.