Evaluation of an Intensive Program for Children With Co-occurring Medical and Emotional Disorders.

The study objective was to assess clinical outcomes and cost avoidance of an intensive day treatment program for children with co-occurring chronic medical disease and emotional problems. Intensive day treatment programs for this population are uncommon, and their effectiveness has not been previously reported. A total of 175 children were enrolled during the 3-year study period. Children had more than 30 medical diagnoses including chronic pain, dysautonomia, neurologic disorders, and diabetes. Complete utilization data were available for 118 patients, and demonstrated decreased hospitalizations and increased behavioral health visits during the 12 months post program compared with 12 months prior. Private insurance and female sex were associated with reduced utilization costs after program participation. Estimated avoided cost for the 118 children was $1 111 485. Patients reported significant improvements in somatic symptoms, sleep problems, inattention, depression, anger, and anxiety. Limited data indicated improvements in school attendance. Additional research addressing other outcomes, such as school-related symptoms, would be helpful.

Refinement of the Reflective Function Questionnaire for Youth (RFQY) Scale B Using Item Response Theory.

We conducted item response theory analyses to refine the Reflective Function Questionnaire for Youth (RFQY) Scale B. Data from a non-clinical sample of young people (n = 737; aged 18-25 years) was used to derive a shortened version of the RFQY. Results were replicated in a clinical sample of inpatient adolescents (n = 467; aged 12-17 year), resulting in a five-item measure, thereafter named the RFQY-5. The RFQY-5 item set was then scrutinized for construct validity against the original 23-item RFQY item set in a randomly selected sample of 100 inpatient adolescents not included in the item response theory replication, and 186 healthy adolescents drawn from the community. Results showed that the RFQY-5 performed similarly as the long version in terms of associations with criterion variables, and outperformed the longer version in discriminating between inpatient and community-dwelling adolescents who differed in their levels of borderline traits. The study provides evidence in support of the use of the RFQY-5 in research and clinical settings.

Paradoxical Effects of Intranasal Oxytocin on Trust in Inpatient and Community Adolescents.

Research suggests that oxytocin, a neuropeptide implicated in attachment, is a promising clinical tool because it increases affiliation and attachment behaviors, which are reduced in a range of psychiatric disorders. Oxytocin has been recommended as a psychiatric treatment for adolescents, but this remains largely unstudied. Skepticism is warranted, based on mixed findings in adults and absence of data across development. The objective of this study was to examine the effect of intranasal oxytocin on attachment-related and non-attachment-related trust in an interactive game, determining how this effect differs among inpatient adolescents and healthy controls and whether this effect is moderated by attachment security. There were 122 adolescents (ages 12-17; n = 75 inpatient, 70% female, 37% Black, 24% Hispanic, 20% White, and 20% multiracial; n = 46 control, 55% female, 75% Caucasian) randomized to receive self-administered intranasal oxytocin or a placebo and play a trust game with their mother and a stranger over the Internet. Oxytocin only affected the trust game behavior of adolescents when attachment security was moderate or low. At these levels, oxytocin increased the trust of patients, such that their behavior was equivalent to that of healthy controls. Paradoxically, oxytocin reduced the investments of healthy control subjects. This study takes a first step toward determining whether, and for whom, oxytocin may have a trust-enhancing effect and challenges simplistic notions of oxytocin as the attachment-chemical of the brain-pointing instead to differential oxytocin effects based upon clinical status (patient vs. control) and attachment security.

The new landscape of medication adherence improvement: where population health science meets precision medicine.

Despite the known health and economic benefits of medications, nonadherence remains a significant, yet entirely preventable public health burden. Over decades, there have been numerous research studies evaluating health interventions and policy efforts aimed at improving adherence, yet no universal or consistently high impact solutions have been identified. At present, new challenges and opportunities in policy and the movement toward value-based care should foster an environment that appreciates adherence as a mechanism to improve health outcomes and control costs (eg, fewer hospitalizations, reduced health care utilization). Our objective was to provide a commentary on recent changes in the landscape of research and health policy directed toward improving adherence and an actionable agenda to achieve system level savings and improved health by harnessing the benefits of medications. Specifically, we address the complementary perspectives of precision medicine and population health management; integrating data sources to develop innovative measurement of adherence and target adherence interventions; and behavioral economics to determine appropriate incentives.

Differential relations of executive functioning to borderline personality disorder presentations in adolescents.

Borderline personality disorder (BPD) in adolescents is highly complex and heterogeneous. Within the disorder, research has suggested the existence of at least two subgroups: one with predominantly internalizing psychopathology features and one with predominantly externalizing psychopathology features. One process that may differentiate these groups is executive functioning (EF), given that poor EF is linked to externalizing psychopathology. Against this background, the current study used a multi-informant approach to examine whether adolescent patients with predominantly externalizing BPD presentations experience greater deficits in EF than adolescent patients with predominantly internalizing presentations. The sample included inpatient adolescents ages 12-17 (M = 15.26; SD = 1.51). Analyses revealed that multiple EF domains distinguished the BPD subgroups. More specifically, adolescents with externalizing presentations exhibited greater difficulties in broad domains related to global executive functioning, metacognition and behavioural regulation and specific domains related to inhibitory control, working memory, planning/organizing, monitoring and organization of materials. While this study is the first to examine EF and adolescent BPD in the context of internalizing and externalizing psychopathology, alternative approaches to examining this question are discussed. Copyright © 2018 John Wiley & Sons, Ltd.

Predictors of Length of Stay in a Psychiatric Adolescent Treatment Program.

Understanding predictors of adolescent inpatient length of stay (LOS) is important in informing treatment outcomes for this age group. The current literature on adolescent LOS remains limited and has been characterized by methodological limitations. In the study described here, we examined a wide range of predictors for LOS in a psychiatric unit for adolescents (N=285), including severity of disorder (previous hospitalizations, self-harm, cognitive impairment and thought disorder, severe depression, history of trauma), types of psychotropic medication, and diagnoses. Our results indicated that LOS is associated with predictors that reflect psychiatric severity-most notably prescription of mood stabilizers and youth-reported internalizing symptoms.

An Examination of Incentive Strategies to Increase Participation in Outcomes Research for an Adolescent Inpatient Unit.

Tracking adolescent outcomes after inpatient hospitalization is important in informing clinical care for this age group, as inpatient care is one of the most expensive treatment modalities. This study examined 4 incentive strategies used to maintain adolescent participation in follow-up research (at 6, 12, and 18 mo) after their discharge from the hospital (N=267). A generalized estimation equation approach was taken to investigate whether different incentive strategies predicted adolescent completion of the follow-up assessments at each time point. Findings demonstrate that implementation of social worker contact significantly differed from other incentive strategies in increasing adolescent completion of follow-up assessments (Z=2.51, P=0.012) over the 3 time points, even when controlling for age and sex. Although these findings ultimately need to be confirmed through a randomized controlled study of incentive strategies, they provide preliminary support for the notion that relational incentives, such as maintaining contact with a member of the clinical team at the hospital, may be particularly important in promoting adolescent participation in outcomes research.

First empirical evaluation of the link between attachment, social cognition and borderline features in adolescents.

OBJECTIVE: Several developmental models of borderline personality disorder (BPD) emphasize the role of disrupted interpersonal relationships or insecure attachment. As yet, attachment quality and the mechanisms by which insecure attachment relates to borderline features in adolescents have not been investigated. In this study, we used a multiple mediational approach to examine the cross-sectional interplay between attachment, social cognition (in particular hypermentalizing), emotion dysregulation, and borderline features in adolescence, controlling for internalizing and externalizing symptoms. METHODS: The sample included 259 consecutive admissions to an adolescent inpatient unit (Mage=15.42, SD=1.43; 63.1% female). The Child Attachment Interview (CAI) was used to obtain a dimensional index of overall coherence of the attachment narrative. An experimental task was used to assess hypermentalizing, alongside self-report measures of emotion dyregulation and BPD. RESULTS: Our findings suggested that, in a multiple mediation model, hypermentalizing and emotion dysregulation together mediated the relation between attachment coherence and borderline features, but that this effect was driven by hypermentalizing; that is, emotion dysregulation failed to mediate the link between attachment coherence and borderline features while hypermentalizing demonstrated mediational effects. CONCLUSIONS: The study provides the first empirical evidence of well-established theoretical approaches to the development of BPD.

Taking stock of medication wastage: Unused medications in US households.

BACKGROUND: Despite the potential deleterious impact on patient safety, environmental safety and health care expenditures, the extent of unused prescription medications in US households and reasons for nonuse remain unknown. OBJECTIVE: To estimate the extent, type and cost of unused medications and the reasons for their nonuse among US households. METHODS: A cross-sectional, observational two-phased study was conducted using a convenience sample in Southern California. A web-based survey (Phase I, n = 238) at one health sciences institution and paper-based survey (Phase II, n = 68) at planned drug take-back events at three community pharmacies were conducted. The extent, type, and cost of unused medications and the reasons for their nonuse were collected. RESULTS: Approximately 2 of 3 prescription medications were reported unused; disease/condition improved (42.4%), forgetfulness (5.8%) and side effects (6.5%) were reasons cited for their nonuse. "Throwing medications in the trash" was found being the common method of disposal (63%). In phase I, pain medications (23.3%) and antibiotics (18%) were most commonly reported as unused, whereas in Phase II, 17% of medications for chronic conditions (hypertension, diabetes, cholesterol, heart disease) and 8.3% for mental health problems were commonly reported as unused. Phase II participants indicated pharmacy as a preferred location for drug disposal. The total estimated cost for unused medications was approximately $59,264.20 (average retail Rx price) to $152,014.89 (AWP) from both phases, borne largely by private health insurance. When extrapolated to a national level, it was approximately $2.4B for elderly taking five prescription medications to $5.4B for the 52% of US adults who take one prescription medication daily. CONCLUSION: Two out of three dispensed medications were unused, with national projected costs ranging from $2.4B to $5.4B. This wastage raises concerns about adherence, cost and safety; additionally, it points to the need for public awareness and policy to reduce wastage. Pharmacists can play an important role by educating patients both on appropriate medication use and disposal.

Psychiatric comorbidity in hospitalized adolescents with borderline personality disorder.

OBJECTIVE: The goal of this study was to carry out the first comprehensive assessment of psychiatric comorbidity in adolescents (aged 12-17 years) with DSM-IV criteria for borderline personality disorder (BPD) compared to a psychiatric comparison group without BPD. Complex comorbidity (a hallmark feature of adult BPD and defined as having any mood or anxiety disorder plus a disorder of impulsivity) was also examined as a distinguishing feature of adolescent BPD. METHOD: Consecutively admitted patients (October 2008 to October 2012) to an inpatient psychiatric hospital received parental consent and gave assent for participation in the study (N = 418), with the final sample after exclusions consisting of 335 adolescent inpatients. A comprehensive, multimethod approach to determining psychiatric comorbidity was used, including both an interview-based (categorical) and a questionnaire-based (dimensional) assessment as well as both parent and adolescent self-report. Measures included the Diagnostic Interview Schedule for Children (NIMH-DISC-IV), Child Behavior Checklist (CBCL), Youth Self-Report (YSR), Car, Relax Alone, Forget, Friends, Trouble (CRAFFT), and the Childhood Interview for DSM-IV Borderline Personality Disorder (CI-BPD). RESULTS: Thirty-three percent of the final sample met criteria for BPD. Adolescent inpatients with BPD showed significantly higher rates of psychiatric comorbidity compared to non-BPD psychiatric subjects for both internalizing (χ²1 = 27.40, P < .001) and externalizing (χ²1 = 19.02, P < .001) diagnosis. Similarly, using dimensional scores for self-reported symptoms, adolescent inpatients with BPD had significantly higher rates of psychiatric comorbidity compared to non-BPD subjects for internalizing (t329 = -6.63, P < .001) and externalizing (t329 = -7.14, P < .001) problems. Parent-reported symptoms were significantly higher in the BPD group only when using a dimensional approach (internalizing: t321 = -3.42, P < .001; externalizing: t321 = -3.32, P < .001). Furthermore, significantly higher rates of complex comorbidity were found for adolescents with BPD (χ²1 = 26.60, P < .001). Moreover, externalizing and internalizing problems interacted in association with borderline traits (B = .25; P < .001). CONCLUSIONS: Similar to findings in adult studies of BPD, adolescents with BPD demonstrate significantly more complex comorbidity compared to psychiatric subjects without BPD.

The measurement of reflective function in adolescents with and without borderline traits.

Reflective function refers to the capacity to reflect on the mind of self and others in the context of the attachment relationship. Reflective function (and its conceptual neighbor, mentalizing) has been shown to be an important correlate of a variety of disorders, including borderline personality disorder (BPD). The current study examined the construct validity of the Reflective Function Questionnaire for Youths (RFQY) in an inpatient sample of adolescents. Adequate internal consistency was established for the RFQY. Significant positive associations with an interview-based measure of reflective function and an experimental-based assessment of mentalization were found for the RFQY. Strong negative relations with BPD features were found and adolescent patients who scored above clinical cut-off for BPD symptoms demonstrated significantly poorer reflective function compared to patients without the disorder. These findings provide preliminary support for the notion that reflective function can be validly and reliably assessed in adolescent populations.

Hypermentalizing in adolescent inpatients: treatment effects and association with borderline traits.

Sharp et al. (2011) recently demonstrated that in adolescents with borderline traits the loss of mentalization is more apparent in the emergence of unusual alternative strategies (excessive theory of mind or hypermentalizing) than in the loss of the capacity per se (no mentalizing or undermentalizing). This suggests that hypermentalizing could be a worthwhile social-cognitive treatment target in adolescents with borderline traits. The aim of the current study was to examine (1) whether a reduction in excessive theory of mind or hypermentalizing is achieved between admission and discharge for adolescent inpatients; (2) whether the hypothesized reduction is more apparent in adolescents meeting criteria for BPD compared with psychiatric controls; and (3) whether other forms of mentalizing would also be sensitive to and malleable by inpatient treatment in the same way we expected hypermentalizing to be. The "Movie for the Assessment of Social Cognition" Task (Dziobek et al., 2006) was administered to consecutive admissions to an adolescent inpatient setting (n = 164) at admission and discharge, alongside measures of borderline symptomology and interview-based diagnosis of BPD. Results demonstrated that 41% (n = 68) of the sample met full or intermediate criteria for BPD on an interview-based measure of BPD. A relation between borderline traits and hypermentalizing that appears to be independent of internalizing and externalizing problems was demonstrated. Hypermentalizing, but not other forms of social-cognitive reasoning (as measured by the Child Eyes Test, Basic Empathy Scale and the Mentalizing Stories Test for Adolescents), was found to be malleable through a milieu-based inpatient treatment. Clinical implications of the findings for the organization of treatment settings for adolescents are discussed.

Teaching medication adherence in US colleges and schools of pharmacy.

OBJECTIVE: To determine and describe the nature and extent of medication adherence education in US colleges and schools of pharmacy. METHODS: A mixed-methods research study was conducted that included a national survey of pharmacy faculty members, a national survey of pharmacy students, and phone interviews of 3 faculty members and 6 preceptors. RESULTS: The majority of faculty members and students agreed that background concepts in medication adherence are well covered in pharmacy curricula. Approximately 40% to 65% of the students sampled were not familiar with several adherence interventions. The 6 preceptors who were interviewed felt they were not well-informed on adherence interventions, unclear on what students knew about adherence, and challenged to provide adherence-related activities for students during practice experiences because of practice time constraints. CONCLUSIONS: Intermediate and advanced concepts in medication adherence, such as conducting interventions, are not adequately covered in pharmacy curriculums; therefore stakeholders in pharmacy education must develop national standards and tools to ensure consistent and adequate medication adherence education.

Borderline personality disorder in adolescents: evidence in support of the Childhood Interview for DSM-IV Borderline Personality Disorder in a sample of adolescent inpatients.

Empirical evidence is increasing in support of the validity of the construct of borderline personality disorder (BPD) in adolescence. There is growing consensus that the early identification and treatment of emerging borderline traits may be an important focus. However, few diagnostic (questionnaire- or interview-based) measures specifically developed or adapted for adolescents and children exist. The Childhood Interview for DSM-IV Borderline Personality Disorder (CI-BPD) [Zanarini, 2003] is a promising interview-based measure of adolescent BPD. Currently, no studies have explicitly been designed to examine the psychometric properties of the CI-BPD. The aim of the current study was to examine various psychometric properties of the CI-BPD in an inpatient sample of adolescents (n = 245). A confirmatory factor analytic approach was used to examine the internal factor structure of the 9 CI-BPD items. In addition, internal consistency, interrater reliability, convergent validity (with clinician diagnosis and 2 questionnaire-based measures of BPD), and concurrent validity (with Axis I psychopathology and deliberate self-harm) were examined. Similar to several adult studies, the confirmatory factor analytic results supported a unidimensional factor structure for the CI-BPD, indicating that the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria on which the CI-BPD is based constitute a coherent combination of traits and symptoms even in adolescents. In addition, other validity criteria were excellent. Taken together, the current study provides strong evidence for the validity of the CI-BPD for use in adolescents.

The relationship between the youth psychopathic traits inventory and psychopathology in a U.S. community sample of male youth.

The Youth Psychopathic Traits Inventory (YPI) is a self-report measure of juvenile psychopathic traits. Validity data for this measure are limited, especially for nonreferred samples. This report investigated the concurrent validity of the YPI by assessing 171 nonreferred male youth (M age = 12.96 years) with a battery of self-, parent-, and peer-report measures including the Child Behavior Checklist (CBCL), the Reactive-Proactive Aggression Questionnaire (RPQ), the Antisocial Process Screening Device (APSD), and a peer-sociometric measure of aggression. Results confirmed the expected correlations between the YPI and measures of proactive aggression, other externalizing and internalizing behavior, and parent-report psychopathic-like traits. In addition, cluster analyses of YPI scores revealed 2 groups of youth (low vs. high) who scored differently on measures of externalizing behavior. This study supports the utility of the YPI as a research tool for assessing juvenile psychopathic traits.

"Better the devil you know": a preliminary study of the differential modulating effects of reputation on reward processing for boys with and without externalizing behavior problems.

Very little is known about the neurobiological correlates of reward processing during social decision-making in the developing brain and whether prior social and moral information (reputations) modulates reward responses in youth as has been demonstrated in adults. Moreover, although externalizing behavior problems in youth are associated with deficits in reward processing and social cognition, a real-life social interaction paradigm using functional neuroimaging (fMRI) has not yet been applied to probe reward processing in such youth. Functional neuroimaging was used to examine the neural correlates of reward-related decision-making during a trust task in two samples of age-matched 11 to 16-year-old boys: with (n = 10) and without (n = 10) externalizing behavior problems. The task required subjects to decide whether to share or keep monetary rewards from partners they themselves identified during a real-life peer sociometric procedure as interpersonally aggressive or kind (vs. neutral). Results supported the notion that prior social and moral information (reputations) modulated reward responses in the adolescent brain. Moreover, boys with externalizing problems showed differential activation in the bilateral insula during the decision phase of the game as well as the caudate and anterior insula during the outcome phase of the game. Similar activation in adolescents in response to reward related stimuli as found in adults suggests some developmental continuity in corticostriatal circuits. Group differences are interpreted with caution given the small group sizes in the current study. Notwithstanding this limitation, the study provides preliminary evidence for anomalous reward responses in boys with externalizing behavior problems, thereby providing a possible biological correlate of well-established social-cognitive and reward-related theories of externalizing behavior disorders.

The criterion validity of the Borderline Personality Features Scale for Children in an adolescent inpatient setting.

The purpose of the current study was to examine the criterion validity of the Borderline Personality Features Scale for Children (BPFS-C) by assessing the performance of the self-report and a newly developed parent report version of the measure (BPFS-P) in detecting a borderline personality disorder (BPD) diagnosis in adolescent inpatients. This study also examined parent-child agreement and the internal consistency of the BPFS subscales. An inpatient sample of adolescents (n = 51) ranging from ages 12-18 completed the BPFS and were administered the Child Interview for DSM-IV Borderline Personality Disorder (CI-BPD) by trained clinical research staff. ROC analyses revealed that the BPFS-C has high accuracy (AUC = .931; Se = .856; Sp = .840) in discriminating adolescents with a diagnosis of BPD, as measured by the CI-BPD, while the BPFS-P has moderate accuracy (AUC = .795; Se = .733; Sp = .720). Parent-child agreement on total scores was significant (r = .687; p < .005). Cronbach's alphas suggested internal consistency for the four subscales of the BPFS. These findings support the criterion validity of this measure, particularly the self-report version, in adolescent inpatient settings.

Theory of mind and emotion regulation difficulties in adolescents with borderline traits.

OBJECTIVE: Dysfunctions in both emotion regulation and social cognition (understanding behavior in mental state terms, theory of mind or mentalizing) have been proposed as explanations for disturbances of interpersonal behavior in borderline personality disorder (BPD). This study aimed to examine mentalizing in adolescents with emerging BPD from a dimensional and categorical point of view, controlling for gender, age, Axis I and Axis II symptoms, and to explore the mediating role of emotion regulation in the relation between theory of mind and borderline traits. METHOD: The newly developed Movie for the Assessment of Social Cognition (MASC) was administered alongside self-report measures of emotion regulation and psychopathology to 111 adolescent inpatients between the ages of 12 to 17 (mean age = 15.5 years; SD = 1.44 years). For categorical analyses borderline diagnosis was determined through semi-structured clinical interview, which showed that 23% of the sample met criteria for BPD. RESULTS: Findings suggest a relationship between borderline traits and "hypermentalizing" (excessive, inaccurate mentalizing) independent of age, gender, externalizing, internalizing and psychopathy symptoms. The relation between hypermentalizing and BPD traits was partially mediated by difficulties in emotion regulation, accounting for 43.5% of the hypermentalizing to BPD path. CONCLUSIONS: Results suggest that in adolescents with borderline personality features the loss of mentalization is more apparent in the emergence of unusual alternative strategies (hypermentalizing) than in the loss of the capacity per se (no mentalizing or undermentalizing). Moreover, for the first time, empirical evidence is provided to support the notion that mentalizing exerts its influence on borderline traits through the mediating role of emotion dysregulation.

The role of child and parental mentalizing for the development of conduct problems over time.

The current study aimed to investigate the role of parental and child mentalizing in the development of conduct problems over time in a community sample of 7- to 11-year-olds (N = 659). To measure child mentalizing, children were asked to complete a social vignettes task at baseline as a measure of distorted mentalizing. Parents (primarily mothers) were asked to complete the same task, guessing their child's responses in the social scenarios as a measure of maternal mentalizing. Conduct problems were evaluated using repeated measures from multi-informant (self-, teacher-, and parent-report) questionnaires completed at baseline and 1-year follow-up. As expected, children who had an overly positive mentalizing style were more likely to be reported by teachers as having conduct problems at 1-year follow-up. These findings held when controlling for baseline conduct problems, IQ, SES, and sex. Findings for maternal mentalizing were significant for follow-up parent-report conduct problem symptoms at the bivariate level of analyses, but not at the multivariate level when controlling for baseline conduct problems and age. These findings extend previous reports by providing predictive validity for distorted mentalizing in the development of conduct problems.

The cross-informant concordance and concurrent validity of the Borderline Personality Features Scale for Children in a community sample of boys.

The Borderline Personality Disorder Features Scale for Children (BPFSC) is currently the only dimensional measure specifically developed to assess borderline features in children and adolescents. Few studies have investigated this measure for its concurrent validity and concordance between youth self-report and parent-report versions. To this end, the current study had two aims: (1) to investigate the cross-informant concordance (youth self-report vs. parent-report) of the BPFSC; and (2) to examine the concurrent validity of the BPFSC by showing that youth scoring high on the BPFSC also show poor clinical and psychosocial functioning, as measured by a standard Axis I scale. A community sample (N = 171) of boys between the ages of 8 and 18 completed the BPFSC and a self-report measure of Axis I psychopathology. Parents completed a newly developed parent-report version of the BPFSC (BPFSP) and a standard measure of Axis I psychopathology to index clinical and psychosocial functioning. Findings confirmed expectations. Modest concordance between parent- and self-report ratings were found. In addition, youth with borderline features showed poorer clinical and psychosocial functioning in all domains, especially where externalizing problems were concerned. Concurrent validity and modest parent-child concordance were demonstrated for the BPFSC. The BPFSC and BPFSP show promise as dimensional measures to assess borderline features in boys. However, a criterion validity study is needed before the measure can be used.