Validity of the multidimensional assessment profile of disruptive behavior in autistic toddlers.

Objective: Early measurement of atypical disruptive behavior within autistic children is critical for later referrals to behavioral screenings, diagnoses, and services. Disruptive behavior in autistic toddlers is often measured using a categorical approach and identifies the presence or absence of behavior. In contrast, dimensional approaches evaluate behavior on a spectrum of typical to atypical by measuring the clinical salience of disruptive behavior. We sought to assess the validity of the Infant/Toddler version of the multidimensional assessment profile of disruptive behavior (MAP-DB-IT), a dimensional approach measurement tool, in a sample of autistic toddlers. Methods: Autistic toddlers (n = 82, M age = 33.2 months, SD = 6.28 months) and their mothers received 8 weeks of caregiver-mediated social communication intervention. Mothers completed the MAP-DB-IT and the Infant Toddler Social Emotional Assessment (ITSEA) across three timepoints: before intervention, immediately after intervention, and at 3 months post-intervention follow-up. The MAP-DB-IT provided scores for three subdomains: temper loss, noncompliance, and aggression (generically or specifically with siblings). Ratings on the MAP-DB-IT were compared to the ITSEA using several analytic strategies such as evaluating (a) the internal consistency of the MAP-DB-IT domain scores; (b) the convergent validity between the two measures; and (c) its convergent change due to intervention and if this varied by child characteristics. Results: The MAP-DB-IT demonstrated excellent internal consistency across all four subdomains. We evaluated convergent validity and found positive correlations between the (a) ITSEA externalizing and MAP-DB-IT aggression domain, (b) ITSEA externalizing and MAP-DB-IT aggression with siblings domain, and (c) ITSEA dysregulation and MAP-DB-IT temper loss domain. Conclusion: The MAP-DB-IT is a valid measurement tool for disruptive behavior in autistic toddlers. Clinicians should consider the use of the MAP-DB-IT for young autistic clients presenting with disruptive behavior to (a) discriminate between early developmentally appropriate tantrums from clinically salient dysregulation, and (b) refer to additional behavioral evaluations and services.

Autistic Children's Irritability During Social Communication Assessments.

PURPOSE: Accurate measurement of autistic children's social communication is critical for assessing skills, setting intervention goals, evaluating change over time, determining service eligibility, and determining classroom placement. There are various types of assessments, some of which use specific tasks to elicit social communication. Structured tasks may frustrate children, inadvertently elicit irritability, and have a cascading effect on their ability to communicate. To date, no studies have evaluated how differing types of social communication assessments may exacerbate children's irritability and impact assessment scores. We examined the extent to which (a) social communication assessment type (structured vs. naturalistic) impacts autistic children's irritability and (b) child irritability is associated with social communication scores. METHOD: Autistic toddlers (n = 114, Mage = 33.09 months, SD = 6.15) completed the Communication and Symbolic Behavior Scales (CSBS; structured) and a 10-min play-based mother-child interaction (MCX; naturalistic). Child irritability was scored on both assessments using a global rating scale of 0-15. RESULTS: Child irritability during the CSBS was significantly higher than during the MCX (V = 4892, p < .001, r = .68). Higher irritability was associated with lower CSBS social communication scores (B = -0.05, p = .03), but not MCX scores (B = 0.04, p = .13; Theil's F = 6.92, p = .009). CONCLUSIONS: Our findings suggest that the CSBS may pose unique challenges for autistic children, as it led to higher rates of irritability and negatively affected children's social communication scores. Evaluating the association between assessment type and irritability supports the complete characterization of autistic children's experience during assessments and clinicians in obtaining a more representative measure of social communication.

Understanding Internalizing and Externalizing Behaviors in Autistic Toddlers.

PURPOSE: The majority of autistic toddlers present with clinically significant levels of internalizing or externalizing behaviors. Despite the prevalence of internalizing and externalizing behaviors in caseloads, the overwhelming majority of speech-language pathologists (SLPs) have not received specialized instruction in how to support children with these behaviors. The purpose of this study was to identify which child and caregiver characteristics are most associated with internalizing and externalizing behaviors in autistic toddlers in order to consider how SLPs may tailor their treatment to better support the individual needs of autistic children. METHOD: Participants included 109 mothers and their autistic children between 18 and 48 months of age. This study was a secondary analysis of data from a randomized clinical trial. Participants' baseline data included a variety of child (i.e., expressive language, receptive language, restricted and repetitive behavior [RRB], and nonverbal cognition) and caregiver (i.e., self-efficacy and responsiveness) characteristics. Seemingly unrelated regressions were conducted to determine which characteristics were associated with internalizing and externalizing behaviors in autistic toddlers. RESULTS: Higher RRB scores were associated with both higher internalizing and externalizing behavior scores. A lower nonverbal cognition score was also associated with higher internalizing behavior scores but to a lesser extent than RRB. CONCLUSION: These findings suggest that SLPs may support internalizing and externalizing behaviors in autistic children by taking RRBs and nonverbal cognition into consideration.

Parent-Implemented Positive Behavior Support Strategies for Young Children on the Autism Spectrum: A Pilot Investigation.

PURPOSE: Parents of children on the autism spectrum enrolled in early intervention often receive coaching to address both social communication and disruptive behavior, which are the two most frequently reported concerns by parents. Intervention techniques for both are often recommended to be implemented across daily routines and require the parents to learn new ways of interacting with their child. A sequential approach to instructing parents in these key intervention targets may reduce burden and increase adherence. METHOD: This multiple-baseline design pilot study included three mother-child dyads who received instruction in a disruptive behavior intervention immediately following a social communication intervention. Maternal maintenance of social communication strategies and child disruptive behaviors were measured during probes throughout the study. RESULTS: Results indicate that although mothers readily learned to implement the techniques, fidelity of implementing social communication strategies declined after introduction of the positive behavior support strategies. CONCLUSIONS: A sequenced approach to parent-mediated intervention is feasible and acceptable. Clinical implications and future directions are discussed. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.19528978.

RAHI-SATHI Indo-U.S. Collaboration: The Evolution of a Trainee-Led Twinning Model in Global Health Into a Multidisciplinary Collaborative Program.

BACKGROUND: In recent years there has been a surge in the number of global health programs operated by academic institutions. However, most of the existing programs describe partnerships that are primarily faculty-driven and supported by extramural funding. PROGRAM DESCRIPTION: Research and Advocacy for Health in India (RAHI, or "pathfinder" in Hindi) and Support and Action Towards Health-Equity in India (SATHI, or "partnership" in Hindi) are 2 interconnected, collaborative efforts between the University of Massachusetts Medical School (UMMS) and Charutar Arogya Mandal (CAM), a medical college and a tertiary care center in rural western India. The RAHI-SATHI program is the culmination of a series of student/trainee-led research and capacity strengthening initiatives that received institutional support in the form of faculty mentorship and seed funding. RAHI-SATHI's trainee-led twinning approach overcomes traditional barriers faced by global health programs. Trainees help mitigate geographical barriers by acting as a bridge between members from different institutions, garner cultural insight through their ability to immerse themselves in a community, and overcome expertise limitations through pre-planned structured mentorship from faculty of both institutions. Trainees play a central role in cultivating trust among the team members and, in the process, they acquire personal leadership skills that may benefit them in their future careers. CONCLUSION: This paradigm of trainee-led twinning partnership promotes sustainability in an uncertain funding climate and provides a roadmap for conducting foundational work that is essential for the development of a broad, university-wide global health program.

A clinical perspective on the relevance of research domain criteria in electronic health records.

OBJECTIVE: The limitations of the DSM nosology for capturing dimensionality and overlap in psychiatric syndromes, and its poor correspondence to underlying neurobiology, have been well established. The Research Domain Criteria (RDoC), a proposed dimensional model of psychopathology, may offer new insights into psychiatric illness. For psychiatric clinicians, however, because tools for capturing these domains in clinical practice have not yet been established, the relevance and means of transition from the categorical system of DSM-5 to the dimensional models of RDoC remains unclear. The authors explored a method of extracting these dimensions from existing electronic health record (EHR) notes. METHOD: The authors used information retrieval and natural language processing methods to extract estimates of the RDoC dimensions in the EHRs of a large health system. They parsed and scored EHR documentation for 2,484 admissions covering 2,010 patients admitted to a psychiatric inpatient unit between 2011 and 2013. These domain scores were compared with DSM-IV-based ICD-9 codes to assess face validity. As a measure of predictive validity, these scores were examined for association with two outcomes: length of hospital stay and time to all-cause hospital readmission. Together, these analyses were intended to address the extent to which RDoC symptom domains might capture clinical features already available in narrative notes but not reflected in DSM diagnoses. RESULTS: In mixed-effects models, loadings for the RDoC cognitive and arousal domains were associated with length of hospital stay, while the negative valence and social domains were associated with hazard of all-cause hospital readmission. CONCLUSIONS: These findings show that a computationally derived tool based on RDoC workgroup reports identifies symptom distributions in clinician notes beyond those captured by ICD-9 codes, and these domains have significant predictive validity. More generally, they point to the possibility that clinicians already document RDoC-relevant symptoms, albeit not in a quantified form.

An electronic health records study of long-term weight gain following antidepressant use.

IMPORTANCE: Short-term studies suggest antidepressants are associated with modest weight gain but little is known about longer-term effects and differences between individual medications in general clinical populations. OBJECTIVE: To estimate weight gain associated with specific antidepressants over the 12 months following initial prescription in a large and diverse clinical population. DESIGN, SETTING, AND PARTICIPANTS: We identified 22,610 adult patients who began receiving a medication of interest with available weight data in a large New England health care system, including 2 academic medical centers and affiliated outpatient primary and specialty care clinics. We used electronic health records to extract prescribing data and recorded weights for any patient with an index antidepressant prescription including amitriptyline hydrochloride, bupropion hydrochloride, citalopram hydrobromide, duloxetine hydrochloride, escitalopram oxalate, fluoxetine hydrochloride, mirtazapine, nortriptyline hydrochloride, paroxetine hydrochloride, venlafaxine hydrochloride, and sertraline hydrochloride. As measures of assay sensitivity, additional index prescriptions examined included the antiasthma medication albuterol sulfate and the antiobesity medications orlistat, phentermine hydrochloride, and sibutramine hydrochloride. Mixed-effects models were used to estimate rate of weight change over 12 months in comparison with the reference antidepressant, citalopram. MAIN OUTCOME AND MEASURE: Clinician-recorded weight at 3-month intervals up to 12 months. RESULTS: Compared with citalopram, in models adjusted for sociodemographic and clinical features, significantly decreased rate of weight gain was observed among individuals treated with bupropion (ß [SE]: -0.063 [0.027]; P = .02), amitriptyline (ß [SE]: -0.081 [0.025]; P = .001), and nortriptyline (ß [SE]: -0.147 [0.034]; P < .001). As anticipated, differences were less pronounced among individuals discontinuing treatment prior to 12 months. CONCLUSIONS AND RELEVANCE: Antidepressants differ modestly in their propensity to contribute to weight gain. Short-term investigations may be insufficient to characterize and differentiate this risk.

Stratification of risk for hospital admissions for injury related to fall: cohort study.

OBJECTIVE: To determine whether the ability to stratify an individual patient's hazard for falling could facilitate development of focused interventions aimed at reducing these adverse outcomes. DESIGN: Clinical and sociodemographic data from electronic health records were utilized to derive multiple logistic regression models of hospital readmissions for injuries related to falls. Drugs used at admission were summarized based on reported adverse effect frequencies in published drug labeling. SETTING: Two large academic medical centers in New England, United States. PARTICIPANTS: The model was developed with 25,924 individuals age ≥ 40 with an initial hospital discharge. The resulting model was then tested in an independent set of 13,032 inpatients drawn from the same hospital and 36,588 individuals discharged from a second large hospital during the same period. MAIN OUTCOME MEASURE: Hospital readmissions for injury related to falls. RESULTS: Among 25,924 discharged individuals, 680 (2.6%) were evaluated in the emergency department or admitted to hospital for a fall within 30 days of discharge, 1635 (6.3%) within 180 days of discharge, 2360 (9.1%) within one year, and 3465 (13.4%) within two years. Older age, female sex, white or African-American race, public insurance, greater number of drugs taken on discharge, and score for burden of adverse effects were each independently associated with hazard for fall. For drug burden, presence of a drug with a frequency of adverse effects related to fall of 10% was associated with 3.5% increase in odds of falling over the next two years (odds ratio 1.04, 95% confidence interval 1.02 to 1.05). In an independent testing set, the area under the receiver operating characteristics curve was 0.65 for a fall within two years based on cross sectional data and 0.72 with the addition of prior utilization data including age adjusted Charlson comorbidity index. Portability was promising, with area under the curve of 0.71 for the longitudinal model in a second hospital system. CONCLUSIONS: It is potentially useful to stratify risk of falls based on clinical features available as artifacts of routine clinical care. A web based tool can be used to calculate and visualize risk associated with drug treatment to facilitate further investigation and application.

Effect of gender on treatment and outcomes in severe aortic stenosis.

The aim of this study was to evaluate the effect of gender on operative rates and outcomes in men and women with severe aortic stenosis. An institutional echocardiographic database was used to identify all adult patients with severe aortic stenosis from 2004 through 2005. Only patients with class I indication for aortic valve replacement (AVR) during the period of follow-up were included in the study. Three hundred sixty-two patients were identified with severe aortic stenosis and class I indication for AVR (52% women). Overall operative rate for the cohort was 72%. In patients who underwent AVR, Kaplan-Meier survival rates were the same for men and women. Sixty-four percent of women versus 81% of men underwent AVR (p <0.001). After adjusting for multiple covariates, women had a 2.1-fold lower odds of undergoing AVR compared to men (p = 0.02). After matching for age and Society of Thoracic Surgery risk score, women underwent AVR at a 19% lower relative rate compared to men (p = 0.03); when stratified by gender, there was no difference in reasons for not undergoing AVR. In conclusion, despite similar outcomes after surgery, women with severe aortic stenosis are less likely than men to undergo AVR.