Application of the Toxic Stress Schema: An Exemplar for School Nurses.

For many children of color, the cumulative impact of pre-existing stressors, disparities, and pandemic-related losses has contributed to a toxic level of stress. Toxic stress can disrupt healthy brain development making children vulnerable to physical and mental health problems. School nurses are the primary health professionals who interact with children daily during the academic year, which positions them to identify risk factors within the social determinants of health that contribute to the development of toxic stress. The Toxic Stress Schema (TSS) provides a framework for assessment and care planning related to social determinants of health and potential sources of stress and/or buffering support for the physical and mental well-being of children. A case study approach is used to demonstrate the application of the TSS to school nursing and provide the basis for conceptualizing a plan of care and identifying resources to support the child's physical and mental health.

Shared genetic risk between eating disorder- and substance-use-related phenotypes: Evidence from genome-wide association studies.

Eating disorders and substance use disorders frequently co-occur. Twin studies reveal shared genetic variance between liabilities to eating disorders and substance use, with the strongest associations between symptoms of bulimia nervosa and problem alcohol use (genetic correlation [rg ], twin-based = 0.23-0.53). We estimated the genetic correlation between eating disorder and substance use and disorder phenotypes using data from genome-wide association studies (GWAS). Four eating disorder phenotypes (anorexia nervosa [AN], AN with binge eating, AN without binge eating, and a bulimia nervosa factor score), and eight substance-use-related phenotypes (drinks per week, alcohol use disorder [AUD], smoking initiation, current smoking, cigarettes per day, nicotine dependence, cannabis initiation, and cannabis use disorder) from eight studies were included. Significant genetic correlations were adjusted for variants associated with major depressive disorder and schizophrenia. Total study sample sizes per phenotype ranged from ~2400 to ~537 000 individuals. We used linkage disequilibrium score regression to calculate single nucleotide polymorphism-based genetic correlations between eating disorder- and substance-use-related phenotypes. Significant positive genetic associations emerged between AUD and AN (rg = 0.18; false discovery rate q = 0.0006), cannabis initiation and AN (rg = 0.23; q < 0.0001), and cannabis initiation and AN with binge eating (rg = 0.27; q = 0.0016). Conversely, significant negative genetic correlations were observed between three nondiagnostic smoking phenotypes (smoking initiation, current smoking, and cigarettes per day) and AN without binge eating (rgs = -0.19 to -0.23; qs < 0.04). The genetic correlation between AUD and AN was no longer significant after co-varying for major depressive disorder loci. The patterns of association between eating disorder- and substance-use-related phenotypes highlights the potentially complex and substance-specific relationships among these behaviors.

The DNP Degree: Are We Producing the Graduates We Intended?

OBJECTIVE: This study addressed how recently graduated doctor of nursing practice (DNP) nurses describe their current practice, how their supervisors describe the DNP's current practice, and whether nurse and supervisor descriptions of the practices reflect the American Association of Colleges of Nursing (AACN) DNP Essentials and, if so, how? BACKGROUND: Introduced in 2004, the goal of DNP programs was to educate advanced practice RNs for effective leadership in complex healthcare environments. The value of the DNP degree for nurses in healthcare systems is evolving. METHODS: We used conventional content analysis to inductively describe how DNP graduates from 7 different schools and their supervisors described the practice of the recently graduated DNPs. Interviews were reviewed to assess whether the AACN DNP Essentials were enacted in practice. RESULTS: The overarching theme was "becoming more: re-envisioning self as an agent of change." CONCLUSIONS: Results support the claim that DNP education prepares advanced practice nurses for leadership across complex healthcare systems. Evidence of the DNP Essentials is realized when graduates perceive themselves as equal to other leaders and capable of driving change using evidence and effective collaboration.

Reprint of "Epigenetics, maternal prenatal psychosocial stress, and infant mental health".

This paper provides a summary of literature on epigenetic effects and infant health outcomes of maternal psychosocial stress during pregnancy. A search of literature yielded a large body of publications between 2008 and 2018. Relevant articles were selected, and additional sources were located from ancestry searches of reference lists. Results implicate maternal prenatal stress as a source of epigenetic mechanisms that affect fetal brain development and program risk for emotional dysregulation and mental disorders over a lifetime and across generations. Implications for nursing practice are explored at multiple levels of policy advocacy, public education, primary prevention, screening and intervention.

Epigenetics, maternal prenatal psychosocial stress, and infant mental health.

This paper provides a summary of literature on epigenetic effects and infant health outcomes of maternal psychosocial stress during pregnancy. A search of literature yielded a large body of publications between 2008 and 2018. Relevant articles were selected, and additional sources were located from ancestry searches of reference lists. Results implicate maternal prenatal stress as a source of epigenetic mechanisms that affect fetal brain development and program risk for emotional dysregulation and mental disorders over a lifetime and across generations. Implications for nursing practice are explored at multiple levels of policy advocacy, public education, primary prevention, screening and intervention.

The influence of social-developmental context and nurse visitation intervention on self-agency change in unmarried adolescent mothers.

Pregnancy among unmarried adolescents has been linked to negative personal control beliefs. In contrast, self-agency beliefs about control over future possibilities have been linked to delay in subsequent childbearing. In this secondary analysis, we examined factors associated with self-agency change in 429 unmarried adolescent mothers from intervention and control groups of a nurse home visitation study. Adolescent mothers who participated in a sustained relationship with a nurse made greater gains in self-agency than did control group mothers (p = .034). Adolescents with lower cognitive ability who were behind their age-appropriate grade level in school made the greatest self-agency gains.

Rating of Eating Disorder Severity Interview for Children: psychometric properties and comparison with EDI-2 symptom index.

OBJECTIVE: This study aimed to evaluate the psychometrics of the Rating of Eating Disorder Severity Interview for Children (REDS-C) and compare it with the Eating Disorder Inventory-2 symptom index. METHODS: The psychometrics of the REDS-C were analyzed utilizing data from 336 patients, of ages 8 to 18 years. Receiver operator curve analyses were performed to evaluate the ability of the REDS-C and the Eating Disorder Inventory-2 symptom index to discriminate severity of eating disorder symptoms in relationship to an objective standard, defined as hospitalisation for medical stabilisation beyond 1 week. RESULTS: Three factors were identified using 14 of the 16 original REDS-C items. Resulting subscales demonstrated acceptable reliability and validity. The receiver operator curve results demonstrated the usefulness of the 14-item version of the REDS-C in predicting hospitalisation greater than 7 days as an indicator of symptom severity. DISCUSSION: The 14-item REDS-C is a reliable tool to assist clinicians in evaluating the severity of eating disorder symptoms in children and adolescents.

A Schema of Toxic Stress Informed by Racism, Transgenerational Stress, and Disadvantage.

INTRODUCTION: The Toxic Stress Schema (TSS) is an ecological framework with a social justice lens for identifying and alleviating stress and strengthening social determinants of health for children and families of color impacted by the COVID-19 pandemic and the cumulative effects of racism and generational, systemic inequities. METHOD: Relevant literature is reviewed, and examples were provided to illustrate the differential impacts of the "stress superstorm" of 2020 had on children of color based on their family's position on the advantage-disadvantage continuum. RESULTS: The utility of the TSS framework as a model for advanced nursing practice is demonstrated, and recommendations are formulated for the pediatric nurse practitioner's role in health policy. DISCUSSION: The COVID-19 pandemic elucidated the historical inequities experienced by children and families of color. The TSS framework provides a model for recognizing, organizing, and implementing.

Common Genetic Variation and Age of Onset of Anorexia Nervosa.

Background: Genetics and biology may influence the age of onset of anorexia nervosa (AN). The aims of this study were to determine whether common genetic variation contributes to age of onset of AN and to investigate the genetic associations between age of onset of AN and age at menarche. Methods: A secondary analysis of the Psychiatric Genomics Consortium genome-wide association study (GWAS) of AN was performed, which included 9335 cases and 31,981 screened controls, all from European ancestries. We conducted GWASs of age of onset, early-onset AN (<13 years), and typical-onset AN, and genetic correlation, genetic risk score, and Mendelian randomization analyses. Results: Two loci were genome-wide significant in the typical-onset AN GWAS. Heritability estimates (single nucleotide polymorphism-h 2) were 0.01-0.04 for age of onset, 0.16-0.25 for early-onset AN, and 0.17-0.25 for typical-onset AN. Early- and typical-onset AN showed distinct genetic correlation patterns with putative risk factors for AN. Specifically, early-onset AN was significantly genetically correlated with younger age at menarche, and typical-onset AN was significantly negatively genetically correlated with anthropometric traits. Genetic risk scores for age of onset and early-onset AN estimated from independent GWASs significantly predicted age of onset. Mendelian randomization analysis suggested a causal link between younger age at menarche and early-onset AN. Conclusions: Our results provide evidence consistent with a common variant genetic basis for age of onset and implicate biological pathways regulating menarche and reproduction.

From objectives to competencies: operationalizing the NONPF PMHNP competencies for use in a graduate curriculum.

In the summer of 2004, the faculty in the psychiatric mental health nurse practitioner (PMHNP) Program at Oregon Health and Science University School of Nursing began the redesign of an objective-based curriculum to a competency-based curriculum. The competencies were based on the 2003 National Organization of Nurse Practitioner Faculties (NONPF) PMHNP competencies. This article describes the background and rationale for the curriculum redesign, the transition process, our resulting set of curriculum competencies, associated learning strategies, and some of the barriers and benefits we encountered. It is hoped that this and other articles describing the implementation of the NONPF PMHNP advance practice competencies will promote further dialogue and the development of best practices regarding competency-based education in advanced practice nursing.

Challenges in diagnosis and treatment of comorbid eating disorders and mood disorders.

PURPOSE: This paper explores complex challenges in diagnosis and treatment of patients with comorbid eating disorders and mood disorders. An integrative review of the literature examines overlapping symptoms, phenotypes, neural circuits, and genetic factors for these disorders. A case study illustrates how the integration of knowledge from research and practice can inform a diagnostic formulation and multifaceted treatment plan. CONCLUSIONS: Patients with complex clinical presentations inspire a search for research and clinical literature that helps build the neuroscience foundations of advanced practice. PRACTICE IMPLICATIONS: Sharing clinical challenges and processes of discovery is a form of scholarship that promotes the evolution of advanced psychiatric nursing practice.

Genome-wide association study identifies eight risk loci and implicates metabo-psychiatric origins for anorexia nervosa.

Characterized primarily by a low body-mass index, anorexia nervosa is a complex and serious illness1, affecting 0.9-4% of women and 0.3% of men2-4, with twin-based heritability estimates of 50-60%5. Mortality rates are higher than those in other psychiatric disorders6, and outcomes are unacceptably poor7. Here we combine data from the Anorexia Nervosa Genetics Initiative (ANGI)8,9 and the Eating Disorders Working Group of the Psychiatric Genomics Consortium (PGC-ED) and conduct a genome-wide association study of 16,992 cases of anorexia nervosa and 55,525 controls, identifying eight significant loci. The genetic architecture of anorexia nervosa mirrors its clinical presentation, showing significant genetic correlations with psychiatric disorders, physical activity, and metabolic (including glycemic), lipid and anthropometric traits, independent of the effects of common variants associated with body-mass index. These results further encourage a reconceptualization of anorexia nervosa as a metabo-psychiatric disorder. Elucidating the metabolic component is a critical direction for future research, and paying attention to both psychiatric and metabolic components may be key to improving outcomes.

Screening for childhood eating disorders in primary care.

OBJECTIVE: Early identification is essential to reduce disabling complications of eating disorders that occur during stages of bone growth and organ development. This study sought to examine health-screening practices of pediatricians and adolescent medicine physicians in a metropolitan area of the Pacific Northwest. METHOD: 70 pediatric and adolescent medicine practices were contacted, 34 (49%) participated, and 20 (29%) returned health forms. Five pediatricians participated in a follow-up focus group. Data collection and analysis occurred between June 2005 and April 2006. RESULTS: 71% (N = 24) of participating practices relied on clinical interviews to detect eating disorders. Less than half of analyzed health-screening forms included questions specific to eating disorders. A pediatrician focus group revealed barriers to identification of eating disorders. CONCLUSION: Fast-paced appointments and patients who withhold information compromise identification of eating disorders in pediatric and adolescent medicine practices. Barriers to detection highlight the need for enhanced professional and parent education, practical changes in screening tools and processes, and more frequent appointments when risk factors are present.

Epigenetics: An Emerging Framework for Advanced Practice Psychiatric Nursing.

PURPOSE: The aims of this paper are to synthesize and report research findings from neuroscience and epigenetics that contribute to an emerging explanatory framework for advanced practice psychiatric nursing. CONCLUSIONS: Discoveries in neuroscience and epigenetics reveal synergistic mechanisms that support the integration of psychotherapy, psychopharmacology, and psychoeducation in practice. PRACTICE IMPLICATIONS: Advanced practice psychiatric nurses will benefit from an expanded knowledge base in neuroscience and epigenetics that informs and explains the scientific rationale for our integrated practice.

Accessing self-development through narrative approaches in child and adolescent psychotherapy.

TOPIC: Narrative psychotherapy with children and adolescents. PURPOSE: To demonstrate the integration of developmental theory with narrative approaches to psychotherapy as a means of accessing self-development during childhood and adolescence. SOURCES: Published literature and the author's experience in using narrative therapy with an 8-year-old and his foster mother. CONCLUSIONS: When informed by developmental theory, narrative approaches can be used effectively with children and adolescents to assist them in constructing positive life stories that can influence their identity formation.

Military deployment and reintegration: a systematic review of child coping.

TOPIC: Child coping with parent military deployment and family reintegration. PURPOSE: A systematic review of research literature was conducted to examine the effects of deployment and family reintegration on children in military families. SOURCES USED: A search of CINAHL, PubMed, Psyc-INFO, and SocINDEX databases was performed using the terms "military family," "military child," "child coping," "deployment," and "reintegration." The search was limited to publications between 2001 and 2014 to focus on the effects of Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND). Twenty-seven research reports met inclusion criteria. CONCLUSIONS: Three themes were extracted: A child's coping is influenced by (a) the child's age and development, (b) the mental health and coping of the non-deployed parent during deployment, and the mental health of both parents during family reintegration, and (c) the pre-existing resilience/vulnerability, cumulative risks, and resources of the child and family.

The neurobiology of risk and pre-emptive interventions for anorexia nervosa.

TOPIC: The neurobiology of risk and pre-emptive interventions for anorexia nervosa. PURPOSE: This article is based on a presentation at the March 2012 annual conference of the International Society of Psychiatric Mental Health Nurses. SOURCES: A review of literature and clinical practice experience. CONCLUSIONS: Advances in genetics and neuroimaging provide evidence of a recognizable phenotype of traits and neuropsychological characteristics that precede symptom onset in children at risk for anorexia nervosa. Early recognition of the phenotype and experiences that can potentiate symptom expression provides the basis for pre-emptive interventions that may avert or delay the onset and reduce symptom severity.

Applying Benner's Model to Psychiatric Mental Health Nurse Practitioner Self-Ratings of Role Competence.

BACKGROUND: Cross-sectional survey research elicited self-perceptions of role competence from practicing psychiatric mental health nurse practitioners (PMHNPs) and new PMHNP graduates. OBJECTIVES: Examine relationships between PMHNP perceptions of competence, prior basic-level nursing experience, and years of PMHNP practice. STUDY DESIGN: Self-ratings of competence were elicited by a questionnaire designed from Benner's model. The relationship between prior nursing experience and perceptions of competence was examined by chi-square analysis. Changes in PMHNP competence rankings over years of practice were examined with Kruskal-Wallis and Mann-Whitney procedures. RESULTS: Self-perceptions of competence increased in seven role dimensions as PMHNPs progressed through years of practice (p < .000). Gains in perceptions of competence occurred between career entry and 3 to 5 years of practice in all but one role dimension. Prior nursing experience did not significantly increase perceptions of competence among PMHNP graduates. CONCLUSIONS: Self-perceptions of competence progressively and significantly increased over years of PMHNP practice among participants in this study.