Psychosocial supports within pediatric nephrology practices: A pediatric nephrology research consortium survey.

BACKGROUND: The landscape of available psychosocial services within pediatric nephrology care is poorly characterized. However, the effects of kidney disease on emotional health and health-related quality of life are well documented, as is the impact of social determinants of health on kidney disease outcomes. The objectives of this study were to assess pediatric nephrologists' perceptions of available psychosocial services and to elucidate inequities in access to psychosocial care. METHODS: A web-based survey was distributed to members of the Pediatric Nephrology Research Consortium (PNRC). Quantitative analyses were performed. RESULTS: We received responses from 49 of the 90 PNRC centers. With regards to dedicated services, social work was most commonly available (45.5-100%), followed by pediatric psychology (0-57.1%) and neuropsychology (0-14.3%), with no centers having embedded psychiatry. Availability of psychosocial providers was positively associated with nephrology division size, such that as center size increased, access to various psychosocial providers increased. Notably, the majority of respondents indicated that perceived need for psychosocial support exceeds that which is currently available, even at centers with higher levels of current support. CONCLUSIONS: Within the US, there is wide variability in the availability of psychosocial services within pediatric nephrology centers despite a well-documented necessity for the provision of holistic care. Much work remains to better understand the variation in funding for psychosocial services and in utilization of psychosocial professionals in the pediatric nephrology clinic, and to inform key best practices for addressing the psychosocial needs of patients with kidney disease.

The pressure's on: understanding neurocognitive and psychological associations with pediatric hypertension to inform comprehensive care.

The prevalence of hypertension is increasing in pediatric populations. While clinical data and practice guidelines identify the impact of hypertension on organ dysfunction and emphasize the importance for end-organ damage screening, the bidirectional effects of pediatric hypertension on neurocognitive and psychological outcomes are understudied. The objective of this review is to highlight the association between hypertension and cognition, attention, learning, and mental health in children and adolescents. In doing so, this review provides a framework and toolkit to integrate neuropsychology and psychology into the screening and management stages of pediatric hypertension. By recognizing the effects of hypertension on cognition, behavior, and mental health, screenings and interventions can be implemented to proactively and comprehensively improve the health outcomes for children with blood pressure concerns.

COVID-19 issues related to pediatric neuropsychology and inpatient rehabilitation - challenges to usual care and solutions during the pandemic.

Objective: To describe the challenges related to COVID-19 affecting pediatric neuropsychologists practicing in inpatient brain injury rehabilitation settings, and offer solutions focused on face-to-face care and telehealth.Methods: A group of pediatric neuropsychologists from 12 pediatric rehabilitation units in North America and 2 in South America have met regularly since COVID-19 stay-at-home orders were initiated in many parts of the world. This group discussed challenges to clinical care and collaboratively problem-solvedsolutions.Results: Three primary challenges to usual care were identified, these include difficulty providing 1) neurobehavioral and cognitive assessments; 2) psychoeducation for caregivers and rapport building; and 3) return to academic instruction and home. Solutions during the pandemic for the first two areas focus on the varying service provision models that include 1) face-to-face care with personal protective equipment (PPE) and social distancing and 2) provision of care via remote methods, with a focus on telehealth. During the pandemic,neuropsychologists generally combine components of both the face-to-face and remote care models. Solutions to the final challenge focus on issues specific to returning to academic instruction and home after an inpatient stay.Conclusions: By considering components of in-person and telehealth models of patient care during the pandemic, neuropsychologists successfully serve patients within the rehabilitation setting, as well as the patient's family who may be limited in their ability to be physically present due to childcare, illness, work-related demands, or hospital restrictions.

Feasibility of psychosis risk assessment for adolescents diagnosed with autism.

LAY ABSTRACT: Individuals with autism may experience a variety of psychiatric symptoms that may cause distress and difficulty functioning. The tools that exist to help evaluate symptoms for psychosis for individuals with autism are limited. We investigated whether a specialized interview for symptoms of psychosis risk could be used for adolescents with autism. We recruited 21 adolescents with autism and 22 typically developing adolescents and interviewed them using the Structured Interview for Psychosis-Risk Syndromes. Participants were asked to rephrase interview questions as a way to understand how they interpreted the question. Their responses were evaluated by clinicians and third-party raters to determine potential response errors. Results of the study showed that youth with autism who have intact language skills are able to answer questions about psychosis risk symptoms as well as their typically developing peers. In general, adolescents across both groups who had more difficulty with nonliteral language (understanding words with multiple meanings) had more difficulty completing the Structured Interview for Psychosis-Risk Syndromes. Problematic items that required more clarification by the clinician involved misinterpretation of words/phrases or questions. Care should be taken to ensure adolescents understand the intent of interviewer questions when assessing risk of psychosis.

Impacts of sex and the estrous cycle on associations between post-fear conditioning sleep and fear memory recall.

Women are at greater risk than men for developing posttraumatic stress disorder (PTSD) after trauma exposure. Sleep, especially rapid-eye-movement sleep (REMS), has been considered a contributing factor to the development of PTSD symptoms through its effects on the processing of emotional memories. However, it remains unknown if sex and sex hormones play a role in the hypothesized impact of sleep on the development of PTSD. Animal models have methodological advantages over human studies in investigating this research question; however, animal models of sleep in PTSD have been tested only with males. C57BL/6 mice (7 males and 15 females) were exposed to 15 footshocks in a footshock chamber, and 5 min after the last footshock, were returned to their home cages for telemetric electroencephalographic sleep recording. Nine to thirteen days later, mice were returned to the footshock chamber for 10 min without footshocks. Fear recall rates were computed by comparing freezing behaviors in the footshock chamber immediately after the footshocks to those during fear context reexposure. Males had significantly lower recall rates compared to metestrous females (that received footshocks on metestrus). Overall, males slept more than both proestrous females (that received footshocks on proestrus) and metestrous females during the dark period. Regression analyses revealed that average REMS episode durations after footshocks were differentially associated with recall rates across groups, such that the association was positive in males, but negative in proestrous females. Results suggest that both sex and the estrous cycle modulate the associations between REMS continuity and fear memory consolidation.

The impact of age on the validity of psychosis-risk screening in a sample of help-seeking youth.

Self-report screening instruments offer promise in furthering early identification of at-risk youth, yet current efforts are limited by false positive rates. Identifying moderators of accuracy is a potential step towards improving identification and prevention efforts. We investigated the moderating effect of age on self-reported attenuated positive symptoms from the Prime Screen and clinician diagnosed clinical high-risk/early psychosis (CHR/EP) status. Participants (N = 134) were racially diverse, lower-income, help-seeking adolescents and young adults from a primarily urban community. The overall model predicting CHR/EP status was significant, with results suggesting the presence of a trending interaction between age and Prime Screen symptoms. Analyses indicated that number of items endorsed to predict CHR/EP decreased with age (youngest group [M = 12.99] cut off = 6 items; middle age group [M = 14.97] cut off = 3; oldest age group [M = 18.40] cut off = 1). Although younger participants endorsed more risk items on average, follow up analyses suggested that the Prime Screen was a more accurate predictor of clinician-diagnosed-risk among older participants relative to their younger peers. The current study builds on the literature identifying moderators of psychosis-risk screening measure accuracy, highlighting potential limitations of CHR/EP screening tools in younger populations.

Ineffective Homeschooling in a Child with a Learning Disability.

CASE: Charles is a 10-year-old African-American male who presents to the Developmental Behavioral Pediatrics Clinic for evaluation of his learning. His primary care provider (PCP) was concerned that his developmental delays were negatively affecting his ability to engage in his homeschooling curriculum and also that his mother seemed unaware of the severity of his delays. Neuropsychological evaluation had been recommended by the PCP several times in the past, but the family declined. At one point, the PCP had considered potential child protective services (CPS) referral for medical neglect because of missed appointments and lack of follow-through on recommendations, which motivated the parent to bring him to this appointment.Medical history was significant for failure to thrive and hypotonia in infancy. Charles received physical therapy through early childhood for hypotonia and motor coordination deficits. His mother removed him from public school and initiated homeschooling in kindergarten after he suffered a dental injury at recess of which she was not notified. The current homeschooling (fourth grade) approach was described as "off and on" activities for 3 hours daily. His mother acknowledged that she struggled to get him to participate as he preferred using the computer and tablet rather than doing school work, and they also argued regularly about his impulsive eating. The patient's mother also described her own medical conditions that contributed to a high degree of stress and fatigue, which she felt made homeschooling more difficult.On examination, the patient was obese and had widely set, almond-shaped eyes; a wide-based gait; an immature pencil grasp; and a mild truncal and appendicular hypotonia. Performance on the Kaufman Brief Intelligence Test, second edition, was below average for the verbal scale (78) and low average for the nonverbal scale (89). On the Wechsler Individualized Achievement Test, third edition, he was unable to perform any multiplication, could not write his own last name (was practicing tracing at home per maternal report), and read at a below first-grade reading level (standardized scores could not be calculated). His conversations with the examiner were mainly limited to the topic of video games. He spoke in short sentences with approximately 85% intelligibility but with coordinated gaze. He appeared mentally exhausted as testing progressed.Feedback to the parent included concern for a learning disability possibly associated with a genetic condition such as Prader-Willi syndrome (because of the history of hypotonia and impulsive eating), and genetic testing was recommended. Because of Charles' difficulty accessing the homeschool curriculum, a special education evaluation through the local public school district was also recommended, but his mother resisted, stating that she felt public special education "keeps children like him down" by focusing primarily on African-American children and stigmatizing their differences.The mother does not return phone calls made 1 month later to follow-up on considering a special education evaluation, and team members raise concern about medical neglect. What would you do next?

The association between sleep dysfunction and psychosis-like experiences among college students.

Sleep problems are prominent and pervasive clinical issues experienced by many people with psychotic disorders, often causing distress and functional impairment. Sleep problems are also related to psychosis-like experiences (PLE; non-diagnosable phenomenon such as transient perceptual disturbances, unusual thoughts, periodic suspiciousness) in epidemiological studies. Prior studies in this field have used brief measures that precluded the ability to test (1) whether risk for psychosis-like experiences are related to specific sub-types of sleep disturbance, and (2) whether sleep disturbance is specifically related to clinically significant (i.e., distressing) psychosis-like experiences. The current project examined the relation between specific sleep issues, and PLEs and distress associated with PLEs, in a college sample. Participants (N=420) completed the Prodromal Questionnaire-Brief (PQ-B), which assesses PLEs and associated distress, and the Iowa Sleep Disturbances Inventory - extended version (ISDI-E), which assesses thirteen separate disturbed sleep domains. Symptoms of fragmented sleep, sleep hallucinations, and night anxiety significantly correlated with PLEs, and several sleep domains were significantly associated with PLE-related distress.

Outcomes of a Psychoeducational Intervention to Reduce Internalized Stigma Among Psychosocial Rehabilitation Clients.

OBJECTIVE: This community-based randomized controlled trial was carried out to test the Ending Self-Stigma (ESS) psychoeducational intervention, which is designed to help adults with serious mental illnesses reduce internalization of mental illness stigma and its effects. METHODS: A total of 268 adults from five different mental health programs in Maryland took part. After baseline interview, consenting participants were randomly assigned to the nine-week ESS intervention or a minimally enhanced treatment-as-usual control condition. Participants were assessed by using symptom, psychosocial functioning, and self-stigma measures at baseline, postintervention, and six-month follow-up. Demographic characteristics were assessed at baseline. RESULTS: Compared with participants in the control condition, ESS group participants showed significant decreases on the stereotype agreement and self-concurrence subscales of the Self Stigma of Mental Illness Scale, significant improvement on the alienation and stigma resistance subscales of the Internalized Stigma Mental Illness measure, and a significant increase in recovery orientation from baseline to postintervention. None of these differences were sustained at six-month follow-up. CONCLUSIONS: Results indicate that ESS was useful in helping to reduce key aspects of internalized stigma among individuals with mental illnesses and that advances in the delivery, targeting, and content of the intervention in the field may be warranted to increase its potency.

Trauma and psychosis symptoms in a sample of help-seeking youth.

Although childhood trauma is generally considered to be a risk factor for later development of psychosis, the influence of trauma on the specific presentation of psychosis symptoms in high-risk and first-episode samples remains unclear. The current study aims to investigate the association of trauma with psychosis and psychosis-risk symptoms among patients with early indications of psychosis as well as in a comparison group receiving mental health services for non-psychosis concerns. Participants (N=125) were assessed for history of exposure to trauma using the KSADS-PL and psychosis-risk symptoms using the Structured Interview for Psychosis-Risk Syndromes (SIPS). Individuals were categorized as "clinical high risk/early psychosis" or "low-risk for psychosis" on the basis of SIPS criteria. The association of traumatic events with specific symptoms was explored within each group. Exposure to one or more traumatic events was more common within the early psychosis group (85%) relative to the low-risk group (65%). Within both groups, trauma significantly correlated with the severity of clinician-rated positive - but not negative, disorganized, or general - symptoms. Within the low-risk group, there was a significant association between violent traumas and heightened suspiciousness. Within the early psychosis group, both violent and non-violent traumas predicted elevated grandiosity. The prevalence of traumatic events within this adolescent and young adult clinical sample was high. Trauma history significantly predicted greater positive symptoms. The apparent influence of trauma exposure on specific symptoms was unique in each group.

Context matters: The impact of neighborhood crime and paranoid symptoms on psychosis risk assessment.

Psychosis risk assessment measures probe for paranoid thinking, persecutory ideas of reference, and suspiciousness as part of a psychosis risk construct. However, in some cases, these symptoms may reflect a normative, realistic, and even adaptive response to environmental stressors rather than psychopathology. Neighborhood characteristics, dangerousness for instance, are linked to levels of fear and suspiciousness that can be theoretically unrelated to psychosis. Despite this potential confound, psychosis-risk assessments do not explicitly evaluate neighborhood factors that might (adaptively) increase suspiciousness. In such cases, interviewers run the risk of misinterpreting adaptive suspiciousness as a psychosis-risk symptom. Ultimately, the degree to which neighborhood factors contribute to psychosis-risk assessment remains unclear. The current study examined the relation between neighborhood crime and suspiciousness as measured by the SIPS among predominantly African American help-seeking adolescents (N=57) living in various neighborhoods in Baltimore City. Uniform Crime Reports, including violent and property crime for Baltimore City, were used to calculate a proxy of neighborhood crime. This crime index correlated with SIPS suspiciousness (r(55)=.32, p=.02). Multiple regression analyses demonstrated that increased neighborhood crime significantly predicted suspiciousness over and above the influence of the other SIPS positive symptoms in predicting suspiciousness. Findings suggest that neighborhood crime may in some cases account for suspiciousness ascertained as part of a psychosis risk assessment, and therefore sensitivity to contextual factors is important when evaluating risk for psychosis.

Comparison of measures of functioning for use with treatment-seeking adolescents experiencing attenuated symptoms of psychosis.

AIM: A growing body of research documents a relation between psychosis risk and functional impairment. Although a general picture of psychosis risk and impaired functioning is emerging, less is known about how different functional measures relate to specific psychosis-risk symptoms. METHODS: The current study examines the relative contribution of psychosis-risk symptoms across multiple measures of functioning in a sample of treatment-seeking adolescents and young adults. RESULTS: Results indicate that different domains of psychosis-risk symptoms (negative and positive psychotic symptoms, related affective symptoms) contribute differentially to measures of different types of functioning. CONCLUSION: Study of the relation between psychosis-risk symptoms and different measures of functional impairment can potentially contribute towards a more efficient use of measures of functioning and help inform individualized treatment considerations.

Social and psychological contributions to the co-occurrence of sub-threshold psychotic experiences and suicidal behavior.

PURPOSE: Psychotic experiences and suicidal behavior commonly co-occur in the general population, which can have implications for suicide prevention approaches. However, little is known about the nature of this relation in non-clinical samples. This cross-sectional study aimed to address a research gap by testing whether the relation between psychotic experiences and suicide-related outcomes (ideation, intent, and attempts) is explained by common social and psychological factors. METHODS: Young adult college students (N = 590) were assessed for psychotic experiences, suicidal behavior, and a comprehensive set of 24 potential shared risk factors selected through review of past epidemiological studies and meta-analyses. Nonparametric bootstrapped regression models were used to examine whether these factors attenuated or eliminated the associations between psychotic experiences and suicide-related outcomes. RESULTS: Psychotic experiences were associated with greater risk for suicidal ideation and behaviors. Adjustment for psychosocial factors, particularly those contributing to cumulative stress, accounted for the associations between psychotic experiences and suicide-related outcomes, except broadly defined suicidal ideation. CONCLUSIONS: These results suggest that the robust associations between psychotic experiences and suicidal behavior demonstrated in past studies may be primarily explained by shared risk factors, rather than by causal relations. In our sample, suicidal behavior and sub-threshold psychosis appear to be trans diagnostic clinical outcomes that share common causes, notably cumulative stress, but do not cause one another.

Impact of Family History in Persons With Dual Diagnosis.

OBJECTIVE: This study examined relationships among family history of alcohol, drug, and psychiatric problems and substance use severity, interpersonal relationships, and service use in individuals with dual diagnosis. METHODS: Data were collected with the family history section of the Addiction Severity Index administered as part of three studies of individuals with dual disorders (N=413). Participants were categorized into family history risk groups for each problem domain based on the number of first and second degree relatives with alcohol, drug, or psychiatric problems. RESULTS: Rates of alcohol, drug, and psychiatric problems were high across family member categories and highest overall for siblings. Over two-thirds of the sample was categorized in the high-risk group in the alcohol problem domain, almost half of the sample was categorized as high-risk in the drug problem domain, and over a third of the sample was categorized as high-risk in the psychiatric problem domain. Across problem domains, individuals in the high-risk group reported more relationship problems with parents and siblings and higher rates of lifetime emotional, physical, and sexual abuse than did those in the low or moderate-risk groups. CONCLUSIONS: Family history of alcohol, drug, and psychiatric problems is associated with greater rates of poor family relationships and history of abuse. Assessment of these different forms of family history in multiple family members can aid treatment providers in identifying individuals with dual disorders who may benefit from trauma-informed care as part of their overall mental health and substance abuse treatment services.

Posttraumatic stress disorder and one-year outcome in methadone maintenance treatment.

BACKGROUND: Although opiate use may be associated with posttraumatic stress disorder (PTSD), it is not clear whether PTSD is associated with retention in methadone maintenance. OBJECTIVES: To evaluate among those receiving methadone maintenance at an urban methadone maintenance clinic the frequency of life-time traumatic experiences, the predictors and prevalence of current PTSD, and whether PTSD affects retention at 1 year. METHODS: Eighty-nine people participated in the study. The Post Traumatic Diagnostic Scale was used to determine the prevalence of PTSD. The Life Stressor Checklist Revised was used to evaluate trauma history. Logistic regression analyses examined associations between demographic characteristics, substance use, trauma-related variables, and PTSD. Similar logistic regression analyses were used to examine retention in methadone maintenance at 1 year. RESULTS: The mean number of reported lifetime stressful events was 8.0 (SD = 3.7). Twenty-seven percent were diagnosed with PTSD. Nearly 92% of those with PTSD had co-occurring depressive symptoms. Female gender (adjusted odds ratio [AOR][95% CI]; 3.89 [1.07-14.01]), number of traumatic events (AOR [95% CI]; 1.34 [1.13-1.61]), and less education (AOR [95% CI]; 4.13 [1.14-14.98]) were significantly associated with PTSD. Those with a toxicology positive screen were 80% less likely to remaine in methadone maintenance at 1 year (OR [95% CI]; 0.20 [0.07-0.52]). PTSD diagnosis was not significantly associated with treatment retention at 1 year (OR [95% CI]; 0.61 [0.23-1.64]). CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Future studies are needed to determine if treatment of PTSD that is integrated into methadone maintenance programs may impact continued substance abuse use and thereby improve retention in care.

Psychosis risk screening in youth: a validation study of three self-report measures of attenuated psychosis symptoms.

Brief self-report questionnaires that assess attenuated psychosis symptoms have the potential to quickly and effectively screen many people who may benefit from clinical monitoring or early intervention. The current study sought to examine and compare the criterion validities of attenuated symptoms screening tools with diagnoses obtained from the clinician-administered Structured Interview for Psychosis Risk Syndromes (SIPS). Three screening questionnaires (Prime Screen, Prodromal Questionnaire-Brief, and Youth Psychosis At-Risk Questionnaire-Brief) were administered just prior to the SIPS interview in a sample of adolescents and young adults seeking mental health services. Using thresholds recommended by instrument authors as well as empirically derived optimal thresholds, the sensitivity, specificity, positive predictive value, and overall accuracy of each self-report measure with regard to SIPS diagnosis were obtained. Screeners correlated highly with the SIPS and demonstrated equivalent overall efficiency in capturing psychosis risk status. All three screeners appear to be useful and valid assessment tools for attenuated symptoms, with each instrument demonstrating relative benefits. The validation of attenuated symptoms screening tools is an important step toward enabling early, wide-reaching identification of individuals on a course toward psychotic illness.

Schizotypy, psychotic-like experiences and distress: an interaction model.

Psychotic-like experiences (PLEs) have been found to exist on a continuum in both general and clinical populations. Such experiences may characterize normal and abnormal variations in personality, as well as prodromal or high risk states for the development of psychotic disorders. High risk paradigms tend to emphasize distress and impairment associated with PLEs, yet the extent to which individuals find PLEs to be distressing likely depends on moderating factors. In particular, individuals high in trait schizotypy may differ in their appraisal and reaction to PLEs. The current study examines the relationship between schizotypy, PLEs, and distress associated with PLEs in a college sample. Participants (N=355) completed the Schizotypal Personality Questionnaire - Brief Version (SPQ-B), which assesses schizotypal traits, and the Prodromal Questionnaire - Brief Version (PQ-B), which assesses both PLEs and associated distress. Schizotypy was found to significantly moderate the association between PLEs and subjective distress. Individuals high in trait schizotypy reported more PLEs, yet less distress associated with PLEs, relative to individuals low in trait schizotypy. Implications for high-risk state assessment are discussed.

Convergent and discriminant validity of attenuated psychosis screening tools.

Brief self-report questionnaires that assess attenuated psychotic symptoms have the potential to screen many people who may benefit from clinical monitoring, further evaluation, or early intervention. The extent to which recently developed screening instruments demonstrate sound psychometric properties is an important issue toward the implementation of these measures in clinical practice. This study examines the convergent validity, discriminant validity, and test-retest reliability of four recently developed screening instruments. Screening instruments were included in an assessment battery and administered to a sample of 355 college students. Screening scores support the convergent and discriminant validity and the test-retest reliability of these measures.