Faculty Bibliography

The New York State Office of Mental Health has implemented the browser based Psychiatric Clinical Knowledge Enhancement System (PSYCKES) medication application throughout its inpatient system of care. PSYCKES provides detailed current medication regimens and histories, as well as medication best practices reports at the patient, psychiatrist, ward, and facility levels. South Beach Psychiatric Center (SBPC) has made specific use of a best practices report which details proportions of caseloads and number of patients on two or more concurrent antipsychotic medications. Psychiatrists received extensive application and desktop support and individual and group training was conducted. PSYCKES current and historical medication regimens were reviewed for individual cases and best practices reports were used in psychiatry supervision from January 2004 to March 2005. SBPC psychiatrists achieved marked reductions in the proportions of their caseloads on two or more concurrent antipsychotics. Although we cannot impute causality from this pre-post implementation design, the results of this evaluation suggest that the use of PSYCKES was effective in reducing such regimens for inpatients.

CONTEXT: Child psychosocial issues and maternal depression are underidentified and undertreated, but we know surprisingly little about the barriers to identification and treatment of these problems by primary care pediatricians. OBJECTIVES: The purpose of this work was to determine whether (1) perceived barriers to care for children's psychosocial issues and maternal depression aggregate into patient, physician, and organizational domains, (2) barrier domains are distinct for mothers and children, and (3) physician, patient, and practice/organizational characteristics are associated with different barrier domains for children and mothers. METHODS: We conducted a cross-sectional survey of the 50,818 US nonretired members of the American Academy of Pediatrics. Of a random sample of 1600 members, 832 (745 nontrainee members) responded. This was a mailed 8-page survey with no patients and no intervention. We measured physician assessment of barriers to providing psychosocial care for children's psychosocial problems and maternal depression. RESULTS: Pediatricians frequently endorse the lack of time to treat mental health problems (77.0%) and long waiting periods to see mental health providers (74.0%) as the most important barriers to the identification and treatment of children's psychosocial problems. For maternal depression, pediatricians most often endorsed lack of training in treatment (74.5%) and lack of time to treat (64.3%) as important barriers. Pediatricians' reports of barriers clustered into physician and organizational domains. Physician domains were distinct for children and mothers, but organizational domains were not. Several physician and practice characteristics are significantly associated with the 4 barrier scales, and different characteristics (eg, sociodemographic, attitudinal, and practice features) were related to each barrier area. CONCLUSIONS: Pediatricians endorse a wide range of barriers with respect to the diagnosis and treatment of children's mental health problems and maternal depression. The specificity of factors relating to various barrier areas suggests that overcoming barriers to the identification and treatment of child mental health problems and maternal depression in primary care pediatrics is likely to require a multifaceted approach that spans organizational, physician, and patient issues. In addition, comprehensive interventions will likely require social marketing approaches designed to engage diverse audiences of clinicians and their patients to participate.

Transient reductions in serotonin levels during tryptophan depletion (TD) are thought to impair reward processing in healthy volunteers, while another facet of the serotonergic system, the serotonin transporter (5-HTTLPR) short allele polymorphism, is implicated in augmented processing of aversive stimuli. We examined the impact and interactions of TD and the serotonin promoter polymorphism genotype on reward and punishment via two forms of instrumental learning: passive avoidance and response reversal. In this study, healthy volunteers (n=35) underwent rapid TD or control procedures and genotyping (n=26) of the 5-HTTLPR for long and short allele variants. In the passive avoidance task, tryptophan-depleted volunteers failed to respond sufficiently to rewarded stimuli compared to the control group. Additionally, long allele homozygous individuals (n=11) were slower to learn to avoid punished stimuli compared to short allele carriers (n=15). TD alone did not produce measurable deficits in probabilistic response reversal errors. However, a significant drug group by genotype interaction was found indicating that in comparison to short allele carriers, tryptophan-depleted individuals homozygous for the long allele failed to appropriately use punishment information to guide responding. These findings extend prior reports of impaired reward processing in TD to include instrumental learning. Furthermore, they demonstrate behavioral differences in responses to punishing stimuli between long allele homozygotes and short allele carriers when serotonin levels are acutely reduced.

CONTEXT: Considerable work implicates abnormal neural activation and disrupted attention to facial-threat cues in adult anxiety disorders. However, in pediatric anxiety, no research has examined attention modulation of neural response to threat cues. OBJECTIVE: To determine whether attention modulates amygdala and cortical responses to facial-threat cues differentially in adolescents with generalized anxiety disorder and in healthy adolescents. DESIGN: Case-control study. SETTING: Government clinical research institute. PARTICIPANTS: Fifteen adolescents with generalized anxiety disorder and 20 controls. MAIN OUTCOME MEASURES: Blood oxygenation level-dependent signal as measured via functional magnetic resonance imaging. During imaging, participants completed a face-emotion rating task that systematically manipulated attention. RESULTS: While attending to their own subjective fear, patients, but not controls, showed greater activation to fearful faces than to happy faces in a distributed network including the amygdala, ventral prefrontal cortex, and anterior cingulate cortex (P<.05, small-volume corrected, for all). Right amygdala findings appeared particularly strong. Functional connectivity analyses demonstrated positive correlations among the amygdala, ventral prefrontal cortex, and anterior cingulate cortex. CONCLUSIONS: This is the first evidence in juveniles that generalized anxiety disorder-associated patterns of pathologic fear circuit activation are particularly evident during certain attention states. Specifically, fear circuit hyperactivation occurred in an attention state involving focus on subjectively experienced fear. These findings underscore the importance of attention and its interaction with emotion in shaping the function of the adolescent human fear circuit.

Objectives. In 2 studies, we aimed to describe the content of mothers' verbal warnings to their young children and to investigate whether mothers modify their warnings based on the type of dangerous situation and children's age. Study 1. Mothers of 12-, 18-, and 24-month-olds reported in a telephone interview the words and phrases they would use to prevent their children from falling, touching dangerous objects, ingesting poisonous substances, and running away. The words "no," "don't," and "stop" were the most frequent warnings across ages. Mothers also used warnings to elicit their children's attention, regulate children's location, modify children's actions, and to highlight the properties and consequences of specific dangers. The content, diversity and complexity of mothers' warnings varied with children's age and the type of dangerous situation. Study 2. We observed mothers in the laboratory as they warned their 12- and 18-month-old children not to walk down 50 degrees slopes. As in Study 1, mothers primarily relied on the words "no," "don't," and "stop," but again used warnings to elicit attention, regulate location, modify actions, and describe the danger. Mothers used more complex and diverse warnings with older versus younger children. Conclusions. Although simple warnings, such as 'no," "don't," and "stop" hold privileged status at all ages, mothers express a rich array of warnings that are attuned to children's age and the dangers of the situation.

Objective. We examined how parents' expectations about their infants' crawling ability and crawling attempts in a locomotor task affect parenting choices about ensuring infants' safety and providing appropriate challenges. Design. Mothers and fathers of 34 11-month-old infants adjusted a ramp to the steepest slopes they thought their infants could safely crawl down, would attempt to crawl down, and they would allow their infants to crawl down independently. Results. Most parents expected their infants to attempt slopes that were steeper than their ability and generally emphasized safety only by permitting infants to crawl down slopes that were within infants' expected ability. More fathers than mothers displayed parenting choices emphasizing challenge by allowing their infants to attempt slopes beyond their ability. Conclusions. Both mothers and fathers expected infants to attempt impossibly steep slopes, but mothers were more likely to adopt safety-oriented parenting choices. Wide disagreements within dyads and inconsistencies in individual parents' estimates might increase the chances of infants incurring injuries.

The proportionality of blood oxygen level-dependent (BOLD) response during a cognitive task and that from a hypercapnic challenge was investigated in cortical structures involved in working memory (WM). Breath holding (BH) following inspiration was used to induce a BOLD response characteristic of regional vasomotor reactivity but devoid of metabolic changes. BOLD effects measured during BH were used to normalize individual subject activations during WM, which effectively reduced the confounding influence of individual- and region-specific differences in hemodynamic responsivity common to both tasks. In a study of seven subjects, the BH calibration reduced intersubject variability in WM effect amplitude by 24.8% (P < 0.03). Reduced intersubject variability resulted in a 23.7% increase in group WM activation voxel extent significant at P < 0.001, with further increases at more stringent thresholds. Because the BH task does not require CO(2) inhalation or other invasive manipulations and is broadly applicable across cortical regions, the proposed approach is simple to implement and may be beneficial for use not only in quantitative group fMRI analyses, but also for multicenter and longitudinal studies.

OBJECTIVE: Deficits in motor inhibition may contribute to impulsivity and irritability in children with bipolar disorder. Studies of the neural circuitry engaged during failed motor inhibition in pediatric bipolar disorder may increase our understanding of the pathophysiology of the illness. The authors tested the hypothesis that children with bipolar disorder and comparison subjects would differ in ventral prefrontal cortex, striatal, and anterior cingulate activation during unsuccessful motor inhibition. They also compared activation in medicated versus unmedicated children with bipolar disorder and in children with bipolar disorder and attention deficit hyperactivity disorder (ADHD) versus those with bipolar disorder without ADHD. METHOD: The authors conducted an event-related functional magnetic resonance imaging study comparing neural activation in children with bipolar disorder and healthy comparison subjects while they performed a motor inhibition task. The study group included 26 children with bipolar disorder (13 unmedicated and 15 with ADHD) and 17 comparison subjects matched by age, gender, and IQ. RESULTS: On failed inhibitory trials, comparison subjects showed greater bilateral striatal and right ventral prefrontal cortex activation than did patients. These deficits were present in unmedicated patients, but the role of ADHD in mediating them was unclear. CONCLUSIONS: In relation to comparison subjects, children with bipolar disorder may have deficits in their ability to engage striatal structures and the right ventral prefrontal cortex during unsuccessful inhibition. Further research should ascertain the contribution of ADHD to these deficits and the role that such deficits may play in the emotional and behavioral dysregulation characteristic of bipolar disorder.

Restricted and repetitive behaviors (RRBs) on the Autism Diagnostic Interview- Revised (ADI-R: Lord, Rutter, & Le Couteur (1994) were examined in 165 children with Autism Spectrum Disorders (ASD), 49 children with non-spectrum developmental disorders (DD), and 65 children with typical development (TD) at approximately 2 years of age. A factor analysis found evidence for a repetitive sensorimotor (RSM) factor and an insistence on sameness (IS) factor. Behaviors that loaded on the RSM factor were prevalent in children with ASD and significantly more common and severe than in children with DD or TD. On average, children with ASD had more RSM behaviors. Behaviors that loaded on the IS factor were relatively uncommon and did not differ in prevalence or severity across groups

Violence towards others by a minority of psychotic individuals is a significant public health concern. The severity of this other-directed violence (ODV) in the community may be influenced by insight into illness and adherence to psychotropic medications; however, few studies have tested these associations. Sixty male psychotic inpatients, legally detained at a forensic unit in New York City, were assessed with semi-structured interviews, supplemented with information from hospital and official records, family members and the treating clinician. Results indicated that in this unique sample of detained persons with psychotic disorders; (1) increase in the severity of community violence is associated with medication non-adherence, all dimensions of poor insight into illness, and several previously reported covariates such as substance use comorbidity; (2) no relationship was found between insight and adherence in this particular sample; (3) multivariate analyses showed that select covariates, along with medication adherence, and select insight domains predicted a total of 73% of the magnitude of ODV behavior in this sample. Overall, medication non-adherence explained a large amount of how violently participants behaved toward others. Since non-adherence was independent of poor insight, it may be more worthwhile for clinicians to develop treatment strategies to target medication adherence without directly addressing an elusive target such as insight into illness. Treatment addressing medication adherence needs to concomitantly target substance use behaviors since the latter was responsible for a substantial increase in ODV