Appraising risk factors of aggression in children and adolescents at psychiatric inpatient units.

This study examined predictors of aggression and assessed whether different subgroups of children and young people (CYP) display varying risks of aggressive incidents during hospitalization. Data from 10,090 children admitted to the psychiatric inpatient units of Cincinnati Children's Hospital between April 2010 and June 2021 were analysed. Multivariable logistic regression models were used to determine significant predictors associated with aggression, followed by average marginal effects and cluster analyses to rank and establish clusters by the order of predictor importance. About 32.5% reported positive history of an aggressive incident. The mean BRACHA score was doubled compared to those without a prior history. The primary analysis showed that both younger and male CYPs had higher odds of aggressive incidents. We also found that CYP with an African descent, not being able to live with both biological parents, those who reported positive history of psychiatric hospitalisation, and prior externalising behaviours had higher odds of aggressive incidents. These findings have important clinical and public health implications, as they provide valuable knowledge for healthcare professionals to improve prevention strategies for aggression amongst this vulnerable population.

A Large Naturalistic Study on the BRACHA: Confirmation of the Predictive Validity.

Aggression is a major challenge on child/adolescent inpatient psychiatric units. A screening instrument to accurately identify risk is urgently needed. To determine the predictive validity of the Brief Rating of Aggression by Children and Adolescents (BRACHA). Prospective cohort study. BRACHA is administered by clinical staff in the emergency department (ED) prior to inpatient psychiatric admission. A consecutive sample of 10,054 admitted patients from 2010-2021. No patients refused screening nor were excluded. BRACHA administered to patients in the ED prior to admission at Cincinnati Children's Hospital Medical Center (CCHMC). Patient behavioral outcomes measured by Overt Aggression Scale (OAS), categorizing aggression as verbal or physical, then as towards self, others, or objects. Female patients comprised 53.6% (n = 5,386) of the sample. Most patients were white (n = 6,556, 65.2%). Patients ranged in age from 4 to 18 years, with a mean age of 13.6 ± 3.1 years. A single biological parent (n = 5,317, 52.9%) was the predominant living arrangement among patients. The Area Under the Curve (AUC), as an assessment of predictive validity across all possible cut-offs of BRACHA scores ranged from 0.640 (aggression to self) to 0.758 (physical aggression towards others). Our findings support the BRACHA as a useful predictive instrument for aggression in inpatient psychiatric admissions from ED regardless of length of stay. Treating staff are then able to immediately classify risk level and inform care plans for all lengths of hospitalization. Applies to potential risk for aggression, except for self-aggression. Future data analyses will evaluate demographic factors to determine which improve predictive power of the BRACHA and can be used to create a BRACHA calculator. To our knowledge, this naturalistic outcomes study is one of the largest in psychiatry. The BRACHA will continue to be studied to evaluate risk for aggression on inpatient units and aim to assist in keeping unit staff and patients safe.

Systematic Review of Religiosity's Relationship with Suicidality, Suicide Related Stigma, and Formal Mental Health Service Utilization among Black Americans.

Rates of suicide have increased among Black Americans. Suicide is now the 3rd leading cause of death for Black Americans between the ages of 1-19 and the 4th leading cause of death for Black Americans aged 20-44. Due to the increasing need in the community, a marked increase in literature focusing on suicide in the Black community has been published since 2018. To build a better understanding of the current state of the literature on suicidality among Black Americans and to offer suggestions for further areas of research, a systematic review was conducted. Spirituality and religious beliefs are often an important cultural focus in the Black community. Some religious beliefs pose potential unintended regarding the sanctity of life among Black Americans. The focus of this systematic review was religiosity's effect on suicidality among Black Americans. Religiosity was found to have a protective effect against suicidality among Black Americans while discouraging formal mental health services utilization. This systematic review also reveals a dearth of research on the relationship between religiosity and suicide related stigma. Areas for further research are mentioned, and religious institutions as mental health intervention centers are encouraged.

Management of Emotion Dysregulation and Outbursts in Children and Adolescents.

PURPOSE OF REVIEW: Emotion dysregulation and outbursts are very common reasons for referral to child and adolescent mental health services and a frequent cause of admission to hospitals and residential programs. Symptoms of emotion dysregulation and outburst are transdiagnostic, associated with many disorders, have the potential to cause severe impairment and their management presents a major challenge in clinical practice. RECENT FINDINGS: There are an increasing number of psychosocial interventions that demonstrate promise in improving emotion dysregulation and outbursts. Acute care systems to manage the most severely ill patients have limited best practice guidelines but program advancements indicate opportunities to improve care models. Pharmacotherapy may be of assistance to psychosocial interventions but must be used with caution due to potential adverse effects. Much remains to be discovered however evidence informed, targeted treatments for specific populations show potential for future improvements in outcomes.

Psychiatric Education for Pediatric Emergency Medicine Fellows: Should We be Doing More?

The number of psychiatric encounters is steadily increasing across all pediatric emergency departments. Based on this growing national crisis, we hypothesized there is a lack of robust education in behavioral/mental health emergencies during pediatric emergency medicine (PEM) fellowship. METHODS: This was a cross-sectional survey of PEM fellowship directors. The survey was submitted to the Pediatric Emergency Medicine Program Director Survey Committee via REDCap to all 83 fellowship directors. RESULTS: Fifty-five (66%) PEM fellowship directors completed the survey from September 2019 to December 2019. Forty-three (78%) programs provide some type of didactic teaching, although only 7 (13%) programs offer more than 5 hours of didactics over 3 years of fellowship. Six (11%) programs offer electronic resources, 13 (24%) offer simulations in psychiatry, and only 4 (7%) programs require any type of psychiatry rotation. Forty-six (84%) programs do not currently use psychiatric emergencies as a competency for evaluating PEM fellows. Program directors felt significantly more confident in faculty than graduating fellows in the management of numerous diagnoses including agitation (P < 0.001), homicidal ideation (P = 0.044), neuroleptic malignant syndrome (P = 0.006), acute dystonia (P < 0.001), and heroin overdose (P = 0.022). Ninety-six percent felt online curricula would be helpful to address this knowledge gap. CONCLUSIONS: Despite growing behavioral/mental health needs in the pediatric emergency department, there continues to be opportunity to improve psychiatric education during PEM fellowship. Program directors felt more confident in faculty than graduating fellows with several psychiatric diagnoses. Pediatric emergency medicine fellowship directors expressed a strong interest in online tools to assist in the education of PEM fellows.

Predicting the time trend of first episodes of aggressive behaviors in pediatric psychiatric inpatient units.

The goal of the current study is to assess whether the scores of Brief Rating of Aggression by Children and Adolescents (BRACHA) at the emergency room (ER) can predict the aggressive incidents at pediatric psychiatric inpatient units. The study aims to identify predictors for two outcome measurements: 1) hazard rates for the first aggressive incident and 2) numbers of days between admission and the first aggressive incident, using the Cox regression model and Poisson regression model, respectively. The clinical records of a total of 5,610 adolescents admitted into the pediatric psychiatric inpatient units of Cincinnati Children's Hospital Medical Center were extracted for the analysis. The aggressive incident was defined as a score >0 from any category of the Overt Aggression Scale (OAS) and the high-aggressive incident was defined as a score ≥ 2 from any category of the OAS. The results indicate that the BRACHA score was not associated with high-aggressive incidents (hazard ratio: 0.98, p = 0.7543). Similarly, the BRACHA scores was only associated with the number of days from admission to the first aggressive incident (Poisson regression coefficient: 0.24, p < 0.0001) but not the number of days from admission to the first high-aggressive incident (Poisson regression coefficient: 0.03, p = 0.3994). Furthermore, the second peak of first aggressive incidents during the hospitalization highlights the importance of interventions at the end of the inpatient treatment course. To summarize, BRACHA scores based on initial assessments at the ER could correlate with first aggressive incidents, but not the first high-aggressive incidents.

A Framework-Based Approach to Assessing Mental Health Impacts of the COVID-19 Pandemic on Children and Adolescents.

The COVID-19 pandemic has yielded extensive impacts globally in the year of 2020. Although the mental health of children and adolescents may be particularly susceptible to stressors stemming from the pandemic and anti-contagion policies, most ongoing efforts are geared toward curbing the viral spread. In the current perspective, we have identified four domains of factors corresponding to an ecological framework that may directly or indirectly influence the mental health of children and adolescents during the pandemic. The evidence suggests that anti-contagion policies might trigger cascades that impact the mental health of children and their families through multiple different sectors that used to form a safety net for youths. Additionally, children with neuropsychiatric disorders could experience exacerbated symptoms during the pandemic. Furthermore, the risk of domestic violence has surged during the pandemic, which further compounds the imminent mental health crisis. A mental health pandemic could be inevitable if no proactive prevention strategies were in place. Therefore, we recommend understanding each individual mental health risk pathway via the ecological framework in order to develop integrative prevention and intervention strategies.

Adherence with an Acute Agitation Algorithm and Subsequent Restraint Use.

Timely use of pharmacological interventions to treat acute agitation has the potential to decrease physical restraint use. The aim of this study is to determine if adherence to standardized pharmacological recommendations for the treatment of acutely agitated pediatric patients decreases physical restraint use. Additionally, this study aims to identify predictors of physical restraint use and describe treatment related adverse events. This is a retrospective chart review of patient visits between September 1, 2016 and August 31, 2017. Patient visits were included if the patient presented to the pediatric emergency department, met ICD-10 codes, and received pharmacologic management or physical restraint to treat acute agitation. The differences in rate of physical restraint was assessed between patients treated according to the standardized pharmacological recommendations and patients who were not. 447 patients were included with a mean age of 13 years. No significant difference in physical restraint use was found when standardized pharmacological recommendations were followed compared to when they were not (P = 0.16). Only presentation on day shift when compared to evening shift resulted in increased odds of being restrained (OR 2.03; 95% CI 1.18, 3.50). Nine adverse events possibly related to medications were identified with none considered to be of significant clinical concern. Standardized pharmacological treatment recommendations was not associated with a decrease in physical restraint use for agitated patients presenting to the pediatric emergency department. The pharmacologic strategies utilized were generally safe and well tolerated in this patient population.

Individual prediction of symptomatic converters in youth offspring of bipolar parents using proton magnetic resonance spectroscopy.

Children of individuals with bipolar disorder (bipolar offspring) are at increased risk for developing mood disorders, but strategies to predict mood episodes are unavailable. In this study, we used support vector machine (SVM) to characterize the potential of proton magnetic resonance spectroscopy (1H-MRS) in predicting the first mood episode in youth bipolar offspring. From a longitudinal neuroimaging study, 19 at-risk youth who developed their first mood episode (converters), and 19 without mood episodes during follow-up (non-converters) were selected and matched for age, sex and follow-up time. Baseline 1H-MRS data were obtained from anterior cingulate cortex (ACC) and bilateral ventrolateral prefrontal cortex (VLPFC). Glutamate (Glu), myo-inositol (mI), choline (Cho), N-acetyl aspartate (NAA), and phosphocreatine plus creatine (PCr + Cr) levels were calculated. SVM with a linear kernel was adopted to classify converters and non-converters based on their baseline metabolites. SVM allowed the significant classification of converters and non-converters across all regions for Cho (accuracy = 76.0%), but not for other metabolites. Considering all metabolites within each region, SVM allowed the significant classification of converters and non-converters for left VLPFC (accuracy = 76.5%), but not for right VLPFC or ACC. The combined mI, PCr + Cr, and Cho from left VLPFC achieved the highest accuracy differentiating converters from non-converters (79.0%). Our findings from this exploratory study suggested that 1H-MRS levels of mI, Cho, and PCr + Cr from left VLPFC might be useful to predict the development of first mood episode in youth bipolar offspring using machine learning. Future studies that prospectively examine and validate these metabolites as predictors of mood episodes in high-risk individuals are necessary.

Lessons Learned to Building Stakeholder Engagement during the Initial Stages of Pragmatic Research Development and Implementation.

Research does not occur in a vacuum. Effective stakeholder engagement occurs on several levels, including outside influence and cooperation inside the institution. Little guidance around designing and implementing pragmatic mental health research exists. The following paper outlines lessons learned during the initial stages of research design and implementation for a project focused on mental health treatment outcomes.

Finding warning markers: Leveraging natural language processing and machine learning technologies to detect risk of school violence.

INTRODUCTION: School violence has a far-reaching effect, impacting the entire school population including staff, students and their families. Among youth attending the most violent schools, studies have reported higher dropout rates, poor school attendance, and poor scholastic achievement. It was noted that the largest crime-prevention results occurred when youth at elevated risk were given an individualized prevention program. However, much work is needed to establish an effective approach to identify at-risk subjects. OBJECTIVE: In our earlier research, we developed a risk assessment program to interview subjects, identify risk and protective factors, and evaluate risk for school violence. This study focused on developing natural language processing (NLP) and machine learning technologies to automate the risk assessment process. MATERIAL AND METHODS: We prospectively recruited 131 students with or without behavioral concerns from 89 schools between 05/01/2015 and 04/30/2018. The subjects were interviewed with two risk assessment scales and a questionnaire, and their risk of violence were determined by pediatric psychiatrists based on clinical judgment. Using NLP technologies, different types of linguistic features were extracted from the interview content. Machine learning classifiers were then applied to predict risk of school violence for individual subjects. A two-stage feature selection was implemented to identify violence-related predictors. The performance was validated on the psychiatrist-generated reference standard of risk levels, where positive predictive value (PPV), sensitivity (SEN), negative predictive value (NPV), specificity (SPEC) and area under the ROC curve (AUC) were assessed. RESULTS: Compared to subjects' sociodemographic information, use of linguistic features significantly improved classifiers' predictive performance (P < 0.01). The best-performing classifier with n-gram features achieved 86.5 %/86.5 %/85.7 %/85.7 %/94.0 % (PPV/SEN/NPV/SPEC/AUC) on the cross-validation set and 83.3 %/93.8 %/91.7 %/78.6 %/94.6 % (PPV/SEN/NPV/SPEC/AUC) on the test data. The feature selection process identified a set of predictors covering the discussion of subjects' thoughts, perspectives, behaviors, individual characteristics, peers and family dynamics, and protective factors. CONCLUSIONS: By analyzing the content from subject interviews, the NLP and machine learning algorithms showed good capacity for detecting risk of school violence. The feature selection uncovered multiple warning markers that could deliver useful clinical insights to assist personalizing intervention. Consequently, the developed approach offered the promise of an accurate and scalable computerized screening service for preventing school violence.

What have we learned from the time trend of mass shootings in the U.S.?

Little is known regarding the time trend of mass shootings and associated risk factors. In the current study, we intended to explore the time trend and relevant risk factors for mass shootings in the U.S. We attempted to identify factors associated with incidence rates of mass shootings at the population level. We evaluated if state-level gun ownership rate, serious mental illness rate, poverty percentage, and gun law permissiveness could predict the state-level mass shooting rate, using the Bayesian zero-inflated Poisson regression model. We also tested if the nationwide incidence rate of mass shootings increased over the past three decades using the non-homogenous Poisson regression model. We further examined if the frequency of online media coverage and online search interest levels correlated with the interval between two consecutive incidents. The results suggest an increasing trend of mass shooting incidences over time (p < 0.001). However, none of the state-level variables could predict the mass shooting rate. Interestingly, we have found inverse correlations between the interval between consecutive shootings and the frequency of on-line related reports as well as on-line search interests, respectively (p < 0.001). Therefore, our findings suggest that online media might correlate with the increasing incidence rate of mass shootings. Future research is warranted to continue monitoring if the incidence rates of mass shootings change with any population-level factors in order to inform us of possible prevention strategies.

An Atypical Presentation of Pediatric Acute Neuropsychiatric Syndrome Responding to Plasmapheresis Treatment.

Here we report a case of a 15-year-old female who had originally been diagnosed and treated unsuccessfully for schizophrenia, psychosis, severe anxiety, and depression. More in-depth history revealed an abrupt onset of her symptoms with remote acute infections and many exhibited characteristics of obsessive compulsive disorder with rituals. Work-up for underlying infectious, immunodeficiency, and autoimmune causes was unrevealing except for very high levels of anti-neuronal antibodies which have been linked to Pediatric Acute-onset Neuropsychiatric Syndrome (PANS). Treatment options were discussed with the family and it was decided to use a course of plasmapheresis based on previous studies demonstrating efficacy and its safety profile. After course of therapy, there was a dramatic resolution of her psychosis, OCD traits, and anxiety. She was able to stop all of her antipsychotic and anxiety medications and resume many of her previous normal daily activities. The effect of this treatment has been sustained to the present time. This case emphasizes the importance of exploring nontraditional treatments for severe, treatment-resistant mental illness which requires a multidisciplinary approach. Further research is warranted in larger populations to investigate pathomechanisms and treatment of PANs/PANDAs.

Automated Risk Assessment for School Violence: a Pilot Study.

School violence has increased over the past ten years. This study evaluated students using a more standard and sensitive method to help identify students who are at high risk for school violence. 103 participants were recruited through Cincinnati Children's Hospital Medical Center (CCHMC) from psychiatry outpatient clinics, the inpatient units, and the emergency department. Participants (ages 12-18) were active students in 74 traditional schools (i.e. non-online education). Collateral information was gathered from guardians before participants were evaluated. School risk evaluations were performed with each participant, and audio recordings from the evaluations were later transcribed and manually annotated. The BRACHA (School Version) and the School Safety Scale (SSS), both 14-item scales, were used. A template of open-ended questions was also used. This analysis included 103 participants who were recruited from 74 different schools. Of the 103 students evaluated, 55 were found to be moderate to high risk and 48 were found to be low risk based on the paper risk assessments including the BRACHA and SSS. Both the BRACHA and the SSS were highly correlated with risk of violence to others (Pearson correlations>0.82). There were significant differences in BRACHA and SSS total scores between low risk and high risk to others groups (p-values <0.001 under unpaired t-test). In particular, there were significant differences in individual SSS items between the two groups (p-value <0.001). Of these items, Previous Violent Behavior (Pearson Correlation = 0.80), Impulsivity (0.69), School Problems (0.64), and Negative Attitudes (0.61) were positively correlated with risk to others. The novel machine learning algorithm achieved an AUC of 91.02% when using the interview content to predict risk of school violence, and the AUC increased to 91.45% when demographic and socioeconomic data were added. Our study indicates that the BRACHA and SSS are clinically useful for assessing risk for school violence. The machine learning algorithm was highly accurate in assessing school violence risk.

Eye Gaze Patterns Associated with Aggressive Tendencies in Adolescence.

Social information processing theory hypothesizes that aggressive children pay more attention to cues of hostility and threat in others' behavior, consequently leading to over-interpretation of others' behavior as hostile. While there is abundant evidence of aggressive children demonstrating hostile attribution biases, less well documented is whether such biases stem from over-attendance and hypersensitivity to hostile cues in social situations. Over-attendance to hostile cues would be typified by deviations at any stage of the multi-stage process of social information processing models. While deviations at later stages in social information processing models are associated with aggressive behavior in children, the initial step of encoding has historically been difficult to empirically measure, being a low level automatic process unsuitable for self-report. We employed eye-tracking methodologies to better understand the visual encoding of such social information. Eye movements of ten 13-18 year-old children referred from clinical and non-clinical populations were recorded in real time while the children viewed scenarios varying between hostile, non-hostile and ambiguous social provocation. In addition, the children completed a brief measure of risk of aggression. Aggressive children did attend more to the social scenarios with hostile cues, in particular attending longest to those hostile scenarios where the actor in the scenario had a congruent emotional response. These findings corroborate social information processing theory and the traditional bottom-up processing hypotheses that aggressive behavior relates to increased attention to hostile cues.

The Generalized Anxiety Disorder 7-item scale in adolescents with generalized anxiety disorder: Signal detection and validation.

BACKGROUND: In pediatric patients with anxiety disorders, existing symptom inventories are either not freely available or require extensive time and effort to administer. We sought to evaluate a brief self-report scale-the Generalized Anxiety Disorder 7-item scale (GAD-7)-in adolescents with generalized anxiety disorder (GAD). METHODS: The Pediatric Anxiety Rating Scale (PARS) and the GAD-7 were administered to youth with GAD (confirmed by structured interview). Relationships between the measures were assessed, and sensitivity and specificity was determined with regard to a global symptom severity measure (Clinical Global Impression-Severity). RESULTS: In adolescents with GAD (N = 40; mean age, 14.8 ± 2.8), PARS and GAD-7 scores strongly correlated (R = 0.65, P ≤ .001) and a main effect for symptom severity was observed (P ≤ .001). GAD-7 scores ≥11 and ≥17 represented the optimum specificity and sensitivity for detecting moderate and severe anxiety, respectively. CONCLUSIONS: The PARS and GAD-7 similarly reflect symptom severity. The GAD-7 is associated with acceptable specificity and sensitivity for detecting clinically significant anxiety symptoms. GAD-7 scores may be used to assess anxiety symptoms and to differentiate between mild and moderate GAD in adolescents, and may be more efficient than the PARS.

White matter volumes in youth offspring of bipolar parents.

BACKGROUND: Studying youth at high risk of developing bipolar disorder may clarify neurobiological factors associated with vulnerability to this illness. We present here a baseline characterization of brain structure in youth at-risk for bipolar disorder. METHODS: Magnetic resonance images were obtained from 115 child and adolescent offspring of bipolar disorder type I subjects and 57 healthy child and adolescent offspring of healthy parents (healthy control offspring). Offspring of parents with bipolar disorder were divided into healthy bipolar offspring (n=47) or symptomatic bipolar offspring (n=68), according to presence or absence of childhood-onset psychopathology. All bipolar offspring were free of major mood and psychotic disorders. Gray (GM) and white matter (WM) volumes were compared between groups using voxel-based morphometry. RESULTS: No differences in GM volumes were found across groups. Healthy bipolar offspring presented with decreased WM volumes in areas of the right frontal, temporal and parietal lobes, and in the left temporal and parietal lobes compared to healthy control offspring. Symptomatic bipolar offspring did not present with any differences in WM volumes compared to either healthy bipolar offspring or healthy control offspring. LIMITATIONS: Cross-sectional design and heterogeneous sample of symptomatic bipolar offspring. CONCLUSIONS: WM volume decreases in areas of the frontal, occipital, and parietal lobes are present in bipolar offspring prior to the development of any psychiatric symptoms, and may be a correlate of familial risk to bipolar disorder. In this large cohort, we have not found evidence for regional GM volume abnormalities as an endophenotype for bipolar disorder.

Beyond DSM-5 and IQ Scores: Integrating the Four Pillars to Forensic Evaluations.

The current adult and child forensic psychiatrist is well trained, familiar, and comfortable with the use of the semi-structured Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, APA 2013 (DSM-5) [In APA, 2003] interview style. The author's assertion is not that this method is invalid or unreliable; rather, that it can be complemented by integrating elements of the defendant's four pillar assessment. Assessing the four pillars expands on the information provided by a semi-structured DSM-5-style interview in psychiatry. The four pillars are the foundation of a person's personality; temperament, cognition (learning abilities or weaknesses), cognitive flexibility (theory of mind) and internal working models of attachment, within the backdrop of the family and of the social and cultural environment in which they have lived. The importance of the study of four pillars is based on the understanding that human behavior and psychopathology as a complex and multifaceted process that includes the level of social-emotional maturity and cognitive abilities (In Delgado et al. Contemporary Psychodynamic Psychotherapy for Children and Adolescents: Integrating Intersubjectivity and Neuroscience. Springer, Berlin, 2015). The four pillars are not new concepts, rather they had been studied by separate non-clinical disciplines, and had not been integrated to the clinical practice. As far as we know, it wasn't until Delgado et al. (Contemporary Psychodynamic Psychotherapy for Children and Adolescents: Integrating Intersubjectivity and Neuroscience. Springer, Berlin, 2015) incorporated the four pillars in a user-friendly manner to clinical practice.

A Pilot Study on Developing a Standardized and Sensitive School Violence Risk Assessment with Manual Annotation.

School violence has increased over the past decade and innovative, sensitive, and standardized approaches to assess school violence risk are needed. In our current feasibility study, we initialized a standardized, sensitive, and rapid school violence risk approach with manual annotation. Manual annotation is the process of analyzing a student's transcribed interview to extract relevant information (e.g., key words) to school violence risk levels that are associated with students' behaviors, attitudes, feelings, use of technology (social media and video games), and other activities. In this feasibility study, we first implemented school violence risk assessments to evaluate risk levels by interviewing the student and parent separately at the school or the hospital to complete our novel school safety scales. We completed 25 risk assessments, resulting in 25 transcribed interviews of 12-18 year olds from 15 schools in Ohio and Kentucky. We then analyzed structured professional judgments, language, and patterns associated with school violence risk levels by using manual annotation and statistical methodology. To analyze the student interviews, we initiated the development of an annotation guideline to extract key information that is associated with students' behaviors, attitudes, feelings, use of technology and other activities. Statistical analysis was applied to associate the significant categories with students' risk levels to identify key factors which will help with developing action steps to reduce risk. In a future study, we plan to recruit more subjects in order to fully develop the manual annotation which will result in a more standardized and sensitive approach to school violence assessments.

Neurofunctional Differences Among Youth With and at Varying Risk for Developing Mania.

OBJECTIVE: To examine prefrontal and amygdala activation during emotional processing in youth with or at varying risk for developing mania to identify candidate central prodromal risk biomarkers. METHOD: Four groups of medication-free adolescents (10-20 years old) participated: adolescents with first-episode bipolar I disorder (BP-I; n = 32), adolescents with a parent with bipolar disorder and a depressive disorder (at-risk depressed [ARD]; n = 32), healthy adolescents with a parent with bipolar disorder (at-risk healthy [ARH]; n = 32), and healthy adolescents with no personal or family history of psychiatric illness (healthy comparison [HC]; n = 32). Participants underwent functional magnetic resonance imaging while performing a continuous performance task with emotional and neutral distracters. Region-of-interest analyses were performed for the bilateral amygdala and for subregions of the ventrolateral prefrontal cortex and anterior cingulate cortex. RESULTS: Overall, no group differences in bilateral amygdala and ventrolateral prefrontal cortex (Brodmann area [BA] 45/47) activation during emotional or neutral stimuli were observed. The BP-I group exhibited lower right pregenual anterior cingulate cortex activation compared with the HC group, and activation in the left BA 44 was greater in the ARH and ARD groups compared with the HC group. BP-I and ARD groups exhibited blunted activation in the right BA 10 compared with the ARH group. CONCLUSION: During emotional processing, amygdala and ventrolateral prefrontal cortex (BA 45/47) activation does not differ in youth with or at increasing risk for BP-I. However, blunted pregenual anterior cingulate cortex activation in first-episode mania could represent an illness biomarker, and greater prefrontal BA 10 and BA 44 activations in at-risk youth could represent a biomarker of risk or resilience warranting additional investigation in prospective longitudinal studies.