What Makes Us Who We Are?

As child and adolescent psychiatrists, it is our job to identify factors that influence the behaviors seen in front of us. Often the question is asked whether these factors are primarily due to nature or nurture: Is someone born a "bad kid," or are there environmental exposures that lead to less than ideal behaviors? Factors such as racism, poverty, bullying, social isolation, and even where we grow up could play a part in the behaviors seen. This is one of the most rewarding, but at times can be one of the most frustrating, parts of our job as child and adolescent psychiatrists. Hopefully we can explore the factors influencing behaviors seen by the children we work with, highlighting the good in them and the situations that have led to the concerns seen. At the same time, we can become frustrated knowing that some of these factors are difficult for us to change as an individual child and adolescent psychiatrist, such as racism, poverty, inequalities in education, or family support. Bearing witness to these societal issues and their impact on our patients hopefully sparks advocacy efforts toward larger system changes.

Rupture and Repair.

Rupture and repair are key ingredients to connection. When ruptures in relationships occur, which they will, it is important to revisit the situation to work on restoring safety, regulation, attunement, and understanding. Through engaging in this process and providing consistent secure base and safe haven supports, conflicts have the opportunity to heal. Developmentally, the practice of rupture and repair begins during infancy and early childhood, laying the foundation for secure attachment. What happens when ruptures repeatedly occur without repair? How does this impact self-esteem and the narratives children create about themselves as they grow? As you can imagine, repeated rupture without repair can lead to mistrust, cognitive distortions, resentment, and emotional stunting. As child and adolescent psychiatrists, we can help families understand that relationships, like people, can bend without breaking-and that a healthy serving of humble pie can be just what the doctor ordered.

The Impact of Postpartum Depression on the Early Mother-Infant Relationship during the COVID-19 Pandemic: Perception versus Reality.

Postpartum depression (PPD) can interfere with the establishment of affective bonds between infant and mother, which is important for the cognitive, social-emotional, and physical development of the child. Rates of PPD have increased during the COVID-19 pandemic, likely due to the added stress and limited support available to new parents. The present study examined whether parenting-related stress, perceived bonding impairments, the quality of observed mother-infant interactions, and salivary oxytocin levels differ between depressed and non-depressed mothers, along with differential impacts of COVID-19 on depressed mothers. Participants included 70 mothers (45 depressed, 25 controls) with infants aged 2-6 months. All data were collected remotely to ease participant burden during the pandemic. Depression was associated with experiences of heightened parenting-related stress and bonding difficulties. These differences were not observed during mother-infant interactions or in salivary oxytocin levels. Differences in COVID-19-related experiences were minimal, though depressed mothers rated slightly higher stress associated with returning to work and financial impacts of the pandemic. Findings highlight the importance of early intervention for PPD to mitigate long-term effects on mothers, children, and families. Additionally, they underscore the need for early intervention to support the developing mother-infant dyad relationship during this crucial time.

The Cost of Avoidance.

As child psychiatrists, it is our job to ask questions, and many of us would say we are really good at it. We work with our patients to open up about their experiences, discussing fear, sadness, hope, and joy. By modeling this ability to open up in the office, we help guide children and adolescents through using other skills rather than avoidance. Although avoidance has its place at times, we help show our patients the connection between anxiety and avoidance. This necessity to embrace and challenge fears can be a difficult skill for our patients and also their families. Children bring forward questions that parents may want to avoid, fearing the answer might be more difficult for the child than the rejection of having the question avoided all together. As someone who works with children with chronic illnesses, this avoidance of the question can in fact increase the fear and anxiety of the child or adolescent. When talking to children, often they will express a greater fear than the reality of the situation because they determine that if their parent is avoiding the question, it must be really bad. This same struggle with avoidance can be true for us as child psychiatrists as well. The necessity to take on roles of leadership or run a team often presents itself, but excuses can come up to help us avoid these roles. We might say we are not properly trained, we did not go into medicine to do those responsibilities, or we are too busy. By avoiding these responsibilities, we are setting ourselves up for more frustration. As teams struggle, we have to follow the lead of others without the same clinical knowledge, which may result in additional errors. We must remember to practice what we preach and to identify the cost of avoidance.

Kaleidoscopes.

I remember the magic of looking through a kaleidoscope as a little girl. Brilliant, vibrant colors coming together to make symmetrical shapes that seemed as precise as they were chaotic. Each look through the lens offered something new and spectacular, different than the intricate images seen before. With a little shake and turning of a tube and the sound of colored beads, pebbles, or small pieces of glass swirling together, mirrors connect with the light in just a way to produce the beauty that we see. Who would have thought that such a small disruption leading to the destruction of a pattern could make room for the same materials to come together again to form something fantastic, though different? Each turn or shake of a kaleidoscope could represent life changes or new perspectives that require some level of deconstruction before evolving into magnificence. Or you can simply be a kid who likes pretty pictures and wild shapes, experiencing joy and the spirit of adventure with each look. Whatever your experience, interpretation, or developmental stage, kaleidoscopes allow us to appreciate wonder, creativity, and the power of play, all rolled into one mercurial lens.

The Developing Child.

As children age, there are set milestones that we follow clinically to help track fine motor, gross motor, social, and language development. Because we know what a 2-month-old vs 4-month-old vs 1-year-old child should be able to do, we are able to assess whether a given child is on track developmentally. In pediatrics, three developmental stages are assessed and, if, behind there is a clear next step, often to involve early intervention. In child psychiatry, work has been done to establish stages of development as well, seen through the work of Piaget, Erickson, and others. These stages help to define the thoughts and behaviors expected for different-aged children, and thus can help with putting together our diagnostic formulation. The difficulty is that these stages are much broader temporally then the early motor, social, and language developmental milestones. Students may also be participating in the same experiences, such as the same grade level, even though they are at different developmental levels based on their age when they started school, as there could be as much as a year difference between those in a given grade. This has led to concerns about being able to distinguish a child struggling with attention-deficit/hyperactivity disorder (ADHD) relative to a child who is younger than his peers, as teachers may compare a young child to their older peers when filling out assessment forms.1 These are the developmental questions that we often must ponder as child psychiatrists, inasmuch as mental health and behavioral development are complex and influenced by many factors. In this month's Book Forum, Rishab Chawla looks more into these questions in the review of Nasty, Brutish and Short by Scott Hershovitz, pointing out that there is an overlap between the skills of a child psychiatrist to assess the behavioral impact of these developmental questions and the philosophical questions that younger children start to ponder. The child's developmental understanding of right and wrong will better help us to assess the behaviors that present to us in the office. As Rishab points out in the review, we must ask more about these children whom we see regarding these philosophical questions to better understand some of the behaviors present. Looking more deeply into a student's understanding of these questions may better help us to distinguish developmentally appropriate or inappropriate behaviors.

Seeking Meaning in the Void.

One of the most important jobs in elementary school can be distilled down to 2 words: line leader. This is the mighty carrot to mobilize ordinarily sluggish children through their morning routine, as they look forward to standing proudly at the front of their classroom line. I have witnessed this phenomenon myself, as my first-grade son was chosen to be the glorious line leader of room 15. He moved with a sense of urgency in the morning to pack his backpack, fill his water bottle, and put on his shoes and socks, all with zero parental prompting. After I dropped him off, I secretly watched through the chain-link fence as he skipped over to his class with his head held high to claim his hard-earned position as the Tuesday line leader. The look of pride on his face was undeniable. This leadership position truly meant something to him, giving him a sense of purpose. As he marched his class to the same classroom door that they walk through every day, it was clear that the kid walking through the door had a little more shine than he had the day before.

Remodeling Broken Systems: Addressing the National Emergency in Child and Adolescent Mental Health.

A national emergency in child and adolescent mental health was declared in the United States in 2021 in the wake of the COVID-19 pandemic. This Open Forum discusses potential solutions to better support child and adolescent mental health by improving or expanding school-based mental health services, child psychiatry access programs, virtual mental health services, and new models of care (e.g., integrated youth services hubs and crisis stabilization units). The success of such programs is dependent on stable funding, strong leadership and accountability, robust and well-trained workforces, systems integration, and attention to health equity.

The Power of Shared Experience.

The experiences of others can often be used as a motivator, caution tale, point of education, and much more. Parents describe their own experiences to help their children make the right choices, including avoiding some mistakes they might regret. We watch movies and read books about historical figures, actors, athletes, and other famous people to better understand how their experiences shaped the person they became. More recently the growth of influencer culture has led people to watch videos to make decisions based on what the person tells them of their own experience. The difficulty is that many of these experiences have been selectively crafted to fit what makes a good movie or to promote a product.

Peek-A-Boo, I See You!

Peek-A-Boo is a beloved game played around the world, crossing language and cultural barriers alike. In addition to reinforcing the magical principle of object permanence, Peek-A-Boo generates laughter and shared joy that is contagious. While engaging with a patient diagnosed with postpartum depression, I was delighted to witness the power of this game on full display. When her 10-month-old son grew fussy as she discussed her matrescence, the patient gave me a playful look before abruptly covering her eyes with both hands. She waited a moment, then quickly uncovered her eyes while squealing "Peek-A-Boo, I see you!" I can still hear his gasp of surprise followed by a hearty, deeply committed belly laugh that echoed in the room. Why is this game so universally loved? Is it because it promotes connection, can be used as a powerful learning tool, or perhaps because it reinforces the idea that things stick around even when you can't see them? Maybe it is all of these things swirling together at once, built on a deeper principle that feeling seen and accepted without condition feels pretty darn good. Either way, I walked away from that encounter reminded of the simple truth that laughter-especially from a spirited baby-can be the best medicine.

Representation Matters.

In the world of pediatrics, studies have shown that the majority of dermatology textbooks display pictures primarily of White skin.1 This lack of representation has led to pediatricians and dermatologists having less exposure to dermatologic conditions such as eczema in Black and Brown skin, even though studies show that it can be more prevalent in these populations.2 As such, trainees and others have advocated for and created more diverse picture libraries to better represent dermatologic presentations in various skin colors.3.

Adventures in Fortnite: Selections From Connect Corner.

JAACAP Connect, our developmental journal, began publishing in 2014 to support "the development of writing and editing skills among members of the American Academy of Child and Adolescent Psychiatry." JAACAP Connect "is dedicated to engaging trainees and practitioners in the process of continuous and applied career learning through readership, authorship, and publication experiences that emphasize translation of research findings into the day-to-day clinical practice of child and adolescent psychiatry." Over the past 8 years, dozens of new or early career authors have worked closely with JAACAP Connect editors to develop manuscripts into published articles.

Patterns of Peripartum Depression and Anxiety During the Pre-Vaccine COVID-19 Pandemic.

Background: Pregnant people are vulnerable to new or worsening mental health conditions. This study aims to describe prevalence and course of symptomatic depression and anxiety in pregnancy during the pre-vaccine COVID-19 pandemic. Methods: This is a prospective cohort study of pregnant individuals with known or suspected COVID-19. Participants completed Edinburgh Postnatal Depression Scale (EPDS) and Generalized-Anxiety Disorder-7 (GAD-7) questionnaires at 34weeks gestational age, 6-8weeks postpartum, and 6months postpartum. Prevalence of symptomatic depression and anxiety at each visit was described. Univariable logistic regression analysis was used to determine the association between demographic and clinical factors and symptomatic depression or anxiety. Results: 317 participantswere included. The prevalence of antepartum depression was 14.6%, 10.3%, and 20.6% at 34weeks gestational age, 6-8weeks postpartum, and 6months postpartum, respectively. The rate of anxiety was 15.1%, 10.0%, and 17.3% at 34weeks gestational age, 6-8weeks postpartum, and 6months postpartum, respectively. A prior history of depression and/or anxiety (p's<0.03), as well as higher EPDS and GAD-7 scores at enrollment (p's<0.04) associated with depression and anxiety throughout pregnancy and the postpartum period. Quarantining during pregnancy was associated with symptomatic anxiety at 34weeks gestational age in univariate (P=0.027) analyses. COVID-19 diagnosis and hospitalization were not associated with depression or anxiety. Conclusions: Depression and anxiety were prevalent throughout pregnancy and the postpartum period, particularly in those with prior depression and/or anxiety and who quarantined. Strategies that target social isolation may mitigate potential adverse consequences for pregnant people, and continued vigilance in recognition of depression and anxiety in pregnancy should be considered.

We're Not Sure We Like It but We Still Want More: Trainee and Faculty Perceptions of Remote Learning During the COVID-19 Pandemic.

OBJECTIVE: In this study, the authors aim to compare perceptions of remote learning versus in-person learning among faculty and trainees at a single institution during the COVID-19 pandemic and to evaluate the impact that a brief faculty training on best practices in online teaching would have on faculty attitudes towards remote learning. METHODS: The authors conducted an attitude survey on remote learning among trainees and faculty members approximately 3 months after the transition from in-person to remote learning. The authors then conducted a faculty training on best practices in online teaching followed by an evaluation survey. Study findings were examined descriptively and by Fisher's exact testing. RESULTS: The response rates for the attitudes survey were 68% among trainees and 61% among faculty. Trainees and faculty perceived in-person learning more favorably than remote learning across a variety of domains, including overall enjoyment, interpersonal connection, ability to communicate, and concentration. Despite these trends, only 10% of trainees and 14% of faculty felt that all lectures would be most effectively delivered in-person when this becomes possible again. The response rate for the faculty training evaluation survey was 16%. Compared to non-attendees, faculty attendees reported more confidence in their ability to teach remotely (89% vs 56%, p=0.02) but not increased optimism (89% vs 63%, p=0.06). CONCLUSIONS: The study findings suggest that both trainees and faculty perceive remote learning negatively compared to in-person learning but still feel that some lectures should be delivered remotely even after a return to in-person learning is possible.

Emergency department use among postpartum women with mental health disorders.

Background: Mental health disorders are becoming more recognized in pregnancy. Whether mental health disorders are associated with health services utilization after child birth is not completely understood. Objective: This study aimed to investigate postpartum emergency department use within 30 days of delivery among women with preexisting mental health disorders during pregnancy. Study Design: This was a retrospective cohort study evaluating emergency department use among postpartum women with or without mental health disorders who delivered at an academic center between January 2014 and June 2018. Demographic and outcome data were medical record abstracted and analyzed. Multivariate regression was performed to adjust for covariates. Results: During the study period, 13,605 women delivered at the institution, 2355 of whom (17.3%) had an underlying mental health disorder. The primary diagnoses of mental health disorder were anxiety (48.8%), depression (34.8%), substance use disorder (11.4%), bipolar disorder (3.4%), psychosis (0.7%), and other (0.8%). There were a total of 565 emergency department visits within 30 days of delivery. Women who presented to the emergency department after delivery were more likely to have public insurance, identify as black or Asian, and have an underlying mental health disorder. Among women with mental health disorders, 155 (6.6%) used the emergency department within 30 days of their delivery compared with 410 (3.6%) of patients without mental health disorder (adjusted odds ratio, 1.74; 95% confidence interval, 1.42-2.13; P<.001). When assessing the risk of emergency department usage per the type of mental health disorder, anxiety (adjusted odds ratio, 1.73; 95% confidence interval, 1.31-2.27) and depression (adjusted odds ratio, 2.13; 95% confidence interval, 1.59-2.86) carried the highest risk. Compared with women without mental health disorders, women with underlying mental health disorders had more presentations for hypertension (15.5% vs 11.2%) and psychiatric evaluations (4.5% vs 0.2%; both P<.001). Conclusion: Women with mental health disorders use the emergency department during the postpartum period for psychiatric and obstetrical reasons more frequently than women without mental health disorders. Increased surveillance, treatment, and follow-up during pregnancy and the early postpartum period may be warranted for this high-risk population.

Chronic restraint stress causes anxiety- and depression-like behaviors, downregulates glucocorticoid receptor expression, and attenuates glutamate release induced by brain-derived neurotrophic factor in the prefrontal cortex.

Stress and the resulting increase in glucocorticoid levels have been implicated in the pathophysiology of depressive disorders. We investigated the effects of chronic restraint stress (CRS: 6 hours × 28 days) on anxiety- and depression-like behaviors in rats and on the possible changes in glucocorticoid receptor (GR) expression as well as brain-derived neurotrophic factor (BDNF)-dependent neural function in the prefrontal cortex (PFC). We observed significant reductions in body weight gain, food intake and sucrose preference from 1 week after the onset of CRS. In the 5th week of CRS, we conducted open-field (OFT), elevated plus-maze (EPM) and forced swim tests (FST). We observed a decrease in the number of entries into open arms during the EPM (anxiety-like behavior) and increased immobility during the FST (depression-like behavior). When the PFC was removed after CRS and subject to western blot analysis, the GR expression reduced compared with control, while the levels of BDNF and its receptors remained unchanged. Basal glutamate concentrations in PFC acute slice which were measured by high performance liquid chromatography were not influenced by CRS. However, BDNF-induced glutamate release was attenuated after CRS. These results suggest that reduced GR expression and altered BDNF function may be involved in chronic stress-induced anxiety--and depression-like behaviors.

Acute occupancy of brain serotonin transporter by sertraline as measured by [11C]DASB and positron emission tomography.

BACKGROUND: In vivo determination of serotonin transporter (5-HTT) occupancy by selective serotonin reuptake inhibitors (SSRI) using positron emission tomography (PET) can aid in determination of dosing. Previous studies used chronic SSRI administration that may down-regulate 5-HTT and used the cerebellum as reference region despite measurable 5-HTT. We examine the reference region and occupancy after acute sertraline dosing. METHODS: We conducted autoradiography of human postmortem cerebellum to determine an optimal reference region. We quantified 5-HTT binding using [(11)C]DASB and arterial input functions in 17 healthy volunteers. Baseline PET scans were followed by a scan 4-6 days after 25 mg to 100mg of daily sertraline. Several modeling methods and outcome measures were assessed. RESULTS: Cerebellar gray matter is the optimal reference region. Occupation of 5-HTT sites saturates at low plasma sertraline levels (K(D) = 1.9 ng/ml) with maximal occupancies of 106.8 +/- 8.3% across all brain regions. There is a weak correlation between oral sertraline and plasma sertraline. Occupancy measures vary based on the reference region and outcome measure used. CONCLUSIONS: Occupancy studies and postmortem autoradiography can help define the optimal reference region. Reference tissue modeling using the optimal reference region returns the same occupancy measures as those determined using an arterial input function.