Psychometric Properties of the Preschool Age Psychiatric Assessment (PAPA) in Farsi: Based on DSM-5.

Objectives: The first onset of many psychiatric disorders usually occurs in childhood or adolescence. The structured interview of Preschool Age Psychiatric Assessment (PAPA) was developed in response to the need for a standardized and reliable method to assess psychiatric disorders in preschool-age children. This study aimed to translate DSM-5-based PAPA into Farsi and evaluate its face and content validity and reliability. Materials & methods: The procedure was a forward translation of PAPA to Farsi, evaluation for face and content validity, finalization of items within the expert panel, backward translation to English, matching the original PAPA with randomly selected items from the backward translation version, and revision as needed, and finally evaluation for the validity of the changes for localization and cultural considerations. The interviews based on the final Farsi version were performed on thirty parents of children from two to five years old (chosen from Tabriz health centers) to determine the reliability and were repeated at an interval of two weeks. Results:  The mean of CVI=0.91 and Modified Kappa=0.90 were obtained, and reliability with Cronbach's alpha was 0.89. Conclusion:  The Farsi version of the DSM-5-based PAPA diagnostic interview has good face and content validity and reliability.

Early life adversity and psychopathology in preschoolers: mechanisms and moderators.

Developmental theories suggest that exposure to early life adversity (ELA) alters developing emotional response systems, predicting risk for psychopathology across the life span. The present study examines whether negative emotionality (NE), a trait-like measure of emotionality that develops during early childhood, mediates the association between ELA and psychopathology in a representative sample of 917 preschoolers (Mage = 3.84). Additionally, we explored whether cognitive control, which supports attentional focusing and inhibition and has been identified as a transdiagnostic protective factor, moderates the impact of heightened emotionality following adversity on psychopathology risk. We utilized parent report of adversity, psychopathology, and NE and parent report and task-based measures of cognitive control. Structural equation modeling of cross-sectional data revealed that NE partially mediated the link between ELA and psychopathology symptoms. Moreover, parent-reported cognitive control buffered this link such that the effect of ELA on psychopathology through NE was stronger in children with low versus high cognitive control. These results identify elevated NE as one mechanism linking ELA and psychopathology, specifically among children with poorer top-down control, informing our understanding of key risk and protective factors among adversity-exposed children.

Associations of preschool reactive bed-sharing with sociodemographic factors, sleep disturbance, and psychopathology.

OBJECTIVE: To advance understanding of early childhood bed-sharing and its clinical significance, we examined reactive bed-sharing rates, sociodemographic correlates, persistence, and concurrent and longitudinal associations with sleep disturbances and psychopathology. METHODS: Data from a representative cohort of 917 children (mean age 3.8 years) recruited from primary pediatric clinics in a Southeastern city for a preschool anxiety study were used. Sociodemographics and diagnostic classifications for sleep disturbances and psychopathology were obtained using the Preschool Age Psychiatric Assessment (PAPA), a structured diagnostic interview administered to caregivers. A subsample of 187 children was re-assessed approximately 24.7 months after the initial PAPA interview. RESULTS: Reactive bed-sharing was reported by 38.4% of parents, 22.9% nightly and 15.5% weekly, and declined with age. At follow-up, 48.9% of nightly bed-sharers and 88.7% of weekly bed-sharers were no longer bed-sharing. Sociodemographics associated with nightly bed-sharing were Black and (combined) American Indian, Alaska Native and Asian race and ethnicity, low income and parent education less than high school. Concurrently, bed-sharing nightly was associated with separation anxiety and sleep terrors; bed-sharing weekly was associated with sleep terrors and difficulty staying asleep. No longitudinal associations were found between reactive bed-sharing and sleep disturbances or psychopathology after controlling for sociodemographics, baseline status of the outcome and time between interviews. CONCLUSIONS: Reactive bed-sharing is relatively common among preschoolers, varies significantly by sociodemographic factors, declines during the preschool years and is more persistent among nightly than weekly bed-sharers. Reactive bed-sharing may be an indicator of sleep disturbances and/or anxiety but there is no evidence that bed-sharing is an antecedent or consequence of sleep disturbances or psychopathology.

Distinct Associations of Deprivation and Threat With Alterations in Brain Structure in Early Childhood.

OBJECTIVE: The dimensional model of adversity and psychopathology hypothesizes deprivation and threat impact distinct neurobiological pathways, such as brain structure. This hypothesis has not been examined longitudinally or in young children. This study tested longitudinal associations between threat and deprivation measured in preschool and brain structure in childhood. It was hypothesized that threat would be associated with amygdala and hippocampal subcortical volume and deprivation would be associated with cortical thickness in association cortex. METHOD: The study included T1-weighted scans from 72 children (5-10 years old, 54.2% female participants). Threat was measured by the presence of domestic violence, sexual abuse, physical abuse, or neighborhood violence. Deprivation was measured by the presence of neglect. Associations of deprivation or threat with brain structure were examined controlling for other dimension (deprivation or threat) and nuisance covariates using whole-brain vertex-wise analyses. Subcortical volume was extracted, and the same associations were examined using multiple regression. RESULTS: Threat was associated with widespread decreases in cortical surface area across the prefrontal cortex and other regions. Threat was not associated with amygdala or hippocampal volume. Deprivation was associated with increased thickness in occipital cortex, insula, and cingulate. CONCLUSION: Results suggest distinct associations of deprivation and threat on brain structure in early childhood. Threat is associated with widespread differences in surface area, and deprivation is associated with differences in cortical thickness. These observations are consistent with work in adolescence and adulthood and reflect how dimensions of adversity differentially impact neural structure.

Adaptive Behavior in Young Autistic Children: Associations with Irritability and ADHD Symptoms.

Attention-deficit/hyperactivity disorder (ADHD) symptoms affect 40-60% of autistic children and have been linked to differences in adaptive behavior. It is unclear whether adaptive behavior in autistic youth is directly impacted by co-occurring ADHD symptoms or by another associated feature of both autism and ADHD, such as increased irritability. The current study examined relationships between irritability, ADHD symptoms, and adaptive behavior in 3- to 7-year-old autistic children. Results suggest that, after adjusting for co-occurring ADHD symptoms, higher levels of irritability are associated with differences in social adaptive behavior specifically. Understanding relationships between irritability, ADHD, and adaptive behavior in autistic children is critical because measures of adaptive behavior, such as the Vineland Scales of Adaptive Functioning, are often used as a proxy for global functioning, as well as for developing intervention plans and measuring outcomes as primary endpoints in clinical trials.

Association of adversity with psychopathology in early childhood: Dimensional and cumulative approaches.

BACKGROUND: The association between adversity and psychopathology in adolescents and adults is characterized by equifinality. These associations, however, have not been assessed during early childhood when psychopathology first emerges. Defining adversity using both dimensional and cumulative risk approaches, we examined whether specific types of adversity are differentially associated with psychopathology in preschool-aged children. METHODS: Measures of threat, deprivation, and total adversities (i.e., cumulative risk) were calculated based on parent-reported information for 755 2- to 5-year old children recruited from pediatric primary care clinics. Logistic regression was used to estimate cross-sectional associations between type of adversity and anxiety, depression, ADHD, and behavioral disorder diagnoses. RESULTS: Threat and cumulative risk exhibited independent associations with psychopathology. Threat was strongly related to behavioral disorders. Cumulative risk was consistently related to all psychopathologies. CONCLUSIONS: Using mutually adjusted models, we identified differential associations between threat and psychopathology outcomes in preschool-aged children. This selectivity may reflect different pathways through which adversity increases the risk for psychopathology during this developmentally important period. As has been observed at other ages, a cumulative risk approach also effectively identified the cumulative impact of all forms of adversity on most forms of psychopathology during early childhood.

Parental perception of mental health needs in young children.

BACKGROUND: There is evidence of unmet psychiatric needs in children under 6. These young children are dependent on their parents to identify their mental health needs. This study tested child and parent associations with parent perception of young child mental health need. METHOD: Parents of 917 children (aged 2-6 years) completed a diagnostic interview about their child assessing depression, anxiety, ODD/CD, ADHD, and impairment. Parents were surveyed about their own depression, anxiety, and asked about their psychiatric impairment. Parents were also asked whether they perceived their child as having a mental health need. RESULTS: Only 38.8% of children who met criteria for a diagnosis were perceived by their parents as having a need, similar to previously studied rates in school-aged children. Perception of need was associated with higher levels of symptoms and impairment. Thresholds for at least half of parents perceiving their child as having a need were relatively high: 19 or more symptoms, or 4 or more impairments. There was evidence of specificity: children with depressive disorders were more likely to be perceived as in need compared with other disorders. In terms of parent factors, more parental depressive symptoms were associated with higher perception of child need when the child had a diagnosis. Parental psychological impairment was associated with higher perception of need when the child had no diagnosis. CONCLUSIONS: Most preschool children that meet criteria for a psychiatric disorder are not perceived as needing help by their parents, which is dependent on both child and parent factors.

Children's Beliefs about Pain: An Exploratory Analysis.

Functional abdominal pain (FAP) is one of the most common childhood medical complaints, associated with significant distress and impairment. Little is known about how children understand their pain. Do they attribute it to personal weakness? Do they perceive pain as having global impact, affecting a variety of activities? How do they cope with pain? We explored the pain beliefs of 5- to 9-year-old children with FAP using a novel Teddy Bear Interview task in which children answered questions about a Teddy bear's pain. Responses were analyzed quantitatively and qualitatively. Results indicate that the majority of young children with FAP are optimistic about pain outcomes. Children generated many types of coping strategies for Teddy's pain and adjusted their calibration of Teddy's pain tolerance dependent on the activity being performed. Early warning signs also emerged: a subset of children were pessimistic about Teddy's pain, and several children identified coping strategies that, while developmentally appropriate, could lead to excessive help seeking if not intervened upon (e.g., physician consultation and shot). The Teddy Bear Interview allows children to externalize their pain, making it a useful tool to access cognitive pain constructs in younger children. Thus, these findings highlight the importance of early intervention for childhood FAP.

Psychometric properties of the Persian version of preschool age psychiatric assessment (PAPA) for attention-deficit/hyperactivity disorder: Based on DSM-5.

Childhood and adolescence psychiatric disorders affect subsequent stages; early diagnosis of these disorders, such as attention-deficit/hyperactivity disorder (ADHD), is necessary. There is no reliable and valid diagnostic interview for ADHD in Asian Persian or Farsi speaking countries. The DSM 5-based version of the interview was sent to the 14 child and adolescent and general psychiatrists to ensure the validity of the ADHD section of the PAPA interview through an online website. Out of 59 health centers, 15 centers were selected via systematic random sampling. Three hundred children participated in the study. ADHD questions of the PAPA had the power to differentiate, with a sensitivity of 0.92, a specificity of 0.01. It had positive diagnostic value = 95.83 %, negative diagnostic value = 98.91 %, negative correlation ratio = 0.12, overall diagnostic accuracy = 98.67 % and diagnostic chance ratio = 2085.35. ADHD questions of the PAPA diagnostic interview can diagnose ADHD in preschool as a reliable tool based on DSM-5.

Computer Vision Analysis for Quantification of Autism Risk Behaviors.

Observational behavior analysis plays a key role for the discovery and evaluation of risk markers for many neurodevelopmental disorders. Research on autism spectrum disorder (ASD) suggests that behavioral risk markers can be observed at 12 months of age or earlier, with diagnosis possible at 18 months. To date, these studies and evaluations involving observational analysis tend to rely heavily on clinical practitioners and specialists who have undergone intensive training to be able to reliably administer carefully designed behavioural-eliciting tasks, code the resulting behaviors, and interpret such behaviors. These methods are therefore extremely expensive, time-intensive, and are not easily scalable for large population or longitudinal observational analysis. We developed a self-contained, closed-loop, mobile application with movie stimuli designed to engage the child's attention and elicit specific behavioral and social responses, which are recorded with a mobile device camera and then analyzed via computer vision algorithms. Here, in addition to presenting this paradigm, we validate the system to measure engagement, name-call responses, and emotional responses of toddlers with and without ASD who were presented with the application. Additionally, we show examples of how the proposed framework can further risk marker research with fine-grained quantification of behaviors. The results suggest these objective and automatic methods can be considered to aid behavioral analysis, and can be suited for objective automatic analysis for future studies.

Digital Behavioral Phenotyping Detects Atypical Pattern of Facial Expression in Toddlers with Autism.

Commonly used screening tools for autism spectrum disorder (ASD) generally rely on subjective caregiver questionnaires. While behavioral observation is more objective, it is also expensive, time-consuming, and requires significant expertise to perform. As such, there remains a critical need to develop feasible, scalable, and reliable tools that can characterize ASD risk behaviors. This study assessed the utility of a tablet-based behavioral assessment for eliciting and detecting one type of risk behavior, namely, patterns of facial expression, in 104 toddlers (ASD N = 22) and evaluated whether such patterns differentiated toddlers with and without ASD. The assessment consisted of the child sitting on his/her caregiver's lap and watching brief movies shown on a smart tablet while the embedded camera recorded the child's facial expressions. Computer vision analysis (CVA) automatically detected and tracked facial landmarks, which were used to estimate head position and facial expressions (Positive, Neutral, All Other). Using CVA, specific points throughout the movies were identified that reliably differentiate between children with and without ASD based on their patterns of facial movement and expressions (area under the curves for individual movies ranging from 0.62 to 0.73). During these instances, children with ASD more frequently displayed Neutral expressions compared to children without ASD, who had more All Other expressions. The frequency of All Other expressions was driven by non-ASD children more often displaying raised eyebrows and an open mouth, characteristic of engagement/interest. Preliminary results suggest computational coding of facial movements and expressions via a tablet-based assessment can detect differences in affective expression, one of the early, core features of ASD. LAY SUMMARY: This study tested the use of a tablet in the behavioral assessment of young children with autism. Children watched a series of developmentally appropriate movies and their facial expressions were recorded using the camera embedded in the tablet. Results suggest that computational assessments of facial expressions may be useful in early detection of symptoms of autism.

Cognitive impact of early separation from migrant parents: A spectrum of risk and key mechanisms in child development contexts. A commentary on Hou et al., (2020).

Prolonged separation from migrant parents may lead to child development risks, despite the potential benefits from improved financial circumstances. Within the substantial literature on the health and well-being of the so-called left-behind children, the cognitive impact of parental migration has been inconclusive across different settings globally. In this issue, Hou et al.'s study in rural China focused on school-age children who experience persistent absence of both migrant parents since infancy, and revealed disadvantages in language comprehension outcomes among these children, despite the mitigating effect of higher household income. While results from this study are limited to the ongoing parent-child separation, previous absence of migrant parents has been suggested to have long-lasting negative effects in studies of adolescents in reunited families. Findings from Hou and colleagues' study highlight the needs to better understand migration-related parent-child separation during sensitive developmental periods in infancy and early childhood. A spectrum of risk due to parental migration should be established, accounting for the timing and duration of migration and care arrangements, in order to better identify the at-risk children in communities affected by out-migration. Future research should further explore the mediating and moderating factors in child's environments, and evaluate post-separation adjustment among reunited families after parents' return migration. Research evidence on these aspects will inform the development of tailored intervention programs for left-behind children, and strengthen the abilities of families and communities in best serving the needs of children affected by prolonged parental absence.

Author Correction: Atypical postural control can be detected via computer vision analysis in toddlers with autism spectrum disorder.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Development and Examination of the Reactive Attachment Disorder and Disinhibited Social Engagement Disorder Assessment Interview.

The fifth edition of the Diagnostic and Statistical Manual (DSM) categorizes reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED) as two separate disorders, and their criteria are revised. For DSED, the core symptoms focus on abnormal social disinhibition, and symptoms regarding lack of selective attachment have been removed. The core symptoms of RAD are the absence of attachment behaviors and emotional dysregulation. In this study, an international team of researchers modified the Child and Adolescent Psychiatric Assessment for RAD to update it from DSM-IV to DSM-5 criteria for RAD and DSED. We renamed the interview the reactive attachment disorder and disinhibited social engagement disorder assessment (RADA). Foster parents of 320 young people aged 11 to 17 years completed the RADA online. Confirmatory factor analysis of RADA items identified good fit for a three-factor model, with one factor comprising DSED items (indiscriminate behaviors with strangers) and two factors comprising RAD items (RAD1: failure to seek/accept comfort, and RAD2: withdrawal/hypervigilance). The three factors showed differential associations with clinical symptoms of emotional and social impairment. Time in foster care was not associated with scores on RAD1, RAD2, or DSED. Higher age was associated with lower scores on DSED, and higher scores on RAD1.

Building digital innovation capacity at a large academic medical center.

Academic medical centers (AMCs) today prioritize digital innovation. In efforts to develop and disseminate the best technology for their institutions, challenges arise in organizational structure, cross-disciplinary collaboration, and creative and agile problem solving that are essential for successful implementation. To address these challenges, the Digital DesignLab was created at NYU Langone Health to provide structured processes for assessing and supporting the capacity for innovative digital development in our research and clinical community. Digital DesignLab is an enterprise level, multidisciplinary, digital development team that guides faculty and student innovators through a digital development "pipeline", which consists of intake, discovery, bootcamp, development. It also provides a framework for digital health innovation and dissemination at the institution. This paper describes the Digital DesignLab's creation and processes, and highlights key lessons learned to support digital health innovation at AMCs.

Parenting and prenatal risk as moderators of genetic influences on conduct problems during middle childhood.

This study examines interactions of heritable influences, prenatal substance use, and postnatal parental warmth and hostility on the development of conduct problems in middle childhood for boys and girls. Participants are 561 linked families, collected in 2 cohorts, including birth parents, adoptive parents, and adopted children. Heritable influences on internalizing and externalizing (including substance use) problems were derived from birth mothers' and fathers' symptoms, diagnoses, and age of onset from diagnostic interviews, and the proportion of first-degree relatives with the same type of problems. Smoking during pregnancy (SDP) and alcohol use during pregnancy were assessed retrospectively from birth mothers at 5 months postpartum. Earlier externalizing problems and parental warmth and hostility and were assessed at 1 assessment prior to the outcome (Cohort II: 4.5 years; Cohort I: 7 years). Conduct problems were symptoms from a diagnostic interview assessed at age 6 (Cohort II) or 8 (Cohort I). Findings from regression analyses suggest that (a) SDP plays an important role for the development of conduct problems, (b) some relatively well-accepted effects (e.g., parental hostility) were less important when simultaneously considering multiple factors influencing the development of conduct problems, and (c) main effects of genetic risk and SDP, and interactions among genetic risk and postnatal warmth, SDP and postnatal warmth, and genetic risk, SDP, and postnatal hostility for conduct problems were important for boys' but not girls' conduct problems. Replication is needed, but the current results provide preliminary but empirically grounded hypotheses for future research testing complex developmental models of conduct problems. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Computer vision analysis captures atypical attention in toddlers with autism.

To demonstrate the capability of computer vision analysis to detect atypical orienting and attention behaviors in toddlers with autism spectrum disorder. One hundered and four toddlers of 16-31 months old (mean = 22) participated in this study. Twenty-two of the toddlers had autism spectrum disorder and 82 had typical development or developmental delay. Toddlers watched video stimuli on a tablet while the built-in camera recorded their head movement. Computer vision analysis measured participants' attention and orienting in response to name calls. Reliability of the computer vision analysis algorithm was tested against a human rater. Differences in behavior were analyzed between the autism spectrum disorder group and the comparison group. Reliability between computer vision analysis and human coding for orienting to name was excellent (intra-class coefficient 0.84, 95% confidence interval 0.67-0.91). Only 8% of toddlers with autism spectrum disorder oriented to name calling on >1 trial, compared to 63% of toddlers in the comparison group (p = 0.002). Mean latency to orient was significantly longer for toddlers with autism spectrum disorder (2.02 vs 1.06 s, p = 0.04). Sensitivity for autism spectrum disorder of atypical orienting was 96% and specificity was 38%. Older toddlers with autism spectrum disorder showed less attention to the videos overall (p = 0.03). Automated coding offers a reliable, quantitative method for detecting atypical social orienting and reduced sustained attention in toddlers with autism spectrum disorder.

Sensory Over-Responsivity: An Early Risk Factor for Anxiety and Behavioral Challenges in Young Children.

Anxiety disorders are prevalent and significantly impact young children and their families. One hypothesized risk factor for anxiety is heightened responses to sensory input. Few studies have explored this hypothesis prospectively. This study had two goals: (1) examine whether sensory over-responsivity is predictive of the development of anxiety in a large prospective sample of children, and (2) identify whether anxiety mediates the relationship between sensory over-responsivity and behavioral challenges. Children's sensory and anxiety symptoms were assessed in a community sample of 917 at 2-5 and again in 191 of these children at 6 years old. Parents also reported on a number of additional behavioral challenges previously found to be associated with both sensory over-responsivity and anxiety separately: irritability, food selectivity, sleep problems, and gastrointestinal problems. Forty three percent of preschool children with sensory over-responsivity also had a concurrent impairing anxiety disorder. Preschool sensory over-responsivity symptoms significantly and positively predicted anxiety symptoms at age six. This relationship was both specific and unidirectional. Finally, school-age anxiety symptoms mediated the relationship between preschool sensory over-responsivity symptoms and both irritability and sleep problems at school-age. These results suggest sensory over-responsivity is a risk factor for anxiety disorders. Furthermore, children who have symptoms of sensory over-responsivity as preschoolers have higher levels of anxiety symptoms at school-age, which in turn is associated with increased levels of school-age behavioral challenges.

Atypical postural control can be detected via computer vision analysis in toddlers with autism spectrum disorder.

Evidence suggests that differences in motor function are an early feature of autism spectrum disorder (ASD). One aspect of motor ability that develops during childhood is postural control, reflected in the ability to maintain a steady head and body position without excessive sway. Observational studies have documented differences in postural control in older children with ASD. The present study used computer vision analysis to assess midline head postural control, as reflected in the rate of spontaneous head movements during states of active attention, in 104 toddlers between 16-31 months of age (Mean = 22 months), 22 of whom were diagnosed with ASD. Time-series data revealed robust group differences in the rate of head movements while the toddlers watched movies depicting social and nonsocial stimuli. Toddlers with ASD exhibited a significantly higher rate of head movement as compared to non-ASD toddlers, suggesting difficulties in maintaining midline position of the head while engaging attentional systems. The use of digital phenotyping approaches, such as computer vision analysis, to quantify variation in early motor behaviors will allow for more precise, objective, and quantitative characterization of early motor signatures and potentially provide new automated methods for early autism risk identification.