Faculty Bibliography

BACKGROUND: Irritability is prevalent and impairing in pediatric bipolar disorder (BD) but has been minimally studied using neuroimaging techniques. We used magnetoencephalography (MEG) to study theta band oscillations in the anterior cingulate cortex (ACC) during frustration in BD youth. ACC theta power is associated with attention to emotional stimuli, and the ACC may mediate responses to frustrating stimuli. METHODS: We used the affective Posner task, an attention paradigm that uses rigged feedback to induce frustration, to compare 20 medicated BD youth (14.9+/-2.0 years; 45% male) and 20 healthy controls (14.7+/-1.7 years; 45% male). MEG measured neuronal activity after negative and positive feedback; we also compared groups on reaction time, response accuracy, and self-reported affect. Patients met strict DSM-IV BD criteria and were euthymic. Controls had no psychiatric history. RESULTS: BD youth reported more negative affective responses than controls. After negative feedback, BD subjects, relative to controls, displayed greater theta power in the right ACC and bilateral parietal lobe. After positive feedback, BD subjects displayed lower theta power in the left ACC than did controls. Correlations between MEG, behavior, and affect were nonsignificant. CONCLUSION: In this first MEG study of BD youth, BD youth displayed patterns of theta oscillations in the ACC and parietal lobe in response to frustration-inducing negative feedback that differed from healthy controls. These data suggest that BD youth may display heightened processing of negative feedback and exaggerated self-monitoring after frustrating emotional stimuli. Future studies are needed with unmedicated bipolar youth, and comparison ADHD and anxiety groups.

A comprehensive review of structured family support programs in children's mental health was conducted in collaboration with leadership from key national family organizations. The goals were to identify typologies of family support services for which evaluation data existed and identify research gaps. Over 200 programs were examined; 50 met criteria for inclusion. Programs were categorized by whether they were delivered by peer family members, clinicians, or teams. Five salient components of family support were identified: (a) informational, (b) instructional, (c) emotional, (d) instrumental, and (e) advocacy. Clinician-led programs were heavily represented (n = 33, 66%), followed by family-led (n = 11, 22%), and team-delivered (n = 6, 12%) programs. Key differences between programs delivered by clinicians or by peer family members were found in the degree of emphasis, research methodology, and outcomes. However, the content of the components was similar across all three program types. There are both important differences in emphasis across typologies of family support provided by clinicians, family members, or teams as well as important similarities in content. Family-delivered support may be an important adjunct to existing services for parents, although the research base remains thin. A research agenda to promote more rigorous evaluations of these services especially those delivered by peer family members is critical.

The industrialization of health care, underway for several decades, offers instructive guidance and models for speeding access of children and families to clinically and cost effective preventive, treatment, and palliative interventions. This industrialization--i.e., the systematized production of goods or services in large-scale enterprises--has the potential to increase the value and effects of care for consumers, providers, and payers (Hayes and Gregg in Integrated behavioral healthcare: Positioning mental health practice with medical/surgical practice. Academic Press, San Diego, 2001), and to generate efficiencies in care delivery, in part because workforce responsibilities become more functional and differentiated such that individuals with diverse educational and professional backgrounds can effectively execute substantive clinical roles (Rees in Clin Exp Dermatol, 33, 39-393, 2008). To date, however, the models suggested by this industrialization have not been applied to children's mental health services. A combination of policy, regulatory, fiscal, systemic, and organizational changes will be needed to fully penetrate the mental health and substance abuse service sectors. In addition, problems with the availability, preparation, functioning, and status of the mental health workforce decried for over a decade will need to be addressed if consumers and payers are to gain access to effective interventions irrespective of geographic location, ethnic background, or financial status. This paper suggests that critical knowledge gaps exist regarding (a) the knowledge, skills, and competencies of a workforce prepared to deliver effective interventions; (b) the efficient and effective organization of work; and (c) the development and replication of effective workforce training and support strategies to sustain effective services. Three sets of questions are identified for which evidence-based answers are needed. Suggestions are provided to inform the development of a scientific agenda to answer these questions.

Education and mental health integration will be advanced when the goal of mental health includes effective schooling and the goal of effective schools includes the healthy functioning of students. To build a solid foundation for this reciprocal agenda, especially within the zeitgeist of recent educational reforms, a change in the fundamental framework within which school mental health is conceptualized is needed. This change involves acknowledging a new set of priorities, which include: the use of naturalistic resources within schools to implement and sustain effective supports for students' learning and emotional/behavioral health; inclusion of integrated models to enhance learning and promote health; attention to improving outcomes for all students, including those with serious emotional/behavioral needs; and strengthening the active involvement of parents. A strong research agenda to support these new priorities is essential.

Summary. Functional principal component regression (FPCR) is a promising new method for regressing scalar outcomes on functional predictors. In this article, we present a theoretical justification for the use of principal components in functional regression. FPCR is then extended in two directions: from linear to the generalized linear modeling, and from univariate signal predictors to high-resolution image predictors. We show how to implement the method efficiently by adapting generalized additive model technology to the functional regression context. A technique is proposed for estimating simultaneous confidence bands for the coefficient function; in the neuroimaging setting, this yields a novel means to identify brain regions that are associated with a clinical outcome. A new application of likelihood ratio testing is described for assessing the null hypothesis of a constant coefficient function. The performance of the methodology is illustrated via simulations and real data analyses with positron emission tomography images as predictors

OBJECTIVE: To document prospective weight and anthropometric changes in children and adolescents during the first 12 weeks of treatment with risperidone and evaluate metabolic outcomes including plasma leptin levels. METHOD: Eight patients with psychotic disorders (ages 11-17) who had started risperidone (mean: 1.80 mg/day; sd = 1.04) in the prior 4 weeks participated in this observational study. Fasting morning blood samples were obtained at baseline and week 8 to assess glucose, leptin, cortisol, insulin, and triglycerides. Measures of body mass index (BMI), weight, waist and hip circumference, blood pressure, and heart rate were obtained weekly. RESULTS: Participants increased in mean weight (4.16 kg; sd = 4.36; p = 0.03) and BMI (1.47 kg/m(2); sd = 1.53; p = 0.03) with five out of eight gaining at least 7% of baseline body weight. They had a 4.03 cm (sd = 3.82; p = 0.02) increase in waist circumference and a 5.17 cm (sd = 3.68; p = 0.01) increase in hip circumference. Leptin trended higher, but did not reach statistical significance. There were no significant changes in glucose, insulin, cortisol, blood pressure, or heart rate. CONCLUSION: Subjects experienced significant increases in weight, BMI, hip and waist circumference during the first 3 months of treatment. Better powered research with more advanced anthropometric assessment is warranted to further elucidate mechanisms of antipsychotic associated weight gain in youth

Both attention biases to threat and a serotonin-transporter gene polymorphism (5-HTTLPR) have been linked to heightened neural activation to threat and the emergence of anxiety. The short allele of 5-HTTLPR may act via its effect on neurotransmitter availability, while attention biases shape broad patterns of cognitive processing. We examined individual differences in attention bias to emotion faces as a function of 5-HTTLPR genotype. Adolescents (N=117) were classified for presumed SLC6A4 expression based on 5-HTTLPR-low (SS, SL(G), or L(G)L(G)), intermediate (SL(A) or L(A)L(G)), or high (L(A)L(A)). Participants completed the dot-probe task, measuring attention biases toward or away from angry and happy faces. Biases for angry faces increased with the genotype-predicted neurotransmission levels (low>intermediate>high). The reverse pattern was evident for happy faces. The data indicate a linear relation between 5-HTTLPR allelic status and attention biases to emotion, demonstrating a genetic mechanism for biased attention using ecologically valid stimuli that target socioemotional adaptation.