The Pediatric Inflammatory Bowel Disease Medical Home: A Proposed Model.

Care for patients with inflammatory bowel disease (IBD) can be complex and costly. Care delivery models to address these challenges and improve care quality are essential. The patient-centered medical home (PCMH), which was developed in the primary care setting, has recently been applied successfully to the adult IBD population. Following the tenets of the PCMH, this specialty medical home (SMH) emphasizes team-based care that is accessible, comprehensive, patient/family-centered, coordinated, compassionate, and continuous and has demonstrated improved patient outcomes. Children and young adults with IBD have equally complex care needs, with additional challenges not faced by the adult population such as growth, physical and psychosocial development, and transition of care from pediatric to adult providers. Thus, we advocate that the components of the PCMH are equally-if not more-important in caring for the pediatric patient population. In this article, we review what is known about the application of the PCMH model in adult IBD care, describe care delivery within the Center for Pediatric and Adolescent IBD at Nationwide Children's Hospital as an example of a pediatric IBD medical home, and propose a research agenda to further the development and dissemination of comprehensive care delivery for children and adolescents with IBD.

This article summarizes the literature regarding the adult inflammatory bowel disease medical home, highlights the need for similar models in pediatrics using the Nationwide Children's Hospital program as an example, and outlines next steps to support research and development of the pediatric IBD medical home.

Physiological linkage and affective dynamics in dyadic interactions between adolescents and their mothers.

This study examined physiological linkage (specifically, linkage in respiratory sinus arrhythmia; RSA) between parents and youth (aged 11-17) across conflict and fun activity discussion tasks. We also examined whether observed, momentary negative affect or parental depressive symptoms, would moderate patterns of RSA linkage across the interaction tasks. RSA linkage was assessed using a multilevel actor-partner interdependence model (APIM). Participants were 59 mother-adolescent dyads, including mothers with or without clinically significant depressive symptoms. Both mothers and teens evidenced stable RSA over time (actor effect), although the stability of maternal RSA was moderated by maternal depression, with maternal depressive symptoms related to slower RSA return to baseline. There was a significant partner influence on youth RSA, with maternal RSA positively related to subsequent youth RSA. However, this effect was moderated by maternal depression and maternal negative affect (NA), with low maternal depression/low maternal NA related to dyadic synchrony, whereas high depression or high NA led to attenuation of this relationship. Results demonstrate the importance of understanding the dynamic and complex nature of family interactions in the context of depression.

The psychophysiology of parenting: Individual differences in autonomic reactivity to positive and negative mood inductions and observed parental affect during dyadic interactions with children.

Parenting is a complex activity driven, in part, by parental emotional and physiological responses. However, work examining the physiological underpinnings of parenting behavior is still in its infancy, and very few studies have examined such processes beyond early childhood. The current study examines associations between Autonomic Nervous System (ANS) indices of parents' physiological reactivity to positive and negative mood states and observed parental affect during a series of discussion tasks with their adolescent child. Respiratory Sinus Arrhythmia (RSA) was measured as an index of parasympathetic nervous system (PNS) activation while viewing film clips designed to induce neutral, sad, and amused mood states. Parental positive affect, anger, and distress were observed during a series of parent-child discussion tasks, which included an ambiguous discussion regarding adolescent growth, a conflict discussion, and a fun-activity planning discussion. Results supported the association between aspects of parental physiological reactivity and observed affect during dyadic interactions. Further, RSA interacted with maternal depression to predict observed positive affect, anger, and distress, although differences across tasks and specific emotions were found regarding the nature of the interaction effects. Overall, results suggest that such neurobiological processes may be particularly important predictors of parental behavior, particularly in at-risk populations. (PsycINFO Database Record

A Broad Consideration of Risk Factors in Pediatric Chronic Pain: Where to Go from Here?

Pediatric chronic pain is a significant problem associated with substantial functional impairment. A variety of risk factors have been found to be associated with chronic pain in youth. The greatest amount of evidence appears to support that temperament, anxiety, depression, subjective experience of stress, passive coping strategies, sleep problems, other somatic-related problems, and parent and/or family factors are important variables. However, a great deal of this research focuses on a single risk factor or on multiple risk factors in isolation. Much of the literature utilizes older diagnostic criteria and would benefit from replication, larger sample sizes, and comparison across pain disorders. Problems also exist with disagreement across definitions, resulting in inconsistency or unclear use of terms. Furthermore, recent consideration has suggested that outcome measures should include functional disability in addition to pain. A second generation of research is needed to shed light on the complex interactions that likely play a role in the transition from acute to chronic pain. Building on recent calls for changes in research in this area, we propose the next steps for this research, which involve consideration of both biopsychosocial and developmental contexts.

Long-Term Effects of the Family Check-Up in Early Adolescence on Risk of Suicide in Early Adulthood.

The impact of the Family Check-Up (FCU), a school-based prevention program, as delivered in public secondary schools on suicide risk across adolescence, was examined. Students were randomly assigned to a family-centered intervention (N = 998) in the sixth grade and offered a multilevel intervention that included (1) a universal classroom-based intervention, (2) the FCU (Dishion, Stormshak, & Kavanagh, 2011), and (3) family management treatment. Engagement with the FCU predicted significant reductions in suicide risk across adolescence and early adulthood.

Binge drinking, depression, and electrocortical responses to emotional images.

Binge drinking and depression are highly prevalent, associated with cognitive and affective impairments, and frequently co-occur. Yet little research has examined their joint relations with such processing impairment. The current study examines the relation between symptoms of depression, binge drinking, and the magnitude of early (early posterior negativity, EPN) and later (P3 and late positive potential, LPP) visual processing components of affectively negative, positive, and neutral visual stimuli. Participants included 42 undergraduate students recruited on the basis of depressive symptoms. Results of repeated measures analyses of variance (ANOVAs; Depression × Binge × Emotion × Laterality) showed that binge drinkers exhibited lower LPP amplitudes for negative images, compared with nonbinge drinkers, regardless of depression, consistent with motivational models of alcohol abuse. Otherwise, differences across depressed and nondepressed groups were largest among binge drinkers, including a pattern of stronger early attentional engagement (EPN) to negative and neutral images, but decreased later processing (P3 and LPP) across all emotional categories, consistent with a vigilance-avoidance response pattern.

A prospective open-label trial of paliperidone monotherapy for the treatment of bipolar spectrum disorders in children and adolescents.

RATIONALE: Treatment studies for the management of pediatric bipolar disorder are limited. OBJECTIVES: This study evaluates the safety and efficacy of paliperidone monotherapy as an acute treatment of mania and related symptoms in youth with bipolar spectrum disorders. METHODS: An 8-week, prospective, open-label paliperidone monotherapy trial to assess effectiveness and tolerability in treating pediatric bipolar spectrum and related disorders (depression, psychosis, attention-deficit/hyperactivity disorder [ADHD]). Assessments included the Young Mania Rating Scale (YMRS), Clinical Global Impression scale (CGI), Children's Depression Rating Scale-Revised (CDRS-R), and Brief Psychiatric Rating Scale (BPRS). Adverse events were assessed through spontaneous self-reports, vital signs, weight monitoring, and laboratory analysis. RESULTS: Fifteen youth with bipolar spectrum disorders (YMRS at entry: 32.8 ± 6.1) were enrolled in the study and 11 (73 %) completed the 8-week trial. The total daily dose of paliperidone at study endpoint was 3 mg in 12 subjects and 6 mg in three subjects. Treatment with paliperidone was associated with statistically significant levels of improvement in mean YMRS scores (-18.7 ± 13.9, p < 0.001) at endpoint. Paliperidone treatment also resulted in significant improvement in the severity of ADHD and psychotic symptoms. Although treatment with paliperidone was generally well tolerated and was not associated with clinically significant change in cardiovascular or metabolic parameters, increases in body weight (4.1 ± 5.5 lb) were substantial. CONCLUSIONS: Open-label paliperidone treatment appears to be beneficial in the treatment of bipolar spectrum disorders and associated conditions in youth. Future placebo-controlled studies are warranted to confirm these findings.

Further evidence for robust familiality of pediatric bipolar I disorder: results from a very large controlled family study of pediatric bipolar I disorder and a meta-analysis.

OBJECTIVE: To determine the risk for bipolar I disorder in first-degree relatives of children with DSM-IV bipolar I disorder via meta-analysis and expanded controlled study. DATA SOURCES AND EXTRACTION: For the meta-analysis, PubMed was searched for scientific articles published in the world literature in English through 2011. The keywords searched were bipolar disorder, first-degree relatives, family study, and control. All online abstracts were reviewed, and relevant full manuscripts were collected and reviewed. Citations were also examined for other potentially relevant articles. The analysis included only controlled family studies that examined rates of bipolar I disorder in all first-degree relatives (parents and siblings) of pediatric bipolar I probands and that had age- and sex-matched controls. Family history studies were excluded, as were studies that were not in English, did not report bipolar I rates for all first-degree relatives, or reported only bipolar spectrum rates. Also excluded were family studies that included only adult probands. A meta-analysis was conducted of the 5 controlled family studies of pediatric bipolar I probands that met the search criteria using the random-effects model of DerSimonian and Laird. METHOD: For the family study, our previous sample of DSM-IV bipolar I probands was greatly expanded using structured diagnostic interviews. The new study included 239 children aged 6-17 years who satisfied full DSM-IV diagnostic criteria for bipolar I disorder (n = 726 first-degree relatives), 162 attention-deficit/hyperactivity disorder (ADHD) probands (without bipolar I disorder; n = 511 first-degree relatives), and 136 healthy control probands (without ADHD or bipolar I disorder; n = 411 first-degree relatives). The Kaplan-Meier cumulative failure function was used to calculate survival curves and cumulative lifetime risk in relatives. Cox proportional hazard models were used to calculate the risk of bipolar I disorder in relatives. RESULTS: The pooled odds ratio for bipolar I disorder in relatives was estimated to be 6.96 (95% confidence interval [CI], 4.8-10.1). First-degree relatives of bipolar I probands were also significantly more likely than first-degree relatives of both ADHD probands (hazard ratio [HR] = 3.02; 95% CI, 1.85-4.93; P < .001) and control probands (HR = 2.83; 95% CI, 1.65-4.84; P < .001) to have bipolar I disorder. CONCLUSIONS: Our results document an increased familial risk for bipolar I disorder in relatives of pediatric probands with DSM-IV bipolar I disorder.

A magnetic resonance spectroscopy study of the anterior cingulate cortex in youth with emotional dysregulation.

BACKGROUND: The main aim of this study was to use proton Magnetic Resonance Spectroscopy (MRS) to identify brain biomarkers for emotional dysregulation in youth as measured by subscales of the Child Behavior Checklist (CBCL). METHODS: We measured glutamate (Glu) concentrations in the anterior cingulated cortex (ACC) of 37 pediatric subjects (aged 6-17 years) using high field (4.0 Tesla) proton Magnetic Resonance Spectroscopy (MRS). Subjects were grouped based on combined T scores on three subscales (Anxiety/Depression, Aggression and Attention) of the CBCL previously associated with deficits in the regulation of emotion. Subjects were stratified into those with high (> 180) (N=10) and low (< 180) (N=27) scores. LIMITATIONS: Limitations include small sample size, wide age range studied, focus on Anterior Cingulate Cortex (ACC) only, and that some subjects received psychopharmacological treatments. RESULTS: We found a statistically significant correlation between Glu levels in the ACC and CBCL dysregulation profile scores among subjects with high dysregulation profile scores. CONCLUSIONS: These results suggest that glutamatergic dysregulation in the ACC may represent a useful biomarker of emotional dysregulation in youth. Further investigation into the causality, time line and utility as a predictive metric is warranted.