64th annual meeting

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Journal of the American Academy of Child & Adolescent Psychiatry

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Volume 56 | Number 10S | October 2017

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SUPPLEMENT TO


SCIENTIFIC PROCEEDINGS

64TH ANNUAL MEETING October 23–28, 2017 Washington, DC

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Journal of the American Academy of

Child & Adolescent Psychiatry EDITOR-IN-CHIEF ASSOCIATE EDITOR DEPUTY EDITORS

ASSISTANT EDITORS

JOHN F. MCDERMOTT ASSISTANT EDITOR-IN-RESIDENCE FORMER EDITORS

INTERNATIONAL EDITORS-AT-LARGE

EDITORS-AT-LARGE FOR METHODOLOGY AND STATISTICS

EDITORIAL OFFICE

Andrés Martin, MD, MPH

EDITORIAL BOARD

James J. Hudziak, MD Stephen V. Faraone, PhD Ellen Leibenluft, MD Douglas K. Novins, MD John Piacentini, PhD John T. Walkup, MD Robert R. Althoff, MD, PhD Reviews

Michael H. Bloch, MD, MS Kelly N. Botteron, MD Christoph U. Correll, MD Samuele Cortese, MD, PhD Melissa P. DelBello, MD, MS

Jeff Q. Bostic, MD, EdD Continuing Medical Education

Daniel P. Dickstein, MD

Schuyler W. Henderson, MD, MPH Book Forum

Stacy S. Drury, MD, PhD

Laura M. Prager, MD Clinical Perspectives Oliver M. Stroeh, MD Mina K. Dulcan, MD (1998-2007) John F. McDermott, Jr., MD (1988-1997) Melvin Lewis, MD (1976-1987) Eveoleen N. Rexford, MD (1966-1976) Irene M. Josselyn, MD (1962-1965) Tony Charman, PhD United Kingdom Ruth Feldman, PhD Israel Luis A. Rohde, MD Brazil Peter Szatmari, MD Canada Frank Verhulst, MD Netherlands Garry Walter, MD, PhD Australia Stephen J. Glatt, PhD Michael C. Monuteaux, ScD Mark Olfson, MD, MPH Angela M. Reiersen, MD, MPE Priya J. Wickramaratne, PhD Eric A. Youngstrom, PhD Mary K. Billingsley, ELS Managing Editor Kristine Pumphrey Assistant Managing Editor Alyssa Murphy, MA Editorial Manager

Guido K.W. Frank, MD Jean A. Frazier, MD Daniel A. Geller, MBBS, FRACP Mary Margaret Gleason, MD Anne L. Glowinski, MD, MPE Benjamin I. Goldstein, MD, PhD Christian Hopfer, MD Leslie Hulvershorn, MD, MSc Sheryl H. Kataoka, MD, MSHS Guilherme V. Polanczyk, MD, PhD Jonathan Posner, MD Manpreet K. Singh, MD, MS Argyris Stringaris, MD, PhD, MRCPsych Chad M. Sylvester, MD, PhD Eva Szigethy, MD, PhD Anita Thapar, MD, PhD Jeremy Veenstra-VanderWeele, MD Tonya White, MD, PhD

Journal of the American Academy of

CHILD & ADOLESCENT PSYCHIATRY The Journal of the American Academy of Child & Adolescent Psychiatry is a benefit of membership in the American Academy of Child & Adolescent Psychiatry. To become a member or provide a change of address, please contact Member Services at the American Academy of Child and Adolescent Psychiatry by phone at 202.966.7300 ext 2004; or fax at 202.464.0131; or mail to AACAP, 3615 Wisconsin Avenue, NW, Washington, DC, 20016. AACAP membership includes a Journal subscription. Membership dues: General - $450; Affiliate - $395; Corresponding - $305; Resident - $75. Medical Students can be AACAP members for no charge. Subscriptions vary by member type and location. Journal of the American Academy of Child & Adolescent Psychiatry (ISSN 0890-8567) is published monthly for the American Academy of Child & Adolescent Psychiatry by Elsevier, 230 Park Avenue, Suite 800, New York, NY 10169. Business Office: 1600 John F. Kennedy Boulevard, Suite 1800, Philadelphia, PA 19103-2899. Accounting and Circulation Offices: 3251 Riverport Lane, Maryland Heights, MO 63043. Periodicals postage paid at New York, NY and additional mailing offices. POSTMASTER: Send address changes to Elsevier, Journal Returns, 1799 Highway 50 East, Linn, MO 65051. CUSTOMER SERVICE (orders, claims, online, change of address): Please visit our Support Hub page https://service.elsevier. com for assistance. Address changes must be submitted four weeks in advance. YEARLY SUBSCRIPTION RATES: United States and possessions: Individual $356; Student and Resident $234. All other countries (prices include airspeed delivery): Individual $506; Student and Resident $373. To receive student/resident rate, orders must be accompanied by name of affiliated institution, date of term and the signature of program/residency coordinator on institution letterhead. Orders will be billed at the individual rate until proof of status is received. Current prices are in effect for back volumes and back issues. Further information on this journal is available from the Publisher or from this journal’s website (http://www. jaacap.org). Information on other Elsevier products is available through Elsevier’s website (http://www.elsevier.com). Advertising information. Advertising and classified advertising orders and inquiries can be sent to: USA, Canada, and South America, Bob Issler, 20 Sylvan Avenue, Metuchen, NJ 08840; e-mail [email protected]. Europe and the rest of the world, Julie Toop; phone +44 (0) 1865 843016; fax +44 (0) 1865 843976; e-mail [email protected]. Author inquiries For inquiries relating to the submission of articles (including electronic submission where available), visit http://www. elsevier.com/authors. The site also provides the facility to track accepted articles and set up e-mail alerts to inform you of when an article’s status has changed, as well as detailed artwork guidelines, copyright information, frequently asked questions, and more. Please see Information for Authors for individual journal. Contact details for questions arising after acceptance of an article, especially those relating to proofs, are provided after registration of an article for publication. The paper used in this publication meets the requirements of ANSI/NISO Z39.48-1992 (Permanence of Paper). English language help service: Upon request, Elsevier will direct authors to an agent who can check and improve the English of their paper (before submission). Please contact [email protected] for further information. Reprints. For queries about author offprints, e-mail [email protected]. To order 100 or more reprints for educational, commercial, or promotional use, contact Derrick Imasa at 212-633-3874, Elsevier Inc., 230 Park Ave, Suite 800, New York, NY 10169. Fax: 212-462-1935; email: [email protected]. Reprints of single articles may be obtained at www.jaacap.org. Ó 2017 American Academy of Child and Adolescent Psychiatry. All rights reserved.

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COUNCIL PRESIDENT Gregory K. Fritz, MD PRESIDENT-ELECT Karen Dineen Wagner, MD, PhD SECRETARY Tami D. Benton, MD TREASURER Warren Y.K. Ng, MD ASSEMBLY CHAIR Mark S. Borer, MD PAST PRESIDENT Paramjit Toor Joshi, MD EXECUTIVE DIRECTOR Heidi B€ uttner Fordi, CAE John E. Schowalter Resident Member of Council Lan Chi Krysti Vo, MD Jerry M. Wiener Resident Member of Council Aaron Roberto, MD Council Members

Manal Assi, MD Gabrielle A. Carlson, MD Lisa M. Cullins, MD Timothy F. Dugan, MD Cathryn Galanter, MD Shashank V. Joshi, MD Debra E. Koss, MD Douglas A. Kramer, MD Melvin D. Oatis, MD Karen Pierce, MD Applications for membership may be obtained from Member Services American Academy of Child and Adolescent Psychiatry 202.966.7300 ext 2004 www.aacap.org 3615 Wisconsin Avenue, NW Washington, DC, 20016

THE SCIENTIFIC PROCEEDINGS of the 64th Annual Meeting of the American Academy of Child & Adolescent Psychiatry

Washington, DC • October 23-28, 2017 Judith A. Crowell, MD, Editor Carmen J. Head, MPH, CHES, Director of Research, Grants, & Workforce Esha Gupta, Medical Science Writer Sarah Hellwege, MEd, Assistant Director of Research, Training, & Education Lisell Perez-Rogers, Grants & Research Program Manager

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AACAP'S 64TH ANNUAL MEETING: 2017 SCIENTIFIC PROCEEDINGS AACAP Leadership

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Letter From the AACAP President

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Letter From the JAACAP Editor-in-Chief

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Letter From the AACAP Program Chair

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Letter From the Scientific Proceedings Editor

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CME Credits

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SYSTEMS OF CARE SPECIAL PROGRAM An all-day session that provides multiple presentations on systems of care methodologies. Expert speakers address the commonalities and differences within the context of a best practices perspective with a focus on required tasks in the development, enhancement, and maintenance of effective systems of care.

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CLINICAL PERSPECTIVES Similar to Symposia, Clinical Perspectives present a particular topic related to treatment, research method, service delivery, or clinical care, which is evidence-based, but also includes the “art” and clinical wisdom of the practice of child and adolescent psychiatry. These programs are three hours long and open to all attendees.

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EXTENDED WORKSHOPS Extended Workshops provide additional time and opportunity to master evidence-based therapeutic interventions, and are designed to provide the participant with sufficient expertise to implement newly learned treatment approaches or interventions into their clinical practices. They are full-day ticketed programs that are limited to 40 attendees.

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HONORS PRESENTATIONS Presentations made by Distinguished Member Award winners based on their research or work.

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INSTITUTES Institutes focus on “how to do it” with respect to clinical problems, academic areas, or a blending of the two. Institutes are designed for attendees who wish to be taught a comprehensive and authoritative overview of a topic area. Institutes are full-day programs and require a ticket.

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NEW RESEARCH POSTERS Authors present the results of data-rich research or clinical reports with opportunity for feedback from viewers. There are six New Research Poster Sessions throughout the meeting, and they are open to all attendees. Poster Session 1 Adolescence, Early Childhood, Inpatient, Neuroimaging, Pharmacotherapy

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Poster Session 2 S176 Cognitive-Behavioral Therapy, Depressive Disorders, Diversity and Culture, External Consultation/Schools/Forensic/Community, Family Therapy, Forensic Issues, Group Therapy, Health Care Economics/Managed Care/Population Health, Neuromodulation, Obsessive-Compulsive Disorder, Outpatient, Pediatric Consultation Liaison, Prevention, Systems of Care, Training Issues

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Poster Session 3 S202 Complementary and Integrative Medicine, Diagnostic Methods, Epidemiology, Feeding and Eating Disorders, Intellectual Disabilities, Oppositional Defiant Disorder, Protective Factors, Risk Factors, Sleep-Wake Disorders, Social Media/Use of Electronics, Specific Learning Disorders, Suicidal/Self-Injury Behavior, Treatment Planning Poster Session 4 S228 AIDS/HIV, Anxiety Disorders, Developmental Psychopathology, Disruptive Behavior Disorders, Disruptive Mood Dysregulation Disorder, Divorce/Adoption/Foster Care, Health Care Economics/Managed Care/Population Health, Irritability/Dysregulation, Medical Factors Affecting Psychological Disorders, Neuroanatomy/Neurophysiology, Parenting/Child Care/Abuse/ Neglect, Personality Disorders, Schizophrenia and Other Psychotic Disorders, Sexuality and Gender Issues, Somatic Symptom and Related Disorders, Tic Disorders/Stereotypic Disorders, Trauma- and Stressor-Related Disorders Poster Session 5 S253 Aggression/Violence, Autism Spectrum Disorder, Behavioral Therapy, Bipolar Spectrum Disorders, Disorders Due to Another Medical Condition, Infancy, Neuroanatomy/Neurophysiology, Normal Child Development, Partial Hospitalization, Residential Treatment, Transitional-Age Youth Poster Session 6 Attention-Deficit/Hyperactivity Disorder, Other or Mixed, Substance Related and Addictive Disorder

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SYMPOSIA Symposia are data-driven programs that present perspectives on different aspects of a topic or differing views of the same topic. These programs are three hours in length and open to all attendees.

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WORKSHOPS Workshops provide instruction on treatment, research method, delivery, or organization of services, and are designed to encourage discussion in a small group. They are limited to 30 attendees, and a ticket is required for attendance.

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REFERENCE Common Acronyms

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Key Words

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Disclosures

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Subject Index

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Author Index

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How to Cite: Format: Authors. Presentation title [AACAP abstract number]. Journal title. Year; volume: page range. DOI. Example: Horner MS, Novins DK, Martin A, et al. How to get published: practical tips, strategies, and methods from JAACAP and JAACAP Connect [AACAP abstract Workshop 12]. J Am Acad Child and Adolesc Psychiatry. 2017;56(suppl):S350. http://dx.doi.org/10.1016/j.jaac.2017.07.748.

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2017 SCIENTIFIC PROCEEDINGS

AACAP Research Committee

Melissa P. DelBello, MD, MS, Co-Chair Jean A. Frazier, MD, Co-Chair Michael H. Bloch, MD, MS Christoph U. Correll, MD David Cochran, MD, PhD Daniel P. Dickstein, MD Stacy S. Drury, MD, PhD Craig A. Erickson, MD Bradley Peterson, MD Adelaide S. Robb, MD Neal D. Ryan, MD Moira A. Rynn, MD Manpreet K. Singh, MD, MS Matthew Wright, MD Timothy E. Wilens, MD Benedetto Vitiello, MD Bonnie Zima, MD

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AACAP Program Committee

Boris Birmaher, MD, Chair James J. McGough, MD, Deputy Chair Micah J. Sickel, MD, PhD, Local Arrangements Co-Chair Regina Bussing, MD, MSHS Angel A. Caraballo, MD Barbara J. Coffey, MD, MS Judith Ann Crowell, MD Rasim Somer Diler, MD Anne Cecilia Duffy, MD Laurence Lee Greenhill, MD R. Andrew Harper, MD Ryan Herringa, MD, PhD Manon Hillegers, MD, PhD Jae-Won Kim, MD, PhD Soo-Jeong Kim, MD Alice R. Mao, MD Jon McClellan, MD Michael P. Milham, MD, PhD Wanjiku Njoroge, MD Roberto Ortiz-Aguayo, MD Caroly Pataki, MD Gregory Sayer, MD Shawn S. Sidhu, MD Jeffrey Robert Strawn, MD Shelly Tran, MD

AACAP’S 64th ANNUAL MEETING

Letter From the AACAP President Welcome to Washington, DC! It is with great pleasure that I welcome you to our 64th Annual Meeting. We are expecting a large turnout in our nation’s capital, Washington, DC, for this meeting, which brings together child and adolescent psychiatrists from across the globe and delivers the best in continuing medical education. The goal of the meeting is to help advance AACAP’s mission to “promote the healthy development of children, adolescents, and families through research, training, prevention, comprehensive diagnoses, and treatment.” Our Annual Meeting will offer something of great value for every child and adolescent psychiatrist and highlight many key issues. In the second year of my Presidential Initiative, focused on integrating mental health and primary medical care, there continue to be many opportunities that involve educating child and adolescent psychiatrists about models for integrated care. A wealth of programming on this topic is infused throughout the entire meeting and featured in several Clinical Perspectives, Workshops, Symposia, and other special Annual Meeting sessions. Be sure to attend the Simon Wile Symposium on Friday, October 27, for a session entitled “Super-Powered Child Psychiatry Access Programs! Adding Value From System-Wide Gregory K. Fritz, MD Integration, Early Childhood Interventions, and Quality Improvement Initiatives.” Don’t miss AACAP President the Karl Menninger, MD, Plenary on Wednesday, October 25. In this session, AACAP President-Elect, Karen Dineen Wagner, MD, PhD, will present an address entitled “Depression Awareness and Screening in Youth,” introducing her Presidential Initiative. On Saturday, October 28, I will be interviewing AACAP Distinguished Life Fellow Charles H. Zeanah, Jr., MD, Director of the Institute of Infant and Early Childhood Mental Health at Tulane University. I am also excited about the unique opportunity for advocacy with our nation’s leaders to advance children’s mental health through legislation. Be sure to join us on Monday for the AACAP Legislative Program and Congressional Visits, which will equip you with the necessary know-how and materials to successfully lobby your own US Representative and Senators on AACAP’s policy priorities, followed by a trip to Capitol Hill for meetings with legislators and policy-makers from your home districts. I commend and thank AACAP’s Program Committee, chaired by Boris Birmaher, MD, who is assisted by the members of the Committee, Deputy Program Chair James J. McGough, MD, and staff, led by Jill Brafford, CMP, MTA, Director of Meetings and Continuing Medical Education, and Lucinda Flowers, CMP, Assistant Director of Meetings. Their job is an interesting, complex, and delicate one that includes creating the call for papers, carefully reviewing every submission (over 425 this year!), making sure that key areas are covered and the program is balanced, creating a schedule, and fitting it all into the available meeting rooms. The rigor and care of the process and time that goes into every program is truly impressive. The attendees get the easy part – enjoying the meeting and its varied presentations, as well as the city and the events that have been knowledgeably planned and orchestrated by the Local Arrangements Committee, headed this year by co-chairs, J. Michael Houston, MD, and Micah J. Sickel, MD, PhD. The Scientific Proceedings is a handy tool, particularly as you create your own personal meeting schedule. It helps to provide a bird’s eye view on the content of many Annual Meeting sessions and posters and serves as a great reference after the meeting. This is the second year that the Scientific Proceedings is made available as a supplement of the Journal of the American Academy of Child & Adolescent Psychiatry (JAACAP). As a supplement, the Scientific Proceedings is available online at no charge to AACAP members whether they attend the meeting or not, and individual abstracts can be cited as the published content of a scientific journal. Special thanks to Judith Crowell, MD, Scientific Proceedings Editor, Carmen J. Head, MPH, CHES, Director of Research, Grants, and Workforce, Mary K. Billingsley, ELS, JAACAP Managing Editor, Esha Gupta, Medical Science Editor, Sarah Hellwege, MEd, Assistant Director of Research, Training, and Education, Lisell Perez-Rogers, Grants and Research Program Manager, and Alyssa Murphy, JAACAP Editorial Manager, for their detailed work on this year’s Scientific Proceedings. I look forward to an excellent meeting in Washington, DC, and I hope you do, too. It’s always a high point of my year, especially as I get to see old friends and have the chance to meet new ones – all of us committed to improving the mental health of children. Sincerely yours,

Gregory K. Fritz, MD AACAP President www.jaacap.org

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Letter From the JAACAP Editor-in-Chief I am pleased and honored to join my esteemed colleagues in presenting the scientific proceedings of AACAP’s 64th Annual Meeting, published as an online-only JAACAP supplement issue. Now in its second year, this issue brings together the Annual Meeting and the Journal, two cornerstones of the Academy’s robust research and education program. Although the AACAP Program Committee’s rigorous call for papers and review process remains as it has always been, publication of the proceedings in JAACAP provides unique benefits, ensuring that the Annual Meeting abstracts are archived and citable as scholarly journal content, and allowing for greater dissemination and discoverability. Like all JAACAP articles, each abstract receives a digital object identifier (DOI), a unique and persistent alphanumeric identification code that is guaranteed never to change and that can be used to cite and link to the content. And the benefits are not only one-sided – JAACAP articles are often born as posters and Annual Meeting presentations, so in a sense, we are publishing here what will become future issues of the Journal, and we encourage presenters and speakers to consider JAACAP when later exploring options for full-length article publication. The Annual Meeting abstracts are available to meeting attendees as a printable PDF and via the AACAP App, and are also available to AACAP members and JAACAP subscribers like any other JAACAP issue, via the Journal’s website, mobile options, and other Elsevier portals, such as ScienceDirect.

Andrés Martin, MD, MPH JAACAP Editor-in-Chief

I would like to express my thanks to the team that brought this issue to fruition: the AACAP Program Committee, led by Boris Birmaher, MD, and James J. McGough, MD; Judith A. Crowell, MD, Scientific Proceedings Editor; Jill Z. Brafford, CMP, MTA, and the Meetings and CME Department; Carmen J. Head, MPH, CHES, and the Research, Grants, and Workforce Department; Mary K. Billingsley, ELS, and the JAACAP Editorial Office; Esha Gupta, Medical Science Editor; and the JAACAP production team at Elsevier led by Publishing Director Josh Spieler. I hope that you enjoy the meeting and find the proceedings book and the opportunities it represents to be as exciting and valuable as I do. I look forward to seeing you in Washington, DC!

Andrés Martin, MD, MPH JAACAP Editor-in-Chief

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Letter From the AACAP Program Chair Welcome to DC and to AACAP’s 64th Annual Meeting! As Chair of the Program Committee, I am thrilled to welcome everyone to Washington, DC, and am excited to see so many colleagues from around the country and the world! Special welcome to all medical students and residents in attendance – we hope that you find your professional home with AACAP. Jill Brafford, Lucinda Flowers, Katherine Chen, Erica Allen, and the entire AACAP staff, in addition to the Local Arrangements Committee, worked very hard to organize this meeting. As well, the Program Committee volunteered countless hours securing a selection of top quality presentations to ensure that the full breadth of the field is covered in the program. Thank you to the Program Committee, and especially James J. McGough, MD, Deputy Program Chair, and to all the individuals and committees who submitted excellent sessions and have provided me with valuable feedback throughout the year; this meeting couldn’t happen without everyone’s hard work!

Boris Birmaher, MD

This year’s program continues to reflect Dr. Fritz’s Presidential Initiative on Integrated Care, AACAP Program Committee Chair and also includes themes for all interests, from basic and clinical research to practical clinical issues. We have many highly educational and informative Institutes, Workshops, Clinical Case Conferences, Clinical Consultation Breakfasts, Symposia, Clinical Perspectives, Member Services Fora, Poster Sessions, and new this year, Extended Workshops that highlight important, relevant topics, as well as very interesting Media Theatre movies related to child and adolescent psychiatry. I also look forward to both talks at the Annual Meeting by Sir Michael Rutter, MD. He is speaking at the Noshpitz Cline History Lecture on “How Have Longitudinal Study Findings Changed Our Thinking About Families and Children Over the Last 50 Years?” as well as co-presenting at the James C. Harris, MD, Developmental Neuropsychiatry Forum on “Neurodevelopmental Consequences of Early Childhood Adversity: Insights From Children Raised in Institutions.” We included some timely special programs such as systems of care, integrated care, wellness, excessive use of electronics, gun violence, the effects of “13 Reasons Why,” new challenges with children of illegal immigrants and LGBT communities, and updated research in complementary medicine and psychopharmacology. As always, the large majority of educational sessions are accredited for continuing medical education (CME), and attendees can receive up to 50 CME credits by attending the entire meeting. As you’ve come to expect, we will continue to offer:  Proceedings abstracts published in JAACAP with a special online edition  Free WiFi: complimentary wireless internet throughout the meeting space and hotel rooms at the Marriott and Omni  The AACAP App: The App allows you to fully navigate the meeting without paper (including electronic session evaluations)  Online tools to access a variety of meeting-related documents and information  The Self-Assessment Exam: A free, 100-question, 8 CME credit exam that will help assess your level of knowledge to guide your selection of sessions at the Annual Meeting  Wellness programming, so please make sure to take advantage of the now twice-daily yoga and meditation classes, wellness-related educational sessions, as well as various fun exercise programs in and around the city of DC! NEW this year, we’re offering:  Extended Workshops: Extended Workshops offer a ‘deep dive’ into evidence-based therapeutic interventions for the attendees, extending the normal workshop to 6-8 hours 

Outings in DC, including docent-led tours of two world-renowned museums: the National Gallery of Art and the United States Holocaust Memorial Museum

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Clinical Practica, including day-long, highly informative programs held at the National Institute of Mental Health and Gallaudet University

So again, we welcome you to our exciting Nation’s Capital, and to this year’s Annual Meeting! With best wishes,

Boris Birmaher, MD Program Chair www.jaacap.org

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Letter From the Scientific Proceedings Editor Welcome to Washington, DC! For the past two years, I chose quotes about New York and San Antonio to introduce my welcome letter – I hope the quotes captured the feel of those cities in positive ways. Searching the internet for quotes about Washington, DC, led me to set aside that idea for this year, as I could find virtually no quotes that were complimentary! I, however, love having the meetings here in DC with its history, monuments, Smithsonian Museums and National Zoo, and diverse restaurants, as well as AACAP’s headquarters. The scientific proceedings of AACAP’s 64th Annual Meeting describe the wide-ranging program of events and presentations assembled this year. The Program Committee, under the continuing leadership of Boris Birmaher, MD, and James J. McGough, MD, did excellent work in selecting an interesting and varied set of presentations that reflects the range of our discipline. We had the guidance and wonderful support of our AACAP staff, led by Jill Zeigenfus Brafford and Lucinda Flowers, in selecting the program contents. The team that prepared and edited this year’s publication of the proceedings include AACAP staff members, Carmen J. Head, MPH, CHES, Director of Research, Grants, and Workforce, Sarah Hellwege, MEd, Assistant Director, Research, Training, and Education, and Lisell Perez-Rogers, Grants and Research Program Manager, our Medical Science Editor, Esha Gupta, and myself.

Judith A. Crowell, MD Scientific Proceedings Editor

Enjoy the meeting and have fun in Washington! Judith A. Crowell, MD Scientific Proceedings Editor

Registrant Agreement AACAP takes pride in its rigorous development of our CME programs. On your registration form, you are required to sign the following statement: “By registering for this meeting, registrant grants AACAP and its sublicensee(s) the right to record his/her presentation, remarks, appearance, or other participation, and to reproduce and distribute such recording by any means and for any purpose without payment to the registrant. Registrant also agrees that he/she will not reproduce, distribute, summarize, adapt, publicly perform, or publicly display any presentation or accompanying materials, in whole or in part, for commercial purposes without prior written authorization from the copyright owner(s), nor will registrant use the AACAP name or logo in connection with any commercial use of such materials without written authorization from AACAP.” At the beginning of each presentation, speakers are required to make the following statement: “This presentation and the accompanying materials are protected by copyright and may not be reproduced, distributed, or summarized, in whole or in part, for any commercial purpose without prior written authorization from the copyright owner(s). In addition, AACAP’s name and logo may not be used in connection with any commercial use of these presentation materials without AACAP’s prior written authorization.” You may not take photographs or use any recording devices at any time during this session, without the expressed, written consent of AACAP. AACAP requires open and full disclosure of all funding and sponsorship. Additional information about funding will be provided in response to written inquiry. DSM and DSM-5 are registered trademarks of the American Psychiatric Association. The American Psychiatric Association is not affiliated with nor endorses this seminar.

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CME Credits The American Academy of Child and Adolescent Psychiatry is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The American Academy of Child and Adolescent Psychiatry designates this live activity for a maximum of 50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. The following is a breakdown of maximum CME credits offered by session type: 3 credits for each Clinical Case Conference, 1.5 credits for each Clinical Consultation Breakfast, 3 credits for each Clinical Perspectives, 6-8 for each Clinical Practicum, 6-8 for each Extended Workshop, 0.75-3 credits for each Honors Presentation, 6-8 credits for each Institute, 2.5 for the James C. Harris, MD, Developmental Neuropsychiatry Forum, 1.5 credits for the Karl Menninger, MD Plenary, 1.5 credits for the Lawrence A. Stone, MD Plenary, 2-3 credits for each Media Theatre, 1-3 credits for each Member Services Forum, 1.5 credits for the Noshpitz Cline History Lecture, 1-3 credits for each Other Program, 1.5 credits for each Special Interest Study Group, 3 credits for each Symposium, 6.75 credits for the Systems of Care Special Program, 1.5 credits for the Town Meeting, 1.5 credits for the Training and Education Luncheon, and 3 credits for each Workshop.* The following programs are not accredited for CME: Caucuses, Committee Meetings, Corporate Roundtable, Distinguished Member Awards Lunch, International Orientation, Junior Research Scholars Lunch, Medical Students and Residents Networking Hour, Monitor Orientation, Networking for International Attendees and Presentation of International Awards, New Research Posters**, Open Mic Night, Medical Students, Residents, and Fellows: Meet Life Members at 2017 AACAP Annual Meeting, and Young Leaders Awards Breakfast. *Workshop 6: Helping You Know What You Don’t Know-A Self-Assessment Review of Psychopharmacology offers ABPNapproved self-assessment credit and will offer its own separate CME certificate. The credit earned from this session should not be included with the master CME certificate used for the rest of the meeting. ** New this year – New Research Posters no longer offer CME credit.

Self-Assessment Exam

The American Academy of Child and Adolescent Psychiatry designates this enduring material for a maximum of 8 AMA

PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. The American Board of Psychiatry and Neurology has reviewed the Annual Meeting SelfAssessment and has approved this program as part of a comprehensive self-assessment program, which is mandated by the ABMS as a necessary component of maintenance of certification. The 2017 Annual Meeting Self-Assessment Exam is designed to help you assess your level of knowledge regarding current psychiatric practice and clinical advances in the field and use feedback to guide your selection of sessions at the Annual Meeting. The Exam expires on November 6, 2017.

How do you earn CME credit? 

Annual Meeting

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CME credit is earned by attending educational sessions. For each hour you attend an educational session, you earn 1 AMA PRA Category 1 Credit™. It is your responsibility to keep track of the sessions you attend. AACAP does not keep records of registrants’ attendance at individual Annual Meeting sessions. CME Credit is earned by completing the 100-question exam and evaluation. Users should then review their exam feedback to determine future CME activity planning.

How can I obtain a CME certificate from the 64th Annual Meeting? 

Annual Meeting

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Within one week following the meeting, attendees are emailed a link to the General Evaluation Form which needs to be completed online. Once completed, you can print or save the CME certificate from your personal computer. Remember to confirm that AACAP has your correct email address when you register for the meeting. You will be able to print out your Annual Meeting SelfAssessment Exam CME certificate once the 100-question exam and evaluation survey are completed.

Can I earn CME credits by purchasing the session recordings or notebooks from the 64th Annual Meeting? No. CME credit is not available for session recordings or notebooks purchased from the 64th Annual Meeting.

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2017 Systems of Care Special Program

Systems of Care Special Program: Making an Impact in What Matters: Risk, Resiliency, and Systemic Approaches to Social Determinants of Behavioral Health in Youth Justine Larson, MD; Lisa R. Fortuna, MD

Monday, October 23, 2017 Washington Marriott Wardman Park ABSTRACT Objectives: This special program will provide child and adolescent psychiatrists and other mental health providers with a framework for understanding the role of social determinants of mental illness and resiliency in youth. The program has been organized by AACAP’s Committee on Community Based Systems of Care in collaboration with members of the Committee on Diversity and Culture. Methods: Following introductions with AACAP’s President and the co-chairs of the program, Gary Blau, the Chief of the Child and Family Branch in the Center of Mental Health Services (CMHS) will present regarding policy, priorities, and initiatives related to addressing the needs of children and adolescents with social and demographic factors that place them at risk for behavioral health disorders. Margarita Alegria will discuss the epidemiology of child mental health with a focus on race, poverty, and culture. Kiara Alvarez will then present an ecological approach to clinical care with Latino youth. After a panel and table top discussions, Dr. Patrick Tolan will address the impact of violence in urban environments. The audience will then hear from a mother and her son who will discuss their experiences in the mental health and juvenile justice systems. Dr. Thomas Hoffman will discuss the needs of children in rural communities. Dr. Renee Boynton will follow with a presentation on cultivating community-based strategies to promote child well-being using a collective impact approach. Next a team from Boston Children’s Hospital will discuss the Trauma Systems Therapy (TST) approach for addressing trauma and risk in vulnerable youth. Results: This day-long program is not meant to be exhaustive but will cover a range of topics important to the field, and will offer a framework to consider evidence-supported approaches for addressing social determinants of behavioral health with special consideration of vulnerable populations. Conclusions: Child and adolescent psychiatrists often do not have an opportunity to consider how their work, whether clinical, research or policy, may impact social determinants of health, and how child and adolescent psychiatrists can play a role in advocacy and strength-building. Whether clinician, policy maker, administrator, or researcher, the child and adolescent psychiatrist would be well-served to consider the social determinants that impact risk and resiliency in seriously emotionally disturbed youth.

Sponsored by AACAP's Community-Based Systems of Care Committee and Diversity and Culture Committee

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CLINICAL PERSPECTIVES 1 Health Promotion in Pediatric Mental Health 2 Impact on Youth by Marijuana’s Changing Legal Status and Access: Implications for Clinicians 3 School Refusal Across the Lifespan: Childhood, Adolescence, and Young Adulthood 4 Sexts, Lies, and Video Chat: Evaluating and Addressing High-Risk Online Behaviors 5 Should I Use Genetic Data to Guide My Practice? 6 Understanding Comorbid Symptom Dimensions in Autism Spectrum Disorder 7 What Primary Care Providers Really Want: Four Models of Collaboration in Early Childhood Mental Health Care 8 Clinical Guidelines for Navigating Media Use 9 Engaging Youth in Preparation for and Recovery From Disasters and Traumatic Events 10 Human Sex Trafficking: A Modern Day Slavery 11 Integrating Care Across the Specialty Pediatric Continuum: OutcomesDriven Engagement of Families and Teams 12 International Clinical Perspectives: International Models of Pediatric Integrated Care: Obstacles and Innovations 13 Neurogenetic Syndromes Associated With Autism Spectrum Disorder: Three Syndromes That Include Atypical Social Interaction 14 Predicting Violence: The Why, the How, and the What to Do: A BestEvidence Guide for the Mental Health Practitioner 15 Psychiatric, Cognitive, Legal, and Public Health Challenges Facing Refugee Children: An Integrated Approach 16 Beyond the Prescription Pad: Psychotherapy Interventions for Parents/ Caregivers of Youth With Serious Mental Illnesses and Treatment Nonadherence 17 Caught in the Net: How Electronic Media Affects Mental Illness in Children and Adolescents 18 Current Developments in Quality Improvement 19 Identifying, Preventing, and Treating Suicidal Youth 20 Innovative Interdisciplinary Approaches to Community Violence in Youth 21 Inpatient Treatment of Children With Autism and Intellectual Disability: Three Innovative Models 22 Is Integrated Care the Answer for Childhood Trauma? Approaches, Challenges, and Future Directions 23 Pediatric Autoimmune Encephalopathies: What Should a Child Psychiatrist Know? 24 Personality Disorders in Young People: A Primer for the Generalist 25 Application of Advances in Developmental Research in Infants to Psychotherapeutic Work With Children and Adolescents 26 An Exploration of Pharmacogenomics (2017 Update): How Do We Apply Current Science to Our Clinical Practice? 27 Considerations in the Assessment and Treatment of Transitional Age Youth Across the Diagnostic Spectrum 28 Management of Agitation/Aggression in the Pediatric Emergency Department, Inpatient Pediatrics Floor, and Beyond 29 Management of Severe Psychopathology in Youth With Autism Spectrum Disorder and Intellectual Disability Who Present to an Outpatient Psychiatry Clinic 30 Pediatric Medicine Update for the Child Psychiatrist: Medical Therapies for Transgender Youth, Postural Tachycardia Syndrome, and Updates on Contraceptives 31 Romance on the Internet: A Clinical Perspective 32 Somatic Symptom Disorders: Update on Diagnosis and Treatment 33 Update on Early Childhood Regulation: Emotion, Sleep, and Feeding 34 Update on Epilepsy for Child Psychiatrists 35 When Prevention Is Not Enough: Treatment and Empowerment of Pregnant Teens and Teen Moms 36 Child and Adolescent Psychiatrists and Attorneys: Advocating Together for the Best Interests of Children 37 Clinical and Research Insights Into the Assessment and Treatment of Anxiety and Obsessive-Compulsive Disorder in Youth With Autism Spectrum Disorder 38 Creative Psychotherapies in Child and Adolescent Psychiatry 39 Implementing Clinical Pathways for Acute Behavioral Health Issues in Pediatric Medical Settings 40 Shame, Stigma, and Challenges for Mental Health Providers: Foundations for Understanding the Burden of Stigma in Child and Adolescent Psychiatry Across Three Continents

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41 Skill Building in Family-Centered Pediatric Integrated Care 42 Stimulants: Issues in Clinical and Ethical Usage 43 Tell Me About Your Motherboard: Diagnosing and Treating Internet Gaming Disorder and Other Online Addictions 44 Treating Avoidant Restrictive Food Intake Disorder Using a Multidisciplinary Approach: Tales From the Trenches 45 Common Medical Comorbid Clinical Conundrums: Diagnostic Clarification and Treatment Implications 46 Suicide Prevention and Resilience at Children’s (SPARC) Program: An Innovative Program Aimed to Reduce Suicide Events in Adolescents With Suicidal Behaviors 47 Developing a Community-Based Continuum of Care for Children With Developmental Disabilities 48 Failure to Launch: What Every Child and Adolescent Psychiatrist Needs to Know to Help Facilitate Successful College Transition 49 Impact on Caregivers Working With Refugee Populations 50 Life Members Wisdom Clinical Perspectives: Care Integration for Childhood Sexual Abuse: Posttraumatic Stress Disorder, Heroin, and Other Adverse Outcomes 51 Microaggressions, Macroaggressions, Injury, and Healing: An Update 52 Moodiness in Adolescents and Adults With Attention-Deficit/ Hyperactivity Disorder: Strategies for Assessment and Treatment 53 Risky Business: Clinical Management of Problematic Substance Use in College-Aged Youth 54 Sexting and Social Media: Risk-Taking Behavior in the 21st Century 55 Social Media Use in Disaster Response: What Helps and What Harms 56 A Tale of Two Departments: How Implicit Bias Divides Us and Can Unite Us 57 Getting Children to Accept Limits: Developmental and Family Perspectives on the Regulation of Behavior and Emotion 58 Global Perspectives on Child and Adolescent Mental Health Services 59 Healing Arts: Cultural Symbolism in Children’s Art in Chinese, Islamic, Middle Eastern, Native American, and African American Cultures 60 Integrating Child Maltreatment Exposure and Impact in Comprehensive Assessment, Diagnosis, and Treatment in Child Psychiatry 61 Interventions for Child Psychiatrists to Support Children, Adolescents, and Their Families in the Midst of the Opioid Epidemic 62 #NoFilter: Social Media Tips From the AACAP Youth Connection and Media Committee 63 Pathways and Protocols in Somatic Symptom and Related Disorders: Putting the Functional in Functional Disorders 64 Preadolescent Moodiness and Attention-Deficit/Hyperactivity Disorder: Effective Strategies for Assessment and Treatment 65 The Future of Training: International Opportunities and Partnerships in Child and Adolescent Psychiatry 66 The Sibling Effect 67 TED Talks Meets Perspectives: (Clinical) Ideas Worth Spreading 68 Working With Vulnerable Youth and Families 69 Children of Incarcerated Parents 70 Electroconvulsive Therapy in Youth With Serious Mental Illness: Indications, Efficacy, and Ethical Considerations, and a Case Study in Catatonia 71 From the Bedside to State-Wide: A Tour of Integrated Care Models Across the Country 72 Implementing and Operating Pediatric Telepsychiatry Programs 73 The Hidden Message: How Implicit Bias Impacts Girls and How Clinicians Can Help Them 74 Unwanted Youth: Unaccompanied Minors and Family Detention in the United States 75 Child Psychological Abuse: An Old Concept, a New Diagnosis 76 Sex Talk: Promoting Healthy Outcomes by Facing Difficult Discussions 77 Individualized Deferred Disposition Docket: Addressing Mental Illness in the Juvenile Court 78 Part 1: Complementary and Integrative Medicine in Child and Adolescent Psychiatric Disorders: Fact, Fiction, and Challenges in Clinical Education and Residency Training 79 Psychotherapy Techniques for Treating the Medically Ill or Injured Child 80 Part 2: Complementary and Integrative Medicine in Child and Adolescent Psychiatric Disorders: Fact, Fiction, and Challenges in Clinical Education and Residency Training 81 Positive Use of Digital Technology to Reach and Treat Youth in the Modernized Era

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82 Protecting Youth Online: The Law, the Risks, and Clinicians’ Roles 83 Psychiatric Crisis Services for Children and Families: Mobilizing Resources and Thinking “Outside the Box” to Meet Community Needs 84 Psychotropic Polypharmacy: A Serious Concern Among Children and Adolescents in the United States of America Foster Care System 85 Communication and Language Disorders in Clinical Populations From a Broad Perspective

CLINICAL PERSPECTIVES 1 HEALTH PROMOTION IN PEDIATRIC MENTAL HEALTH Scott Shannon, MD, University of Colorado, scottshannon@ cowisp.net; Kristopher Kaliebe, MD, University of South Florida, [email protected]; Mary Rondeau, ND, Wholeness Center, [email protected]; Francisco Navarro, MD, Mind Health Institute, Pasadena, [email protected] Objectives: Exercise, sleep, and diet constitute core foundations of health. Sadly, most mental health professionals feel uncomfortable working in these arenas with patients and families. This workshop will provide practical skills for assessing and then enhancing these critical and relevant health behaviors. Methods: Pediatric obesity has become a national epidemic and a true health crisis. Obesity drives increased risk for internalizing disorders, externalizing disorders, ADHD, sleep problems, and decreased quality of life. It creates higher risk for a range of other health disorders that in turn also deteriorate quality of life. Not surprisingly, pediatric obesity has been linked to exercise, diet, and sleep. Although pediatric obesity is a clear health crisis, a range of other mental health issues is linked to exercise, sleep, and diet. For example, exercise has been demonstrated to be an effective treatment for ADHD and improve executive functions. Diet has an increasingly clear relationship to mood, attention, and anxiety. Sleep and ADHD are closely linked in a likely bidirectional mechanism. Results: Participants are encouraged to actively participate in the workshop with questions, dialogue, and comments. Presenters share insights and experiences to create an atmosphere of practical application. Participants have increased knowledge and treatment models of how to incorporate a prescribed fitness program in an outpatient setting. They also feel comfortable assessing sleep quality and problems in children. Conclusions: Childhood and adolescence are critical time periods for growth and brain development. When a child’s health becomes compromised, mental health and quality of life suffer. The field of child and adolescent psychiatry has become more focused on treating pathology than supporting health. Prescribed fitness, sound sleep, and proper nutrition provide a benefit to a pediatric mental health practice. The participant leaves the workshop ready to encounter fitness, sleep, and diet issues in their practice with enhanced comfort and clinical acumen. Fitness/exercise, sound sleep, and proper nutrition are supports that enhance the mental health and well-being of all children.

PRE, OBE, SLP Sponsored by AACAP's Complementary and Integrative Medicine Committee http://dx.doi.org/10.1016/j.jaac.2017.07.010

1.1 HEALTH PROMOTION IN PEDIATRIC MENTAL HEALTH Mary Rondeau, ND, Wholeness Center, mary.rondeau@ wholeness.com Objectives: Diet, gut health, and nutritional factors play a role in development and overall mental and physical health. Unfortunately, most mental health professionals feel uncomfortable assessing and making basic nutritional recommendations with patients and families. The nutrition and gut portion of this workshop will provide practical skills for assessing and then

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enhancing these critical and relevant health behaviors as they relate to nutrition in children. Methods: Pediatric obesity has become a national epidemic and a true health crisis. Obesity drives increased risk for internalizing disorders, externalizing disorders, ADHD, sleep problems, and decreased quality of life. There is a growing body of evidence strengthening the connection between nutritional deficiencies, dietary habits, and the enteric microbiome to mental health disorders. Calorically dense, nutrient-poor foods have replaced calorically light, nutrient-dense foods at an alarming rate. The gut microbiome alters the epigenetic expression of genes within the central nervous system. The gut microbiome influences regulation of intestinal health but also influences the immune and nervous systems and vice versa. Rodent models have demonstrated that a diet deficient in magnesium leads to changes in the gut microbiome, which directly related to interleukin-6 production in the hippocampus and subsequent deterioration in behaviors. The gut microbiome, micronutrient intake, and human nutrition meet with what we eat. This presentation reviews several research-supported nutrients that have become deficient in the diet and how to incorporate testing, as well as dietary strategies, into daily practice. Results: Nutrition and gut health play a central role in maintenance of health. Nutritional deficiencies are common among children. Little time is spent on health interviews on dietary quality and dietary recommendation. This program will emphasize nutritional assessment and dietary strategies and how to incorporate into practice. Conclusions: Nutritional recommendations should be a part of mental health treatment protocols for children. The participant leaves the workshop ready to assess and recommend dietary strategies.

PRE, OBE, SLP http://dx.doi.org/10.1016/j.jaac.2017.07.791

1.2 SLEEP AND PEDIATRIC MENTAL HEALTH Scott Shannon, University of Colorado, scottshannon@ cowisp.net Objectives: Sleep issues have been correlated with pediatric anxiety, mood, behavioral disorders, and ADHD. In specific disorders, such as autism spectrum disorder or fetal alcohol syndrome, the rates of sleep disorder may reach 85 percent. Sleep disturbances may be caused by primary mental illness, comorbid mental illnesses, or by the medications prescribed to treat the above. Over the last 50 years, pediatric sleep issues have grown much more common, and total sleep time has fallen noticeably in children. Sleep issues are highly correlated with mental illness in children. For example, rates of key sleep concerns are often elevated fivefold in children diagnosed with ADHD (before the use of stimulant medication) compared with healthy control subjects. Furthermore, the huge overlap between the cognitive symptoms of sleep loss and the profile of ADHD has made this a rich arena for research. For some clinical concerns, such as ADHD, the causation with sleep disorders may be bidirectional; that is, a sleep disorder can create features of ADHD, and ADHD often creates a sleep issue. Methods: This presentation will review the common types of pediatric sleep issues encountered in the clinical practice, how to screen for them, and simple, practical steps to address these issues in actual practice. Results: Sleep plays a central role in the maintenance of health, both physical and mental. This is true at all ages, but it is particularly critical in the pediatric population. Sleep issues are common in a pediatric mental health practice. Child and adolescent psychiatrists play an important role in the screening for and initial treatment of sleep issues in children. This may be made more important by research that demonstrates that parents often under-report sleep issues to their primary care physicians. However, little time in training or continuing education focuses on the issue of sleep disturbances. This program will demonstrate how a large mental health clinic that emphasizes wellness and health promotion screens for sleep issues and how they are commonly addressed. Conclusions: Screening for and treating pediatric sleep issues can play a central role in mental health. Pediatric mental health professionals must evaluate and address sleep concerns.


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1.3 EXERCISE AND PEDIATRIC MENTAL HEALTH Fransisco Navarro, MD, Mind Health Institute, fnavarro@ mhi-pas.com Objectives: Fitness is imperative for physical health. In the last 30 years, the rates of pediatric obesity have tripled in the US. This epidemic is tightly linked to a sedentary lifestyle. Simultaneously, the availability of physical education in American public schools has declined. Exercise has positive impacts on the cardiac system and metabolism and offers a wide range of enhanced cognitive and physical health outcomes. A number of studies document that children who regularly exercise have better cognition, achievement, and behavior. Exercise may be the best method to increase the secretion of brain-derived neurotropic factor (BDNF) and promote learning. Aerobic exercise exhibits a moderate to large effect size on the core symptoms of ADHD in a recent large meta-analysis. Fitness may be one of the best enhancers of learning and school performance that we have uncovered. The benefits to mood may be better recognized. A recent review of 11 trials also demonstrated a significant benefit for adolescent depression. Exercise and fitness may be one of the single best methods we have for enhancing outcomes for children with a high degree of safety, long-term benefits, and a low cost. Methods: This presentation will focus on wellness and fitness assessment as part of a comprehensive psychiatric evaluation. Different fitness modalities and its applications to pediatric mental health issues will be reviewed. Results: Pediatric mental health professionals will have a basic understanding of why, when, and how to prescribe fitness into the treatment plan of a patient in an outpatient setting. There is clear evidence that fitness can have a moderate antidepressant effect, improved executive function, decreased impulsivity, increased levels of BDNF, and many other benefits. Conclusions: Childhood and adolescence is a critical time for brain development. When a child’s mental health becomes compromised, medicine and psychotherapy become the corner stone of treatment. Understanding clearly the impact of incorporating prescribed fitness and treatment models could provide an enhancing effect. Fitness can provide benefits that improve mood, decrease stress and anxiety, and improve cognitive ability. Fitness is not just good for your body, it is good for your brain.


CLINICAL PERSPECTIVES 2 IMPACT ON YOUTH BY MARIJUANA’S CHANGING LEGAL STATUS AND ACCESS: IMPLICATIONS FOR CLINICIANS Theodore A. Petti, MD, MPH, Rutgers University Robert Wood Johnson School of Medicine and Rutgers University Behavioral HealthCare, [email protected]; James J. Hudziak, MD, University of Vermont and Fletcher Allen Health Care, [email protected] Objectives: The goals of this session are to provide an overview of significant changes in the legal status of marijuana and its impact on access of youth to marijuana and synthetic cannabinoids, discuss implications of such changes in states representing different levels of restrictive access for adult, and present options available for advocacy and education for youth. Methods: Key issues and distinctions between the gradients of legalized access to medical marijuana, decriminalization, and legalized recreational use for adults, with arguments for and against the legalization gradient, are summarized. Experiences in different states illustrate diversity across the nation. New Jersey typifies many states with legalized medical marijuanaassociated issues of strict versus lax regulation and current state of affairs, with a push for unrestricted use by adults. Colorado’s experience moving from legalized medical marijuana to marijuana made legal for recreational use by adults allows consideration of the impact of the legalization process on youth perceptions of harm versus harmfulness and the subsequent increases in


availability, social acceptance, introduction of new formulations, and lower prices. Washington state and Oregon have both experienced shorter periods of marijuana legalized for medical use than Colorado and for the lead up to legalization for recreational use. Differences in the approaches implemented to prevent harm to youth can provide insight for policy development. An advocate’s perspective on youth-related issues offers direction for a rational policy for the legal status of marijuana. Key current issues on marijuana policy from a national perspective on health, safety, and policy implications following implementation of marijuana legalization, particularly in relation to marijuana for medical purposes, are summarized. Results: A balanced purview of experiences with the variants of legalized marijuana and synthetic cannabinoids is presented. Conclusions: Issues related to marijuana and synthetic cannabis are critical, given its increased use and decreased perception of harm in youth. Changes in behavior and attitude have been associated with variants of legalization. Education of society, particularly youth and professionals, and advocacy efforts to assure consideration of youth-related issues must be pursued.

ADOL, PUP, PRE Sponsored by AACAP's Adolescent Psychiatry Committee, Psychopharmacology Committee, Health Promotion and Prevention Committee, and Substance Use Committee http://dx.doi.org/10.1016/j.jaac.2017.07.012

2.1 PERSPECTIVES ON MARIJUANA LEGALIZATION: NATIONAL AND NEW JERSEY STATUS Theodore A. Petti, MD, MPH, Rutgers University Robert Wood Johnson School of Medicine and Rutgers University Behavioral HealthCare, [email protected]; J. Calvin Chatlos, MD, Rutgers-University Behavioral Health Care, [email protected] Objectives: The goals of this session are as follows: 1) to provide an overview of key issues related to marijuana legalization and distinctions between gradients to access for medical purposes, decriminalization, or recreational use by adults; and 2) to consider its status in New Jersey and efforts to limit youth access in the national scene context. Methods: A brief program overview includes arguments for and against legalization and concerns of increased marijuana use and decreased perceptions of harm by youth. The latter seems related to the evolving legalization process across the nation. Current status of legalization by states is presented. Factors typical for many states that have legalized medical marijuana are reviewed [e.g., associated issues of strict (New Jersey, New York) vs. lax (California) regulation, push for broader legalization, and youth access to synthetic cannabinoids and adulterated marijuana). The process to develop a New Jersey Regional Council focus on this issue through an AACAP Advocacy Grant, engage in advocacy groups, and create a small work group to address cannabis-related issues of concern culminating in a policy statement are summarized. Based on the American Society for Addiction Medicine’s policy statement addressing marijuana-related issues, the statement advocated only for protection against increased marijuana access by and special consideration for youth and emerging adults in any future legislation. The outcome of a day-long conference is reported that presents the pros and cons of marijuana legalization by national figures, neuroscience for risk of abuse and adverse effects in youth and emerging adults, pharmacologic evidence from empirical studies, and response of panels comprising state legislators, the media, substance abuse providers, physicians, and advocacy representatives. Results: Definitions of terminology, national current legal status of marijuana legalization, and one state’s attempts to address concerns of increased access of youth to marijuana expected to rise with further legalization are presented. Participants are provided with information that should prove useful for future efforts to understand and act. Conclusions: The process of marijuana legalization is rapidly evolving nationally. Information reported allows greater understanding of issues and basis for action.

ADOL, PRE, PUP http://dx.doi.org/10.1016/j.jaac.2017.07.013

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2.2 CLINICAL ISSUES ARISING IN THE CONTEXT OF ADULT RECREATIONAL MARIJUANA LEGALIZATION Christian Hopfer, MD, University of Colorado School of Medicine, [email protected] Objectives: This presentation offers a review the Colorado history of progressive marijuana legalization from medical marijuana to recreational legalization and its impact on adolescents, particularly in the context of treatment settings. Methods: In this session, we will review recent literature and clinical experience in the substance abuse setting. Results: Marijuana that is legally available for adults has multiple implications for adolescent substance use. One potential effect that legalization may have is an increase in adolescent use because of increased availability, greater social acceptance, and possibly lower prices, and this may also be evident in the clinical setting. Legalization has facilitated the introduction of new formulations of marijuana (edible, vaporized) and with higher potencies. Recent literature suggests increases in marijuana related adolescent adverse outcomes. Although previous studies of the effects of adolescent marijuana use provide some guidance on current policy and public health recommendations, many new studies will be needed to answer questions in the context of use within a legal adult environment. Claims that marijuana has medicinal benefits create additional challenges for adolescent prevention and treatment efforts, because they contrast with messages of its harmfulness. Prevention and treatment approaches will need to address perceptions of the safety of marijuana and claims of its medicinal use and consider family-wide effects as older siblings and parents may increasingly and openly consume marijuana and advocate for its use. Conclusions: Widespread legalization and acceptance of marijuana implies that as law enforcement’s approaches to control marijuana use decline, public health, medical, and scientific efforts to understand and reduce negative consequences of adolescent marijuana use need to be substantially increased to levels commensurate with those efforts for tobacco and alcohol. Clinical approaches to address perceptions of harmlessness will be addressed.

ADOL, PRE, PUP Supported by NIH/NIDA Grants DA032555 and DA035804 http://dx.doi.org/10.1016/j.jaac.2017.07.014

2.3 IMPACTS FROM LEGALIZATION AND IMPLICATIONS FOR HEALTH AND SAFETY Kevin A. Sabet, DPhil, Drug Policy Institute at the University of Florida, kevinsabet@ufl.edu Objectives: In this presentation, we will review the Colorado history of progressive marijuana legalization from medical marijuana to recreational legalization and its impact on adolescents, particularly in the context of treatment settings. Methods: We will conduct a review of recent literature and clinical experience in the substance abuse setting. Results: Marijuana that is legally available for adults has multiple implications for adolescent substance use. One potential effect that legalization may have is an increase in adolescent use to as a result of increased availability, greater social acceptance, and possibly lower prices, and this may also be evident in the clinical setting. Legalization has facilitated the introduction of new formulations of marijuana (edible, vaporized) and with higher potencies. Recent literature suggests increases in marijuana-related adolescent adverse outcomes. Although previous studies of the effects of adolescent marijuana use provide some guidance for current policy and public health recommendations, many new studies will be needed that answer questions in the context of use within a legal adult environment. Claims that marijuana has medicinal benefits create additional challenges for adolescent prevention and treatment efforts, as they contrast with messages of its harmfulness. Prevention and treatment approaches will need to address perceptions of the safety of marijuana and claims of its medicinal use; these approaches should also consider family-wide effects, as older siblings and parents may increasingly openly consume and advocate for marijuana use.

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Conclusions: Widespread legalization and acceptance of marijuana implies that, as law enforcement approaches for marijuana control decline, public health, medical, and scientific efforts to understand and reduce negative consequences of adolescent marijuana use need to be substantially increased to levels that commensurate with those efforts for tobacco and alcohol. Clinical approaches to address perceptions of harmlessness will be addressed.


2.4 THE RELATIONSHIP BETWEEN MARIJUANA LAWS AND TEEN USAGE IN OREGON Robert S. McKelvey, MD, Oregon Health and Science University, [email protected] Objectives: The goals of this session are as follows: 1) to describe the relationship between Oregon’s passage of Medical Cannabis and Recreational Cannabis laws and teenage usage in grades 8 and 11; 2) to illustrate changing attitudes toward marijuana usage through media reports and clinical vignettes from teenage patients; and 3) to compare marijuana usage data with alcohol usage data during the same period. Methods: Cannabis usage data based on surveys of 8th and 11th graders in Oregon will be shown in relationship to the passage of medical cannabis (1998) and recreational cannabis (2015) laws. To further illustrate patterns in cannabis usage among teenagers, it will be compared with alcohol usage in the same age group. Efforts to protect youth are detailed and results discussed. Results: These data and corresponding media reports and clinical vignettes will illustrate the growing perception among adolescents in Oregon that legalization is equated with the relative harmlessness of cannabis compared with other substances, especially alcohol. Conclusions: Legalization of cannabis in Oregon, first for medical usage and then for recreational usage, has promulgated the perception among teenagers that it is a relatively harmless substance, despite evidence that it has established risks and that its benefits are often more perceptual than real. Further efforts to address this problem are needed.


2.5 PREVENTION WORKS IN SEATTLE: A COMMUNITY’S RESPONSE TO MARIJUANA LEGALIZATION IN WASHINGTON STATE Ray Chih-Jui Hsiao, MD, University of Washington, rhsiao@u. washington.edu Objectives: The goals of this session as follows: 1) to provide an overview of changes in adolescent marijuana use trends in Washington State following legalization of recreational marijuana use for adults; 2) to describe local and regional prevention efforts in response to marijuana legalization in Washington State using the example of Prevention Works in Seattle; 3) to present examples of advocacy options for child psychiatrists in response to marijuana legalization movement. Methods: As the second state in the United States to legalize recreational use of marijuana by adults, Washington State has begun to experience the impact of marijuana legalization on adolescents. This presentation will review the overall trend of adolescent marijuana use in Washington State and provide examples of local and regional prevention efforts in response to policy changes, with a focus on Prevention Works in Seattle, a federally funded community prevention coalition. Examples of advocacy efforts by child psychiatrists in Washington State will also be presented to provide ideas to psychiatrists in other states facing potential marijuana legalization. Results: Prevention and advocacy efforts at multiple levels will be provided for child psychiatrists to consider. Conclusions: As more states in the United States are considering potentially legalizing recreational marijuana use for adults, the impact on adolescents must be considered. Child and adolescent psychiatrists can play a very

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important role in educating the public and participate in prevention efforts while advocating for public policies that are aimed at protecting youth.

ADOL, PRE, SUD http://dx.doi.org/10.1016/j.jaac.2017.07.017

CLINICAL PERSPECTIVES 3 SCHOOL REFUSAL ACROSS THE LIFESPAN: CHILDHOOD, ADOLESCENCE, AND YOUNG ADULTHOOD Khadijah Booth Watkins, MD, NewYork-Presbyterian/Weill Cornell Medical Center, [email protected]; Anne Marie Albano, PhD, Columbia University Medical Center, [email protected]; Lori K. Evans, PhD, Private Practice, [email protected] Objectives: Approximately one to five percent of all school-aged children exhibit school refusal. In the short term, school absenteeism affects learning, academic performance, and creates problems in family and peer relationships. Long-term consequences may include academic underachievement, premature school dropout, employment difficulties, and increased risk for mental health illness. Without treatment, spontaneous remission from school refusal is unlikely. Despite a clear need for effective interventions, treatment is complex because school refusal is often maintained by a combination of factors. Methods: The functional analytic model of school refusal can be helpful in guiding treatment planning. First, a comprehensive assessment is completed to identify the factors contributing to the maintenance of school refusal. The assessment incorporates the following: 1) a semistructured diagnostic interview, such as the Anxiety Disorder Interview Schedule-Child/Parent; 2) a functional analysis of school refusal behavior; 3) collateral from the school; and 4) self-report symptom measures and measures of school refusal behavior. Once the factors maintaining school refusal are identified, an individualized, multimodal intervention plan is developed, which typically involves medication management, psychoeducation, fear hierarchy construction focused on school reentry, exposure, parental guidance on how to refrain from behaviors that may reinforce school refusal, rewards, and collaboration with the school (and relevant professionals) on school reentry steps. Results: To illustrate the functional analytic model, a case presenting with school refusal at an adolescent partial hospitalization program will be conceptualized using this framework. The multimodal approach to address school refusal will be outlined. Challenges of this approach will be discussed. Conclusions: Identifying an effective framework for guiding school refusal treatment may have important implications for clinicians who treat patients exhibiting school attendance problems.

AD, SCR, TREAT http://dx.doi.org/10.1016/j.jaac.2017.07.019

3.1 TREATING SCHOOL REFUSAL IN ADOLESCENCE: TAKING A MULTIMODAL APPROACH TO TREATMENT IN A PARTIAL HOSPITALIZATION PROGRAM

interview, such as the Anxiety Disorder Interview Schedule (ADIS-IV-C/P); 2) a functional analysis of school refusal behavior; 3) collateral from the school; and 4) self-report symptom measures, as well as measures of school-refusal behavior. Once the factors maintaining school refusal are identified, an individualized, multimodal intervention plan is developed, which typically involves medication management, psychoeducation, fear hierarchy construction focused on school reentry, exposure, parental guidance on how to refrain from behaviors that may reinforce school refusal, rewards, and collaboration with the school (and relevant professionals) on school re-entry steps. Results: To illustrate the functional analytic model, a case presenting with school refusal at an adolescent partial hospitalization program will be conceptualized using this framework. The multimodal approach to address school refusal will be outlined. Challenges of this approach will be discussed. Conclusions: Identifying an effective framework for guiding school refusal treatment may have important implications for clinicians who treat patients exhibiting school attendance problems.


3.2 SCHOOL REFUSAL ACROSS THE LIFESPAN: CHILDHOOD, ADOLESCENCE, AND YOUNG ADULTHOOD Alexandra Zagoloff, PhD, University of Minnesota Medical Center, [email protected] Objectives: School refusal describes a spectrum of avoidance ranging from infrequent and partial absences to complete withdrawal from school (with potential enrollment in online/home school or dropping out). This presentation will provide an overview to set the stage for subsequent panelists. Topics include the following: associated diagnoses, assessment, evidence-based treatments, and opportunities for interdisciplinary collaboration. Methods: This introductory talk will include literature reviews of the topics previously described. Results: School refusal has a prevalence rate of approximately one percent in school-age youth but rises to five percent in clinic-referred youth. Rates are similar for males and females; transitions (e.g., into high school) may be particularly problematic. Youth who avoid school are at risk for educational failure, unemployment, and social/romantic problems. School refusal is frequently associated with anxiety, mood, and disruptive behavior disorders. A comprehensive functional evaluation should address four factors that contribute to this behavior: avoiding triggers for negative affect, avoiding evaluative situations, receiving attention from others, and receiving tangible rewards. Evidence-based approaches to intervention are cognitive-behavioral and family systems oriented. Youths who refuse to attend school often experience somatic complaints. As such, behavioral health providers working with this population will have the opportunity to coordinate care with pediatricians, gastrointestinal specialists, neurologists, nurses, and school counselors. Conclusions: School refusal is a multifaceted problem that cuts across diagnostic groups. Although it can lead to significant impairment, effective treatments exist. Given the wide array of difficulties associated with school refusal, it is an exciting population to treat for those interested in team-based care.


Angela Chiu, PhD, NewYork-Presbyterian/Weill Cornell Medical Center, [email protected] Objectives: Approximately one to five percent of all school-aged children exhibit school refusal. In the short term, school absenteeism affects learning and academic performance and creates problems in family and peer relationships. Long-term consequences may include academic underachievement, premature school dropout, employment difficulties, and increased risk for mental illness. Without treatment, spontaneous remission from school refusal is unlikely. Despite a clear need for effective interventions, treatment is complex because school refusal is often maintained by a combination of factors. Methods: The functional analytic model of school refusal can be helpful in guiding treatment planning. First, a comprehensive assessment is completed to identify the factors contributing to the maintenance of school refusal. The assessment incorporates the following: 1) a semi-structured diagnostic


CLINICAL PERSPECTIVES 4 SEXTS, LIES, AND VIDEO CHAT: EVALUATING AND ADDRESSING HIGH-RISK ONLINE BEHAVIORS Paul E. Weigle, MD, Natchaug Hospital, pweigle@ sbcglobal.net Objectives: The goal of this session is to provide a vital update regarding high risk online behaviors, including cyberbullying, sexting, pathological gaming habits, and engagement in online communities, which support selfharm and suicide. This update will include ways to detect these issues in

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clinical practice, research findings on epidemiology, and methods to best address and treat these issues. Methods: Available literature incorporating the most current research studies, including the authors’ own contributions, are summarized for each topic based on exhaustive ongoing literature reviews. Clinical experience will be incorporated, including specific illustrative cases. Results: Adolescents’ online habits have increased considerably in recent years, bearing novel risks to mental health and safety. Cyberbullying is an increasingly common experience for adolescents, putting victims at greater risk for depression and suicidal attempts. High-risk sexting is similarly common and often leads to depression, sexual harassment, and relationship problems. Youth are now communicating self-harm and suicidal ideation online to peers more typically than in person to parents, complicating and delaying access to needed treatment. Many adolescents share thoughts and experiences regarding self-harm and suicide in online communities, which often encourage disordered behavior. A significant minority of youth develop a pathological video game habit called internet gaming disorder, causing significant impairment and treatment challenges. Regularly accessing online pornography is very common but bears negative correlates on mental health and risks becoming compulsive. Each of these potential pitfalls can be identified, assessed, and addressed in clinical practice to the benefit of our patients. Conclusions: Internet-related mental health problems are an increasingly common phenomenon but often ignored or undetected in clinical practice. A wealth of recent research data and clinical experience helps clinicians to anticipate, recognize, and treat common, novel, and serious complications associated with risky online behaviors in children and adolescents.

BLY, COMP, S Sponsored by AACAP's Media Committee and Adolescent Psychiatry Committee http://dx.doi.org/10.1016/j.jaac.2017.07.023

4.1 CYBERBULLYING, SELF-CYBERBULLYING, AND COERCED SEXTING: EPIDEMIOLOGY AND CLINICAL CORRELATES Elizabeth Englander, PhD, Bridgewater State University, [email protected] Objectives: This presentation will discuss data from recent studies, including one of more than 700 teenagers, examining their destructive digital behaviors and the relationship to measures of psychological health and psychological symptoms. Methods: Qualitative data gathered at the Massachusetts Aggression Reduction Center have identified more methods of cyberbullying than researchers generally explore. Although researchers may ask subjects about cruel comments online, humiliating photos, and mean messages, behaviors such as self-cyberbullying and coerced sexting seem to be important sources of bullying online. Self-cyberbullying, sometimes termed “Digital Munchausen,” refers to youth who create a second persona online for the purposes of cyberbullying themselves; they then bring their “victimization” to the attention of peers in a bid for sympathy and attention. Sexting is often conceptualized as a fun and titillating activity that teenagers engage in voluntarily, but newer data are suggesting that, at times, it may result from negative peer pressure and when that happens, sexters may feel traumatized and harassed. Teenagers between the ages of 17 and 19 years were assessed during both qualitative interviews and quantitative surveys for their psychopathology, their peer relationships, their family functioning, and their digital behaviors. This retrospective study examined the order of events and analyzed the relationship between these more unusual types of cyberbullying with more typical cyberbullying behaviors (such as receiving a cruel message). Results: Both coerced and pressured sexting and self-cyberbullying were markedly more common than hypothesized. Over three years of data, self-cyberbullying was admitted to be approximately 15 percent of subjects each year. Likewise, whereas many sexters admitted to some peer pressure as the motive or partial motive for sexting, a smaller high-risk group experienced very negative peer pressure, including bullying and threats, and reported significantly higher levels of trauma after the sexting.

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Conclusions: Although cyberbullying is a well-known phenomenon today, many assumptions about it seem to be false. This research demonstrates the need to reevaluate conventional assumptions about cyberbullying and digital behaviors.

BLY, COMP, SEX http://dx.doi.org/10.1016/j.jaac.2017.07.024

4.2 YOUTH AND SEXUALLY EXPLICIT INTERNET MATERIAL: SEPARATING TRUTH FROM FICTION Amy Mayhew, MD, MPH, Cambridge Health Alliance, [email protected] Objectives: Juvenile exposure to sexually explicit internet material (SEIM) is nearly ubiquitous, yet a nuanced understanding of what that exposure means, how it influences behavior, and how to minimize negative effects is lacking. This presentation will provide the current literature of children and SEIM, specific risk factors for problematic use and negative impact, and potential strategies for psychiatric intervention. Methods: The data for this presentation are drawn from 1) the current literature on wanted and unwanted exposure to SEIM, the association between blocking or filtering software and unwanted exposure, the association between exposure to SEIM and sexual behavior and attitudes, and particular risk factors that may identify more problematic behavior related to SEIM; and 2) clinical vignettes drawn from psychiatric practice. Results: A review of the current literature and a cross-case analysis revealed particular trends in wanted and unwanted exposure to SEIM, effects of this exposure on sexual behaviors and attitudes among youth, and specific risk factors contributing to a problematic use of SEIM and negative consequences. Psychiatric care should be tailored to helping parents and youth navigate SEIM and identifying those individuals at risk or engaged in problematic use of SEIM. Conclusions: Psychiatrists can help patients and families manage exposure to sexually explicit materials on the internet, have healthy discussions about such materials and sexual behaviors, and identify those youth at risk for negative consequences from SEIM.

ADOL, MED, SEX http://dx.doi.org/10.1016/j.jaac.2017.07.025

4.3 TEXT, CUT, AND POST: HOW ADOLESCENT SOCIAL MEDIA USE INTERACTS WITH SELF-HARM AND SUICIDAL BEHAVIOR Erin L. Belfort, MD, Maine Medical Center, erin.belfort@ gmail.com Objectives: We will discuss clinical implications of social media use among adolescents on self-harm behavior, suicidal behavior, and communication of suicidality. We will offer clinical examples and practical tips on completing a risk assessment in the context of taking a media history. Methods: We will discuss the process of adolescent development in the context of online activities and identify novel challenges to mental health. We will review available research data on the relationship between social media activity, nonsuicidal self-injury (NSSI), and communication of suicidality, incorporating the author’s own research. Results: Adolescents typically preferentially seek sensitive health information and support for topics on depression from informal, nonprofessional sources of advice and information, such as chat rooms, blogs, or social media sites. Adolescents who are at most in need of mental health services may be least likely to seek out these services. Online communities often support, normalize, and encourage risky behaviors, including NSSI and suicide attempts. Increasingly, emergency department visits and psychiatric inpatient admissions are prompted by risky behaviors related to social media, including cyberbullying, NSSI, and communication of suicidality via social media. Conclusions: Adolescent use of social media is ubiquitous and has significant clinical implications for providers working with this population. Adolescents with the highest need for mental health services are more likely to seek help from their peers or informal online sources than from adults or professionals. Peers are often the recipients of communications

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of suicidality, which can delay or prevent access to mental health services. Taking a thorough media history as part of a risk assessment will be emphasized in this presentation, with practical tips and suggestions for clinicians.

ADOL, MED, SIB http://dx.doi.org/10.1016/j.jaac.2017.07.026

4.4 INTERNET GAMING DISORDER: A VIRTUAL ADDICTION Paul E. Weigle, MD, Natchaug Hospital, pweigle@ sbcglobal.net Objectives: The goal of this session is to give a clinical primer on the current state of research regarding internet gaming disorder (IGD), summarizing key points of evidence concerning diagnosis, epidemiology, clinical implications, and evidence-based treatment options. Methods: An ongoing, exhaustive literature review has been conducted on IGD. The resulting hundreds of studies are evaluated for relevancy and level of evidence. The most important and relevant points and themes are consolidated for the presentation, incorporating the author’s clinical experiences. Results: IGD is a behavioral addiction to online games, included in the DSM-5 as a condition requiring further study. A substantial body of international literature documents its prevalence, characteristics, and effects on youth. The diagnosis of internet disorders requires a persistent, recurrent gaming habit, leading to significant distress or impairment, and a number of related symptoms similar to those of substance use disorders but more strictly diagnosed. Structural and functional changes in the brains of affected individuals parallel those occurring in substance use and gambling disorders. Research indicates risk factors (male sex, impulsivity, limited social skills, and poor parental attachment); prognosis (85% stability over 2 years); and clinical outcomes. Impairment caused by the disorder is significant and, if untreated, often leads to new-onset depression, social anxiety, and academic failure, highlighting the importance of proper diagnosis and treatment. Clinical trials provide preliminary evidence of the use of psychotherapeutic and pharmacological treatments for IGD. Conclusions: A substantial minority of youth suffer impairment from IGD, with significant implications for clinical practice. A wealth of research details characteristics of this disorder but remains largely unknown to most practitioners. Clinical implications for identifying and treating patients with IGD will be discussed.

COMP, DIAG, MED http://dx.doi.org/10.1016/j.jaac.2017.07.027

4.5 RAISING GENERATION D: WHAT PARENTS AND CLINICIANS SHOULD KNOW ABOUT CHILDREN AND COMPULSIVE INTERNET USE David Greenfield, PhD, The Center for Internet and Technology Addiction and The University of Connecticut, School of Medicine, [email protected] Objectives: The goal of this session is to provide clinicians with an understanding of clinical and practical issues associated with internet use disorders (IUD). A particular emphasis will be given to family dynamics, safety issues, and setting limits and boundaries, including digital technology monitoring, filtering, and blocking. Treatment of IUDs involves educating parents in creating a comprehensive addiction management and relapse prevention program. Methods: Based on a review of the clinical, didactic, and research literature and nearly 20 years of clinical and research experience treating IUDs and related problems, we have been able to extract many of the most relevant and useful therapeutic and clinical management treatments; with the use of the internet as a “drug of choice” for a sizable percentage of our youth population, specialized internet addiction treatment measures are necessary. As in


all addiction medicine issues, the disorder is a family problem and treatment must actively involve the family, particularly the parents. Results: The treatment and management of IUDs are most effective when using a multimodal approach involving psychotherapeutic and psychoeducational techniques for both identified patients and their parents. Parents must be educated on the etiology of IUDs, neurobiology of addiction, and ways to control the use of these devices in their home. They must be taught about safety issues, digital youth culture, and generational hierarchy boundary issues. Additional safety issues involving the ever-present smartphone and aspects of digital distraction in school, social relationships, and while driving will be addressed. Conclusions: Pathological, compulsive use of the internet is highly prevalent in our youth today. It is no longer acceptable to relegate excessive and addictive levels of technology use as “normal youth behavior.” Many psychiatric practitioners have not adequately educated their patients and families on the critical components of internet abuse/addiction treatment and relapse management. For many of our patients, pathological technology use causes negative sequelae in many functional life spheres, including family life, academic and work performance, social relationship, physical health, safety, and loss of sleep. Practitioners must understand the psychoactive nature of the internet and its addictive potential.

COMP, TREAT, ADOL http://dx.doi.org/10.1016/j.jaac.2017.07.028

CLINICAL PERSPECTIVES 5 SHOULD I USE GENETIC DATA TO GUIDE MY PRACTICE? Erika L. Nurmi, MD, PhD, University of California, Los Angeles, [email protected]; Sunil Q. Mehta, MD, PhD, Mayo Clinic, [email protected]; James T. McCracken, MD, University of California, Los Angeles, jmccracken@mednet. ucla.edu Objectives: As personal genetic testing becomes more available and heavily marketed to consumers, child and adolescent psychiatrists will be asked to order, interpret, and act on test results with increasing frequency. We will review commonly available genetic diagnostic and pharmacogenomic tests relevant to psychiatry, discuss the indications and scenarios where they may be useful, and review the evidence base informing their interpretation. Methods: Lessons learned from other areas of medicine will be discussed in our introductory lecture, highlighting implications for pediatric prescribing. Subsequent presentations will focus on diagnostic genetic tests available for developmental disorders, as well as pharmacogenomics tests for commonly prescribed psychiatric medications. After the presentations, our discussant will synthesize the key points and speculate about how genetic testing will alter the practice of psychiatry in the near term. Results: Data from other areas of medicine argue that genetic data can be useful in guiding treatment but caution against generalizing data collected in adults to pediatric populations. Diagnostic genetic testing can be used to “rule in” genetic conditions and inform discussions about prognosis and family planning but have limited immediate impact on management and cannot rule out genetic factors. Personal drug profiling may provide actionable information in some clinical scenarios; however, wide implementation is not supported by existing data. Conclusions: While genetic information will be critical in advancing precision psychiatry, progress in implementation is limited by the lack of an adequate knowledge base supporting interpretation and clinical action. The clinical utility of wide population screening is unclear; however, certain scenarios may warrant genetic testing. Given that the availability of commercial testing has outpaced responsible scientific and medical evaluation, clinicians must be educated in the appropriate use of genetic data in clinical practice.

DEV, GS, PPC http://dx.doi.org/10.1016/j.jaac.2017.07.030

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5.1 THE USE OF DIAGNOSTIC GENETIC TESTING IN AUTISM AND OTHER NEURODEVELOPMENTAL DISORDERS Sunil Q. Mehta, MD, PhD, Mayo Clinic, [email protected] Objectives: Within the past seven years, the American College of Medical Genetics (ACMG), American Academy of Neurology (AAN), and AAP have changed their practice parameters to recommend diagnostic genetic testing for children with autism spectrum disorders and intellectual disability. AACAP will be updating their practice parameters to join this consensus within the next year. Despite frequently seeing children with neurodevelopmental disorders, many child psychiatrists may be unsure when to order genetic testing, when to refer to other specialties, and how to interpret results. The objectives of this presentation is to provide an overview of current recommendations regarding genetic testing, to survey the different types of genetic tests and when they are indicated, and to discuss the potential risks and benefits of testing for patients and families. Methods: We will review the indications and interpretations of results of chromosomal microarrays, whole-exome sequencing, whole-genome sequencing, and specific gene tests for autism spectrum disorder, intellectual disability, and related neurodevelopmental disorders. We will discuss practical considerations about ordering genetic testing such as insurance coverage, when results would warrant referral to a genetic counselor/medical geneticist, and when to refer to other subspecialties. The potential benefits and ethical/legal risks of genetic testing to patients and families will be reviewed so that learners can obtain informed consent. Finally, we will review the pros and cons of using commercially available genetic testing, both clinical and direct-to-consumer–based tests. Results: Participants will learn when to order genetic testing for patients with neurodevelopmental disorders and feel confident that they can have a thoughtful discussion with families about the risks and benefits of testing. Conclusions: All patients with autism spectrum disorder and intellectual disability should be offered diagnostic genetic testing at least once. Given that many child psychiatrists are involved in the initial diagnosis and ongoing care of these children, it is our responsibility to become familiar with the interpretation and utility of these tests.


5.2 USE OF GENETIC INFORMATION IN CLINICAL PRACTICE: LEVERAGING AVAILABLE EXPERIENCE TO IMPLEMENT PRECISION THERAPEUTICS IN CHILDREN J. Steven Leeder, PhD, PharmD, Children’s Mercy Kansas City, [email protected] Objectives: Dosing guidelines that take into consideration patient genotype have been prepared and published by the Clinical Pharmacogenetics Implementation Consortium (CPIC) for 36 gene-drug pairs. Included among these are several medications used in pediatrics, but clinical implementation of pharmacogenetic (PGx)-based guidelines is limited. Methods: An overview of the current status of PGx in pediatrics is presented. Results: Adaptation of adult experience to pediatrics is limited by a number of factors. For clopidogrel, platelet physiology is markedly different in neonatal populations compared with adults, and maturation of CYP2C19 expression following birth renders all newborns to be phenotypic “poor metabolizers.” PGx studies of SLCO1B1 and statins in children and adolescents with dyslipidemia suggest that the magnitude of the genetic effect may be greater than that observed in adults, with considerable variability observed within genotypes groups. Finally, secondary analysis of published warfarin PGx data in children suggests that the relative contribution of genetic (e.g., VKORC1 and CYP2C9 genotype) and age-related factors may differ between pediatric patients with a primarily thromboembolic indication compared with those who may be prescribed warfarin after cardiac surgery. Moving forward, it will be necessary to differentiate poor response to a medication that is attributed to inadequate exposure from poor response that is attributable to ontogeny or genetic variation affecting the target of drug action. This concept will be presented in the context of CYP2D6 PGx and the ADHD medication, atomoxetine, and illustrate how investigation of the dose-exposure relationship may lead to strategies for investigating the role of genetic variation in drug targets.

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Conclusions: Implementation of effective precision medicine in children will benefit from accurate, genomic-driven precision diagnostics paired with precision therapeutic interventions that address genetic and other factors influencing drug disposition and response.


5.3 GENETIC PROFILING TO INFORM DRUG CHOICE IN PSYCHIATRY Erika Nurmi, MD, PhD, UCLA, , [email protected] Objectives: The successful implementation of pharmacogenomic testing in other areas of medicine has fueled enthusiasm for its adoption in psychiatry. However, the low quality of evidence driving genetic drug response testing and limited predictive ability of provided data are poorly understood by clinicians and patients. Nevertheless, commercial genotyping services that direct personalized prescribing and claim to produce superior outcomes are widely available and often marketed directly to patients. Methods: Genetic variation known to impact psychiatric drug disposition and response will be summarized, highlighting examples driving FDA and practice guidelines. These data will lay the foundation for a discussion of the nature and validity of the genetic information underlying current commercial tests. The evidence base supporting the clinical implementation of genetically guided treatment in psychiatry will be reviewed. A synthesis will help clinicians understand specific conditions warranting testing and the limitations and utility of data returned. Results: Functional genetic polymorphisms in cytochrome P450 genes that metabolize psychiatric medications are not uncommon and may play a significant role in treatment response and adverse effects. As a consequence, pharmacogenomic information is included in the FDA label of many psychiatric drugs, and recommendations have been published by the Clinical Pharmacogenetics Implementation Consortium (CPIC). Little data support genetic predictors of pharmacodynamics, drug action at targets. Despite the small number of genetic variants known to produce meaningful clinical effects and the rudimentary current understanding of the biology of psychiatric drug response, commercial testing is increasingly obtained. Conclusions: The evidence base lags far behind public enthusiasm and marketing claims about genetic drug-response testing. Currently, there are insufficient data to warrant wide clinical implementation, but testing may provide limited benefit in specific cases. Further research is needed to provide a solid evidence base for factors included in clinical tests and to prove that outcomes are clinically meaningful. Before responsible implementation, the healthcare field must be trained to understand, explain, and respond to genetic information provided to guide clinical care.


CLINICAL PERSPECTIVES 6 UNDERSTANDING COMORBID SYMPTOM DIMENSIONS IN AUTISM SPECTRUM DISORDER Fred Robert Volkmar, MD, Yale University School of Medicine, [email protected]; Christopher J. McDougle, MD, Harvard Medical School, cmcdougle@ partners.org Objectives: In this clinical perspective, we hope to provide an empirically grounded, clinically informed presentation of key, non-core symptom dimensions that may co-occur in autism spectrum disorder (ASD). We aim to enhance the capacity for clinicians to understand individuals with ASD, who have co-occurring symptom dimensions, and explore implications for clinical practice and future research. Methods: We will discuss four important symptom dimensions that frequently occur in individuals with ASD—specifically, symptoms of anxiety, OCD, and psychosis and gender-related concerns. In each presentation, we will highlight some of the challenges in deciding how to best formulate these symptoms. To this end, we will discuss which symptoms might be “predicted” from the underlying deficits that characterize ASD and contrast these with symptoms, which are less easily reconciled with these deficits.

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Results: Many of the comorbid symptom dimensions that occur in ASD can be reformulated either as mischaracterized ASD symptoms or non-core ASD symptoms, which are nevertheless the expected consequences of the underlying deficits that characterize ASD. Pharmacologic treatments that typically address these symptom dimensions in non–ASD individuals are variably helpful in those with ASD and may have more side effects. In contrast, ASD-specific behavioral treatments may also reduce the severity of these comorbid symptom dimensions. Conclusions: Understanding comorbid symptoms in ASD is an important clinical challenge. Given the prevalence and diversity of additional psychiatric symptoms in individuals with ASD, it is critical that clinicians are equipped to be able to rationally label these symptoms and formulate them appropriately. This is not simply a theoretical issue, as an appropriate formulation may facilitate an effective treatment plan.

ASD, CM, DIAG http://dx.doi.org/10.1016/j.jaac.2017.07.032

6.1 PSYCHOTIC SYMPTOMS IN AUTISM SPECTRUM DISORDER Gerrit Ian Van Schalkwyk, MD, Brown University, gvs.psych@ gmail.com Objectives: The goal of this session is to explore the diverse challenges in assessing and formulating the occurrence of psychotic symptoms in individuals with autism spectrum disorder (ASD). Methods: To develop an enhanced understanding of this intersection, we will explore available empirical research, applicable neuroscience, and different clinical perspectives on this issue. We will integrate this knowledge, suggest implications for best clinical practice, and identify critical areas for further inquiry. Results: Empirical research has found rates of schizophrenia in sample groups with ASD similar to the general population when strict criteria are applied; however, various psychotic symptoms seem to be overrepresented. One clinical challenge relates to accurately labeling a symptom as psychotic, given the overlap in phenomenology with certain ASD symptoms, such as highly elaborated and fixed special interests. A second challenge is conceptual: when individuals with ASD do present with symptoms that are more clearly psychotic, is this indicative of a comorbid disorder or a further consequence of the underlying ASD? Cutting-edge accounts of ASD in the field of cognitive neuroscience account for the core symptoms of ASD and also predict the occurrence, to some degree, of psychotic symptoms in particular environmental contexts. As highlighted by multiple case series, this conceptual challenge becomes an important clinical one when trying to understand the best treatment approach and probable prognosis of a psychotic presentation in an individual with ASD. Conclusions: Psychotic symptoms in the context of ASD warrant detailed clinical assessment and thoughtful formulation; simply labeling symptoms as indicating a comorbid psychotic disorder will likely provide misleading guidance on clinical management. Further research is required to understand the clinical trajectories of individuals with ASD who experience psychotic symptoms and how they may be best supported.

ASD, DIAG, PSY http://dx.doi.org/10.1016/j.jaac.2017.07.033

6.2 GENDER IDENTITY AND AUTISM SPECTRUM DISORDER Jack L. Turban, MD, Yale University School of Medicine, jack. [email protected] Objectives: The goal of this session is to highlight key conceptual and clinical topics on gender incongruence (GI) in youth with autism spectrum disorder (ASD), exploring what we do and do not know about the relationship between these two phenomena. Methods: A critical review of the relevant literature, including empirical data and consensus-based treatment guidelines, will be presented. Topics will include rates of co-occurrence of GI/ASD, theories underlying the etiology of this co-occurrence, and approaches to treatment for children and adolescents with co-occurrence (both psychological and hormonal approaches). Results: The topic of GI in children and adolescents has gained widespread attention in Western society over the past decade, mirrored by an increase in the


number of referrals to pediatric gender clinics and a surge in research on pediatric gender identity. During this time, researchers have observed a putative relationship between GI and ASD. Some have estimated the rate of ASD in youth experiencing GI to approach 10 percent, compared with one percent in the general population. A suggested approach for understanding the underlying etiology of this co-occurrence and proposed treatment approaches (informed consent, psychological approaches, hormonal interventions) relied on an explicitly developmental approach. A number of key areas for future research exist, including the developmental trajectory of gender identity development in youth with ASD and these youths’ responses to pubertal blockade, cross-sex hormonal therapy, and gender-affirming surgical intervention. Conclusions: The relationship between GI and ASD is a new area of research, and the field contains major gaps in knowledge regarding the developmental trajectory of gender identity development in youth with ASD and the effects of psychotherapeutic, hormonal (i.e., pubertal blockade and cross-sex hormonal therapy), and gender-affirming surgical interventions for these individuals. Although expert consensus agrees that hormonal intervention may be warranted for these patients, additional research is needed to fully understand the etiology and best treatment approaches for youth with this co-occurrence.

ASD, DIAG, GID http://dx.doi.org/10.1016/j.jaac.2017.07.034

6.3 REPETITIVE BEHAVIORS AND OBSESSIVECOMPULSIVE SYMPTOMS IN AUTISM SPECTRUM DISORDERS Michael H. Bloch, MD, MS, Yale University School of Medicine, [email protected] Objectives: The presentation will discuss categorization and measurement of OCD behaviors in individuals with and without autism. We will further discuss how different repetitive behaviors and OCD symptoms may have differential responses to pharmacological therapy and the effects that this may have on clinical trial results. Methods: We will conduct a systematic review to compare the classification of repetitive behaviors and OCD symptoms in children with and without autism spectrum disorder (ASD). We will also examine evidence from previous meta-analyses regarding the pharmacological and behavioral treatment of these symptoms, with an emphasis on cognitive behavioral therapy, SSRI, and antipsychotic agents. Results: Restricted and repetitive behaviors, including stereotyped motor mannerisms, restricted patterns of interest, atypical sensory interests, and the insistence on sameness, are core features of ASD. Repetitive behaviors in autism share some overlap with characteristic symptoms of OCD. Cognitive behavioral therapy, SSRI, and antipsychotic augmentation are all evidencedbased treatments for OCD. Meta-analysis has suggested that SSRI may be less effective in treating OCD symptoms in children with ASD and that antipsychotic agents have significant evidence of efficacy. Conclusions: More research is needed to 1) best classify repetitive and compulsive behaviors in ASD and 2) develop better treatments to minimize the functional impact of these symptoms.

ASD, DIAG, OCD http://dx.doi.org/10.1016/j.jaac.2017.07.035

6.4 ASSESSMENT AND TREATMENT OF ANXIETY IN CHILDREN WITH AUTISM SPECTRUM DISORDER Denis G. Sukhodolsky, PhD, Yale University, denis. [email protected] Objectives: The goal of this session is to discuss current research and clinical implications of evidence-based assessment and interventions for anxiety in children with autism spectrum disorder (ASD). Approximately 40 percent of children with ASD exhibit clinically significant anxiety. Accurate assessment and diagnosis of anxiety are critical for successful treatment of ASD and maximizing trajectories for optimal development. Methods: This presentation will review current research on the assessment and treatment of anxiety in ASD. This presentation will 1) focus on issues of differential diagnosis of the three common anxiety disorders (social,

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separation, and generalized anxiety) in children with ASD; 2) provide an update on dimensional measures of anxiety in children and adolescents; and 3) report new data on measuring anxiety in preschool-aged children with ASD. Results: With regard to the assessment of anxiety, an increasing number of studies indicate that parent ratings and clinical interviews can be used to reliably evaluate and diagnose anxiety in ASD. With regard to the treatment of anxiety, most research has been conducted in the area of behavioral and cognitive behavioral interventions for anxiety in children with higher-functioning (IQ >70) ASD. The principles and practice of these interventions in clinical settings will be discussed, including a review of treatment elements common for treatment of anxiety in children without ASD and specific techniques aimed at ameliorating the impact of the core autism symptoms on anxiety in ASD. New research on the neural mechanisms of CBT for anxiety will be presented. Conclusions: Anxiety is a common and impairing problem in children and adolescents with ASD. There is increasing evidence that anxiety can be accurately and reliably diagnosed and dissociated from the core ASD symptoms. Behavioral and cognitive behavioral interventions can be useful anxiety in ASD. Continuing research is needed to understand neural mechanisms of anxiety and its response to treatment.

AD, ASD, CM http://dx.doi.org/10.1016/j.jaac.2017.07.036

CLINICAL PERSPECTIVES 7 WHAT PRIMARY CARE PROVIDERS REALLY WANT: FOUR MODELS OF COLLABORATION IN EARLY CHILDHOOD MENTAL HEALTH CARE Mary-Margaret Gleason, MD, Tulane University School of Medicine, [email protected]; David W. Willis, MD, Health Resources and Service Administration/ Health and Human Services, [email protected] Objectives: The goal of this session is to present an overview of the rationale for early childhood mental health collaborative care and introduce the clinical perspectives. Methods: Innovative approaches to integrating early childhood mental health into primary care can support the capacity of the medical home to promote mental health and identify children who need additional supports. Early childhood mental health support can reduce current suffering and mitigate long-term mental health risks. This program will present four innovative programs designed to address the specific needs of the community being served, upholding the core principles of early childhood mental health, including a focus on parent-child relationships, and a strength-based approach toward the pediatric partners and families we serve together. Results: Dr. Fallucco will present a model focused on increasing universal screening in pediatric primary care settings and the empirically derived shortened screen that resulted from pediatric partners’ feedback. Dr. Chesher will describe a consultation program housed in two academic programs in Oklahoma, highlighting the didactic series that serves as a core educational activity as well as on-site clinical consultation. Dr. Middleton will describe a community-based consultation program offering both phone/email consultation and on-site consultation in academic settings, community and hospitalbased clinics, and federally qualified health centers. She will present descriptive data related to the program and changes in providers’ attitudes, knowledge, and comfort over the course of the program. Dr. Biel will describe a community-wide needs assessment in an urban setting and the resulting three programs focused on screening, child psychiatry access, and early childhood on-site consultation. Dr. Long will describe her experience as a pediatric partner collaborating with these programs. Finally, Dr. Willis, a pediatrician and Director of Home Visiting and Early Childhood at Health Resource and Service Administration’s Maternal and Child Health Bureau, will discuss the clinical and systems of care implications of these programs. Conclusions: Early childhood mental health consultation is a promising strategy to integrate evidence-based principles of early childhood

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intervention into frontline clinical settings and support the pediatric providers who see these children most frequently.

PRE, CON, EC http://dx.doi.org/10.1016/j.jaac.2017.07.038

7.1 PARTNERING WITH PEDIATRICIANS: EARLY IDENTIFICATION USING THE (BRIEF) EARLY CHILDHOOD SCREENING ASSESSMENT Elise M. Fallucco, MD, University of Florida College of Medicine - Jacksonville, [email protected]; Valentina Bolanos, MPH, University of Florida College of Medicine - Jacksonville, [email protected]; Kitty Leung, MD, University of Florida College of Medicine Jacksonville, [email protected]; MaryMargaret Gleason, MD, Tulane University School of Medicine, [email protected] Objectives: Primary care physicians (PCPs) infrequently screen young children for emotional and behavioral problems (EBP), thus missing opportunities for early intervention. PCPs cite multiple barriers to screening, including time constraints, access to referral resources, and reimbursement. This session describes a model that addressed these barriers and resulted in 1) annual screening of over 5,000 children (ages 36–60 months) at well visits; and 2) the development and validation of a new early childhood screening tool. Methods: PCPs participated in a workshop on early childhood EBP screening that addressed practical challenges of primary care screening. PCPs were encouraged to screen for EBP using the Early Childhood Screening Assessment (ECSA) at all well visits for children (ages 36–60 months) for six months. PCPs completed pre- and post- surveys on their screening practices. Completed ECSAs (N¼2,467) were analyzed with data from a separate sample group (n¼69) that completed both ECSAs and the Diagnostic Infant and Preschool Assessments. This analysis was used to develop and validate the Brief Early Childhood Screening Assessment. Results: After six months of using the 40-item ECSA, 70 percent of providers reported screening at most well visits (vs. 4% baseline, P 0.0001). Nearly every provider (96%) agreed that routine well-visit screening was feasible and practical. Almost all providers (89%) agreed that screening helped to detect more cases of EBP than routine history-taking alone. Nearly all providers (89%) reported that they would continue to screen at well visits. Many providers indicated that they would prefer a shorter screening tool. A 22-item Brief ECSA (cut-off score 9) was developed and demonstrated a sensitivity of 89 percent and a specificity of 85 percent for predicting a psychiatric diagnosis. Conclusions: Child psychiatrists can collaborate with PCPs to promote early identification of emotional and behavioral problems in young children. The Brief ECSA may facilitate screening in primary care.

EC, PRE, RI Supported by the Nemours Foundation and Managed Access to Child Health/SAMHSA Grant 5U79SM059939-04 http://dx.doi.org/10.1016/j.jaac.2017.07.039

7.2 INFANT AND EARLY CHILDHOOD MENTAL HEALTH CONSULTATION: ON THE ROAD TO PREVENTION AND EARLY INTERVENTIONS Tessa L. Chesher, DO, University of Oklahoma, [email protected] Objectives: Pediatricians are in an important position to be able to contribute to positive change in the outcomes of at-risk infants and young children. This session will examine the creation of a pilot project, which focuses on infant and early childhood mental health education and consultation in a community-based university setting. The goals of the Infant and Early Childhood Consultation project are to implement an infant and early childhood consultative service into a general pediatrics clinic and to educate the pediatric medical community on the mental health of at-risk infants and young children and their families.

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Methods: This project is composed of two parts: 1) systematically educating pediatric faculty and residents on infant and early childhood mental health; and 2) consulting with pediatric faculty and residents on infant and early childhood mental health. Surveys regarding knowledge of infant mental health and beliefs about the pediatrician’s role in psychosocial development were given to pediatric residency faculty and residents at two separate university programs. Education included eight one-hour lectures and eight mini-lectures at the clinic. Consultation included approximately 200 hours of in-person consultation in the pediatric residency clinics. Results: Pediatric providers from one academic institution (n¼16) and providers from a separate academic institution (n¼24) participated in this project. Pediatric providers felt the least comfortable in serving children (ages 0-5 years) in the following five areas: emotional difficulties (78%), maternal depression (42%), domestic violence (47%), exposure to traumatic events (49%), and ADHD (50%). This session looks at the process of creating a consultative model, which incorporates systematic education and co-located consultative services, as well as pediatric faculty and resident’s feedback on this model. Conclusions: It is important to increase the number of consultative services in the area of infant and early childhood mental health to not only address the rapid growth of young children being referred for mental health services but also to shift the focus to prevention and early interventions. An innovative model of incorporating an infant and early childhood education into a pediatric residency along with consultative services will be discussed.

CON, EC, INF Supported by the George Kaiser Family Foundation http://dx.doi.org/10.1016/j.jaac.2017.07.040

7.3 PARTNERING IN EARLY CHILDHOOD MENTAL HEALTH: PROGRAM AND PROVIDER OUTCOMES Mary-Margaret Gleason, MD, Tulane University School of Medicine, [email protected]; Melissa Middleton, PhD, Tulane University School of Medicine, [email protected]; Anna Kelley, PsyD, Tulane University School of Medicine, [email protected] Objectives: The goals of this session are to describe the implementation and outcomes of early childhood mental health (ECMH) consultation to primary care providers (PCPs), specifically qualitative and quantitative changes in pediatric PCPs knowledge, practice, and attitudes toward ECMH and assessment of community resources. PCPs are in an excellent position to lead ECMH prevention and first-line intervention efforts. Unfortunately, many PCPs do not receive substantial training in this area during residency. The Tulane Early Childhood Collaborative (TECC) program was developed to address the needs of PCPs and young children. Methods: The TECC model offers both remote and on-site consultation in the PCP office, focusing on identified PCP needs, use of validated screening tools, opportunities for anticipatory guidance, and attention to relationships. PCP attitudes and self-reported knowledge are measured at enrollment, at 12 month, and at 30 month time points. Consult characteristics are tracked. Results: In year one, 95 PCPs were enrolled. At baseline, rates of PCPs who reported that in the average month they had practiced each of these IMH activities zero times were as follows: a rating scale to monitor behavioral symptoms (58.9%), identify trauma exposure (45.3%), diagnose ADHD (41.1%), and diagnose internalizing problems (54.3%). At one year follow-up, the practice of IMH activities increased significantly in rates of using the scale of internalizing problems [t(11) ¼ 2.2, P < 0.05] and identifying trauma exposure [t(11) ¼ 2.6, P < 0.05]. Overall, PCPs reported that they had more comfort in managing ECMH issues [t(11) ¼ 3.4, P < 0.05] and showed a nonsignificant increase in the use of all ECMH practices [t(11) ¼ 2.1, P < 0.055]. Examples of consultant–consultee relationships and innovative practices will be discussed.


Conclusions: Early childhood mental health consultation to primary care physicians may promote comfort and increased use of recommended ECMH strategies.

CON, EC, PRE Supported by the Baptist Community Ministries, Klingenstein Third Generation Foundation, and the Louisiana Office of Public Health http://dx.doi.org/10.1016/j.jaac.2017.07.041

7.4 INTEGRATING EARLY CHILDHOOD MENTAL HEALTH CONSULTATION INTO PRIMARY CARE: MODELS OF SCREENING AND INTERVENTION ACROSS GENERATIONS Matthew G. Biel, MD, MSc, Medstar Georgetown University Hospital, [email protected]; Melissa Long, MD, Children’s National Medical Center, MFLong@ childrensnational.org Objectives: The goals of this session are to report recent findings from a needs assessment process with pediatricians that describes early childhood mental health as an area requiring particular support and consultation from mental health professionals and to describe three programs designed in response to that needs assessment that have the capacity to enhance early childhood mental health care within pediatric primary care. Methods: We surveyed primary care physicians (PCPs) in an East Coast urban setting and identified their knowledge, attitudes, and concerns regarding pediatric mental health (MH), with specific questions addressing Early Childhood Mental Health Consultation (ECMHC). Based on these survey results and other inquiries, we present three innovative models to address identified gaps in care for this population. Results: Of the PCPs surveyed (N¼50), 100 percent reported that there is a high level of unmet need for MH treatment in children. Only 11 percent reported that they could usually meet the needs of children with MH problems. Moreover, 79 percent of PCPs reported that their comfort level and knowledge of identifying and addressing MH problems were lower for children under age five years than for older children, and 68 percent reported that fewer MH resources were available for younger children. We present three emergent programs designed to enhance the capacity of PCPs to identify and address ECMHC as follows: 1) implementation of routine MH screening for perinatal depression and early childhood social/emotional concerns within primary care; 2) mobilization of a citywide child psychiatry access program to deliver support and consultation around ECMHC; and 3) implementation of an integrated ECMHC team within primary care, with an explicit focus on serving families with children ages 0–5 years. Conclusions: Pediatric primary care presents an ideal setting in which to identify and address MH and developmental concerns in young children. Innovative program design and evaluation will identify the most effective and efficient strategies to enhance these approaches to improve ECMHC.

CON, DEV, EC Supported by the J. Willard and Alice S. Marriott Foundation http://dx.doi.org/10.1016/j.jaac.2017.07.042

CLINICAL PERSPECTIVES 8 CLINICAL GUIDELINES FOR NAVIGATING MEDIA USE Kristin A. Dalope, MD, University of Pittsburgh Medical Center, [email protected] Objectives: The goals of this session are to 1) demonstrate a variety of welldeveloped online resources that can support clinicians in discussions about media use with patients and families; 2) provide examples of discussions with families about media; 3) update clinicians about the evolving technology and laws, including potential impact of these laws upon patients; and 4) discuss ethical dilemmas pertaining to professional media use by child and adolescent psychiatrists.

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Methods: Media use can provide both risks and benefits for children, adolescents, families, and professionals. A developmental framework will be provided to help understand media use. Well-developed online resources and tools from AACAP, AAP, and Common Sense Media will be reviewed. Case studies and a video of family therapy will illustrate how primary care providers and mental health professionals can collaborate and integrate these conversations into appointments. Legal concerns pertaining to children and adolescents will be discussed in the context of how professionals may become involved in the legal system through the population with whom they work. In addition, AACAP’s ethics guidelines will help provide a structure through which professionals can evaluate their own use of media and possible implications this may have on eProfessionalism. Results: Clinicians will be presented with a developmental framework, online resources, clinical vignettes, a family therapy session video, legal issues, and e-Professionalism guidelines that they can use to improve their understanding of media use and incorporate into their clinical practices. Conclusions: Practical, collaborative, legal, ethical, and professional considerations pertaining to media use are all important topics that clinicians can integrate into their daily interactions with children, adolescents, and families.

ETH, MED, COMP Sponsored by AACAP's Triple Board and Post Pediatric Portal Programs Committee, Media Committee, and Ethics Committee http://dx.doi.org/10.1016/j.jaac.2017.07.044

8.1 MEDIA AND VIDEO GAME TRENDS ACROSS DEVELOPMENT Roslyn Gerwin, DO, Maine Medical Center, rgerwin@ mmc.org Objectives: The goals of this session are 1) to gain a more understanding of the online world in which children and adolescents are immersed; and 2) to outline general use patterns of digital media and games for children and adolescents, as well as how video game use differs across development. Methods: A literature search was conducted with emphasis on three major reviews: 1) a recent technical report by AAP addressing digital media use in children and adolescents; 2) a 2015 Pew Research Center publication overviewing adolescent social media and technology use; and 3) a 2013 Common Sense Media report on the media use of children. The author’s experience exploring media use will be incorporated, including multimedia examples. Results: Television is still the most common mode of screen use for children 200 CGG repeats (a “full” mutation) in a male leads to intellectual disability, ADHD, and anxiety, among other findings. Full expansion is associated with an absence of FMR1 gene product secondary to transcriptional silencing, and its absence leads to loss of inhibitory signaling through metabotropic glutamate (mGluR) and g-aminobutyric acid (GABA) receptors. The FRAX A phenotype is broad, influenced by the CGG repeat length and gender. AS is a disorder caused by aberrant genomic imprinting (an epigenetic phenomena where one parent’s copy of genetic information is imprinted or “silenced”). Because of an abnormal or absent maternal copy of the UBE3A allele in the 15q11.2-q13 region, AS can arise by one of several mechanisms. Approximately, 90 percent of AS cases can be identified with molecular genetic testing, such as methylation analysis. Conclusions: Genetic tests commonly used to diagnose these neurodevelopmental disorders are as follows: microarrays (for detecting gains or losses of stretches of DNA), methylation analysis (for imprinting disorders), and sequencing (for diagnosing abnormalities at the DNA base level). Indications for testing and examples of results will be presented.

ASD, GS, ND

significantly improve our understanding of potential mechanisms underlying ASD. The session will review neuroimaging findings for three neurogenetic conditions commonly identified in ASD: fragile X syndrome, Down syndrome, and Angelman syndrome. Methods: Studies providing evidence for shared and/or contrasting neuroanatomical features in individuals with genetic conditions compared with the general ASD population will be presented. Information across these syndromes will be synthesized to focus on the relationship of neuroimaging findings to clinical symptoms associated with social cognition. Results: Learning objectives include: 1) an increased understanding of ASD symptoms as they relate to neurogenetic syndromes; 2) a review of neuroimaging features associated with brain structure and function in ASD; and 3) a gain in knowledge of features in neurogenetic syndromes and how they relate to social cognitive neural networks. Conclusions: Genetic technologies have led to a significant increase in the identification of genetic causes for ASD. Improved understanding of associated neuroendophenotypes will provide a clinical framework in which to approach treatment of ASD, as well as provide potential insights into future directions for ASD research.

ASD, IMAGS, ND http://dx.doi.org/10.1016/j.jaac.2017.07.078

13.4 PSYCHOPHARMACOLOGY OF BEHAVIORAL SYMPTOMS IN THREE NEUROGENETIC SYNDROMES ASSOCIATED WITH AUTISM SPECTRUM DISORDER Christopher J. McDougle, MD, Massachusetts General Hospital and Harvard Medical School, cmcdougle@ partners.org Objectives: This presentation will review the results of case reports, case series, retrospective reviews, open-label studies, and RCTs of drugs used to treat behavioral symptoms in neurogenetic syndromes associated with autism spectrum disoder (ASD). Methods: The medical literature was searched to identify published reports of drug treatment of behavioral symptoms in individuals with fragile X syndrome (FXS), Down syndrome (DS), and Angelman syndrome (AS), which are associated with ASD. Results: Results of RCTs from studies of drugs for specific behavioral symptoms in FXS have been published, although consistent positive findings have yet to be demonstrated for most target symptoms. Results of RCTs from studies of drugs for behavioral symptoms associated with DS and AS have yet to be published; in fact, few results from any type of systematic study of drugs for behavioral symptoms in DS and AS have appeared. Conclusions: Additional RCTs of drugs for specific behavioral symptoms are needed in FXS. Pilot studies of drugs for behavioral symptoms in DS and AS are necessary. It is hoped that targeted drug therapies can be identified for behavioral symptoms in disorders with a known genetic etiology.

ASD, GS, PPC http://dx.doi.org/10.1016/j.jaac.2017.07.079

http://dx.doi.org/10.1016/j.jaac.2017.07.077

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13.3 NEUROIMAGING IN THREE SYNDROMES ASSOCIATED WITH AUTISM SPECTRUM DISORDER

PREDICTING VIOLENCE: THE WHY, THE HOW, AND THE WHAT TO DO: A BEST-EVIDENCE GUIDE FOR THE MENTAL HEALTH PRACTITIONER

David S. Hong, MD, Stanford University, dshong@ stanford.edu Objectives: Genetic conditions comprise an increasingly large percentage of syndromes associated with autism spectrum disorder (ASD). Increased understanding of neurobiological features of genetic disorders may also

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Aradhana Bela Sood, MD, Virginia Commonwealth University Health Systems, [email protected] Objectives: Mass shootings and the threat of violence are a concern for the public and clinicians who treat adolescents with the potential to be the cause of the next mass casualty. There is significant interest in improving the

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ability of clinicians to accurately assess and predict risk. This session will provide the audience with the following: 1) systematic overview of the context of violence based on in-depth analyses of high-profile mass shootings about the psychological makeup of individuals with the propensity for mass violence, and 2) a series of presentations that will provide the audience with current and evidence-based models and promising practices to accurately assess the risk of violence and treatment planning for the violent adolescent. Methods: The session has two sections. In the first section, two speakers provide the context for violent behavior and the psychological profiles of mass casualty perpetrators based on their own in-depth analysis of the Virginia Tech and Sandy Hook tragedies. The next speaker will discuss the role of media contagion as a risk factor for encouraging violent behavior in at-risk individuals and guidelines for responsible media coverage of violence on a large scale. The second half of the sessionwill provide the audience with four models of assessing risk for violence with varying degrees of accuracy. Results: In summary, the session will provide the audience with the most current information about risk and threat assessment and provide specific tools to assess environmental and individual risk followed by intervention planning. Conclusions: This “how to” session will provide up-to-date information on risk and threat assessment in children and youth with violent behavior. It will bridge a major gap in knowledge and enhance skills around this topic with the best available evidence. This topic continues to garner national and international attention and produces significant fear in clinicians because of inadequate training in how to approach a high-stakes risk clinical situation.

EBP, AGG, PRE Sponsored by AACAP's Adolescent Psychiatry Committee http://dx.doi.org/10.1016/j.jaac.2017.07.081

14.1 THE SANDY HOOK SCHOOL SHOOTING: MENTALIZATION DEFICITS AND MASS MURDER Harold I. Schwartz, MD, Institute of Living at Hartford Hospital, [email protected] Objectives: When Adam Lanza murdered 26 elementary school students and staff at the Sandy Hook Elementary School in December 2012, he stunned the nation and left behind a trail of questions. This session explores major issues of relevance in the Sandy Hook shooter’s life to extrapolate common denominators in the development of school shooters and explores how mental illness and access to assault weapons play a role in mass shootings. Methods: The presentation will review the cascade of events leading to disaster at the Sandy Hook Elementary School and examine the relationship between ready access to guns, gun mortality rates, and mental illness. The role of psychotic illness, characteristics of personality disorder, and family dynamics commonly identified in shooters will be reviewed. The presentation will argue that a diminution in the capacity for theory of mind and mentalization bordering on solipsism is the common denominator that explains the capacity to shoot. Results: Whereas special education services were provided, they failed to address deficits in social emotional learning; Lanza remained deficient in social connectedness throughout his life. This was compounded by multiple untreated psychiatric disorders, a preoccupation with mass murder, and a life of extreme social withdrawal. Gun homicide data demonstrate that access to weaponry is a more salient issue than presence of mental illness; however, subgroups of the mentally ill, in particular young men in the first episode of psychosis, are at notably higher risk of perpetrating stranger violence, including homicide. A subgroup of school shooters is mentally ill by virtue of severe personality disorder. Conclusions: The single most distinctive common denominator between school shootings is the availability of assault weapons. Most school shooters appear to share personality characteristics, which are suggestive of diminished capacity for theory of mind and mentalization. Extreme forms of solipsistic disconnectedness may be a factor that distinguishes individuals who are capable of mass school shootings. One ray of hope is that social emotional


learning programs have proven to be effective in enhancing empathic connectedness.

AGG, MOD, RF http://dx.doi.org/10.1016/j.jaac.2017.07.082

14.2 ARE SCHOOL RAMPAGE SHOOTERS FOLLOWING MEDIA AND INTERNET SCRIPTS? CRITICAL ASPECTS OF THREAT ASSESSMENT IN CHILDREN AND ADOLESCENTS Deborah Marcia Weisbrot, MD, University Hospital, deborah. [email protected] Objectives: School shootings present less as isolated expressions of rage and more as acts that build on the plans of previous rampages, particularly Columbine. Child and adolescent psychiatrists are frequently called upon to perform threat assessments. The objective of this presentation is to provide clinicians with the information necessary to perform a thorough threat assessment in children and adolescents and to consider the effects of media and the internet. Methods: The speaker will discuss how targeted school violence is the final act on a pathway to violence, along which different psychological, situational, and interpersonal processes are involved, with an emerging pattern of warning behaviors. Leaked intent may be communicated verbally, in drawings, via social media, or the internet. Shooters who have survived and online writings of others who did not described an intense desire for fame and social recognition, as was achieved by the shooters who went before them. The presentation will review evidence for the growing concern that school rampage shooters are following a detailed script made available to them through the media and internet. This “script” has reduced the amount of unique planning, creativity, and initiative required for someone intent on committing a mass shooting. However, some “copycats” who make threats seem to be doing so in order to be at the center of attention and are not planning to carry out an actual rampage. Clinical examples will illustrate how these factors impact threat assessment in youth. Results: Attendees to this session will appreciate the following: 1) the critical issues in school threat assessment; and 2) the degree and intensity of a student’s level of interest in the lives and methods of prior rampage shooters. Attendees will learn how to look for evidence of fixations or intense identifications or preoccupation with violently themed media and when it is necessary to investigate student’s personal websites, blogs, and social networking sites. Conclusions: Threat assessment is challenging, complex, and labor-intensive and plays a central role in the prevention of targeted violence in schools. Clinicians need to become familiar with the multiple issues involved in this process, including the potential role of media and internet influences, as well as potential copycat dynamics.

AGG, MED, RF http://dx.doi.org/10.1016/j.jaac.2017.07.083

14.3 REVIEW OF INTERPERSONAL SAFETY CONCERNS: AN INPATIENT THREAT ASSESSMENT MODEL, AN ADAPTATION OF THE VSTAG Kevin P. Young, PhD, Institute of Living at Hartford Hospital, [email protected] Objectives: Inadequate tools and resources limit prediction of postdischarge violence. Interview necessitates quality self-report. Actuarial methods require ample historical data and are low yield in guiding treatment. Structured professional judgment (SPJ) models blend these approaches, are currently in favor, and can provide treatment targets but are not infallible. Review of Interpersonal Safety Concerns (RISC) is an SPJ clinical adaptation of the Virginia Student Threat Assessment (VSTAG), aimed at identifying risk factors to directly inform risk-mitigation in the inpatient environment. Although the VSTAG calls for a more comprehensive evaluation when high-risk cases are identified in the school environment; RISC assumes case complexity and dictates a comprehensive approach from the start. The model addresses common flaws, such as response bias,

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variability across providers, poor classification rates, and the overwhelmed provider. Methods: Flaws in current approaches, such as difficulty detecting deception, are avoided through the RISC approach. The RISC process yields a hypothesized pathway to violence, classifies aggression type, and assesses 11 risk domains. The semistructured interview assesses both the specific threat as well as the germane risk domains. Data integrity is confirmed via complementary patient/collateral interview and independent psychological/neuropsychological test data. Report writing and therapeutic dissemination of findings will be discussed, as well as “how to” adapt to the RISC framework for unique environments. Results: In addition to using cases to teach the RISC technique, data from our first 100 cases will be used to highlight issues salient to the attendee, including rates of congruence between sources, impact of various psychiatric disorders on risk level, and suicide risk as it co-varies by level of threat. Implications of these findings in general clinical practice will be discussed. Conclusions: By using a systematic, risk-management approach, RISC shifts focus to the identification of factors that increase the risk of carrying out specific threats. Confidence in findings is increased because of collateral information and a reliance on convergent data. Information from this comprehensive approach guides our therapeutic feedback sessions with patient, family, and treatment team.

AGG, ICP, SII http://dx.doi.org/10.1016/j.jaac.2017.07.084

14.4 CHILDREN AND ADOLESCENTS WITH HOMICIDAL IDEATION: RISK FACTORS AND THE MENTAL STATUS EXAMINATION Mirela Loftus, MD, PhD, Institute of Living at Hartford Hospital, [email protected] Objectives: Child and adolescent psychiatrists are often faced with assessing patients who express homicidal thoughts. These assessments occur in various settings as an inpatient or an outpatient; emergency departments or schools need to ultimately determine whether patients can return safely to the community. Although there seems to be some consensus regarding the assessment of potential suicide, such a consensus is lacking when it comes to the assessment of homicide. To date, clinicians are offering estimates of likelihood for acting on homicidal thoughts while taking into account various factors such as risk factors, type of violence, and risk level. However, with the development of the Virginia Student Threat Assessment Guidelines (VSTAG) and subsequent Review of Interpersonal Safety Concerns (RISC) model of assessment of violence, which use an evidence-based, risk management focused approach to assess individual threats, we developed a semistructured approach to screen patients. Methods: Through a case example, the crucial domains that need to be explored to determine the level of risk will be presented. This will include a review of the risk and protective factors that mitigate the potential risk of acting on homicidal thoughts. A structured mental status exam developed in conjunction with the RISC assessment will also be presented. Results: This semistructured approach will serve as a guide in determining further exploration of risk as well as helping in categorizing the underlying pathology as belonging to one of three pathways to violent behavior: psychotic, antisocial, or conflicted. The advantages and disadvantages of using a screen versus a comprehensive threat assessment will be explored. Conclusions: Because of the high variability of clinical presentations of youth with homicidal ideations and the lack of consensus in the assessment of such youth, it is difficult to determine the level of risk and ensuing clinical recommendations. With the development of the VSTAG and subsequently of the RISC assessment model, we have incorporated certain aspects of risk assessment into the review of risk and protective factors of such patients. In addition, we expanded the mental status exam to incorporate certain domains known to be relevant in predicting future acts of violence.

AGG, PRE, RF http://dx.doi.org/10.1016/j.jaac.2017.07.796

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CLINICAL PERSPECTIVES 15 PSYCHIATRIC, COGNITIVE, LEGAL, AND PUBLIC HEALTH CHALLENGES FACING REFUGEE CHILDREN: AN INTEGRATED APPROACH Dorothy E. Stubbe, MD, Yale Child Study Center, Dorothy. [email protected] Objectives: Refugee children and families present with special health and mental health concerns. Cultural and religious factors, language barriers, traumas, and the potential for discrimination are all salient issues. This interdisciplinary presentation addresses issues critical to understanding and treating the needs of refugee children and families. Methods: 1) Interviews of recently settled refugee children convey the struggles and resilience factors displayed by displaced children. 2) Chris George discusses the work of the Integrated Refugee and Immigrant Services (IRIS) in resettling refugees from war-torn countries to Connecticut. IRIS assists refugees in acclimating to and accessing services, with successful outcomes. 3) John Thomas presents an international comparison of immigration laws that affect refugees, including the impact of President Trump’s January 27, 2017 Executive Order banning the entry into the United States of individuals from seven primarily Muslim countries. 4) Caleb Thomas reviews the psychiatric sequelae, neuroimaging changes, and epigenetic evidence on the impact of psychic trauma. 5) Dorothy Stubbe discusses factors related to needs assessment, culturally sensitive engagement, and treatment effectiveness for this population of vulnerable individuals. Results: Legal research reveals that legal status and immigration possibilities vary dramatically among countries and across time. Refugees are at high risk for a variety of mental disorders, and DNA alterations in those suffering from psychological trauma may be epigenetically transferred to offspring. Identifying culturally sensitive supports and meeting basic needs improves outcomes. Engagement through an understanding of beliefs and values and joint goal setting forms the basis for therapeutic interventions. Conclusions: Use of an integrated formulation to characterize resilience, as well as the psychiatric, cognitive, and legal risk factors facing refugee families, may lead to a more collaborative multidisciplinary approach to supporting the needs of recently immigrated children and families. Healers must also be aware of the political climate and form strong alliances and support systems to advocate for these families and maintain a safe environment for them to heal and thrive.

PUP, DS, EC http://dx.doi.org/10.1016/j.jaac.2017.07.089

15.1 NEUROCOGNITIVE CHALLENGES FACING REFUGEE CHILDREN Caleb N. Thomas, Brown University, Caleb_Thomas@ brown.edu Objectives: This presentation reviews the existing literature concerning the neuroscience implications for children in families who experience forced immigration. Methods: Neuroimaging studies, neuropsychological testing findings, epigenetic studies, and psychiatric diagnostics suggest that children and adolescents with chronic and severe stress, such as fleeing from a war-torn area, trauma, loss, and displacement, may result in significant differences between these populations and control youth. Results: Children and adolescents with histories of trauma, including forced migration, demonstrate a variety of psychiatric and neurocognitive deficits. Studies suggest that refugees, populations in need of and seeking asylum, and those undergoing refugee application processes present a much higher variety of mental disorders, including MDD and PTSD. Many of these disorders exhibit great levels of comorbidity among refugee populations. Hyperreactivity of the amygdala and limbic system is seen with neuroimaging. Memory accuracy is frequently impaired. Epigenetic studies have correlated

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chronically highly stressful life events with changes in DNA structures, which may then be passed to offspring. Conclusions: Memory accuracy and mental health have been shown to be correlated with the rights granted (work, school, living, etc.) and asylum acceptance—rejecting refugees, or denying them certain rights, has been suggested to decrease average mental health levels and quality of life.

IMAGS, NEPSYC, PTSD http://dx.doi.org/10.1016/j.jaac.2017.07.090

fact, studies show that immigrants are more likely than native-born Americans to start their own businesses. Conclusions: Refugees, and especially refugee children, face daunting challenges. As Viet Thanh Nguyen wrote in a September 2016 op-ed article in the New York Times, “[R]efugees are the zombies of the world, the undead who rise from dying states to march or swim toward our borders in endless waves.” They may “remain scarred by their history,” but resettlement efforts, properly executed, can minimize the damage.

COPI, DS, PUP

15.2 LEGAL AND PUBLIC HEALTH CHALLENGES FACING REFUGEE CHILDREN


John Thomas, JD, Quinnipiac University School of Law, john. [email protected]


Objectives: This presentation seeks to illuminate the legal challenges facing refugee children and their families. Methods: This member of our panel presents an international comparison of immigration laws, with a particular focus on laws that affect refugees. The presentation begins with the 1951 United Nations Refugee Convention and its related 1967 United Nations Protocol. It then surveys the laws in regions with the greatest refugee crises, including those of Europe, the Middle East, and the United States. With respect to the United States, the presentation emphasizes the impact of President Trump’s January 27, 2017 Executive Order, “Protecting the Nation from Foreign Terrorist Entry into the United States,” which banned entry of people living in Iran, Iraq, Syria, Sudan, Libya, Yemen, and Somalia into the United States. Results: Our legal research reveals that legal status and immigration possibilities vary dramatically from country to country and from time to time. Although most countries’ legal codes embrace the United Nations definition of “refugee,” related laws implement this charge in very different manners, resulting in unpredictable immigration outcomes. In the United States, in particular, the vicissitudes of politics also generate unpredictable outcomes. Conclusions: This presentation concludes by observing that refugee expectations are often incompatible with available legal solutions and public health resources. This tension has particular consequences for refugee children, which our other panel members will address.

BEYOND THE PRESCRIPTION PAD: PSYCHOTHERAPY INTERVENTIONS FOR PARENTS/CAREGIVERS OF YOUTH WITH SERIOUS MENTAL ILLNESSES AND TREATMENT NONADHERENCE

DS, ETH, FCP http://dx.doi.org/10.1016/j.jaac.2017.07.091

15.3 THE PRACTICAL CHALLENGES FACING REFUGEE CHILDREN Chris George, Integrated Immigration and Refugee Services (IRIS), [email protected] Objectives: This presentation seeks to illuminate the practical challenges facing refugee children and their families. In doing so, it uses video recordings of interviews of recent refugee children who have settled in the United States, discusses the hardships that they have endured, and discusses the life’s challenges they face and the demands involved in settling in a new environment. Methods: This panel member describes the work of Integrated Refugee and Immigration Services (IRIS) in New Haven, Connecticut. IRIS has settled refugees from a wide range of war-torn countries, including Sudan, the Democratic Republic of the Congo, Afghanistan, Iraq, and Syria. Their needs are significant, and IRIS is their primary resource as they begin to rebuild their lives after years of persecution and displacement. IRIS helps refugees on the road to self-sufficiency by providing lifesaving support during their transition to life in the United States. IRIS case managers greet refugees and take them to apartments, rented by IRIS and furnished with donated furniture. Results: Refugee resettlement is a demanding, self-help program, with only modest funding from the federal government, but with support from the staff at IRIS. Together with the community, most refugees quickly adjust to their new country and become self-sufficient. Just as quickly, these new Americans add value to our community through cultural enrichment, diversity, and economic growth. We have found that refugees make wonderful neighbors. In


Mary S. Ahn, MD, University of Massachusetts Medical School, [email protected] Objectives: Youth with serious mental illness (SMI) adhere poorly to the recommended medications and other treatments, with prevalence of nonadherence ranging between 30 and 60 percent. Medication nonadherence is multifactorial, but the root causes can be both analyzed and minimized by a strong therapeutic alliance and understanding of the psychological and social factors. Parent/caregivers can be both a supportive, but also an obstructive force in addressing engagement of the youth to treatment. Therefore, child psychiatrists are in a unique position to introduce components of evidence-based psychotherapies targeted toward parents/caregivers into their clinical practice to address treatment nonadherence, even in settings outside of the traditional psychotherapy encounter. This session will introduce strategies based on evidence-based psychotherapies that may be used to address this common problem, specifically in skills addressing engagement of the parent/caregiver. Methods: A review of the rationale for intervening with the family of SMI youth will be provided. Dr. David Miklowitz will present his work on familyfocused therapy for bipolar and psychotic disorders, with a specific focus on interventions for the parents/caregivers. Dr. Anne Lutz will present her work on solution-focused therapy in youth with substance use disorders (SUD), including stimulus videos that demonstrate the impact of intervening with the parents. Dr. Victor Fornari will bridge behavioral and interpersonal psychotherapy interventions for eating disorders (ED) with psychodynamic-informed strategies for ED (once medical stabilization is established) and other maladaptive eating behaviors. Results: With translation of both research and innovative clinical approaches, this session uses different psychotherapeutic strategies that can be used to address treatment nonadherence in youth with SMI. Dr. Mary Ahn will be our expert discussant to lead and moderate the panel to will allow for audience participation and questions. Conclusions: Child psychiatrists working with SMI youth can use modular psychotherapy techniques for the parent/caregiver in a variety of treatment settings to address treatment nonadherence in youth.

PAT, P, TREAT Sponsored by AACAP's Psychotherapy Committee and Early Career Psychiatrist Committee http://dx.doi.org/10.1016/j.jaac.2017.07.094

16.1 FAMILY-FOCUSED THERAPY David J. Miklowitz, PhD, University of California, Los Angeles David Geffen School of Medicine, dmiklowitz@mednet. ucla.edu Objectives: Adolescents or young adults with bipolar disorder (BD) are often nonadherent with medication regimens and behavioral prescriptions (e.g.,

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maintaining regular sleep/wake cycles). Parents are often in the best position to help their offspring get an accurate diagnosis and find appropriate treatments. However, parents sometimes overidentify with the caregiving role, leading to resistance on the part of the offspring. Methods: The speaker will describe the techniques and evidence base of family-focused treatment (FFT) in young people with BD. The bulk of the presentation will be case vignettes that illustrate strategies for promoting adherence. These strategies can be readily adapted in clinical practice. Results: The young person’s medical adherence can be enhanced by the following. 1) Parents must be on the same page about the BD diagnosis and the need for pharmacological and behavioral interventions. This agreement is particularly important in split custody situations in which longstanding resentments are often expressed through disagreements about parenting practices. Education on BD (e.g., symptoms, prognosis, genetic/biological correlates, and the need for consistent medication use and lifestyle changes) should be a core element of family treatment. 2) If the offspring is not cooperative with family sessions, parents may benefit from psychoeducation groups with other parents. 3) Parents must present medication or behavioral options to the offspring in a way that does not undermine the offspring’s strive for independence. Clinicians can stimulate discussions about these issues through communication training exercises. 4) Clinicians should help the adolescent/young adult clarify his or her reasons for nonadherence, which may include the following: side effects, missing the “high” periods, feeling that one is being stigmatized, believing that taking medicines means being controlled by parents, or “grieving over the lost healthy self.” Conclusions: Adherence with medications is a life-long habit that needs to be developed early in the course of the disorder. Parents may enhance the offspring’s acceptance of the diagnosis and its treatments through a measured, educative approach. Clinicians can aid this process by focusing on psychosocial issues that underlie nonadherence.

BD, FAM, FT Supported by NIMH Grants R01-MH093676 and R33-MH097007 http://dx.doi.org/10.1016/j.jaac.2017.07.095

informed therapy; however, involvement of the family may be critical to recovery.

ADOL, EBP, FAM http://dx.doi.org/10.1016/j.jaac.2017.07.096

16.3 SOLUTION-FOCUSED THERAPY Anne B. Lutz, MD, Lutz Child and Family Associates, PC, [email protected] Objectives: At the heart of all therapy lies the human relationship. Learning how to build and navigate the complexities and nuances of establishing a therapeutic alliance, especially in the initial encounter, is arguably one of the most important skills to master. Simultaneous engagement with both youth and families that seemingly have very differing goals takes skill and is paramount in successful treatment. Video vignettes illustrating how the solutionfocused therapy approach can facilitate simultaneous engagement with youth and families who cope with serious mental illness (SMI) will be discussed. Methods: Solution-focused brief therapy is an evidenced-based treatment approach and is in accordance with the positive psychology movement that emphasizes well-being and optimal functioning. Simultaneously activating resources with both youth and families can improve treatment adherence. Participants will begin to learn how to uncover, amplify, and diagnose strengths, resources, and positive attributes in youth and families that are critical for a positive therapeutic outcome while also strengthening the therapeutic alliance. Results: Participants will be given practical “how to” solution-focused conversational tools that can immediately be used in challenging situations to engage youth and families who are coping with SMI, adaptable for any clinical setting. The evidence base for this mode of therapy and the clinical populations that are best served will be discussed. Conclusions: Participants will be able to recognize the unique aspects of solution-focused therapy and how this approach can be used to enhance engagement with youth and families coping with SMI.

EBP, FT, P http://dx.doi.org/10.1016/j.jaac.2017.07.097

16.2 PSYCHODYNAMIC-INFORMED THERAPY Victor Fornari, MD, Zucker Hillside Hospital, vfornari@ northwell.edu Objectives: Nonadherence to treatment for youth with serious mental illness (SMI) is a major cause for relapse, as well as treatment resistance. A demonstration of the importance of psychodynamically-informed therapy in the care of youth with SMI will be described. The treatment of youth with SMI requires an appreciation of the role of the family in the life of the individual, as well as how the participation of the parents in the care can enhance adherence. Methods: Two cases will be presented highlighting the role of psychodynamically-informed therapy with youth with serious eating disorders (ED) to enhance adherence. Close collaboration with the parents, recognizing the developmental and ethical issues that need to be addressed, will be discussed. In one case, the youth willingly accepted the involvement of the parents. In a second case, the youth resisted the parent’s involvement, and the treatment addressed the meaning of excluding the parents for the youth to accept the parent’s participation. Medical stabilization was a priority and often necessitated close family collaboration. Results: There is an ever-growing literature regarding the valuable role of psychodynamically-informed family psychotherapy with youth with serious ED to enhance treatment adherence. Increasing the awareness of the valuable and critical role of engaging parents and/or the entire family in the psychotherapy will be presented. Conclusions: Child and adolescent psychiatrists are in a unique position to provide evidence-based psychotherapy in their clinical practice to enhance the relationship with the patient and the family, as well as treatment adherence and clinical outcomes for the patients. Youth with serious ED are in the position of benefitting from individual psychodynamically-

CLINICAL PERSPECTIVES 17 CAUGHT IN THE NET: HOW ELECTRONIC MEDIA AFFECTS MENTAL ILLNESS IN CHILDREN AND ADOLESCENTS Kristopher Kaliebe, MD, University of South Florida, [email protected] Objectives: Participants will understand a method to integrate clinically relevant effects of various electronic media into a biopsychosocial formulation. Participants will appreciate the reciprocal interactions between the features of child and adolescent psychiatric disorders and these youth’s patterns of social media and technology use. Methods: Four 30-minute presentations are followed by a clinical panel. Results: Social media and communication technologies have complex reciprocal interactions with psychiatric disorders. The biopsychosocial formulation offers a systematic and comprehensive approach to incorporate data on the interactions between electronic media and psychiatric disorders. The core deficits of psychiatric disorders interact with the properties of different technologies and social media. This leads children and adolescents with psychiatric disorders to have diagnosis-specific challenges and opportunities. Conclusions: Research confirms robust effects of electronic media on psychiatric patients. A biopsychosocial formulation and research reviews organized by psychiatric diagnosis offer clinicians tools to use this evidence base effectively.

PSP, MED, COMP Sponsored by AACAP's Media Committee http://dx.doi.org/10.1016/j.jaac.2017.07.099

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17.1 REBOOTING THE PSYCHIATRIC FORMULATION IN THE ERA OF DIGITAL MEDIA Nicholas Carson, MD, FRCPC, Cambridge Health Alliance, [email protected] Objectives: The goal of this session is to describe the value of adapting the traditional biopsychosocial formulation to concerns of media use by children and adolescents. Media use may be seen as a peripheral concern in psychiatric treatment planning, although it is an almost universal behavior among youth across age, sex, class, and culture. Placing media use within a familiar and valuable psychiatric practice, the formulation, may facilitate and organize the assessment and treatment of youth with media-related mental difficulties. Methods: Seminal publications on the biopsychosocial formulation provide useful templates for considering a “media formulation.” We review the predisposing, perpetuating, precipitating, and protective factors relevant to adolescent media use and mental health across biological, psychological, and social domains. Factors are drawn from the evidence base on media use among youth with mental health difficulties. Results: Biological factors relevant to media use include genetic predispositions to addictive behavior and physical functions affected by excessive screen use (e.g., weight, sleep). Relevant psychological factors include how youth disclose private information online, express and explore identity, experience or avoid rejection, and learn about mental health in online spaces. Relevant social-relationship factors include parental engagement with media use by youth, online peer aggression, and development of positive relationships online. Social-environment factors include culturally based preferences and prejudices online that interact with mental health and the important relationship between media use and school culture. Conclusions: When psychiatric assessment reveals media-related concerns, the biopsychosocial approach is a useful framework for generating hypotheses to guide treatment. The biopsychosocial model is familiar to psychiatrists, can help ensure an organized and inclusive assessment, and has the potential to better integrate media use into standard mental health services.

COMP, MED, TREAT http://dx.doi.org/10.1016/j.jaac.2017.07.100

17.2 SOCIAL TOOL OR SOCIAL AVOIDANCE: ELECTRONIC MEDIA USE IN NEURODEVELOPMENTAL DISORDERS Tolga Atilla Ceranoglu, MD, Massachusetts General Hospital, [email protected] Objectives: Concerns over the effects of electronic media use on adolescents have developed over the last two decades. Research on the effects of circumstances of media use has been consistent. There are also multiple views on the potential vulnerability of children with neurodevelopmental disorders to be more at risk to experience these negative effects. Methods: A review of literature media use among youth with neurodevelopmental disorders was carried out on PubMed and PsycINFO databases, with keywords “children and adolescent,” “autism,” “attention-deficit hyperactivity disorder,” “internet,” “online social networks,” “mobile phones,” and “video games,” and resulting articles were then assessed for level of evidence and relevance. Results: Children with autism spectrum disorder (ASD) tend to prefer solitary activities such as electronic media, and contrary to common assumption, they do not use such media for social activity purposes. Children with ADHD also tend to spend more time using media than others and experience more difficulty in limiting and monitoring their own media use. Children with ASD tend to spend significantly more time playing video games than those with typical development or ADHD and spend less time on email and social media. Comorbidity with intellectual disability may pose additional barriers to accessing electronic media, internet communication, and video game use. Problematic media habits correlate with attention and academic problems in a dose-dependent manner. Conclusions: Children with neurodevelopmental disorders are at increased risk for problematic media use. Problematic media use may have deleterious


effects as it may displace normative and protective experiences for a child and may intensify the manifestation of symptoms of an existing condition. Screening for media use habits and guiding caregivers on effective supervision of media use are an important part of psychiatric evaluation and treatment of children with neurodevelopmental disorders.

ADHD, ASD, MED http://dx.doi.org/10.1016/j.jaac.2017.07.101

17.3 FROM FEAR OF MISSING OUT (FOMO) TO FACEBOOK DEPRESSION: ONLINE PERILS AND PROSPECTS FOR YOUTH WITH INTERNALIZING DISORDERS Paul E. Weigle, MD, Natchaug Hospital, pweigle@ sbcglobal.net Objectives: The goals of this session are to understand how internet habits of youth with internalizing disorders affect their prognosis, the online behaviors that exacerbate these disorders, and online resources available to aid in treatment. Methods: An exhaustive, ongoing literature review was conducted on depression and anxiety in relation to internet activities and habits. The resulting studies and review articles were evaluated for relevancy and quality of evidence. The most important and relevant data and ideas are consolidated for the presentation, incorporating the author’s clinical experiences. Results: Adolescents suffering from internalizing disorders spend more time with internet entertainment than their peers. Teenagers suffering from depression and anxiety typically go online to seek help, access information, and share experiences. Teenagers are now more likely to express suicidal thoughts to peers online, which complicates access to treatment and risks contagion. Excessive online habits often expose youth to online bullying or become a behavioral addiction, worsening depression and anxiety in vicious cycles. Adolescents with internalizing disorders frequently find support in online communities, providing relief in the short-term but related to worsening symptoms over time in those who are most engaged. Certain therapeutic smartphone applications, text crisis lines, and video games deliver innovative adjunctive treatments for depression and anxiety, although limited data demonstrate efficacy. Novel online therapies are inexpensive, easily assessable, self-guided, and private and have demonstrated efficacy. However, these treatments can promote secrecy, displace face-to-face connection and the therapeutic relationship, and may displace engagement in conventional treatments. Some evidence-based online treatments are internet-based but therapist-guided and may offer the advantages of online therapies without the drawbacks. Conclusions: Certain online habits and experiences put youth at greater risk for developing or exacerbating depressive and anxiety disorders. In contrast, novel online treatments and tools provide new pathways toward recovery. Psychiatrists must understand these novel risks and opportunities to best assess and treat adolescents suffering from depression and anxiety.

AD, COMP, DDD http://dx.doi.org/10.1016/j.jaac.2017.07.102

17.4 ELECTRONIC MEDIA USE IN YOUTH WITH TRAUMA-RELATED AND EXTERNALIZING DISORDERS: SYMPTOM OR CONTRIBUTING CAUSE? Kristopher Kaliebe, MD, University of South Florida, [email protected] Objectives: The goals of this session are to understand the trends in electronic media usage patterns in children and adolescents with disruptive, impulse-control, and conduct disorders, and trauma- and stressor-related disorders, and to review practical clinical strategies that promote healthy media use in these populations.

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Methods: A literature search on electronic media use and disruptive, impulsecontrol, and conduct disorders, and trauma- and stressor-related disorders was carried out on PubMed and PsycINFO. A literature search relating electronic media to the following features was performed: family conflict, developmental trauma, traumatic stress, and problems with authority, anger, and violence. The most important and relevant data and ideas are consolidated for the presentation, incorporating the author’s clinical experiences. Results: Children who have experienced trauma and those with behavior disorders tend to be heavy users of technology. Furthermore, children growing up in chaotic families and adverse communities often turn to electronics as a way to connect, self-sooth, explore identity, and learn. Yet for children who have already experienced harsh environments, exposure to violent and antisocial content seems to worsen anger, aggression, self-control, and defiance of authority. Reliving trauma through media can perpetuate symptoms. Furthermore, media-related problems often appear in treatment with this population because of their tendency to defy authority, reenact trauma, and seek stimulation. In this circumstance, evidence-based, familyfocused interventions, such as strengthening family bonds, reducing negative communications, shaping new behaviors, and rewarding positive changes, can be applied. Motivational and psychoeducational individual approaches seem to be most effective with these children and adolescents. Conclusions: Research confirms an overall negative effect of electronic media in traumatized populations and children with behavioral disorders, yet this is as much a symptom as a cause. Nonetheless, unhealthy relationships with electronic media can worsen these disorders. Clinicians treating children with disruptive behavior disorders and trauma-related disorders will need to assess for and treat problems related to the media and technologies.

COMP, CD, PTSD http://dx.doi.org/10.1016/j.jaac.2017.07.103

CLINICAL PERSPECTIVES 18 CURRENT DEVELOPMENTS IN QUALITY IMPROVEMENT Oscar Gary Bukstein, MD, MPH, Boston Children’s Hospital, [email protected] Objectives: Participants will recognize the basic elements and examples of the implementation of quality improvement in clinical services for child and adolescent psychiatry. Methods: Through five didactic presentations based on literature review and presenter experience, presenters will provide an overview of quality improvement and a variety of quality improvement projects and examples. Results: The presenters will provide information on the following: 1) definition, dimensions, and process of quality improvement efforts; 2) potential solutions to problems in quality dimensions on inpatient units; 3) the value of measurement-based practice for outcomes in child/adolescent psychiatry practice; 4) quality improvement problem-solving process in dealing with the issue of boarders in a children’s hospital; and 5) the importance of clinical practice guidelines toward establishing quality measures and clinical outcomes. Conclusions: Although mental health clinicians need to be concerned with improved clinical outcomes of specific patients and their families, improved outcomes are often the result of systemic changes, good response to problems, and other domains of quality improvement.

ADMIN, QA Sponsored by AACAP's Quality Issues Committee

reliably safe and high-quality outcomes for patients, families, and staff; 3) integrating quality improvement principles provides a framework to enhance clinical programs and improve clinical team performance; and 4) specific quality improvement efforts that decrease rates of patient and staff injury. Methods: Literature review and case examples will be used. Basic principles of quality improvement science and its role in healthcare will be introduced. Successful efforts to improve patient safety and staff injury across a large inpatient program will be discussed. Results: Participants will be able to 1) understand the dangers associated with inpatient psychiatric care for patients and staff and the need for systematic approach to improve the outcomes for patients and caregivers; 2) understand the usefulness of quality improvement principles in shaping the development and functioning of multidisciplinary care teams; 3) be able to identify strategies to improve patient safety in the acute care setting; and 4) identify methods to engage staff in programs that decrease caregiver injury. Conclusions: The application of quality improvement principles allows the clinician to more effectively manage the complex system of the inpatient setting and put in place effective programs that improve safety for patients and caregivers.

ADMIN, MDM, QA http://dx.doi.org/10.1016/j.jaac.2017.07.106

18.2 USING QUALITY IMPROVEMENT TO ENHANCE SAFETY ON INPATIENT UNITS Michael T. Sorter, MD, Cincinnati Children’s Hospital Medical Center, [email protected] Objectives: Participants will learn about the following: 1) that inpatient psychiatry is a high-risk area for patients and healthcare providers; 2) that development of highly effective healthcare teams are required to deliver reliably safe and high-quality outcomes for patients, families, and staff; 3) that integrating quality improvement principles provides a framework to enhance clinical programs and improve clinical team performance; and 4) that specific quality improvement efforts decrease rates of patient and staff injury. Methods: Literature review and case examples will be presented. Basic principles of quality improvement science and its role in healthcare will be introduced. Successful efforts to improve patient safety and staff injury across a large inpatient program will be discussed. Results: Participants will 1) understand the dangers associated with inpatient psychiatric care for patients and staff and the need for systematic approach to improve the outcomes for patients and caregivers; 2) understand the usefulness of quality improvement principles in shaping the development and functioning of multidisciplinary care teams; 3) be able to identify strategies to improve patient safety in the acute care setting; and 4) identify methods to engage staff in programs that decrease caregiver injury. Conclusions: The application of quality improvement principles allows the clinician to more effectively manage the complex system of the inpatient setting and put into place effective programs that improve safety for patients and caregivers.

AGG, ICP, QA http://dx.doi.org/10.1016/j.jaac.2017.07.107

18.3 MEASURING OUTCOMES IN AMBULATORY PSYCHIATRY


Rajeev Krishna, MD, PhD, MBA, Nationwide Children’s Hospital, [email protected]

18.1 UNDERSTANDING QUALITY IMPROVEMENT

Objectives: The objective of this presentation is to demonstrate how quality improvement techniques and automated assessment systems were used in a large ambulatory psychiatry clinic to build the infrastructure for outcomebased care. Methods: The Institute for Healthcare Improvement (IHI) quality improvement methodology was used to identify barriers to implementation of outcomebased care. A series of interventions using Plan-Do-Study-Act (PDSA) cycles were used to deploy an automated infrastructure for collecting and scoring

Oscar Gary Bukstein, MD, MPH, Boston Children’s Hospital, [email protected] Objectives: In this session, participants will learn about the following: 1) that inpatient psychiatry is a high-risk area for patients and healthcare providers; 2) development of highly effective healthcare teams is required to deliver

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validated assessment scales before visits with providers. The percent of completed assessments was the primary outcome. Provider satisfaction and time efficiency were considered secondary outcomes. A balancing measure of patient satisfaction was monitored. Results: A completion rate goal of 90 percent was successfully achieved and maintained. Contrary to available literature, provider impression was quite positive (4.3 on Likert scale 0–5, 5 ¼ very helpful, 3 ¼ neutral on question of how helpful the system was). Only six percent of providers felt that visit efficiency was negatively affected. All providers felt that documentation efficiency was improved. Overall provider opinion of the system was highly positive. Overall patient satisfaction was also quite positive (4.1 on Likert scale 0–5, 5 ¼ very positive, 3 ¼ neutral on question of utility of the tool), and there was no statistical variation across the duration of implementation or time taken to complete the tool. Conclusions: This presentation describes the use of IHI quality improvement methodology to implement a system of outcome-based care in ambulatory psychiatry. We demonstrate strategies for overcoming the barriers encountered both at a patient and provider level and that systematic outcome data collection can be achieved without disrupting patient or provider satisfaction, or negatively affecting the assessment and treatment process.


18.4 IMPROVING PATIENT FLOW FOR PSYCHIATRIC INPATIENT LEVEL OF CARE ADMISSIONS Courtney Demuth, MPH, Boston Children’s Hospital, [email protected] Objectives: Participants will learn to apply Lean Six Sigma tools to improve patient flow from emergency department entry to psychiatric inpatient admission and balance patient/family experience and stakeholder needs through effective and collaborative process design. Methods: Lean and Six Sigma are business management strategies originally used in production industries to improve efficiency and quality. Lean involves a set of principles, practices, and methods for designing, improving, and managing a process. At its core, Lean focuses on eliminating waste, in particular, waste that uses time and resources that do not add value. Six Sigma aims to make processes uniform and precise through the application of statistical methods. Results: Decreasing patient wait time for access to an inpatient psychiatric placement will improve the patient and family experience and keep patients safer. Managing patients who are awaiting placement consumes significant staff time and energy; reducing wait times will improve staff satisfaction. Decreasing wait time will make space for other patients, who in turn generate higher revenue for the hospital. Conclusions: The flow of behavioral health patients identified as needing a higher level of psychiatric care presents a complex challenge. Overcrowding in the emergency department and medical/surgical floor is most often associated with delayed output, and patients with psychiatric emergencies and behavioral health needs tend to exacerbate this problem. As a result, the current state generates a prolonged length of stay, lack of bed turnover, poor patient handoffs, care coordination challenges, and reduced revenue. In addition to improving flow, it is also important to consider the timing of admissions, which is associated with different staffing models, caregiver availability, and patient wakefulness, all of which may influence the admissions experience.

ADMIN, MDM, QA

Methods: The presenter will provide a literature review and description of AACAP’s clinical practice guidelines (CPG) process. Results: CPGs can help enhance quality by synthesizing available research evidence and delineating recommendations for care based on the available evidence. Practice guideline recommendations will be appropriate to use in developing quality measures. Guideline statements can also be used in other ways, such as educational activities or electronic clinical decision support, to enhance the quality of care that patients receive. Conclusions: CPGs can be an important component of a quality improvement in child and adolescent psychiatry.


CLINICAL PERSPECTIVES 19 IDENTIFYING, PREVENTING, AND TREATING SUICIDAL YOUTH Maryland Pao, MD, National Institute of Mental Health and the National Institutes of Health, [email protected]; Tatiana Falcone, MD, Cleveland Clinic, [email protected]; David A. Jobes, PhD, Catholic University of America, jobes@cua. edu; Lisa M. Horowitz, PhD, MPH, National Institute of Mental Health Intramural Research Program at the National Institutes of Health, [email protected]; Joseph M. Austerman, DO, Cleveland Clinic, [email protected]; Jane Timmons-Mitchell, PhD, Case Western Reserve University, [email protected] Objectives: Participants will be able to learn new tools for suicide screening and identify proximal risk factors when managing youth who are suicidal on the medical floor. They will also be able to recognize chronic medical illnesses that increase the risk of suicide in youth and how to structure treatment after discharge in children at risk for suicide. Suicide remains the most serious complication of any mental health disorder. Youth suicide is now the second leading cause of death among adolescents. Methods: Each of the presenters will share their expertise in working with youth contemplating suicide. Dr. Horowitz will discuss “Screening for Suicide Risk in the Pediatric ED: From Research to Implementation” using the Ask Suicide-Screening Questions. She will present screening guidelines and multidisciplinary roles for successful implementation. Dr. Austerman will focus on management of suicidal patients while hospitalized in general pediatric or intensive care units and provide insight into short-term management of youth who are considered very high risk on the medical floor. Dr. Falcone will review increased suicide risk for several chronic medical illnesses and how early screening can improve recognition of youth at risk for suicide. Dr. TimmonsMitchell will describe treatment after hospitalization that is designed to prevent rehospitalization, including how to partner with community-based, home-based providers and keys to decision making about future care. Dr. Pao will lead the discussion of this workshop. Results: Each presenter will discuss a case, including barriers, to implementing proposed approaches. Active discussion with participants will address these approaches. Conclusions: Participants will leave the workshop with action steps and supporting resources to manage youth at risk for suicide.

CON, S, TREAT Sponsored by AACAP's Physically Ill Child Committee



18.5 THE USE OF CLINICAL PRACTICE GUIDELINES TO ENHANCE THE QUALITY OF CARE

19.1 SUICIDE IN CHRONIC MEDICAL ILLNESS IN CHILDREN

Heather J. Walter, MD, MPH, Boston Children’s Hospital, [email protected] Objectives: Participants will recognize the importance of clinical practice guidelines to enhance the quality of care and methods used to do so.


Tatiana Falcone, MD, Cleveland Clinic, [email protected] Objectives: Over the last 20 years, suicide rates have been increasing worldwide. Although the prognosis of suicide is complex, key psychosocial risk factors have been recognized to help identify individuals who may be at immediate risk. Certain chronic illnesses increase the risk of suicide in youth

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and adolescents. The objectives of this presentation are as follows: 1) to help child psychiatrist identify the risk factors of suicide in several chronic illnesses in children; and 2) to promote increased integration of care and early screening to prevent suicide in youth with chronic illness. Methods: This presentation includes a literature review on the risk factors for suicide in youth with chronic illness, such as epilepsy, asthma, traumatic brain injury, and lupus. Adolescents with chronic physical conditions are 20 percent more likely to report suicidal behavior, ideation, and/or attempts. A population-based study in Denmark suggests that adolescents with epilepsy, asthma, or insulin-dependent diabetes mellitus (IDDM) were at significantly higher risk for suicide attempts. In our study evaluating suicidal thoughts in a pediatric epilepsy clinic, 400 patients were evaluated multiple times (5,303 encounters). Results: Screening patients during a visit with their specialist can improve the probability to detect suicidal ideation (SI) and behavior. Of the 400 patients with epilepsy screened, 106 screened positive for suicide in our clinic. Of these patients, 50.9 percent were male and 49.1 percent were female. Thirteen patients were referred to the emergency department, and 13 suicides were prevented. Conclusions: The development of an algorithm that integrates pediatric epilepsy screening with psychiatry follow-up facilitated the screening of 400 children and youth with epilepsy. Of these, 26.5 percent screened positive for SI, which is a bit higher than rates found in other studies of children with epilepsy. The algorithm proved useful in organizing and systematizing the screening process. Evidence suggests that integrated mental health care in children with chronic illness clinic can help improve care for those children. Routine screening at least every six months for mood disorders and suicidal ideation in populations at high risk could aid in early referral and appropriate treatment and potentially save lives. Screening for mental health is feasible and necessary.

CON, S, TREAT http://dx.doi.org/10.1016/j.jaac.2017.07.797

19.3 MANAGING SUICIDAL PATIENTS FROM THE ED TO THE MEDICAL FLOOR THEN HOME, A PATHWAY Joseph M. Austerman, DO, Cleveland Clinic, [email protected] Objectives: The goals of this presentation are to discuss management of pediatric patients at risk for attempting suicide or self-harm while hospitalized on medical units and to provide a sample of an intervention protocol in patients that are identified as being at risk while hospitalized on medical units or in the emergency department. Methods: Pediatric psychiatric disorders account for an increasing number of pediatric medical admissions due to lack of psychiatric beds. Few studies have explored the rate or management of suicide attempts while patients are hospitalized on medical units even though a Joint Commission review found that 14.25 percent of inpatient suicides occurred while the patient was on a medical unit. Focus is now being placed on identifying patients at risk for suicide but there are no consistent protocols for managing pediatric patients that are at risk for suicide while hospitalized. Efforts are being made to utilize validated screening measures that can identify at-risk patients but there are no validated protocols that offer consistent guidelines on how to manage patients once identified. Results: The development of a standardized protocol for assessment, monitoring, and intervention implementation will be presented, which focuses on management while the patient is hospitalized through connection with outpatient services. Conclusions: Implementation of standardized screening measures tied to a specific protocol of management involving a multidisciplinary team can lead to more timely intervention and improve safety outcomes.


19.2 SUICIDE RISK SCREENING IMPLEMENTATION AND MANAGEMENT OF POSITIVE SCREENS IN PEDIATRIC MEDICAL SETTINGS Lisa M. Horowitz, PhD, MPH, National Institute of Mental Health Intramural Research Program, [email protected] Objectives: The goal of this presentation is to discuss suicide risk-screening research and implementation in the emergency department (ED), inpatient medical unit, and outpatient primary care setting. Particular attention will be paid to the role of mental health clinicians and how they can support/guide hospitals and primary care settings in the implementation process. In February 2016, The Joint Commission issued Sentinel Event Alert 56, recommending that all medical patients be screened for suicide risk by The Joint Commission (in 2016). Given that 80 percent of youth who die by suicide visit a healthcare provider within months prior to their death, this alert paved the way for hospitals to implement strategies to capture young patients at risk. Despite this national effort for identifying youth at risk for suicide in the medical setting, there are no evidence-based guidelines for screening and intervention programs. Non-mental health clinicians on the frontlines require valid, youth-specific and site-specific tools to accurately detect patients at risk for suicide. Even more challenging than screening is the management of the patient who screens positive for suicide risk in the medical setting. Methods: Development of a suicide risk-screening tool designed for the medical setting, the Ask Suicide-Screening Questions (ASQ), will be presented. Validation studies in the inpatient and outpatient setting will also be discussed. In addition, implementation examples will be provided, as well as strategies for the management of positive screens. Results: The ASQ has been implemented in EDs, inpatient medical units, and outpatient primary care settings around the country. Positive screen rates, patient and parent opinions about screening, and management strategies for positive screens will be presented. Conclusions: Universal suicide risk screening for youth in the ED, the inpatient medical unit, and the primary care setting is feasible, valuable, and can help save young lives.


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19.4 SUICIDE PREVENTION IN COMMUNITYBASED CARE: EVIDENCE FOR THE IMPORTANCE OF RESILIENCE Jane Timmons-Mitchell, PhD, Begun Center for Violence Prevention Research and Education, Case Western Reserve University, [email protected] Objectives: The goal of this presentation is to describe an approach to treatment after hospitalization designed to prevent rehospitalization among youth hospitalized for suicide complaint. In addition to clinical practice, a data collection effort is underway to test what variables predict return to the hospital within one year of discharge from the adolescent psychiatric unit. Methods: A total of 650 youth discharged from an adolescent inpatient unit were given a Toolkit at discharge. Exploratory factor analysis (EFA), latent class analysis (LCA), and predictive models were conducted to see whether we could predict who would return within a year. Results: EFA results indicate three factors as follows: 1) suicide risk; 2) personal/historic factors; and 3) resilience. LCA resulted in three groups; resilience may be the important mediating factor for returning to the hospital. Conclusions: By combining a clinical focus with Toolkit data, it may be possible to balance safety with risk by including resilience-promoting factors in treatment and in everyday life for adolescents.


CLINICAL PERSPECTIVES 20 INNOVATIVE INTERDISCIPLINARY APPROACHES TO COMMUNITY VIOLENCE IN YOUTH Seeba Anam, MD, University of Chicago Medicine Comer Children’s Hospital, [email protected]; Elizabeth Thompson, PhD, Center for Child and Family Traumatic Stress - Kennedy Krieger Institute, thompson@ kennedykrieger.org

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Objectives: The goals of this session are as follows: 1) describe how community violence contributes to a widening gap between unmet mental health needs and available trauma-informed mental health resources; 2) compare interdisciplinary approaches to addressing mental health needs of youth exposed to community violence in a high-risk population; and 3) discuss the application of the tenets of collaborative care to scale up interventions for specialized mental health care needs. Methods: A multidisciplinary panel of experts in intervention for youth exposed to community violence will delineate integrative, innovative models of service delivery to increase access to trauma-focused mental health services. Drs. Cicchetti, Dinizulu, Stolbach, and Suarez, who represent three academic medical centers, highlight their novel programs to deliver pediatric trauma-informed services to address the consequences of the epidemic of community violence in Chicago. The discussant, Dr. Thompson, comments on these approaches from the perspective of a child trauma expert working in another major US city struggling with high levels of violence and then leads all panelists and attendees in a discussion of the efficacy and impact of distinct collaborative relationships upon addressing the public health burden of community violence in the youth population. Results: The design and implementation of interdisciplinary approaches that address mental health for youth affected by community violence, with a spectrum of collaborators, are discussed. Barriers and facilitators to the effective service delivery of novel programs in acute medical settings, school systems, faith-based organizations, and community organizations are discussed. Preliminary quantitative and qualitative findings, including review of service utilization, effective coverage statistics, and engagement with stakeholders, are highlighted by the expert panel. Conclusions: This seminar aims to impart knowledge about trauma-informed service delivery, demonstrate novel applications of interdisciplinary collaborative care models, and provide a frame to scale up psychiatric interventions to address a rising public health concern.

PTSD, CON, AGG Sponsored by AACAP's Disaster and Trauma Issues Committee http://dx.doi.org/10.1016/j.jaac.2017.07.114

20.1 THE UNIVERSITY OF CHICAGO MEDICINE REACT PROGRAM: RECOVERY AND EMPOWERMENT AFTER COMMUNITY TRAUMA Bradley Stolbach, PhD, University of Chicago Medicine Comer Children’s Hospital, [email protected]. uchicago.edu Objectives: The goals of this session are as follows: 1) to recognize public health challenges posed by community violence to pediatric populations in Chicago; 2) identify distinct components of hospital-based trauma intervention across settings and disciplines; and 3) describe the application of novel collaborative care models to scale up interventions for trauma-informed care in an urban children’s hospital. Methods: This seminar describes the implementation of a collaborative care model to address the unmet mental health needs of youth affected by community violence. The program aims to facilitate early identification of children who have been affected by community violence through provision of screening, support, psychoeducation, and brief intervention in pediatric emergency department and pediatric intensive care unit settings. A subsequent component of care delivery, the interdisciplinary REACT (Recovery and Empowerment After Community Trauma) Clinic, is described. This clinic, which is codirected by a trauma psychologist and a child psychiatrist, provides trauma-informed psychological and psychiatric needs assessments for patients and access to ongoing trauma-focused therapy, as well as an opportunity for interdisciplinary training for psychology, psychiatry, and pediatrics trainees. The third component, implementation of outpatient evidence-based trauma-informed interventions, is detailed. Specific interventions are surveyed, including Child and Family Traumatic Stress Intervention (CFTSI); Child-Parent Psychotherapy (CPP); and Attachment, Regulation, and Competency (ARC), as well as the identification of providers with expertise in these interventions via use of networks and community-based provider partnerships.


Results: Successes and challenges encountered during the design and implementation of the REACT Program are discussed, along with service utilization statistics and feedback from patients, families, and internal customers (i.e., emergency department personnel and administrators). Conclusions: The seminar highlights how the REACT program aims to address the unmet mental health needs of youth affected by community violence by implementing a collaborative care service delivery model that uses evidence-based, trauma informed assessments and interventions.

AGG, CON, PTSD http://dx.doi.org/10.1016/j.jaac.2017.07.115

20.2 UNIVERSITY AND FAITH-BASED COLLABORATION TO BUILD RESILIENCE FOR AFRICAN AMERICAN YOUTH EXPOSED TO COMMUNITY VIOLENCE Sonya M. Dinizulu, PhD, University of Chicago Medicine Comer Children’s Hospital, [email protected] Objectives: In this session, participants will be able to do the following: 1) learn about community-based best practices to support collaboration between community and psychology/psychiatry institutions; 2) learn how to develop and implement behavioral health promotion programs for youth exposed to violence in faith-based settings; and 3) understand the importance of promoting positive youth development among youth exposed to community violence, as well as why faith-based settings provide unique opportunities to do this work. Methods: Dr. Dinizulu discusses a collaboration between a psychology/ psychiatry academic medical department with a faith-based institution using community-based research methods (e.g., community-based participatory research; The Clinic/Community Intervention Development Model, 2002) to develop a service-learning program for urban African American middle school-age youth (N ¼ 21) exposed to community violence. Specifically, the collaboration involves principle investigator Dr. Dinizulu and her research team and faith-based community members (the advisory board consisting of three adults and three middle school youth; two summer camp faith-based staff). Results: This presentation describes the following: 1) the collaborative processes with a faith-based organization (i.e., youth and adult community members and staff) to develop a sustainable service-learning program (i.e., curricula adaptation, training and supervision of workforce, and tool development) for African American youth (grades 6–8) exposed to community violence; 2) preliminary quantitative and qualitative findings of the program (i.e., acceptability, usability, and fidelity); and 3) the preliminary results of the service-learning model to impact youth mental health (i.e., social-emotional and behavioral functioning), academic motivation, and psychological engagement (i.e., community sense of belonging and social responsibility). Conclusions: Collaborating with faith-based organizations is a promising model to build sustainable positive youth development and behavioral health promotion programs that can address the unmet need of violence-exposed African American youth.

CON, PTSD, STRESS http://dx.doi.org/10.1016/j.jaac.2017.07.116

20.3 A COLLABORATIVE APPROACH FOR VIOLENCE PREVENTION AND TRAUMA INTERVENTION Liza Suarez, PhD, University of Illinois at Chicago, lsuarez@ psych.uic.edu Objectives: The goals of this session are as follows: 1) to describe the socioecological framework for violence prevention and recognize the negative systematic impact of community violence across individuals, relationships, community, and societal levels; 2) to describe best practices for violence prevention and trauma intervention; and 3) to be familiar with community activation as it relates to violence prevention and its implications for health professionals.

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Methods: Children’s exposure to violence is alarmingly common, especially in lower income, predominantly ethnic minority communities. Community violence exposure is associated with a myriad of negative outcomes, including the development of posttraumatic stress symptoms, aggressive and hostile behavior in youth, and the development of substance abuse problems. Given the range of effects resulting from these experiences, public health efforts to ameliorate community violence need to target and collaborate with entire communities and service systems. Results: The Urban Youth Trauma Center (UYTC) adopts an ecologically based, socioculturally-rooted model that integrates prevention and intervention activities for predominantly low-income urban ethnic minority youth. Youth Overcoming Urban Trauma and Healing: A Community Action Network (YOUTH-CAN) is a collaborative communitybased violence prevention training program to improve the community’s ability to reduce and prevent violence and its impact on urban youth. YOUTH-CAN brings together youth service system representatives to cooperate in providing effective trauma-informed and violenceresponsive care for low-income urban ethnic minority youth. Based on a socioecological model for violence prevention, YOUTH-CAN recognizes the negative systematic impact of community violence across individuals, relationships, community, and societal levels and provides a comprehensive framework for applying best practices for violence prevention. Conclusions: After summarizing the program and illustrating strategies for violence prevention, the presenter describes a novel way to measure and promote community member activation and participation in violence prevention efforts. Applications for activation among health professionals are emphasized.

AGG, PTSD, PRE http://dx.doi.org/10.1016/j.jaac.2017.07.117

20.4 A SCHOOL-COMMUNITY COLLABORATION MODEL TO PROMOTE ACCESS TO TRAUMAINFORMED BEHAVIORAL HEALTH SUPPORTS Colleen Cicchetti, PhD, Ann & Robert H. Lurie Children’s Hospital and Northwestern University Feinberg School of Medicine, [email protected] Objectives: The goals of this study are as follows: 1) to demonstrate knowledge of a public health school-community approach to address exposure to violence and trauma; 2) to identify strategies and challenges of building a sustainable district-wide implementation plan; and 3) to describe a model for academic psychiatry departments to promote best practices and build capacity for mental health services through collaboration. Methods: This presentation describes a 10-year partnership between a pediatric hospital’s academic psychiatry department and Chicago Public Schools, the goal of which is to build and sustain behavioral health services and trauma-informed practices within a three-tier public health and educational practice approach. School staff are trained to recognize the impact of trauma and signs of distress and then create district-wide strategies for referral, screening, and intervention. Tier 1 includes training on trauma’s impact; development of multidisciplinary teams to further disseminate training; ongoing coaching and implementation of trauma-informed practices; and training and on-site coaching of the behavioral health team (BHT). Tier 2 includes implementation of evidence-based trauma interventions (Cognitive Behavioral Intervention for Trauma in Schools and Bounce Back) and interventions targeting reactive aggression (anger coping and Think First). Tier 3 includes partnering with school staff and BHTs to connect schools to local mental health providers. Multidisciplinary BHTs collaborate across school, family, and community systems and use data-informed discussions of student needs to match students to the right interventions. Results: Based on preliminary data analysis, schools with BHTs identified and served more students in Tier 2 groups than schools without BHTs. Students have been linked to in-school and community-based services, including individual and group counseling, mentoring, pregnant/parenting services, crisis assessments, restorative justice interventions, case management, and substance abuse counseling.

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Conclusions: Pediatric hospitals can provide consultation, training, technical assistance, and progress monitoring to support sustainable evidencebased mental health services in a large urban school district, addressing unmet mental health needs of youth impacted by community violence and other forms of trauma.

AGG, PTSD, SC http://dx.doi.org/10.1016/j.jaac.2017.07.118

CLINICAL PERSPECTIVES 21 INPATIENT TREATMENT OF CHILDREN WITH AUTISM AND INTELLECTUAL DISABILITY: THREE INNOVATIVE MODELS Matthew Siegel, MD, Spring Harbor Hospital, SIEGEM@ MaineBehavioralHealthcare.org; Bryan H. King, MD, MBA, University of California, San Francisco, [email protected] Objectives: This Clinical Perspectives session presents the latest information on innovative models of inpatient care for children with autism spectrum disorder (ASD) and intellectual disability (ID). Identifying approaches, with a range of intervention intensity and resource dependence that improve inpatient outcomes, enhances dissemination and may facilitate replication. Methods: A multidisciplinary group of three presenters will describe implementation and preliminary outcomes for inpatient treatment of youth with ASD and ID using the following criteria: 1) a low-intensity clinical pathway; 2) a moderate intensity, within-unit, population-specific program; and 3) high-intensity specialized psychiatric units. Results: Implementation of a clinical pathway or a within-unit, populationspecific program was feasible in regular child psychiatry units and was associated with preliminary positive results. Specialized psychiatric unit admission was significantly associated with improved behavioral outcomes. Conclusions: Children with ASD or ID are at high risk for psychiatric hospitalization, and three different models of enhanced inpatient care for this population, featuring varying levels of multidisciplinary supports, may offer paths to improved care and outcomes.

ASD, ICP, TREAT http://dx.doi.org/10.1016/j.jaac.2017.07.120

21.1 A CLINICAL PATHWAY FOR CHILDREN WITH AUTISM SPECTRUM DISORDER IN A GENERAL CHILD PSYCHIATRY UNIT: IMPLEMENTATION AND EVALUATION Sarah Kuriakose, PhD, New York University Child Study Center, [email protected]; Beryl Filton, PhD, New York University Langone Medical Center, beryl.fi[email protected]; Mollie Marr, BA, Oregon Health and Science University, sarah. [email protected]; Victoria Osasah, MPH, New York University Langone Medical Center, sarah.kuriakose@nyumc. org; Matthew Siegel, MD, Spring Harbor Hospital, SIEGEM@ MaineBehavioralHealthcare.org; Jennifer Havens, MD, New York University School of Medicine, [email protected] Objectives: This clinical perspectives session presents preliminary data on the outcomes of a clinical pathway (CP) for children and adolescents with autism spectrum disorder (ASD) or intellectual disability (ID) who were hospitalized in a general child psychiatric unit at a public hospital. Methods: Children with ASD are at greater risk of psychiatric hospitalization than their neurotypical peers. Although care in specialized psychiatry units has preliminary evidence for positive outcomes, the vast majority of children in the United States are treated in general units that are not designed for this challenging population. Review of best practices and expert consensus was used to design and implement a CP in three child and adolescent inpatient units at Bellevue Hospital Center. Fidelity to the CP was examined by use of a

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checklist. Retrospective chart review was used to identify patients eligible for the CP in the 18 months before implementation and compare outcomes (mean length of stay, use of intramuscular medications, and use of restraint) of patients exposed to the CP in the first 18 months of implementation. Results: Treatment fidelity to the CP was acceptable based on checklist review. Record review identified over 70 patients with ASD who were admitted in the 18 months before implementation. Of these patients, approximately 50 percent met CP eligibility criteria. Outcomes for these admissions were compared with outcomes for 30 admissions to the CP. Preliminary analysis indicated improved outcomes post-CP implementation. Conclusions: Expert consensus has indicated that expanded, targeted admission assessment; basic supports for functional communication; predictable routines; developmentally appropriate milieu of activities, including physical activities; and increased density of positive reinforcement are critical elements for effective inpatient care of children with ASD or ID. The design and pilot implementation of a clinical pathway using these elements at Bellevue Hospital Center over 18 months showed that it is feasible to incorporate these principles in a general inpatient child psychiatry unit and may improve outcomes.

ASD, ICP, TREAT Supported by New York University/Bellevue Clinical Innovations Grants http://dx.doi.org/10.1016/j.jaac.2017.07.121

21.2 INTENSIVE INPATIENT TREATMENT FOR CHILDREN WITH AUTISM AND OTHER NEURODEVELOPMENTAL DISORDERS (ICAN): SPECIALTY CARE PROGRAM IN A STATE-OPERATED HOSPITAL Dina Kerasiotis, ARNP, PsyD, New York State Office of Mental Health, [email protected]; Toni Procops, MSW, New York State Office of Mental Health, Dina.kerasiotis@ omh.ny.gov; Jason Smith, MS, New York State Office of Mental Health, [email protected]; Alison Fredlake, MS, New York State Office of Mental Health, [email protected]; Bradley Richman, LCSW, New York State Office of Mental Health, [email protected]. gov; Matthew Siegel, MD, Spring Harbor Hospital, SIEGEM@ MaineBehavioralHealthcare.org; Kenneth C. Spitalny, MD, New York State Office of Mental Health, kenneth.spitalny@ omh.ny.gov Objectives: Youth with autism spectrum disorder (ASD) or intellectual disability (ID) make up an increasing proportion of inpatient psychiatric admissions, and these children may experience higher rates of STAT behavioral medication usage when they are managed with approaches developed for the neurotypical inpatient population. We describe preliminary data from a novel inpatient program (International Center for Autism and Neurodevelopment, ICAN) in a New York State Children’s Psychiatric Hospital. We hypothesized that aggregation of this population in one wing of one of the inpatient units, provision of individualized behavioral plans, a milieu setting focused on teaching and reinforcing social skills, and direct care staff training could lead to a decrease in the number of STAT behavioral medications used. Methods: Four children hospitalized in the general child psychiatric unit met the ICAN program criteria of ASD or ID and were transferred to the ICAN wing. The number of STAT behavioral medications was abstracted from the medication administration records of four subjects for eight weeks before transfer and after a four-week transition period for the eight subsequent weeks. The ICAN program had two direct care staff for up to eight children, which was one more staff person than the standard hospital staffing ratio. Results: The use of STAT medications substantially declined, although this did not reach statistical significance. During the preperiod, an average of 27.8 (SD 24.1) oral STAT medications and 6.25 (SD 5.31) intramuscular (injected)


STAT medications were used compared with 12.0 (SD 11.0) oral and 1.25 intramuscular STAT medications in the postperiod. Use of an antipsychotic drug as the STAT medication declined 81 percent. Notably, two of the four subjects were staffed 1:1 in the pretransfer period, so the effective staffing ratio decreased for these patients. Conclusions: It is feasible to aggregate youth with neurodevelopmental disorders in one wing of a unit within a state-operated child inpatient facility and provide a more specialized population-specific program. Although no causal link can be offered because of the pre/poststudy design and the suggestion of an association is not appropriate given the very small sample group, the decrease in the use of STAT medications after implementation of the ICAN program bears further study.

ASD, ICP, TREAT http://dx.doi.org/10.1016/j.jaac.2017.07.122

21.3 SPECIALIZED INPATIENT PSYCHIATRY UNITS FOR YOUTH WITH AUTISM AND SERIOUS PROBLEM BEHAVIORS: TREATMENT MODEL AND BEHAVIORAL OUTCOMES Kahsi A. Pedersen, PhD, Maine Medical Center Research Institute, [email protected]; Susan L. Santangelo, ScD, Maine Medical Center Research Institute, SSANTANGEL@ mmc.org; Robin L. Gabriels, PsyD, University of Colorado Anschutz Medical Center, Robin.Gabriels@childrenscolorado. org; Giulia Righi, PhD, Bradley Hospital, giulia.righi@lifespan. org; Matthew Siegel, MD, Spring Harbor Hospital, SIEGEM@ MaineBehavioralHealthcare.org Objectives: Children and adolescents with autism spectrum disorder (ASD) are hospitalized for psychiatric reasons at a much higher rate than children who do not have ASD because of serious emotional and behavioral problems, including aggression, self-injury, and tantrum-like behaviors. Methods: This presentation focuses on the model of specialized child psychiatry units for the treatment of children with ASD and serious behavioral challenges and provides comparative outcomes for six specialized units participating in the Autism Inpatient Collection (AIC) study. (n ¼ 350; aged 4– 20 years), with an Autism Diagnostic Observation Schedule (ADOS-2)confirmed ASD diagnosis, were prospectively enrolled in the AIC study, a sixsite consortium investigating phenotypes, genotypes, and behavioral outcomes. A consistent caregiver completed measures at admission, discharge, and two months after discharge and reported their child’s demographics, problem behaviors [Aberrant Behavior Checklist–Irritability (ABC-I) subscale], expressive communication, and adaptive behavior. Changes in problem behavior over time were examined using multilevel model repeated-measures analysis of covariance. Results: The multidisciplinary bio-behavioral treatment model used by these six specialized units was associated with a significant decrease in child problem behaviors from admission to discharge for all study sites and slight increases in problem behaviors from discharge to two months followup, which varied by site. Improvement in problem behaviors, however, was not uniform across sites, even after controlling for significant site differences. Length of stay was the only statistically significant covariate in all models. Conclusions: Hospitalization in specialized child psychiatry units appeared to be effective in reducing the severity of child problem behavior from admission to two months after discharge for children and adolescents with ASD, and length of stay may be a significant factor in this model of care. These results can help inform public policy on investing in services for this growing, highneeds population.

ASD, ICP, TREAT Supported by the Autism Inpatient Collection, the Simons Foundation Autism Research Initiative Grant 296318, and the Nancy Lurie Marks Family Foundation http://dx.doi.org/10.1016/j.jaac.2017.07.123

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CLINICAL PERSPECTIVES 22 IS INTEGRATED CARE THE ANSWER FOR CHILDHOOD TRAUMA? APPROACHES, CHALLENGES, AND FUTURE DIRECTIONS Brooks R. Keeshin, MD, University of Utah School of Medicine, [email protected]; D. Richard Martini, MD, Primary Children’s Hospital and the University of Utah School of Medicine, richard.martini@hsc. utah.edu Objectives: Traumatized children experience ongoing health concerns at higher rates than children with other psychiatric conditions. Therefore, pediatricians are perfectly situated to effectively collaborate with child psychiatry and child mental health colleagues to care for children after trauma. The objective of our presentation is to present integrated care approaches to identify, assess, and treat childhood trauma in outpatient pediatric settings. Methods: Each presentation will focus on specific opportunities and barriers for pediatric and mental health providers to deliver care to traumatized children. Within the presentations, we will focus on two trauma exposures, intimate partner violence and foster care, and two clinical settings, primary care and children’s advocacy centers. Results: Dr. Harriet MacMillan will discuss the identification, assessment, and approach to intimate partner violence exposure among youth in pediatric settings based on the results of a large systematic review, identifying important clinical findings and key clinical interventions. Dr. Heather Forkey will describe the treatment of trauma among foster children. Integrated care includes review of preplacement exposures, familial factors, systems issues, and caregiver relationships. Use of a systematic approach with foster children is critical, as diagnostic challenges threaten the child’s permanency and safety. Dr. Neal Davis will describe the implementation of Safe Environment for Every Kid (SEEK), an evidence-based method of psychosocial screening, motivational interviewing, and connecting to resources to help children and families in areas of social determinants of health. Dr. Brooks Keeshin will present current practices and future opportunities for trauma treatment in children’s advocacy centers. We will review data that suggest high prevalence rates of trauma symptoms, practical trauma evaluation methods, and referral strategies for trauma treatment applicable to the children’s advocacy center setting. Conclusions: Our presentations identify the importance of collaborative approaches in the treatment of trauma-exposed children. The discussant, Dr. Rich Martini, will highlight shared themes in trauma treatment and future opportunities through integrated care systems.

PTSD, FOC, CAN Sponsored by AACAP's Child Maltreatment and Violence Committee and Committee on Collaboration with Medical Professions http://dx.doi.org/10.1016/j.jaac.2017.07.125

22.1 IDENTIFYING AND RESPONDING TO INTIMATE PARTNER VIOLENCE EXPOSURE AMONG CHILDREN AND ADOLESCENTS IN PEDIATRIC SETTINGS Harriet MacMillan, MD, Offord Centre for Child Studies, [email protected]; Susan M. Jack, PhD, McMaster University, [email protected]; Jen MacGregor, PhD, Western University, [email protected]; Nadine Wathen, PhD, Western University, [email protected] Objectives: Although the association between the four main types of child maltreatment (physical, sexual, emotional abuse, and neglect) and a range of psychiatric conditions is well recognized, there is less understanding about the increased risk of impairment experienced by children and adolescents who are exposed to intimate partner violence among caregivers. This presentation will discuss approaches to identifying, assessing, and responding to intimate partner violence exposure in pediatric settings.

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Methods: The presentation will be based on results of a systematic evidence review, which included three main questions and 14 subquestions related to recognition, assessment, and response. Building on an existing high-quality systematic review, a comprehensive search was conducted to identify new studies. Studies meeting inclusion criteria were assessed for risk of bias. An evidence review group of topic experts used a modified GRADE process to develop guidance statements for identification, initial response, and intervention. Results: In total, 2,173 articles were identified, of which 11 articles examining 1,054 participants were included. Most studies involved mothers and children (aged 4–14 years). Recognizing and responding safely to intimate partner violence requires being alert to red flags for abuse exposure, including physical and mental health symptoms and behavioural cues. The initial response to disclosure should prioritize the safety of the child and parent experiencing abuse. Evidence-based options for referral include the following: access to shelters/transition houses and system navigation and support for women and children, psychological interventions for preschoolers, cognitive behaviour therapy (children > 5 years) and child behavioural management skills training plus system navigation and support. Conclusions: Clinicians assessing children and adolescents in pediatric settings need to be alert to the problem of intimate partner violence exposure and familiar with how to inquire about such exposure without placing the child and his/her nonoffending caregiver at risk. Greater emphasis needs to be placed on the importance of recognizing and responding to intimate partner violence exposure among children and adolescents, including referrals to evidence-based interventions.

CAN, AGG, FAM Supported by the Public Health Agency of Canada http://dx.doi.org/10.1016/j.jaac.2017.07.126

22.2 SAFE AND SOUND: TAKING ON TRAUMA WITH CHILDREN IN FOSTER CARE Heather C. Forkey, MD, University of Massachusetts, heather. [email protected] Objectives: Studies demonstrate that a majority (68%) of children have experienced exposure to traumatic events; however, among children in foster care, the rate approaches 100 percent. Serving the needs of this profoundly affected population requires vigilance to their unique situation and context. Although strategies to address trauma are emerging, adaptations for children involved with child welfare need to be considered. This presentation will review the needs of traumatized children in foster care and appropriate clinical response, including diagnosis, treatment planning, and follow-up. Methods: Review of pre-placement exposures and familial factors to be identified will be discussed. The issues with the system that impact identification, diagnosis, and treatment and how they must be managed will be covered. Consideration of how to address trauma in the context of various caregiver relationships and how a treatment can impact safety and stability will be addressed. Results: Pre-placement issues include traumas within the familial context, familial history of trauma, and system’s trauma of placement. Traumasensitive attunement therapy with families demonstrates better outcomes than routine parenting supports. Multiple traumas occurring across the age and developmental spectrum can present variously and impact multiple domains of function, resulting in diagnostic challenges. Unique to these children, trauma-reactive behaviors may further threaten the child’s permanency and safety. These factors increase the pressure to provide pharmacotherapy, yet make management and monitoring of medications more difficult. Caregiver involvement in trauma care must be approached creatively, as caregivers may be unavailable and nontraditional caregivers may be considered. Finally, the impact of caregiver trauma history and secondary trauma on the clinician can influence care. Conclusions: The unique issues of children in foster care need to be considered when addressing trauma for this population, informing the presentation, diagnosis, treatment, and ongoing clinical monitoring of these

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children. Appropriately addressing the trauma of these children with attention to their biologic and foster caregivers has implications, not just for mental health but also for safety and stability before, during, and after placement.

FOC, PTSD, PTA http://dx.doi.org/10.1016/j.jaac.2017.07.127

22.3 USING MEDICAL HOME CARE MANAGEMENT TO ADDRESS PSYCHOSOCIAL RISKS FOR CHILDREN Neal Davis, MD, Intermountain Healthcare, Neal.Davis@ imail.org Objectives: Children exposed to adverse childhood experiences (ACEs) are substantially more likely to encounter challenges to their health and wellness over the course of life. Safe Environment for Every Kid (SEEK) is an evidencebased screening for family stresses and psychosocial risks, which includes motivational interviewing and team collaboration to connect families to supportive resources. Intermountain Healthcare (IH) recently implemented care management teams in pediatric practices and mental health integration as part of a system-wide medical home initiative. Our objective was to explore implementation of SEEK using the infrastructure of medical home care management in pediatric practices. Methods: Two pediatric practices implemented SEEK in 2016. During the first half of the year, all medical providers, nurse care managers, and care management support medical assistants completed the SEEK online training program. In addition, the care management teams worked collaboratively to identify community resources to match the psychosocial screening. During the second half of the year, these two practices implemented SEEK at wellness visits at 2 months, 9 months, 15 months, 2 years, 3 years, 4 years, and 5 years of age. Results: SEEK was successfully implemented within the structure of medical home care management. Care management teams from the two clinics shared information collaboratively regarding community resources. The workflow processes for implementation between the two clinics were similar with medical assistant care team members addressing basic risks, such as smoking in the home or food insecurity, leaving more critical risks such as parental mental health and intimate partner violence to nurse care managers and medical providers. In addition, integrated mental health providers were involved in care as needed. Children who were screened and identified with moderate or critical risks were followed by care management teams. Medical providers and care management team members subjectively noted significant impact on their clinic populations. Conclusions: SEEK is an effective method for identifying children with family stresses and triaging families in need of integrated care versus case management alone using the infrastructure of the IH medical home initiative.

EBP, PRE, STRESS http://dx.doi.org/10.1016/j.jaac.2017.07.128

22.4 OPPORTUNITIES FOR CROSS-SYSTEM COLLABORATION: THE EVALUATION OF TRAUMA IN CHILDREN’S ADVOCACY CENTERS Brooks R. Keeshin, MD, University of Utah School of Medicine, [email protected] Objectives: Children who disclose abuse are regularly evaluated at children’s advocacy centers (CACs), with more than 300,000 evaluations nationwide every year. CAC evaluations may consist of a forensic interview and/or medical evaluation by a pediatric provider specially trained in child abuse. CACs provide children with comprehensive child abuse evaluations, where results are available to child protection, law enforcement, prosecutors, and other agencies charged with the protection and safety of children. However, only recently has the National Children’s Alliance, the organization that oversees most CACs, developed comprehensive guidelines on the role of CACs in the evaluation of trauma. For the child psychiatrist who may be contacted by CACs for assistance, there is little guidance about effective strategies to detect, assess, and refer children with prominent trauma symptoms evaluated in CACs.


Methods: To address this system gap, we will review characteristics of children and families served by CACs, the multidisciplinary structure of CACs, and the goals of CACs. In the context of the CAC structure, we will present the following: 1) data that suggest a high prevalence of both trauma and selfharm/suicidal ideation among youth served at CACs; 2) trauma evaluation methods applicable in a CAC setting; and 3) referral strategies for traumabased treatment when specific trauma symptoms are detected. Results: Among 244 adolescents recently evaluated for trauma at a large urban CAC, more than 40 percent had clinically significant trauma symptoms, and nearly half of them screened positive for any thoughts of self-harm or suicidal ideation. Responding to high prevalence rates, we present quick and practical standardized strategies to detect and assess trauma. In addition, we identify models of integrated care within or in partnership with CACs that increase CAC capacity to respond to high trauma populations, even in resource-poor settings. Conclusions: CACs serve communities by providing coordinated, childfriendly forensic evaluations in suspected child abuse. This early contact with abused youth is ideal to detect and assess trauma in abused youth who are at increased risk for trauma and safety concerns. Standardized approaches to trauma assessment that can be implemented in CACs are critical to the detection and coordinated care of abused children.

CAN, MDM, PTSD http://dx.doi.org/10.1016/j.jaac.2017.07.129

CLINICAL PERSPECTIVES 23 PEDIATRIC AUTOIMMUNE ENCEPHALOPATHIES: WHAT SHOULD A CHILD PSYCHIATRIST KNOW? Lisa B. Namerow, MD, Institute of Living at Hartford Hospital, [email protected]; GenaLynne C. Mooneyham, MD, MS, Duke University Hospital, genalynne. [email protected] Objectives: This presentation will focus on increasing provider awareness of the autoimmune encephalopathies (AEs) and their associated neuropsychiatric symptoms. Patients with AE may present with or without focal neurological signs or symptoms. Likewise, the spectrum of illness associated with AEs is highly variable, with minimal or no findings on the initial medical evaluation. This makes the detection of AE even more complex, and the delay in diagnosis can lead to negative patient outcomes. As such, child and adolescent psychiatrists must familiarize themselves with the recognition of AEs to aid in both their detection and treatment. Methods: Speakers from different clinical backgrounds (neurology, rheumatology, child psychiatry, and neuropsychology) will present on the various aspects of AEs to include the clinical presentation, evaluation, and treatment options currently available. Dr. Gena Mooneyham will serve as discussant and will focus on the role of child psychiatry in the multidisciplinary care needs of patients with AE. Results: Participants will learn about pertinent clinical aspects of autoimmune encephalitis from a multidisciplinary approach. Likewise, this presentation will include information about current clinical guidelines surrounding the treatment of children and adolescents with AEs, both from a psychiatric care perspective and in relation to the immunomodulatory therapies currently available. In addition, participants will become more familiar with the role of the child and adolescent psychiatrist in the diagnosis and management of these complex patients. Conclusions: Given the increasing awareness of AEs over the past decade, the child and adolescent psychiatrist must become familiar with the diagnosis and treatment algorithms currently available. Neuropsychiatric changes are often among the first symptoms identified in patients with AEs. However, there can be diagnostic uncertainty and complexities, which may present a barrier to accessing appropriate care. As such, the child and adolescent psychiatrist must be knowledgeable about how AEs can impact cognition, perception, sensorium, and processing to be able to participate in the multidisciplinary treatment of AE.

NI, DIAG, PSY Sponsored by AACAP's Triple Board and Post Pediatric Portal Programs Committee and Physically Ill Child Committee http://dx.doi.org/10.1016/j.jaac.2017.07.131

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23.1 NEUROPSYCHIATRIC PRESENTATIONS OF AUTOIMMUNE ENCEPHALOPATHIES: A CLINICAL CASE SERIES Lisa B. Namerow, MD, Institute of Living at Hartford Hospital, [email protected] Objectives: This presentation will provide an introduction to the literature summarizing the current complexities in detecting patients with autoimmune encephalopathies (AEs) and will review three cases, which presented with neuropsychiatric findings that led the clinician to consider the diagnosis of AE. In addition, these case presentations will highlight the potential obstacles in making the diagnosis and in collaborating with other medical disciplines to provide a consistent approach to both treatment and recovery. Methods: Three clinical case presentations of patients with AE will be presented, highlighting the acute pattern of the onset of symptoms, the initial “negative” medical workup, the treatments used, the multidisciplinary nature of the treatment team, and the complexity of the clinical course. The first patient presented with acute confusion, disorientation, irritability, and mild paranoia in the setting of mycoplasma disease; another patient developed marked hypervigilance, agitation, and confusion initially thought to be secondary to Hashimoto’s disease; and the last patient developed acute onset Capgras-type delusions with associated impairments in cognition. In all three cases, the patients had normal findings on neurological exam, CT, MRI, EEG, and initial laboratory testing, leading to difficulties in developing a consensus in both diagnosis and appropriate treatment. Results: Participants will gain a more complete understanding of the clinical presentation, course of recovery, and the use of pharmacologic, immunologic, and nonpharmacologic treatments in order to promote a resolution of symptoms. Conclusions: Enhancing the ability of the child and adolescent psychiatrist to recognize the patterns of the neuropsychiatric aspects of the clinical presentation of AEs has become increasingly essential in helping with the detection and treatment of these conditions, given that the identification of the autoantibodies, in the setting of initial negative medical or neurologic focal findings, can take time. The current evidence suggests that delays in the detection and treatment of these syndromes may contribute to a worse prognosis. Therefore, the child and adolescent psychiatrist is well positioned, especially those who work in medical settings, to help to promote and enhance improved outcomes for these patients.

PSY, NI, CON http://dx.doi.org/10.1016/j.jaac.2017.07.132

23.2 UTILITY OF THE MONTREAL COGNITIVE ASSESSMENT AND NEUROPSYCHOLOGICAL SCREENING TOOLS TO IDENTIFY AND MONITOR AUTOIMMUNE ENCEPHALOPATHY Kevin P. Young, PhD, Institute of Living at Hartford Hospital, [email protected] Objectives: Psychiatric manifestations of autoimmune encephalopathy (AE) can confound and delay diagnosis, and treatment delays can have deleterious effects on prognosis. Standard laboratories aimed at identifying the cause of AE can take weeks to process, and tests that can rapidly distinguish psychiatric from medical patients are needed to begin the differential process. As many individuals with AE will present with cognitive symptoms, it is critical to develop concrete methods for identification and ongoing monitoring. Methods: The Montreal Cognitive Assessment (MoCA) was originally designed as a brief screen for mild cognitive impairment in adults but has demonstrated use as a general cognitive screener across numerous populations; mocatest.org currently lists almost 500 citations. It is translated into 62 languages and has multiple forms, increasing utility. We will show how to use the MoCA to guide probabilistic thinking about etiology of psychiatric symptoms associated with AE and subsequent monitoring of course. More advanced neuropsychological testing techniques will also be presented for cases wherein a more comprehensive approach is indicated.

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Results: Our sample group of 168 patients with mental illness aged 12–17 years (44% female) from diverse backgrounds (61% Caucasian) produced a mean MoCA performance of 24.54 (SD ¼ 3.67), which was statistically no different from our sample group of 238 patients aged 18–25 years [mean ¼ 24.55 (SD ¼ 4.08), P > 0.1]. Neither mental illness diagnosis nor demographic variables influenced scores from patients aged 12–25 years, and results were consistent with large, population-based adult norms. Given these MoCA norms within a mental illness population, the use of the MoCA for identification, monitoring, and/or triggering consultations within the management of AE will be considered. Conclusions: The MoCA appears to be a useful and an easily available tool in identifying possible cases of AE and in monitoring treatment efficacy. More detailed but still brief, bedside evaluation can be used to empirically demonstrate degree of change in cognition and confirm MoCA findings. Use of these tools by appropriately trained individuals can expedite treatment, although traditional work-up is still pending, and provide the basis for monitoring treatment efficacy.

DIAG, NEPSYC, PSY http://dx.doi.org/10.1016/j.jaac.2017.07.133

23.3 HOW TO DEFINE AND EVALUATE AUTOIMMUNE ENCEPHALOPATHY: A NEUROLOGIST’S VIEW William Gallentine, DO, Duke University, william.gallentine@ duke.edu Objectives: Autoimmune encephalopathy (AE) has become a more widely recognized cause of abrupt onset neuropsychiatric syndrome. It affects all age groups, and presenting symptoms often vary with age. Several observational studies describing clinical symptoms and diagnostic criteria have been published. At the conclusion of this talk, the learners will be able to 1) recognize clinical signs that should prompt an evaluation for AE; 2) perform an appropriate diagnostic evaluation to assess for AE; and 3) understand newly proposed diagnostic criteria. Methods: Clinical symptoms commonly seen in AE, as described in the literature, as well as our clinical experience at the Duke Children’s Autoimmune Brain Disease clinic, will be discussed. Diagnostic approaches and diagnostic criteria, as defined by experts in the field, will be reviewed. Results: Clinical symptoms that are abrupt in onset and cross multiple domains (cognition, behavioral, seizures, movement disorders, dysautonomia, and sleep disruption) without other clear etiology should raise concern for a possible AE and warrant further evaluation. Psychiatric symptoms can be profound and are often the presenting symptoms in adolescents and adults. Current diagnostic criteria are quite helpful in providing a framework for which this diagnosis may be approached but may have some limitations as they apply to children. Conclusions: AE is an important cause of abrupt onset neuropsychiatric symptoms that requires recognition and appropriate diagnostic evaluation.

DIAG, NI, PSY http://dx.doi.org/10.1016/j.jaac.2017.07.134

23.4 TREATMENT CONSIDERATIONS IN AUTOIMMUNE ENCEPHALOPATHY Heather A. Van Mater, MD, MSc, Duke University, heather. [email protected] Objectives: This presentation will focus on the treatment of autoimmune encephalopathies (AEs), including immunomodulatory treatments and supportive therapies. AE is a broad category of autoimmune brain disease, representing numerous diagnoses, with a range of symptoms and severity. As a result, there are different treatment recommendations based on the clinical features and specific diagnosis. It is important for all providers to recognize the heterogeneity in treatment responses across the spectrum of AE and across immunomodulatory therapies. Understanding the expected pace of improvement is essential when determining treatment effectiveness and assessing which supportive therapies may be necessary over the course of the disease process. Methods: This presentation will include information on current clinical guidelines surrounding the treatment of children and adolescents with AEs.

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Through case discussions, we will review the proposed mechanism of autoimmunity for the various forms of AE and the rationale for treatment selection. Attention will be given to expected trajectory of response, risks of medications, and the importance of concurrent supportive therapy. Results: Participants will gain a general understanding of the rationale for treatment choices, timeline for treatment responses and recovery, and the use of supportive care during both the acute illness and subsequent recovery. Conclusions: Autoimmune brain diseases present unique challenges to the medical community as patients’ symptoms and treatment needs span multiple disciplines. Coordinated, comprehensive care that addresses the breadth of the child’s needs is essential to maximize recovery and minimize suffering. Collaborative care built on a common framework of knowledge encompassing mechanisms of disease and treatment rationale will further expand our understanding of the interlocking pieces of treatment and improve the care for children.

CM, NI, PYI http://dx.doi.org/10.1016/j.jaac.2017.07.135

23.5 AUTOIMMUNE ENCEPHALOPATHY: A LITERATURE REVIEW Saachi K. Tarr, MD, Institute of Living at Hartford Hospital, [email protected] Objectives: The connection between psychiatric symptoms and autoimmune dysfunction has long been suspected by medical practitioners. As early as the 1930s, autoantibodies were reported in patients with schizophrenia. This presentation will serve as an introduction to autoimmune encephalopathy (AE) and its recognition, not just within adult medicine but within pediatrics as well. It will review historical and current literature examining the link between autoimmune disorders and neuropsychiatric disease. Methods: A literature review of AEs with an emphasis on their recognition within the pediatric population will be presented. In addition, the progression of the clinical criteria for diagnosing suspected or probable AE and how that has changed over the past decade will be highlighted. Results: Participants will gain a broad understanding of how neuropsychiatric manifestations of systemic autoimmune disease are becoming increasingly recognized as important criteria for this group of disorders, appreciate historical viewpoints on the connection between autoimmunity and psychiatric symptoms, and learn current trends in the field. Conclusions: The literature on autoimmune-mediated neurological inflammation is rapidly growing and changing. An appreciation of current research is integral to understanding the diagnosis and treatment of AE, and given its association with psychiatric symptoms, it is clearly an important area of knowledge for child and adolescent psychiatrists.

ADOL, CON, NI http://dx.doi.org/10.1016/j.jaac.2017.07.136

CLINICAL PERSPECTIVES 24 PERSONALITY DISORDERS IN YOUNG PEOPLE: A PRIMER FOR THE GENERALIST Carlene MacMillan, MD, Brooklyn Minds, carlene.macmillan@ brooklynminds.com; Bruce Hassuk, MD, New York University and New York State Office of Mental Health, brucehassuk@ gmail.com Objectives: Young people exhibiting emerging personality disorders present across all levels of care. Presentations may include symptoms, such as self-injury, chronic suicidality, aggression, disordered attachment, and emotional dysregulation. However, many practitioners feel ill-equipped to work with this population without specialized training. This presentation is for generalists who want to gain confidence in this area. Attendees will receive an overview of Mentalization-Based Treatment for adolescents (MBT-A) and Good Psychiatric Management (GPM). They will learn how rational prescribing


practices can fit into a comprehensive treatment plan and how they can help families promote recovery. Methods: Dr. Nouvini, a physician whose sister has borderline personality disorder (BPD), will share her perspective regarding family members working effectively to help their loved ones. Dr. Muir will provide an overview of GPM of emerging personality disorders. Dr. Fleisher will explain mentalizing and core MBT-A techniques with clinical examples. Dr. MacMillan will provide guidelines on prescribing medications for this population. Dr. Hassuk will facilitate a dialogue regarding the perspectives presented. Results: Attendees will gain practical tools they can implement when working with young people who are exhibiting personality pathology. Varying perspectives will deepen attendees’ understanding of this population, leading to more confidence and willingness to work with these patients and their families in clinically effective and professionally rewarding ways. Conclusions: All child and adolescent psychiatrists should be able to diagnose and manage the disorders that impact their patients, including personality disorders. General practitioners can gain a working knowledge of how to manage personality disorders by learning from the perspectives of providers who have had success in working with this population using a variety of treatment modalities.

PED, P, SIB Sponsored by AACAP's Consumer Issues Committee, Psychotherapy Committee, and Complementary and Integrative Medicine Committee http://dx.doi.org/10.1016/j.jaac.2017.07.138

24.1 GOOD PSYCHIATRIC MANAGEMENT (GPM) FOR PERSONALITY DISORDERS IN YOUNG PEOPLE Owen S. Muir, MD, New York University, [email protected] Objectives: The good psychiatric management (GPM) model of treatment developed for generalists treating adults with borderline personality disorder is an evidence-based approach in adults. Although it does not have research evidence in the adolescent population, many of the components of GPM will feel immediately comfortable to child and adolescent psychiatrists and will provide confidence in diagnosing and treating adolescents with a broad range of problematic personality traits or even those meeting full criteria for a personality disorder. Methods: The presentation will review the distinctive characteristics of a GPM approach, with adaptations for their application to child psychiatry. Case management; psychoeducation; life-outside-of-treatment goals; a multimodal approach that includes group, individual, family therapies, and medication; focus on the flexibility of duration and intensity of treatment; and an understanding of interpersonal hypersensitivity will be discussed. Given the trends toward nondisclosure of diagnosis in child psychiatry, communicating developmentally informed psychoeducation around disorders of “personality,” and what that might mean in the context of the developing personalities in youth will be described— these problems are better understood not as static illnesses for life but rather as problems that are likely to resolve with treatment. An active, not reactive approach toward treatment that minimizes unnecessary hospitalizations while managing the risk of suicide and self-injury will be addressed. The role of a thoughtful, “not knowing” stance in treaters will be presented. Furthermore, the role of self-disclosure in treating adolescents effectively will be demonstrated. Results: Interactive presentation, as part of the broader presentation, will allow generalist clinicians to understand the skills that need to be “good enough” to do a great job with sometimes difficult adolescent patients, and their often complicated family dynamics. Case material from child psychiatry practice will highlight how GPM principles can be applied to the day-to-day work of child and adolescent psychiatrists. Conclusions: Clinicians will be able to accurately diagnose, educate, and treat young people using the principles of GPM, adapted for the child and adolescent psychiatrist’s practice.

DIAG, PED, P http://dx.doi.org/10.1016/j.jaac.2017.07.139

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24.2 UNDERSTANDING MENTALIZATION-BASED TREATMENT FOR ADOLESCENTS Carl Fleisher, MD, University of California, Los Angeles, cfl[email protected] Objectives: Mentalization-based treatment for adolescents (MBT-A) aims to enhance mentalizing and thereby restore epistemic trust for individuals struggling with self-harm and mood dysregulation. The treatment incorporates family work and has demonstrated effectiveness in two randomized trials across inpatient and outpatient settings. This presentation will provide a basic explanation of the MBT-A model and then give a clinical perspective from Dr. Fleisher’s work, implementing this model in outpatient settings. Methods: Dr. Fleisher will discuss the basic principles of mentalizing, including modifications for work with adolescents. He will clarify how a framework of mentalizing helps us to understand symptoms such as selfharm and mood dysregulation. He will introduce the four failures of mentalizing (hypermentalizing, psychic equivalence, pretend mode, and teleological mode). He will describe how mentalizing leads to epistemic trust and behavior change. He will briefly review data on the effectiveness of MBT. Finally, he will present examples of how to apply these basic skills systematically to work with patients and families. This will include lessons learned from his experience implementing MBT across various populations and settings. Results: Participants will understand the terms mentalizing and epistemic trust and their relevance in all patient–provider interactions. They will learn about the mentalizing stance and specific responses to failures of mentalizing, with the aim of restoring patients’ epistemic trust. Real-world examples from treatment with individuals and their families will provide clinicians with a new approach to difficult cases. Conclusions: Mentalizing theory provides a coherent understanding of adolescent self-harm and mood dysregulation, symptoms that are often confusing, dangerous, and frustrating. Mentalizing techniques are empirically supported; they enable clinicians to treat self-harming adolescents more effectively, avoid iatrogenic interactions, and facilitate trust with patients.

ATTACH, PED, P http://dx.doi.org/10.1016/j.jaac.2017.07.140

24.3 FIRST DO NO HARM: THOUGHTFUL PRESCRIBING PRACTICES FOR YOUNG PEOPLE WITH EMERGING PERSONALITY DISORDERS Carlene MacMillan, MD, Brooklyn Minds, carlene.macmillan@ brooklynminds.com Objectives: Although there are no FDA-approved medications for borderline personality disorder (BPD) in children or adults, child and adolescent psychiatrists are often put in the position of managing psychotropic medications in this population. This presentation will demonstrate how principles from DBT and mentalization-based treatment (MBT) can be applied to managing medications in safe and effective ways. Participants will also be given an overview of the studies that have been done on medications for BPD and for self-harm. Methods: Dr. MacMillan will review the current state of research regarding medications for BPD traits and discuss approaches to targeting symptoms and comorbid conditions. These approaches will involve generally encouraging “more skills and less pills” and at the same time maintaining a validating and curious stance toward concerns that patients and families want to be addressed. Tips to maximize safe use of the medications in a population where chronic suicidality is common will be discussed. Results: Participants will gain confidence in managing the expectations of patients and families around the role of psychotropics in young people with BPD traits. They will understand the current state of the evidence base for the use of medications and how to incorporate managing medications into a more comprehensive treatment plan that includes psychotherapeutic approaches to BPD, including MBT and DBT. Conclusions: As physicians, child and adolescent psychiatrists must follow the principle of “first do no harm.” In prescribing medications for patients with borderline traits who are enduring high levels of distress across several domains, polypharmacy is common but not always effective or safe. Having a thoughtful

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approach to prescribing for this population that incorporates DBT and MBT principles can lead to an improved treatment alliance and better outcomes.

ATTACH, PED, PPC http://dx.doi.org/10.1016/j.jaac.2017.07.141

24.4 THE ROLE OF FAMILY AND SOCIETY IN BORDERLINE PERSONALITY DISORDER TREATMENT OUTCOMES Rosa Nouvini, MD, Stony Brook, [email protected] Objectives: A manifestation of borderline personality disorder (BPD) is tumultuous for interpersonal relationships where those suffering from BPD feel invalidated by loved ones and their loved ones often misunderstand them as being manipulative and immoral. Unfortunately, because of BPD’s underdiagnosis, which leads to its lack of awareness and education, those impacted by this disorder are left to suffer in isolation without knowledge about what it is and how best to deal with it. This presentation will review the therapeutic benefit of educating family members about the neurobiology and symptomatology of BPD, as well as teaching them the skills on how to communicate with their loved ones. Methods: The sister of someone living with BPD will recount the hardships that she and the rest of her family endured during the time when nobody would diagnose her loved one with BPD. She will speak about the alienation they felt after her sister was finally diagnosed; they were told that she was resistant to treatment and had not been given any resources for help and understanding of BPD. She will then describe the drastic change that occurred in her sister and their interpersonal relationships once they entered a BPDcentered support group and attended psychoeducation classes. Based on her positive experience after being educated and supported by a small BPD community, this family member has begun a grassroots advocacy campaign that connects and empowers those impacted by BPD to raise awareness and advocate for better healthcare. She will discuss the impact that this is having on those affected by BPD. Results: The audience will gain an understanding of the importance and benefit of involving family members in patient care from the start of treatment. They will learn about resources they can provide their patient’s families that will allow them to foster therapeutic relationships and improve outcomes. They will also learn about the intense pain and struggle that exists surrounding the stigma of BPD and the necessity to raise BPD awareness to break these societal barriers to better mental healthcare. Conclusions: Education for society as a whole, and especially for those impacted by BPD, is crucial for improving outcomes in BPD mental healthcare.

ATTACH, CONSI, FAM http://dx.doi.org/10.1016/j.jaac.2017.07.142

CLINICAL PERSPECTIVES 25 APPLICATION OF ADVANCES IN DEVELOPMENTAL RESEARCH IN INFANTS TO PSYCHOTHERAPEUTIC WORK WITH CHILDREN AND ADOLESCENTS Shilpa Sachdeva, MD, University of Kansas Medical Center, [email protected]; Nathaniel Donson, MD, Youth Consultation Service Institute for Infant and Preschool Mental Health, [email protected] Objectives: The goals of this session are to synthesize and apply advances in developmental infant research to the psychotherapy of older children and adolescents. Methods: Daniel Schechter, MD, will discuss findings from his studies, which underline the importance of targeting clinical interventions for families exposed to domestic violence and focus on both the caregiver’s PTSD and her mentalizing capacity as related to the quality of her attachment relationships. Alexandra Harrison, MD, will discuss the influence of study of early development on her clinical work as a child psychiatrist and child analyst. She will focus

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on the following: 1) her major commitment to consulting with caregivers of young children; 2) the need for greater clinical attention to regulation and growing regulatory competency; and 3) a shift in clinical emphasis from categorical diagnosis and medical or psychoanalytic intervention toward developmental formulation and scaffolding. Josh Sparrow, MD, will discuss the challenges and limitations of evidence-based parenting interventions for families of young children, including the inherent unsustainability of these interventions, the need for local contextual and cultural adaptations, and the absence of a scientific approach to such adaptations. Dorothy Richardson, PhD, will show that her work with children, adolescents, and their families in relationship-based psychotherapy is informed by multiple therapeutic systems and techniques. She will discuss the development of social communication, attention, and emotion regulation and how dyadic parent–child therapeutic interventions can support children’s developmental capacities. Results: Recent advances in the epigenetic and neurodevelopmental effects of trauma highlight ways that relational stresses impair the regulatory processes of both infants and parents, creating a cascade of disrupted attributions and interactions. These difficulties ultimately impair mutually contingent responsiveness and the parents’ capacity to scaffold a child’s capacity for attention, emotion regulation, and impulse control. Conclusions: It is important for child and adolescent psychiatrists to use their knowledge of infant developmental research to understand the origins of many symptoms in later childhood and use this knowledge in therapeutic planning.

P, INF, ATTACH Sponsored by AACAP's Psychotherapy Committee http://dx.doi.org/10.1016/j.jaac.2017.07.144

25.1 INTEGRATING EXPOSURE THERAPY, INTERACTION GUIDANCE, AND PSYCHODYNAMIC PRINCIPLES TO ADDRESS MUTUAL EMOTIONAL DYSREGULATION IN TRAUMATIZED PARENT-CHILD RELATIONSHIPS Daniel S. Schechter, MD, University of Geneva Hospitals and Faculty of Medicine, [email protected] Objectives: The goal of this session is to synthesize and apply advances in developmental infant research to the psychotherapy of older children and adolescents. Methods: This presentation will discuss findings from the Geneva Early Childhood Stress Project and Parent-Child Interaction Project, which underline the importance of targeting clinical interventions for families exposed to domestic violence. These studies focus on both the caregiver’s PTSD and her mentalizing capacity in relation to the quality of her attachment relationships. Maternal PTSD and level of reflective functioning (RF) as a measurement of her mentalizing capacity contribute to the variance of child emotional and behavioral dysregulation. They also show that the presence and severity of maternal interpersonal violence-related PTSD and level of maternal RF are also related to neural activity in the medial prefrontal cortex, as demonstrated by their subject’s responses to relational stimuli (such as film clips of mother– child separation versus play). This area of the brain is very much implicated in top-down emotion regulation and, especially, regulation of the fear response. A manualized brief psychotherapy, Clinician Assisted Videofeedback Exposure Approach Therapy (CAVEAT), was developed based on the technique Schechter used in a prior New York Project, the Clinician Assisted Videofeedback Exposure Session (CAVES). Results: CAVEAT integrates principles of a number of evidence-based psychotherapies, such as Interaction Guidance, Prolonged Exposure Therapy for PTSD, Child-Parent Psychotherapy, and Minding the Baby. Recent advances in the epigenetic and neurodevelopmental effects of trauma highlight how relational stresses impair the regulatory processes of both infants and parents, creating a cascade of disrupted attributions and interactions. These difficulties ultimately impair mutually contingent responsiveness and the parents’ capacity to scaffold a child’s capacities for attention, emotion regulation, and impulse control. Conclusions: Attachment research provides ways of understanding how early developmental disruptions influence later behaviors and may suggest more appropriate interventions with the child, caregiver, and family.

ATTACH, EC, P


Supported by the National Center of Competence in Research, the Swiss National Science Foundation Grant n 51AU40_125759, the Gertrude von Meissner Foundation, the Oak Foundation, and la Fondation Prim’Enfance. http://dx.doi.org/10.1016/j.jaac.2017.07.145

25.2 DEVELOPMENTAL THEORY AND ITS INTEGRATION WITH PSYCHODYNAMIC CLINICAL THEORY Alexandra Harrison, MD, Cambridge Health Alliance, [email protected] Objectives: The goals of this session are to synthesize and apply advances in developmental infant research to the psychotherapy of older children and adolescents. Methods: This presentation will discuss the influence of study of early development on her clinical work as a child psychiatrist and child analyst. She will focus on 1) her major commitment to consultation to caregivers of young children; 2) the need for greater clinical attention to regulation and growing regulatory competency; and 3) a shift in clinical emphasis from categorical diagnosis and medical or psychoanalytic intervention toward developmental formulation and scaffolding. She will describe some essential features of developmental theory and ways that they can be integrated with psychodynamic clinical theory. Her case illustrations will demonstrate consultation to child caregivers and attention to regulation and growing regulatory competencies and focus on an integrated psychodynamic and developmental formulation and scaffolding. Results: Recent advances in the epigenetic and neurodevelopmental effects of trauma highlight how relational stresses impair the regulatory processes of both infants and parents, creating a cascade of disrupted attributions and interactions. These difficulties ultimately impair mutually contingent responsiveness and the parents’ capacity to scaffold a child’s capacity for attention, emotion regulation, and impulse control. Conclusions: It is important for child and adolescent psychiatrists to use their knowledge of infant developmental research to understand the origins of many symptoms in later childhood and use this knowledge in therapeutic planning.

ATTACH, DEV, P http://dx.doi.org/10.1016/j.jaac.2017.07.146

25.3 CHALLENGES AND LIMITATIONS OF EVIDENCE-BASED PARENTING INTERVENTIONS FOR FAMILIES OF YOUNG CHILDREN Joshua D. Sparrow, MD, Brazelton Touchpoints Center, Boston Children’s Hospital, joshua.sparrow@childrens. harvard.edu Objectives: The goals of this session are to synthesize and apply advances in developmental infant research to the psychotherapy of older children and adolescents. Methods: This presentation will discuss the challenges and limitations of evidence-based parenting interventions for families of young children, drawing on his experience as senior author of the United States Department of Health and Human Services Administration for Children and Families’ Compendium of Parenting Interventions. Challenges to be addressed are as follows: the failure to include a cultural anthropology evidence base, the lack of external validity evidence, the inherent unsustainability of these interventions, the need for local contextual and cultural adaptations, and the absence of a scientific approach to such adaptations. The promise of parent-to-parent peer interventions; the importance of parental self-efficacy, advocacy, and leadership skills; alternative culturally grounded approaches to intervention development; and the role of research-informed policy to support therapeutic interventions will be presented. Results: Recent advances in the epigenetic and neurodevelopmental effects of trauma highlight how relational stresses impair the regulatory processes of both infants and parents, creating a cascade of disrupted attributions and interactions.

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Conclusions: Attachment research provides an understanding of how early developmental disruptions influence later behaviors and may suggest more appropriate interventions with child, caregiver, and family.

ATTACH, PAT, P http://dx.doi.org/10.1016/j.jaac.2017.07.147

25.4 A MULTISYSTEMIC APPROACH TO INFANTPARENT MENTAL HEALTH CASES AND RELATIONSHIP-BASED PSYCHOTHERAPY Dorothy Richardson, PhD, University of Massachusetts, [email protected] Objectives: The goals of this session are to synthesize and apply advances in developmental infant research to the psychotherapy of older children and adolescents. Methods: This presentation will show that her work with children, adolescents, and their families in relationship-based psychotherapy is informed by multiple therapeutic systems and techniques. She would be able to discuss the neurodevelopmental effects of complex trauma and ways that this body of research can inform our case formulations and treatment plans in working with children. She will also discuss the development of social communication, attention, and emotion regulation and ways that dyadic parent–child therapeutic interventions can support children’s developmental capacities. Results: Recent advances in the epigenetic and neurodevelopmental effects of trauma highlight how relational stresses impair the regulatory processes of both infants and parents, creating a cascade of disrupted attributions and interactions. These difficulties ultimately impair mutually contingent responsiveness and the parents’ capacity to scaffold a child’s capacity for attention, emotion regulation, and impulse control. Conclusions: It is important for child and adolescent psychiatrists to use their knowledge of infant developmental research to understand the origins of many symptoms in later childhood and use this knowledge in therapeutic planning. Although obtaining retrospective early life data may be difficult, strategies for working clinically with families, parents, and children, as well as medication selection for child disorders, according to DSM-5, should be appropriately influenced by such information. Attachment research provides an understanding of how early developmental disruptions influence later behaviors and may suggest more appropriate interventions with the child, caregiver, and family.

ATTACH, INF, P http://dx.doi.org/10.1016/j.jaac.2017.07.148

CLINICAL PERSPECTIVES 26 AN EXPLORATION OF PHARMACOGENOMICS (2017 UPDATE): HOW DO WE APPLY CURRENT SCIENCE TO OUR CLINICAL PRACTICE? Lisa B. Namerow, MD, Institute of Living at Hartford Hospital, [email protected]; Barbara J. Coffey, MD, MS, Icahn School of Medicine at Mount Sinai, barbara.coffey@ mssm.edu; Gualberto Ruano, MD, Hartford Hospital, [email protected] Objectives: This Clinical Perspective will provide a background understanding of the development of both pharmacokinetic and pharmacodynamic genetic testing and explore the possible benefits and limitations surrounding the application of pharmacogenomic evaluations in clinical care. Methods: Dr. Salma Malik will provide a review of pharmacogenomics and the information it provides and discuss the additional factors involved in medication tolerance and efficacy. Drs. Mirela Loftus, Osman Qureshi, and Jeff Bishop will then provide an overview of pharmacokinetics and pharmacodynamic testing, including current clinical guidelines from Clinical Pharmacogenomics Implementation Consortium (CPIC) and other consortium

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groups, and examples of how to best interpret and apply the results within the context of the management of patients with psychiatric disorders. Dr. Lisa B. Namerow will then discuss, in the context of the current evidence base, a possible rational approach to incorporating pharmacogenomics testing in clinical practice and directions for future research. Results: Participants will become familiar with the possible role and limitations of pharmacogenomics testing in clinical care. By understanding the background in the development of this technology and the rules that guide the determination of the personalized medication profiles, the participants will be able to integrate these findings within the context of the other complexities of what determines a response to pharmacotherapy to determine how to best use these analyses within a clinical setting. Conclusions: Personalized medicine is becoming an important part of 21st century medicine and clearly has a possible role in the treatment of patients with complex medical and psychiatric disorders. Given that the technology exists to obtain genomic testing for genes that play a role in medication pharmacokinetics and pharmacodynamics, it will be important for the child and adolescent psychiatrist to continue to explore the possible application of this technology in clinical care. This will require enhancing our knowledge base, as well as expanding research opportunities, that will provide clarity on the limitations and benefits of such testing.

PDS, PKS, PPC Sponsored by AACAP's Adolescent Psychiatry Committee, Physically Ill Child Committee, and Psychopharmacology Committee http://dx.doi.org/10.1016/j.jaac.2017.07.150

26.1 UNDERSTANDING THE ORIGINS AND SCIENCE OF PHARMACOGENOMICS Lisa B. Namerow, MD, Institute of Living at Hartford Hospital, [email protected] Objectives: A recent survey reported psychotropic medications prescribed to youth (ages 6–17 years) at roughly nine percent of all of the office visits to a US physician. Furthermore, the rate of psychotropic prescriptions has approached 20 percent over the same period. Research in pharmacogenomics is currently focusing on identifying specific genes and gene products associated with various diseases, which may act as targets for new drugs, and identifying genes and allelic variants of genes that affect our response to current drugs. It is now clear that much individuality in drug response is inherited; this genetically determined variability in drug response defines the research area known as pharmacogenetics. This presentation will review this background of pharmacogenomics and provide a framework for understanding the potential clinical application of this area of “personalized medicine.” Methods: An introductory overview of the evolution of personalized medicine will be provided. This will include a review of the science behind pharmacogenomics, including molecular genetics and genome sequencing. There will also be a review of the basic terminology of pharmacogenomics and a brief overview of pharmacokinetic and pharmacodynamic genes. The presentation will also cover the nomenclature currently used to characterize one’s metabolic status based on the gene findings and ways one uses a genotyping report. There will also be a review of literature highlighting different perspectives regarding the role, limitations, and clinical applications of pharmacogenomics. Results: Participants will become familiar with the possible role and limitations of pharmacogenetic testing by understanding the background in the development of this technology and the rules that guide the determination of the personalized medication profiles. Conclusions: Pharmacogenomic technology offers patients and prescribers an opportunity to individualize prescribing. Clinical pharmacogenomics is still developing, and there are limitations to consider, but the era of more meaningful application of testing results is rapidly evolving. Given the increasing availability of such testing, understanding the potential applications and the potential misuse of such testing is becoming increasingly relevant for the practice of child and adolescent psychiatry.

PDS, PKS, PPC http://dx.doi.org/10.1016/j.jaac.2017.07.151

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26.2 A CLOSER LOOK AT RELEVANT GENES IN PSYCHOPHARMACOLOGY Mirela Loftus, MD, PhD, Institute of Living at Hartford Hospital, [email protected] Objectives: It is now recognized that genetic polymorphisms within the genes that code for proteins involved in the metabolism and the targets of drug therapy can have an even greater influence on the efficacy and toxicity of medications than clinical variables. Virtually every pathway of drug metabolism, transport, and action is susceptible to genetic variation. In addition, within the top 200 selling prescription drugs, 59 percent of the 27 most frequently cited in adverse drug reaction studies are metabolized by at least one enzyme known to have gene variants that code for reduced or nonfunctional proteins. Methods: A review of the current evidence relevant to the key pharmacokinetic and pharmacodynamic genes that may play a role in determining tolerance and response of an individual to pharmacotherapy will be provided. Examples of genes that code for 2D6, 2C9, 2C19, serotonin transporter gene, serotonin receptor gene, MTHFR (methylenetetrahydrofolate reductase), and COMT (catechol-O-methyltransferase) will be discussed. In addition, a review of the relevant resources, such as the PharmGkb website, which can serve as a resource for clinicians, will also be provided. Results: Participants will become familiar with the scientific evidence behind the recognition and identification of some of the important pharmacokinetic and pharmacodynamic genes. They will also learn about some important resources to find updated information relevant to the field of pharmacogenomics. Conclusions: Pharmacogenomic testing, although in its infancy in terms of indications, interpretations, and limitations, is emerging as a powerful tool on a case-by-case basis, especially in complex patients who have a history of significant side effects or lack of response to previous treatments. Therefore, it is important for the child and adolescent psychiatrist to become familiar with the evidence regarding the genes often found on the commercially available pharmacogenomics products to make their own assessments regarding the relative importance of the gene findings that might exist in some of their patients.

GS, PDS, PKS http://dx.doi.org/10.1016/j.jaac.2017.07.152

26.3 PHARMACOGENOMIC GUIDELINE EVALUATIONS OF PSYCHIATRIC MEDICATIONS AND IMPLICATIONS FOR YOUNGER PATIENT POPULATIONS Jeffrey R. Bishop, MS, PharmD, University of Minnesota College of Pharmacy, [email protected] Objectives: Pharmacogenomic (PGx) testing has become increasingly accessible for clinical use in psychiatry. Scientific, philosophical, and practical questions about the clinical use of this information are common. Consensus guidelines by the Clinical Pharmacogenetics Implementation Consortium (CPIC) are evaluations of drug-gene pairs intended to help clinicians understand how available genetic results should be used to optimize drug therapy. The relevance of this information to younger patient populations has not been assessed directly. We will review the CPIC guideline process, evaluations of psychotropic medications, and ways that they relate to younger patient populations by highlighting selected examples of PGx studies in children and adolescents. Methods: CPIC guidelines and FDA PGx labeling related to psychiatric medications will be reviewed. PGx studies of medications in children and adolescents with depression and autism spectrum disorder (ASD) will be evaluated for comparison. Results: PGx information referenced in labeling for psychotropic medications largely involves genetically determined drug metabolism variants that affect pharmacokinetics. CPIC guidelines are currently available for SSRIs and tricyclic antidepressants (TCAs). The clinical and


pharmacokinetic data evaluation in the CPIC antidepressant guidelines was largely derived from studies of adults with mood and anxiety disorders. Antidepressant PGx studies in children and adolescents include smaller study sample groups with mood and anxiety disorders, as well as ASD, who were treated with fluoxetine or citalopram/escitalopram. Pharmacokinetic consequences of CYP2D6 and CYP2C19 poor metabolism in younger patients are difficult to directly compare to adults because of the smaller sizes of the sample groups. Examining CYP2C19 metabolizer relationships with escitalopram dosing for ASD highlight potential clinical differences from findings on mood disorders. Conclusions: PGx evaluations of antidepressant medications are largely derived from adult study sample groups because of data availability. Smaller study sample groups of younger patients make direct comparisons of kinetic and clinical PGx relationships challenging. The generalizability of antidepressant PGx findings from mood disorders to ASD requires further investigation.

GS, PKS, PPC Supported by NIH Grants MH083888 and HD055751 http://dx.doi.org/10.1016/j.jaac.2017.07.153

26.4 PHARMACOGENOMICS IN CLINICAL PRACTICE: DOES IT ALWAYS PREDICT CLINICAL RESPONSE? Osman Qureshi, MD, Eastern Connecticut Health Network, [email protected] Objectives: Pharmacogenomics has become more integrated into clinical practice and is now being used as a potential additional tool to improve efficacy and tolerability of psychotropic medications. Over the past decade, this technology has evolved to include genes influencing a pharmacodynamic response of medications. This presentation will review the components of expanded pharmacogenomic panels that include both pharmacokinetic and pharmacodynamic genes and discuss ways to interpret testing results and consider the possible role and limitations of such an expanded multigene profile. Methods: An overview of the expanded testing panels, including pharmacodynamic genes and interpretation of their polymorphisms, will be discussed. In addition, two cases will be reviewed to become familiar with the application of the genomic panels in clinical practice. Results: Participants will become familiar with the interpretation of expanded testing panels and the impact of pharmacodynamic gene polymorphism in clinical treatment response. Participants will also learn the limitations of genomic testing in predicting clinical response. Conclusions: Pharmacogenomics testing is emerging in clinical practice and becoming more widely accepted. Although it comes with its limitations, it could be a potentially impressive tool that is used to personalize treatment and identify a medication that is more likely to be effective.


26.5 VIEW FROM THE FRONT LINE: A 10-YEAR EXPLORATION OF PHARMACOGENOMICS Lisa B. Namerow, MD, Institute of Living at Hartford Hospital, [email protected] Objectives: The role of pharmacokinetic genes in the field of pharmacotherapy has been an area of interest and clinical investigation at the Institute of Living since 2005. This presentation will provide an overview of our clinical and research experience in an attempt to explore clinical applications of such testing. In addition, following such extensive experience, the possibility of using clinical probe questions to determine patients at risk for P450 vulnerabilities will be presented and further explored.

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Methods: Two exploratory research studies, one looking at genomic findings in patients who had significant behavioral reactions following exposures to SSRIs, and one looking at whether using pharmacogenomic guidance to enhance depression treatment will be presented. Results: Patients (N ¼ 14) who experienced negative reactions to SSRI exposure had a high enrichment of polymorphisms within the 2C9 genes. In the second study (N ¼ 100), although patients whose pharmacotherapy for the treatment of depression was directed through p450 guidance, they did not show any difference in terms of medication discontinuation compared with patients treated without p450 guidance; patients who had 2D6 vulnerabilities did better than expected when guidance was used. Although these findings do not support universal pharmacogenetic testing, the trend that patients with p450 vulnerabilities did as well as patients with no vulnerabilities suggests that for high-risk patients, the use of pharmacogenomic testing may be very helpful. A series of clinical probe questions will be presented, which might serve to detect these at-risk patients. Conclusions: Although the field of pharmacogenomics is rapidly expanding, the research remains limited in terms of clinical application and efficacy. Since the industry has marketed numerous products for clinical use, it remains extremely important that the child and adolescent clinician becomes familiar enough with the science behind this testing to make an informed decision about the use of pharmacogenomic testing within clinical practice.


CLINICAL PERSPECTIVES 27 CONSIDERATIONS IN THE ASSESSMENT AND TREATMENT OF TRANSITIONAL AGE YOUTH ACROSS THE DIAGNOSTIC SPECTRUM Avital E. Falk, PhD, Weill Cornell Medical College, avf2003@ med.cornell.edu; Shannon Bennett, PhD, Weill Cornell Medical College, [email protected] Objectives: The transition from adolescence into early adulthood reflects a sensitive developmental period of risk across the diagnostic spectrum. This period of development can be impacted by accumulated impairments from inadequately treated childhood and adolescent psychopathology and marks an age of risk for the emergence of acute symptoms. Moreover, treatment considerations can be complicated when a young person turns age 18 years. This Clinical Perspective provides an overview of the specific challenges that arise during this time period, as well as strategies for assessment, triage, and treatment of emerging adults. Methods: Each presenter focuses on a specific area of psychopathology and discusses the presentation during this age range, as well as factors to consider during diagnosis, triage, or treatment. There will also be a discussion of the cross-diagnostic factors that should be considered in evaluation and treatment. Results: Across the diagnostic spectrum, special considerations must be made during the emerging adulthood period. Anxiety and depression are common in this age range, and treatment must target both the symptoms of the disorder and accumulated functional impairments to improve independent functioning. Anxiety symptoms are also present in the context of autism spectrum disorder in emerging adulthood, requiring careful assessment of symptoms and differential diagnosis to address new challenges in this developmental stage. In treating bipolar disorders, a familybased approach is pivotal to the recognition and successful treatment and maintenance of treatment gains. Untreated ADHD in college-age youth interferes with academic achievement and can amplify comorbid conditions. Finally, late adolescence and early adulthood are an age range in which vulnerability for substance use disorders is high and can interfere with

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successful symptom management, as well as pose unique risks. Treatment strategies to address these age-specific symptoms and syndromes will be discussed. Conclusions: Emerging adulthood poses challenges across the diagnostic spectrum that require knowledge and expertise. Presenters will provide clinical perspectives on the unique presentations of psychopathology during this developmental stage and discuss how child psychiatrists can implement this knowledge into assessment and treatment.

ADOL, COLST, TREAT http://dx.doi.org/10.1016/j.jaac.2017.07.157

27.1 FAMILY APPROACHES TO BIPOLAR DISORDER IN TRANSITIONAL AGE YOUTH David J. Miklowitz, PhD, University of California, Los Angeles David Geffen School of Medicine, dmiklowitz@mednet. ucla.edu Objectives: Psychoeducation, communication skills training, problem solving, and parenting strategies may improve the course of early-onset bipolar disorder (BD). This presentation addresses complexities of conducting family-focused treatment (FFT) with adolescents and young adults (transitional-aged youth, or TAY) who have been diagnosed with or are at high risk for BD. Methods: After a brief presentation of the evidence base for FFT, the speaker will address key dilemmas in treating this age group. Results: Treatment dilemmas include the following: 1) the TAY’s struggle with gaining independence from the family, given the limitations imposed by the disorder; 2) helping the patient and family distinguish BD from typical adolescence, key features of which are mood instability and family conflict; and 3) determining the best ways to prevent mania/ hypomania. Regular mood tracking can provide a more objective indicator of the youth’s clinical progress. A list of agreed-upon strategies to pursue whether the young adult develops early signs of mania may help reduce hospitalizations. Adolescents and parents can learn a series of strategies to keep family interactions from becoming increasingly aversive and stressful. These will each be discussed and illustrated with case studies. Families can develop a greater awareness of the TAY’s need for decision-making control over necessary medication adjustments—this will also help assure consistency for medication adherence. Conclusions: Late adolescence and young adulthood are critical periods in which family interventions can help promote the gradual achievement of autonomy and independence of the individual with BD.

BD, COLST, FT Supported by NIMH Grants MH077856, and MH62555

RO1MH093676,

MH097007,

MH073871,


27.2 IDENTIFICATION AND TREATMENT OF ATTENTION-DEFICIT/HYPERACTIVITY DISORDER IN YOUNG ADULTS ATTENDING COLLEGE Mary V. Solanto, PhD, Private Practice, [email protected] Objectives: The purpose of this session is to describe the symptom presentation and accompanying functional impairments of emerging adults with ADHD who are attending college and the ongoing efforts to develop and validate interventions to address these impairments. Methods: The presentation will rely on review of the current literature and the clinical experience of the presenter in evaluating and treating college students with ADHD. Results: The DSM-5 provides guidance concerning differences between adults and children in the presentation of ADHD symptoms. ADHD occurs in as many as eight percent of students on US college campuses.

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College students with ADHD report more distractibility and difficulty in planning and completing assignments, have a higher rate of withdrawing from college courses, have lower grade point averages (GPAs), and are more likely to be placed on academic probation. These experiences of underperformance and failure probably contribute to their higher rates of anxiety and depression, as well as worse long-term occupational outcomes. Treatment efforts have focused on developing cognitive behavioral interventions to enhance executive functions of time management, organization, and planning. Although promising, these studies have yet to include a randomized controlled trial and have yet to show improvement in GPA, a critical measure of outcome. The presenter will describe a group cognitive behavioral intervention currently under development to target executive dysfunction. Conclusions: ADHD in college students is associated with significant functional impairment. Efforts are underway to develop targeted interventions.

ADHD, CBT, COLST http://dx.doi.org/10.1016/j.jaac.2017.07.159

27.3 TAILORING EVIDENCE-BASED TREATMENTS FOR EMERGING ADULTS WITH ANXIETY OR DEPRESSION Avital E. Falk, PhD, Weill Cornell Medical College, avf2003@ med.cornell.edu Objectives: Anxiety and depressive disorders have an extremely high prevalence rate among college-age young adults. Existing conditions may worsen in the face of stressors associated with this time period, such as moving away from home, lack of parental accommodation, and increased social and selfcare responsibilities. Recognizing anxiety among this population can be challenging, given that symptoms manifest in the form of avoidance and withdrawal, and it may take many weeks or months before parents or other family members realize that their young adults have withdrawn from classes, work, or social settings. Alternatively, their avoidance of anxiety triggers may be mistakenly identified as laziness. Treatment requires involvement from family and other supports to gradually expose the individual to anxiety-provoking situations and developmental tasks that are required for successful independent functioning in this age range. Methods: Traditional CBT for anxiety and depression is an effective psychosocial intervention for emerging adults; however, this population may require an increased focus on facing the tasks that living independently demands. Treatment for this population includes the incorporation of exposure to tasks that enhance functioning with less support from parents, such as daily self-care tasks, finances, and academic and social interactions. Results: Recognition of how anxiety and depression manifest and present in emerging adulthood is essential, as the worsening of these disorders in youth in this sensitive period can lead to significant functional impairment. Incorporating this developmentally specific understanding can inform augmented treatment strategies that are tailored versions of traditional CBT for this age range. Conclusions: Emerging adulthood is a particularly high-risk period for the emergence or worsening of anxiety and depression. Understanding the developmental trajectory of anxiety and depression can help in the tailoring of effective treatment methods to meet the needs of this population.

AD, COLST, DDD http://dx.doi.org/10.1016/j.jaac.2017.07.160

27.4 OVERCOMING MEASUREMENT CHALLENGES OF ANXIETY IN YOUTH WITH AUTISM SPECTRUM DISORDER Lawrence Scahill, MSN, PhD, Marcus Autism Center, [email protected] Objectives: Treatment of anxiety in youth with autism spectrum disorder (ASD) is hampered by inadequate measures. This presentation


describes steps toward a new parent-rated measure of anxiety for youth with ASD. Methods: After the systematic review of six focus groups with parents, we generated 72 candidate anxiety items. The 72-item measure (scored 0–3) was completed online by 990 parents of children with communitydiagnosed ASD. Factor analysis identified a single factor 41-item scale. A separate sample group of 80 children participated in a comprehensive clinical evaluation in one of three sites. Here, we present the results on the 41-item measure from the online survey and the clinical assessment. Results: Mean age of youth on the online survey (N ¼ 990) was 11.4 + 3.71 years; 80 percent were boys. Mean on the 41-item anxiety measure was 47.3 + 22.81. Based on parent report, 63.5 percent were in special education; 37.8 percent were disabled intellectually. Mean scores on the Aberrant Behavior Checklist (ABC) were consistent with mild behavioral problems. Pearson correlations of the online parent-rated 41-item anxiety measure with ABC-Irritability and ABC-Social Withdrawal (for social disability) subscales were 0.51 (P < 0.001) and 0.42 (P < 0.001). For the 80 participants in the clinical evaluation (mean age 11.2 + 3.03 years; 80% males), the mean score on the 41-item anxiety measure was 52.1 + 22.37. Again, the mean ABC scores were consistent with mild behavioral problems. Correlations of the 41-item anxiety measure were 0.68 (P < 0.001) with the ABC-Irritability and 0.44 (P < 0.001) with the ABCSocial Withdrawal subscales. The clinical evaluation also included the Children’s Yale-Brown Obsessive Compulsive Scale (CYBOCS)-ASD, Screen for Child Anxiety-Related Disorders (SCARED) (parent-rated anxiety), and the clinician-rated Pediatric Anxiety Rating Scale (PARS)ASD. Correlations were 0.06 (P ¼ 0.64), 0.79 (P < 0.001) and 0.58 (P < 0.001), respectively. Conclusions: Youth with ASD show anxiety symptoms ranging from mild to severe. In sample groups of youth with mild behavioral problems, the 41-item scale measures a separate construct from repetitive behavior (CYBOCS-ASD) and social disability (ABC-Social Withdrawal subscale). Scores on the 41-item measure were strongly associated with the ABCIrritability subscale, the parent-rated SCARED, and the PARS-ASD. Additional analyses will examine test-retest and further pruning of the 41-item scale.

AD, ASD, COLST Supported by NIMH Grants R01 MH099021 http://dx.doi.org/10.1016/j.jaac.2017.07.161

27.5 SUBSTANCE USE DISORDERS AND TRANSITIONAL AGE YOUTH Jonathan Avery, MD, NewYork-Presbyterian/Weill Cornell Medical Center, [email protected] Objectives: The primary objective is to explore the nature of substance use disorders (SUDs) in transitional-age youth. The audience will learn about risk factors of SUD, substance use patterns, co-occurring disorders, and treatment considerations in this age group. Methods: The current literature on this topic will be reviewed, including studies such as the Monitoring the Future Study and the Cannabis Youth Treatment Study. Treatment considerations, such as stigma and medicationassisted treatment, will be addressed. Results: Transitional-age youth, especially individuals with co-occurring disorders and a trauma history, are vulnerable to develop a SUD. Whereas this age group is smoking fewer cigarettes than before, they are misusing marijuana and prescription medications at high rates. Effective treatments for SUDs exist, and medications such as buprenorphine and naltrexone are increasingly being prescribed. Barriers to treatment, such as stigma and limited resources, need to be addressed. Conclusions: SUDs in transitional-age youth are common. Clinicians need to be prepared to identify risk factors for misuse and to treat SUDs when they occur.

ADOL, COLST, SUD http://dx.doi.org/10.1016/j.jaac.2017.07.162

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CLINICAL PERSPECTIVES 28 MANAGEMENT OF AGITATION/AGGRESSION IN THE PEDIATRIC EMERGENCY DEPARTMENT, INPATIENT PEDIATRICS FLOOR, AND BEYOND Megan Mroczkowski, MD, Columbia University Medical Center, [email protected]; Vera Feuer, MD, Northwell Health - Long Island Jewish Medical Center, [email protected] Objectives: Agitation in pediatric acute care settings is common and disruptive. We begin with a case example of an agitated patient on a pediatric medical unit. Data from a survey of 38 North American children’s hospitals will outline the prevalence, screening methods, clinical guidelines, and physician training in the management of agitation. We will describe two children’s hospitals’ practices and summarize the literature on medications for agitation. We conclude with the Consensus Guidelines for PRN Medication for Agitation in the emergency department. Methods: A case presentation will be followed by data from a national survey of pediatric hospitalists and consultation/liaison psychiatrists. A Clinical Pathway for management of agitation will be described. By use of a Medline and PsycINFO search from January 1, 1996 to January 1, 2017, we will summarize the literature on psychopharmacological management of agitation in pediatric patients. By use of the Delphi method for consensus guideline development, a team of emergency department-based child and adolescent psychiatrists from across the United States created the Consensus Guidelines. Results: Results of the survey of 38 North American academic children’s hospitals revealed that 85.5 percent of the respondents encountered agitation in pediatric patients at least once a month. Most viewed agitation in pediatric patients as highly important, yet 55.1 percent do not screen for risk factors of agitation; 65.3 percent reported no clinical guidelines for agitation; and 57.1 percent indicated no physician training in pediatric agitation. A multidisciplinary clinical pathway for agitation in pediatric patients will be outlined. Evidence for the following medication classes will be described: antihistamines, benzodiazepines, typical antipsychotic drugs, atypical antipsychotic drugs, mood stabilizers, antidepressants, and stimulants. The Consensus Guidelines outline standardized recommendations for medications. Conclusions: Agitation in pediatric patients is a concern continent-wide, but there is little training or standardization of care. Clinical Pathways exist and can ensure identification and early management. Data about psychopharmacological management of agitation exist, and updated Consensus Guidelines provide standardized guidelines for the management of agitation.

EBP, AGG, CON Sponsored by AACAP's Emergency Child Psychiatry Committee and Physically Ill Child Committee http://dx.doi.org/10.1016/j.jaac.2017.07.164

28.1 BARRIERS TO MANAGEMENT OF AGITATION ON THE MEDICAL FLOOR Maalobeeka Gangopadhyay, MD, Columbia University Medical Center, [email protected] Objectives: Pediatric agitation is a challenge to manage on inpatient medical units as a result of a multitude of factors both inherent to the agitation, as well as to the milieu. In addition to the safety risks it poses to patients and staff, agitation contributes to increased hospital expenditures. The goal of this presentation is to review the potential etiologies of agitation and discuss the identified barriers to managing agitation on the medical floor at our institution. Methods: This presentation will center around a case that exemplifies the challenges associated with assessment and management of agitation and aggression on the consult service. A review of the literature was conducted to

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identify the most recent evidence concerning assessment and management of agitation on pediatric medical units. Results: Although there is limited research on the assessment and management of agitation on the medical floor, there is increasing recognition of the need for standardized guidelines on medication administration and utilization of hospital resources to improve the milieu and train staff in deescalation and aggression management. Establishing a timeline about the agitation and identifying the etiology of agitation are central to creating appropriate strategies. The psychiatrist should consider the effects of stimulation (noxious and otherwise), as well as the alienating features of a medical unit (e.g., contact isolation, attachment to EEG, etc.), and the reduction in physical, social, and emotional outlets for frustration, pain, fear, and anxiety. Working with parents, nurses, and ancillary staff collaboratively aids the psychiatrist in contributing to a plan that can be implemented on the floor. Conclusions: Management of agitation on the medical floor can be a challenge for child psychiatrists working in a milieu with limited resources and personnel who are not universally trained in de-escalation or aggression management. However, child psychiatrists can bring to the table their understanding of development and behavior and their liaison skills in creating partnerships to create a safety net for agitated children.

AGG, CON, EBP http://dx.doi.org/10.1016/j.jaac.2017.07.165

28.2 PEDIATRIC AGITATION AND BEHAVIORAL ESCALATION: A SURVEY OF 38 NORTH AMERICAN HOSPITALS Nasuh Malas, MD, MPH, University of Michigan, nmalas@ med.umich.edu Objectives: Pediatric acute agitation and behavioral escalation (PAABE) is common and disruptive to pediatric inpatient healthcare. We describe national and institutional PAABE perceptions and practices, as well as our process of developing institutional resources and guidelines for the prevention, identification, and management of PAABE. Methods: A national survey was emailed to pediatric hospitalists and consultation/liaison psychiatrists through their respective professional listservs. In addition, an institutional survey was provided to all physicians, nursing, and staff caring for pediatric patients across University of Michigan Health System. A broad-based multidisciplinary workgroup was developed to identify problem areas in the evaluation and management of PAABE. LEAN methodology was used to identify problem areas and develop solutions to those problem areas at our institution. Results: Responses were obtained from 38 North American academic children’s hospitals. Of the respondents, 85.8 percent encountered PAABE at least once a month and as frequently as every week. Most respondents rated PAABE as highly important, yet 55.1 percent of respondents did not screen for risk factors for PAABE; 65.3 percent reported no PAABE clinical guidelines; and 57.1 percent indicated no physician training in PAABE. Our institutional data showed similar trends across disciplines. In addition, a majority of providers used benzodiazepines almost exclusively for the management of PAABE. We developed resources and a clinical practice guideline to address PAABE across the hospital system. This included universal screening on admission and transfer, educational resources and online modules, a caregiver-elicited form to describe calming strategies and triggers for PAABE on admission, a color-coded nonpharmacologic intervention guide for care providers, and a resource for diagnostically focused initial pharmacologic management of PAABE. Conclusions: Several pediatric hospitals identify PAABE as a great concern, yet there is little training or standardization of care in PAABE. There is a need to consolidate existing knowledge regarding PAABE while developing enhanced collaboration, training, and resources in inpatient PAABE. We describe our experience as a potential model to systematically address PAABE.


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28.3 DISCUSSION OF CLINICAL PATHWAYS FOR AGITATION Anik Jhonsa, MD, Children’s Hospital of Philadelphia, [email protected] Objectives: Agitation and aggression in pediatric settings can lead to disruption in care and lead to dangerous and harmful situations for patients and staff. This presentation aims to describe the role that clinical pathways can play in the management of agitated and aggressive behavior. Methods: Multidisciplinary teams worked together on the establishment of clinical pathways at The Children’s Hospital of Philadelphia aimed at providing clear and consistent means for approaching patients with behavioral difficulties. These pathways allow for care to be proactive when patients present to the hospital to attempt to minimize potential for harm. Results: Given that there are limited guidelines with regard to best practices for management of agitation and aggression in pediatric hospital settings, these clinical pathways can serve as a basis for approaching all patients. Establishment of clinical pathways allows for consistent delineation of responsibilities for all staff (nursing, front line clinicians, social work, etc.) to be involved in working with the patient from the time they arrive at the hospital. Our data have consistently shown that the majority of restraints in the pediatric emergency departments occur within the first 30 minutes of a patient arriving before any mental health providers are involved in the case. Our clinical pathways have allowed us to empower frontline non-mental health providers to assess patients and provide interventions to allow for immediate intervention to reduce episodes of agitation and aggression. Additionally, these pathways provide firmer guidelines to frontline providers for when (and when not) to proceed with pharmacologic intervention and what strategies should be attempted before administration of medication. Conclusions: Agitated and aggressive behavior can be difficult to manage in pediatric settings that are not often accustomed to routinely dealing with similar events. Establishment and implementation of clinical pathways provide pediatric teams with firm guidelines for ways to approach care. This can often lead to de-escalation of situations that, in the past, would have required pharmacologic intervention or physical restraint.


28.4 PEDIATRIC AGITATION MANAGEMENT IN THE PSYCHIATRIC EMERGENCY DEPARTMENT: THE EVIDENCE BASE Megan Mroczkowski, MD, Columbia University Medical Center, [email protected] Objectives: Annually, 30 million children present to emergency departments (EDs); three to four percent present with behavioral health chief complaints, such as agitation; 15 percent of patients with agitation are restrained, and 23 percent of patients with autism spectrum disorder (ASD) are restrained or sedated. This section investigates how agitation/aggression is treated in the pediatric ED setting and asks whether there is a standard practice or evidence-or empirical-drive practice. Methods: A literature search was conducted using publications in Medline and PsycINFO from January 1, 1996 to January 1, 2017. This yielded 906 results. A study was included if the patients were less than age 18 years, the patient had agitation or aggression, the topic was psychopharmacological management, and the management was acute. Studies were excluded if the topic was nonpsychopharmacological treatment strategies. Results: There are no RCTs for agitation or aggression in pediatric EDs; the majority of studies were case-control, retrospective chart reviews, and case reports. The following classes of medications will be described,


along with the evidence guiding their support: 1) antihistamines (one RCT of PRN diphenhydramine vs. placebo); 2) benzodiazepines (no studies identified the use of benzodiazepines for this indication); 3) typical antipsychotic drugs (haloperidol: RCT and haloperidol vs. lithium); 4) atypical antipsychotic drugs [risperidone: RCT on an inpatient unit, two RCTs for the intellectually disabled patients; olanzapine: open-label, prospective study; intramuscular (IM) ziprasidone vs. IM olanzapine, retrospective chart review; ziprasidone vs. IM haloperidol and IM lorazepam]; 5) stimulants (RCT of methylphenidate extended-release tablets vs. methylphenidate using aggression as secondary outcome measure); 6) mood stabilizers (lithium: RCT on inpatient unit); and 7) antidepressants (bupropion: four-site RCT). The most recent Consensus Guidelines for this topic will be discussed: Treatment Recommendations for the Use of Antipsychotics for Aggressive Youth (TRAAY) Parts I and II (2003) and the Treatment of Maladaptive Aggression in Youth: CERT Guidelines I and II (2012). Conclusions: There are four FDA-approved medications for agitation/ aggression; two of these are for patients with ASD. Atypical antipsychotic drugs have the largest effect size, followed by stimulants and typical antipsychotic drugs.


28.5 CONSENSUS GUIDELINES FOR PRO RE NATA MEDICATION FOR AGITATION IN THE EMERGENCY DEPARTMENT Ruth Gerson, MD, Bellevue Hospital/NYU School of Medicine, [email protected] Objectives: More and more youth are presenting to emergency departments (EDs) in psychiatric distress. Many of these youth present with agitated behavior or aggression as a result of psychosis, anxiety, mania, intoxication, or in relation to underlying behavioral disorder. Agitated patients can be dangerous to themselves, staff, and other patients in the ED and may require restraint. Although reduction of restraint and injury is a priority of every ED, there are little published data on the use and efficacy of PRN medications to treat or prevent acute agitation. In the absence of evidence-based guidelines, expert guidance is needed to assist clinicians in choosing effective and appropriate PRN medications for acute agitation. Methods: The Delphi method for consensus guideline development was used by a team of ED-based child and adolescent psychiatrists from across the United States. By use of an iterative, blinded process to reduce bias, participants reviewed existing or published PRN medication algorithms and guidelines for acute agitation and then developed consensus guidelines with identification of areas of dissension and need for further research. Results: There were significant variations in preferred medications across geography and type of ED setting (medical vs. psychiatric ED). Participants emphasized the importance of nonpharmacologic de-escalation strategies; clinical diagnostic assessment, even in the moment of acute agitation; consideration of individual patient factors in choosing medications; and careful monitoring for efficacy and adverse effects. A range of medications, including antipsychotic drugs, antihistamine, benzodiazepine, and a-adrenergic medications, was recommended. Conclusions: There are currently no AACAP Practice Parameters for the psychopharmacological management of agitation, and there is little published literature comparing effectiveness of different PRN medications or comparing those medications to placebo. Expert consensus guidelines such as these provide much-needed guidance to ED clinicians. These guidelines also demonstrate areas where further research is needed, especially into the comparative efficacy of different PRN medications in patients of different ages, clinical presentations, and diagnostic/treatment history.

ADOL, CON, EBP http://dx.doi.org/10.1016/j.jaac.2017.07.169

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CLINICAL PERSPECTIVES 29 MANAGEMENT OF SEVERE PSYCHOPATHOLOGY IN YOUTH WITH AUTISM SPECTRUM DISORDER AND INTELLECTUAL DISABILITY WHO PRESENT TO AN OUTPATIENT PSYCHIATRY CLINIC Alice R. Mao, MD, Baylor College of Medicine, maobrams@ aol.com; Janice L. Forster, MD, Pittsburgh Partnership, [email protected]; Nancy C. Shenoi, Baylor College of Medicine, [email protected] Objectives: Individuals with autism spectrum disorder (ASD), intellectual disabilities, and neurodevelopmental syndromes comprise a complex group with unique needs. As a group, they face significant stressors while having limited coping abilities and tolerance for change. Maladaptive behaviors, including self-injury and aggression, can impair daily functioning and cause stress to the caregivers and the treatment team. On occasion, this can necessitate emergency psychiatric treatment. This series is designed to provide clinicians with current knowledge on the management of these patients, including specific therapies and overall strategies for developing a treatment plan. Methods: Presenters will review current empirical evidence and provide additional information from their extensive direct clinical experience treating youth with ASD in the general outpatient and specialty clinic settings. Topics will include the evaluation and management of comorbid anxiety disorders, impulsive aggression, and self-injurious behavior, with an emphasis on minimizing functional impairment. Treatment strategies, including pharmacological treatment and therapy, will be discussed. Caregiver stress and clinician stress will be presented as factors that can impact the treatment course. De-escalation techniques will be provided for emotional outbursts, temper tantrums, and acute agitation. A case-based approach will aid discussion. Results: Participants will learn about the characteristics of severe anxiety, impulsive aggression, and related behaviors in youth with ASD. They will gain an understanding of treatment strategies and de-escalation techniques. They will consider working with caregivers to manage stress and develop a treatment plan. They will discuss a case taken from the clinical experience of the presenters. Conclusions: Anxiety disorders and aggressive behaviors are extremely common in this population, as are emotional outbursts, temper tantrums, and self-injurious behaviors. Any clinician working with youth with ASD needs to be aware of symptoms and current evidence regarding management. Understanding these considerations has a significant short-term and long-term impact on the developmental course of these individuals and is essential for ensuring that their clinical needs are adequately met.

AGG, ASD, SIB http://dx.doi.org/10.1016/j.jaac.2017.07.171

29.1 OUTPATIENT MANAGEMENT OF IMPULSIVE AGGRESSION AND ACUTE AGITATION IN AUTISM SPECTRUM DISORDER Alice R. Mao, MD, Baylor College of Medicine, maobrams@ aol.com Objectives: Impulsive aggression is a common symptom in youth with autism spectrum disorder (ASD). Despite efforts to minimize these episodes, there are times when a child may become acutely aggressive and violent in an outpatient setting. This can pose a danger to the child and to others in the immediate environment. Aggression in inappropriate social contexts and out of proportion to stimuli severely limits daily functioning for children with ASD. Caregivers and clinicians often feel helpless to resolve the situation in a chaotic environment and may have little guidance or prior experience. The goal of this session is to provide participants with the tools to evaluate and manage these maladaptive behavior patterns in the outpatient clinical situation.

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Methods: Dr. Alice Mao will review the following for discussion: 1) empirical evidence on assessment and management of impulsive aggression; 2) potential treatment targets and comorbid conditions impacting behavior; and 3) efficacy of applied behavioral analysis (ABA), pharmacologic options, and deescalation techniques for acute episodes. Results: Participants will recognize the components of impulsive aggression and learn ways to help family and staff reduce occurrence of these behaviors. They will be able to collaborate with families to develop a de-escalation plan and develop a protocol for resolving these episodes when they occur in the clinic. Considerations include the following: 1) managing the immediate environment of the child; 2) communicating with the child; and 3) minimizing harm to others in the area. Risk assessment is also necessary to determine need for hospitalization, the most appropriate pharmacologic interventions, and additional treatment options. Treating underlying comorbidities can help prevent future episodes. Conclusions: Appropriate preparation and treatment of impulsive aggression dramatically improve the day-to-day lives of youth with ASD and their caregivers. A combination of medication and therapy can decrease the risk of aggression, and staff preparation can improve safety in the clinic. De-escalation techniques are an essential tool for clinicians working with this population.

ASD, PSP, PPC http://dx.doi.org/10.1016/j.jaac.2017.07.172

29.2 EVALUATION AND MANAGEMENT OF SELF-INJURIOUS BEHAVIOR IN AUTISM SPECTRUM DISORDER Janice L. Forster, MD, Pittsburgh Partnership, [email protected] Objectives: Self-injurious behavior (SIB) in autism spectrum disorder (ASD) is among the most difficult behaviors to manage. It occurs across a variety of comorbid diagnoses and genetic syndromes associated with ASD. The phenomenology of SIB for each individual can be remarkably stable and chronic. A functional behavioral analysis of symptoms is essential, as sensory needs, communication abilities, social drive, and environmental circumstances are key to understanding the predisposing, precipitating, and perpetuating factors that are necessary to develop a case formulation and intervention plan. The author will present a unifying scheme for understanding the sensory, topographical, social, and neurochemical context for SIB that informs treatment planning. Methods: Literature review and direct clinical experience will inform this presentation. Examples of SIB phenomenology and successful interventions will be described. Results: Among neurodevelopmental disorders, an appreciation of the frequency, intensity, and topography of SIB can offer syndromal specificity. An individual’s tolerance of sensory issues is an essential component to functional behavioral analysis and to the development of a positive behavioral plan. Similar to stereotypic behaviors, SIB is a powerful modulator of both sensory deprivation, as well as overload, and it serves to sustain the autonomic balance between sympathetic and parasympathetic input. However, SIB is rarely tolerated in any social context, and countertransference to these phenomena can become powerful perpetuating factors. Substitution of an acceptable mode of sensory stimulation can manage both the social context and the SIB. In addition, a variety of classes of psychotropic medication contribute to behavioral pharmacotherapy of SIB. Medications can be used to treat an underlying mood disorder, modulate the person’s response to the environment, manage the reward drive, and decrease impulsivity leading to SIB. Conclusions: The social context, frequency, severity, and topography of SIB can provide a window through which underlying brain neurochemistry is understood, which in turn informs treatment. At the conclusion of this presentation, the clinician will have an understanding of why SIB occurs and will become familiar with a range of practical interventions to manage it in outpatient practice.

ASD, PSP, SIB http://dx.doi.org/10.1016/j.jaac.2017.07.173

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29.3 UNDERSTANDING AND MANAGING EMOTIONAL OUTBURSTS AND TANTRUMS IN AUTISM SPECTRUM DISORDER Linda M. Gourash, MD, Pittsburgh Partnership, wfgourash@ aol.com Objectives: Emotional outbursts and temper tantrums are common problems associated with youth diagnosed with autism spectrum disorder (ASD). The intensity and frequency of these behaviors are highly variable, and youth rarely outgrow them. A functional analysis of behavior is essential to treatment planning, but helping parents understand their child’s pattern of behavior that leads up to the tantrum can improve the implementation of a positive behavior plan. The author is a developmental and behavioral pediatrician with extensive experience counseling families of youth with ASD on how to modulate factors in the caregiving environment to decrease tantrums and emotional outbursts. Communication style is one of the most important factors (e.g., tone of voice, use of gesture, rate of speech, and grammatical complexity). Nonverbal aspects of communication are also important (e.g., facial expression, body posture, and interpersonal distance). The objectives of this presentation are to provide a conceptual overview of tantrum behavior and to describe practical ways to help parents change behavior by modifying their communication style. Methods: Literature review and extensive clinical outpatient experience inform this presentation. Results: Common antecedents to temper tantrums in ASD are cognitive rigidity, intolerance of uncertainty, frustration, embarrassment, or disappointment. Caregiver communication is a powerful modulator of these environmental antecedents. The “Anatomy of a Tantrum” is a paradigm for understanding the behavioral characteristics of the tantrum in real time. The clinician can use this as a teaching tool to inform caregivers about the optimal point in time to use communication to thwart escalation. It also provides a conceptual framework for understanding when and how to use verbal and nonverbal communication effectively. Recent research that focuses on the interaction between amygdala activity and serotonin transporter supports this type of intervention. Conclusions: The clinician attending this presentation will appreciate that counseling families about their style of communication with their child with ASD can increase their insight into the antecedents of tantrum behavior, as well as provide tools for successful intervention.

AD, ASD, PSP http://dx.doi.org/10.1016/j.jaac.2017.07.174

29.4 MANAGEMENT OF ANXIETY IN YOUTH WITH AUTISM SPECTRUM DISORDERS Roma A. Vasa, MD, Kennedy Krieger Institute, vasa@ kennedykrieger.org Objectives: Anxiety disorders are one of the most common psychiatric conditions affecting youth with autism spectrum disorder (ASD). These disorders can be severely impairing, disrupt educational programming and family life, and contribute to irritability and serious mental health disturbances. Longterm anxiety can affect residential planning and limit employment opportunities. Therefore, it is critical to educate clinicians on how to assess and treat this condition in their clinical practice. This session will cover the nuts and bolts of how to manage anxiety in individuals with ASD who present for an outpatient clinic visit. Methods: Two of the following sources of data will be reviewed: 1) data on the phenomenology and assessment of anxiety; and 2) treatment data, which includes medications, psychotherapy, and other psychosocial interventions. Clinical strategies will also be based on the presenter’s extensive clinical experience in managing psychopathology in youth with ASD for over 20 years. Results: Four topics will be covered in this session as follows: 1) how clinicians and parents can prepare for an outpatient clinic visit when the child with ASD is anxious; 2) specific strategies to assess anxiety with focus on how to differentiate anxiety from ASD; 3) selecting the right treatment, with emphasis on psychopharmacological interventions, given the limited data; and 4) family


and educational interventions. Clinical cases will be presented to illustrate specific points. Conclusions: Anxiety is a significant problem in youth with ASD. Clinicians will leave this session with a better understanding of how to manage this condition in their practice.

AD, ASD, PSP http://dx.doi.org/10.1016/j.jaac.2017.07.175

29.5 THE OTHER PATIENTS: CAREGIVER AND CLINICIAN STRESS IN TREATING AUTISM SPECTRUM DISORDER Ashok P. Yerramsetti, Baylor College of Medicine, yerramse@ bcm.edu Objectives: Youth with autism spectrum disorder (ASD) and severe psychopathology present unique challenges. Caregivers must expend significant time and resources on their daily care and treatment, often at great personal cost. This can cause caregivers anxiety, deplete finances, and strain family relationships. In addition, clinicians often need to treat multiple classes of ASD symptoms with varying levels of success. They can face enormous pressure exerted by families and by their own expectations for progress. Thus, many clinicians are hesitant to take on these patients, further exacerbating the existing shortage of specialists. This presentation will focus on the scope of these problems and discuss recommendations for their improvement. Methods: Empirical evidence on the following topics will be reviewed: 1) reported stressors and their effects on caregivers of youth with ASD; 2) clinician burnout in child psychiatry; and 3) barriers to care in the diagnosis/ treatment of these patients. Emphasis will be on the prognostic impact of these factors. Possible solutions will be presented, drawing from the literature and from the collective experiences of the faculty involved in this Clinical Perspective. Results: Participants will better understand how caring for ASD youth impacts caregivers and clinicians. They will discuss how to screen for caregiver difficulties during clinic visits and provide resources when necessary. From the clinician’s perspective, they will discuss potential reasons why some clinicians may be hesitant to take on these patients, including but not limited to the following: 1) lack of confidence in their knowledge of severe symptoms; 2) fears of clinic disruption by acutely agitated patients; and 3) overall stress in managing patients with limited potential for improvement. Possible solutions include increased education about this topic at the primary care and trainee level. Clear, easily accessible guidelines and collaboration with the family to set reasonable expectations will also be helpful in stress management. Conclusions: Caregiver and clinician stress are important aspects of caring for youth with ASD, which can influence patient care. Clinicians will leave with greater awareness and strategies for potentially alleviating these problems.

ASD, COPI, STRESS http://dx.doi.org/10.1016/j.jaac.2017.07.176

CLINICAL PERSPECTIVES 30 PEDIATRIC MEDICINE UPDATE FOR THE CHILD PSYCHIATRIST: MEDICAL THERAPIES FOR TRANSGENDER YOUTH, POSTURAL TACHYCARDIA SYNDROME, AND UPDATES ON CONTRACEPTIVES Kristi Kleinschmit, MD, University of Utah School of Medicine, [email protected]; Mary T. Gabriel, MD, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, [email protected] Objectives: The goal of this presentation is to present pediatric medicine updates on populations seen in child psychiatry settings. These presentations will review up-to-date clinical care standards or consensus in these

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populations and highlight the ways in which child psychiatrists can augment their own skill sets and collaborate. Methods: Subspecialists in pediatric adolescent medicine, cardiology, and a triple-board trainee will present a pediatric medicine clinical perspective on diagnosis, management, and psychiatric overlap of transgender medical therapies; autonomic nervous system dysfunction, including postural tachycardia syndrome (POTS); and a review of changes in recommendations for contraception choices for adolescents. Results: Dr. Dowshen will discuss evaluation and treatment recommendations for gender-nonconforming children and adolescents. Dr. Moak will present an overview of the diagnosis and treatment of types of autonomic nervous system dysfunction in adolescents, including POTS. Dr. Gargaro will present a review of changes in recommendations for contraception choices for adolescents. Conclusions: This clinical perspective will provide important medical information relevant to child psychiatry practice and will provide recommendations for improved care and enhanced pediatric subspecialist-psychiatric collaboration in caring for children and their families.

ADOL, GID, CVF Sponsored by AACAP's Triple Board and Post Pediatric Portal Programs Committee and Training and Education Committee

fatigue, and is characterized by an increase in heart rate and absence of orthostatic hypotension upon standing. It typically presents between the ages of 15 and 25 years, overwhelmingly in females, and has an estimated prevalence of approximately 0.2 percent. Symptoms of POTS can overlap with other types of autonomic dysfunction and be similar to symptoms of common mental illnesses, and POTS can be related to autoimmune conditions. A recent consensus statement was developed by the Heart Rhythm Society with class I–III recommendations for diagnosis, work-up, and multidisciplinary treatment of this condition. Methods: Dr. Moak will present an overview of POTS and other relevant types of autonomic dysfunction, focusing on the underlying physiology, diagnosis, treatment, and symptom overlap with mental illnesses. Case presentations will be used to enhance learning. Results: Attendees will gain a better understanding of the diagnosis, physiology, and consensus for treatment recommendations for POTS and other types of autonomic nervous system dysfunction in teenagers. Conclusions: This update will provide important information to child psychiatrists to aid in their care of children and adolescents with autonomic dysfunction.

CVF, CM, DIAG http://dx.doi.org/10.1016/j.jaac.2017.07.180


30.1 PEDIATRIC MEDICINE UPDATES FOR THE CHILD PSYCHIATRIST: CARING FOR TRANSGENDER AND GENDERNONCONFORMING YOUTH Nadia Dowshen, MD, Children’s Hospital of Philadelphia, [email protected] Objectives: According to recent population-based studies, approximately 0.3 to one percent of the population in the United States identifies as transgender or gender nonconforming. Transgender is an umbrella term that refers to individuals whose gender identity and expression may differ from their sex assigned at birth. Transgender adolescents are at high risk for poor physical and mental health outcomes, including high rates of human immunodeficiency virus infection, depression, anxiety, and suicide attempts. These health risks are attributed to the discrimination and isolation frequently reported by transgender individuals. Recently, interdisciplinary models of care have been developed to provide medical and psychosocial support for gender-nonconforming youth. This presentation will review key concepts, including distinguishing between gender identity and sexuality, diagnosis of gender dysphoria, and medical options for treatment, including puberty blockers and cross-gender hormones, as well as gender-affirming surgical procedures. Methods: A thorough discussion of evaluation and treatment recommendations for gender-nonconforming children and adolescents will be provided based on the World Professional Association of Transgender Health (WPATH) and Endocrine Society Guidelines. Current best practices will also be reviewed. Case studies will be presented to highlight common clinical challenges in this population. Results: Attendees will better understand the WPATH guidelines and medical options for treatment of gender-nonconforming youth and become more competent in discussing these treatments with their patients. Conclusions: This update will provide important information for child psychiatrists in the emerging area of medical care of transgender children and adolescents.

GID, MDM, SP http://dx.doi.org/10.1016/j.jaac.2017.07.179

30.2 PEDIATRIC MEDICINE UPDATES FOR THE CHILD PSYCHIATRIST: POSTURAL TACHYCARDIA SYNDROME AND AUTONOMIC NERVOUS SYSTEM DYSFUNCTION Jeffrey Moak, MD, Children’s National Health System, [email protected] Objectives: Postural tachycardia syndrome (POTS) is a syndrome that can consist of symptoms, such as light-headedness, tremor, weakness, and

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30.3 PEDIATRIC MEDICINE UPDATES FOR THE CHILD PSYCHIATRIST: LONG-ACTING REVERSIBLE CONTRACEPTIVES Beth Gargaro, MD, University of Utah School of Medicine, [email protected]; Sharyn Malcolm, MD, MPH, Children’s National Health System, smalcolm@ childrensnational.org Objectives: For years, long-acting reversible contraceptives (LARC) have been available and recommended for adult sexually active women. In 2012, the American College of Obstetrics and Gynecology (ACOG) updated their recommendations about LARC use among teenagers. Many practicing physicians are still unaware of the specific recommendations. Child and adolescent psychiatrists frequently work with teenagers and have a unique opportunity to help counsel their teenage patients on their contraceptive choices. Methods: Dr. Gargaro will present the updated guidelines, published in 2012 and reaffirmed in 2016 by ACOG, including specifics about the different types of LARC, and will demonstrate how to best counsel patients about LARC options. Results: Attendees will be better informed and feel more comfortable talking with their teenage patients about LARC. Conclusions: This update will provide important information for child psychiatrists working with sexually active teenagers regarding contraceptive choices.

ADOL, CON, SEX http://dx.doi.org/10.1016/j.jaac.2017.07.181

CLINICAL PERSPECTIVES 31 ROMANCE ON THE INTERNET: A CLINICAL PERSPECTIVE Sandra L. Fritsch, MD, Children’s Hospital Colorado, Sandra. [email protected]; Garrett Sparks, MD, University of Pittsburgh, [email protected] Objectives: Adolescents are developing their romantic and sometimes sexual relationships in a context of a digital world, which may be unfamiliar to their psychiatrists. Methods: Our presentations will review the relevant material for child and adolescent psychiatrists to understand and evaluate the romantic and sometimes sexual relationships in today’s digital context, including a review of normal romantic relationship development; association with mental health concerns; the role of texting and sexting; risk assessment of youth using digital communications for romantic relationships; an overview of the

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sites and applications available for such purposes and their risks and benefits, as well as a focus on lesbian, gay, bisexual, and transgender youth; and an interactive case presentation to allow clinicians to “integrate” their learning. Results: Adolescents use texting, sexting, and web and mobile platforms to communicate romantic and sexual feelings with regularity. This can lead to higher risk behaviors and significant interactions with mood, anxiety, personality, and other disorders. Adolescents are not always aware of the risks that these communication technologies bring. A case-based discussion highlights ways that these cases play out in practice with two interactive case presentations. Conclusions: Child and adolescent psychiatrists will be better prepared to evaluate and manage their patients with a more in-depth understanding of the digital world in which their patients live and sometimes love.

ADOL, MED, SEX Sponsored by AACAP's Consumer Issues Committee and Media Committee http://dx.doi.org/10.1016/j.jaac.2017.07.183

31.1 THE DEVELOPING BRAIN AND ONLINE ROMANCE: MEET THE PARENTS Erin L. Belfort, MD, Maine Medical Center, erin.belfort@ gmail.com Objectives: This presentation will review how adolescents engage with digital technologies as part of exploration of the self, one’s sexuality, and intimate relationships. There will be discussion on how this may create conflicts in families and how parents can help their children navigate safely. Methods: Adolescents’ brains are rapidly developing and changing in the milieu of hormonal shifts and changes. The frontal lobes, the executive function control center, are not fully myelinated, which helps us understand how bright teenagers can make impulsive decisions and engage in risky behaviors without foreseeing future consequences. The tasks of adolescence include identity consolidation (who am I?), as well as mastering intimacy (who do I want to be with?). These tasks are not new to adolescence, yet they are uniquely challenging in the digital age. Results: Adolescents are naturally curious about exploring their bodies, sexuality, and intimacy. It is easy for adolescents to find online pornography, which is arguably not the best resource for sex education. Some studies have linked online pornography exposure with unhealthy sexual attitudes and behaviors. Mobile dating and hook-up applications and the practice of “sexting” or sending sexually explicit text messages are also increasingly popular among teenagers today. This presentation will examine the complex relationship between the adolescent brain, explorations of intimacy in the digital age, and the interface with parents. Conclusions: Adolescent exploration of sexuality and intimacy is developmentally appropriate and natural although complicated by the limited ability of adolescents to foresee future consequences and the increasing use of internet pornography and mobile/online dating/hook-up applications. This may become a source of conflict and disagreement among families. This presentation will review the ways in which adolescents are exploring sexuality and intimacy in the digital age and how families can help navigate their teenage children through these unchartered waters.

ADOL, FAM, SEX http://dx.doi.org/10.1016/j.jaac.2017.07.184

31.2 ONLINE GAMING AND ROMANCE Roslyn Gerwin, DO, Maine Medical Center, rgerwin@ mmc.org Objectives: Participants will increase understanding of virtual romantic relationships in the context of online games for adolescents and transitional age youth. Methods: Internet and literature searches were performed. In 2015, the Pew Research Institute published a report entitled “Teens, Technology, and Romantic Relationships.” This presentation will include a review of current knowledge around technology use and influence on adolescent romantic relationships through online gaming. Clinical and personal experiences will also be incorporated, as well multimedia examples.


Results: Exploring the establishment of romantic relationships is an important part of adolescent development. The virtual world may represent a safe alternative to real-life experimentation for many adolescents and transitional age youth. Internet dating is certainly not a new phenomenon; however, the advent of online games provides a new platform. Formats include both games that simulate dating, as well as the immersive worlds of online role-playing games. In these worlds, highly customizable fantasy characters, or “avatars,” serve as personal representations. These relationships offer the opportunity to participate in high levels of commitment, even up to in-game marriage ceremonies. A subset of players also use the virtual world to pursue relationships outside of their real-life partners. Social media allows for simultaneous real-life communication, with some relationships transitioning to in-person status. Relationship simulation role-playing games are a video game subgenre using preformed avatars, with a goal of achieving romantic success that constitutes “winning” the game. Adolescent romances are a common theme. Sexually explicit content is accessible for older adolescents, with a censored version available for all ages. There are dating sites specifically dedicated to gamer or “geek” culture, with varying levels of credibility. Video games also represent a common shared activity in adolescent relationships, with 31 percent reporting talking with their partner while playing together. Conclusions: Child and adolescent clinicians are charged with being effective guides through the evolving digital landscape. Knowledge of the online world is essential for clinicians to remain effective.

ADOL, MED, SEX http://dx.doi.org/10.1016/j.jaac.2017.07.185

31.3 ONLINE SEXUAL COMMUNICATIONS IN ADOLESCENTS: RISKS AND REALITIES Carlene MacMillan, MD, Brooklyn Minds, [email protected] Objectives: Participants will be able to describe common online sexual communications among adolescents and appreciate how common they are in this population. Participants will gain insight around the risks associated with online sexual communications and ways to discuss these behaviors with young people and parents. Methods: Case vignettes on adolescents and young adults engaging in behaviors on their electronic devices, including sexting, “camming,” ghosting, and joining sugar daddy websites, will highlight the prevalence, risks, and psychological appeal of these trends. Guidelines regarding talking with parents and patients about these aspects of the digital landscape will be provided. Results: Prevalence estimates of sexting among adolescents range from 15 to 20 percent by self-report, but exact numbers are difficult to know with certainty. Higher percentages of adolescents report receiving sexually explicit texts. Sexting is associated with other risky sexual behaviors both on the internet and in the “real world.” Longitudinal studies of online sexual communications in young people suggest that some people are more vulnerable than others, depending on a variety of personality, social, and digital factors. Risky online sexual communications can lead to a range of lasting consequences, including significant emotional and legal consequences. Other online sexual communications that have the potential to generate income for young people, including use of webcams as camboys or camgirls for paid performances and postings on sites to find an older adult willing to act as a “sugar daddy,” are also popular. While “camming” is ostensibly for individuals 18 and older, clinical experience suggests that younger adolescents sometimes participate in this activity. In 2016, the most popular sugar daddy website had 1.9 million users, and one third of these individuals was college students. Conclusions: Digital technologies have presented a wide array of opportunities for young people to engage in online sexual communication. Some young people are more vulnerable than others to engage in risky online sexual activities. Understanding the nature of common platforms where young people go online for sexual, financial, and social gains is important for child and adolescent psychiatrists to provide appropriate guidance to patients and their families.

ADOL, COMP, PAT http://dx.doi.org/10.1016/j.jaac.2017.07.186

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31.4 SPOTLIGHT ON WEB-BASED AND MOBILE APPLICATIONS USED BY ADOLESCENTS FOR ROMANTIC CONNECTION, WITH SPECIAL FOCUS ON LGBT YOUTH Owen S. Muir, MD, New York University, owenmuir@ gmail.com Objectives: By the end of this session, clinicians will be able to 1) identify which mobile and internet resources exist for social and romantic connections, their age “limitations,” their functionality, which resources are popular with adolescents, and the risks associated with them; and 2) identify special concerns for lesbian, gay, bisexual, and transgender (LGBT) patients and be familiar with technological options used by LGBT patients to connect, with an emphasis on those that put LGBT patients in a higher sexual risk category. Methods: A PowerPoint presentation will review the myriad options for social connection available to patients and romantic-specific sites for dating and “hooking up,” as well as an overview of mobile applications (apps) on which adolescent patients may participate. Furthermore, adolescent romance and dating norms will be examined in the context of these mobile tools, and LGBT-specific apps and cultural norms will be explored. Results: Adolescents are able to engage with a variety of online and mobile tools for connection and with the option of mis-statement of age, hooking up with others. From common websites, such as Facebook and Twitter, to more dating-specific sites, such as OKCupid, and mobile apps, such as Snapchat, What’s app, kik, and others, adolescents have a world of “private” or seemingly private communications with them at all times, as well as camera-equipped devices with which to document and share their lives. Furthermore, LGBT patients have gay- or lesbian-specific applications, such as Grindr for men who have sex with men with its 3.5 million users in 192 countries, that offer even more options in terms of meeting, dating, and even anonymous high-risk sex all at their disposal. Furthermore, one in five Grindr users between ages 18 and 24 years have never been tested for human immunodeficiency virus (HIV) in their lives and often report being HIV-negative instead of untested. In addition, there are positive online resources available to help the LGBT community. Conclusions: More specific knowledge of the digital culture in which our patients live and the specific apps and websites that allow these interactions will allow child psychiatrists to expertly interview their patients. Furthermore, cultural knowledge allows comprehensive assessments of all aspects of their social and romantic lives. Gay and lesbian students also have specific apps, culture, and risk factors that we need to be aware of to effectively evaluate this subgroup of potentially high-risk patients.

ADOL, HO, SEX http://dx.doi.org/10.1016/j.jaac.2017.07.187

CLINICAL PERSPECTIVES 32 SOMATIC SYMPTOM DISORDERS: UPDATE ON DIAGNOSIS AND TREATMENT Daniel T. Williams, MD, Columbia University Medical Center, [email protected]; Kenneth Gorfinkle, PhD, Columbia University Medical Center, [email protected]; Boris Rubinstein, MD, MPH, Columbia University Medical Center, [email protected] Objectives: The workshop updates current clinical perspectives on the differential diagnosis, treatment, and management of somatic symptom disorders and malingering, as reformulated in DSM-5. Methods: Changes implemented in DSM-5 from the former DSM-IV diagnostic categories will be briefly reviewed. Treatment modalities for which there is supportive clinical evidence will be outlined, together with adjustments needed based on age and intellectual and educational levels of patients and parents. Evidence-based treatment studies will be noted. Video illustrations will be used. Opportunity for questions, as well as staff-participant interaction, will be provided. Results: Somatization is the tendency to use somatic metaphors to convey emotions that are difficult to express directly. Symptoms may be conveyed via

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unconscious (somatoform) or conscious (factitious/malingering) channels. DSM-5 relieves the clinician from having to form a premature diagnostic distinction regarding this symptom. Review of relevant epidemiologic and neurophysiological studies can enhance clinical perspectives on the developmental course of these disorders, thus enhancing both diagnostic sophistication and treatment efficacy potential. Treatments for which substantial clinical experience and some controlled data do exist include CBT, familycentered and psychodynamic therapy, pharmacological treatment of comorbid conditions, and hypnosis for treating dissociative features in somatic symptom disorders. We will address these in some detail. Conclusions: Prognosis for these patients is influenced by the following: 1) the nature, chronicity, and severity of the underlying psychopathology; 2) the nature, chronicity, and severity of external stressors; 3) the intrinsic strengths of the patient; and 4) the effectiveness of the patient’s support system, including the comprehensiveness of treatment.

CON, SOM, TREAT http://dx.doi.org/10.1016/j.jaac.2017.07.189

32.1 SOMATIC SYMPTOM DISORDERS: UPDATE ON DIAGNOSIS AND TREATMENT Kenneth Gorfinkle, PhD, Columbia University Medical Center, [email protected] Objectives: A review and update of somatization disorders will delineate clinical challenges in evaluation and treatment of individuals with factitious disorders, malingering, and psychological factors affecting medical conditions. Methods: Special emphasis will be given to the role of anxiety and cognitive overload in the diagnosis and treatment of type 1 and type 2 diabetes. Results: Clinical criteria for assessment of factitious disorders and malingering will be reviewed in the context of phobic avoidance of hypoglycemia and insulin restriction in service of weight loss (diabulima). Cognitive-behavioral approaches to diagnosis and assessment will be reviewed.


32.2 TRAVERSING THE MINEFIELD: SOMATIZATION IN THE CONSULTATION/LIAISON SERVICE Boris Rubinstein, MD, MPH, Columbia University, br10@cumc. columbia.edu Objectives: Children presenting with physical symptoms, without a defined cause, present a particular challenge for pediatricians and child and adolescent psychiatrists. Child psychiatrists are usually not adept at assessing physical complaints, and pediatricians usually are not comfortable interviewing children with mental health problems and often do not know what questions to ask or how to ask them. In addition, pediatricians, especially those without much experience such as residents, are often exasperated and put off by children and adolescents presenting with somatic symptom disorders. These cases, often seen by the consultation and liaison (C/L) service, present a challenge for the C/L psychiatrist as she/he walks a minefield among patients, parents, and the medical team, serving different roles as consultant, educator, therapist, collaborator, and manager for all of them. Methods: By use of clinical vignettes and a review of the literature, we will examine the role of the C/L psychiatrist and review different approaches in the treatment and management of this difficult clinical problem. Results: The C/L psychiatrist often works under severe time constraints, having to arrive at a diagnosis and present a treatment plan before the patient is discharged. Management of these cases requires that the child psychiatrist understands that she/he is dealing with different cultures with different needs and expectations. She/he needs to clearly define their role as consultant, determine who is or are the patients, and develop a treatment plan that is feasible considering the patient’s developmental level, biological vulnerabilities, the family’s strengths and weaknesses, and the resources available in the community. Conclusions: Managing children with somatoform disorders can be a most difficult situation that challenges even the most experienced clinicians. Developing a good working relationship with the pediatric team, avoiding

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jargon, and offering practical, well-formulated treatment plans that take into consideration the needs of the children and their families can result in good clinical outcomes.


Conclusions: The presenter will show how a longer intervention, ClinicianAssisted Videofeedback Exposure Approach Therapy (CAVEAT), integrates the two evidence-based approaches discussed to address mutually dysregulated mother–toddler interactions during this sensitive period and to reduce the risk of enduring child regulatory disturbances and intergenerational transmission of violence and trauma.

INF, PTSD, ATTACH

CLINICAL PERSPECTIVES 33 UPDATE ON EARLY CHILDHOOD REGULATION: EMOTION, SLEEP, AND FEEDING Joyce N. Harrison, MD, Johns Hopkins University, jharri47@ jhmi.edu Objectives: The ability to self-regulate attention, emotions, and behavior is central to optimal functioning throughout the life course and is associated with a range of developmental outcomes in later life. The goal of this Clinical Perspectives presentation is to provide a brief overview of disorders of regulation, including sleep, feeding, and emotion, as well as the neurobiology of regulation, and original research on an intervention targeted toward mutually dysregulated mother–toddler interactions. Methods: This Clinical Perspectives will consist of five presentations with discussion of underlying biologic basis and specific problems with regulation of sleep, appetite, and emotion. Current models of intervention will be described and will include the use of clinical and video vignettes. Results: Participants will have an understanding of a range of problems with regulation, including sleep, feeding, and emotion in very young children. Additionally, participants will appreciate the importance of correctly identifying some underlying etiologies of dysregulation to guide appropriate interventions. Conclusions: Child and adolescent psychiatrists need to be aware of the importance of identification and early intervention for regulation of feeding, sleep, and emotion because of its potential impact on future developmental outcomes.

INF, DEV, EC Sponsored by AACAP's Infant and Preschool Committee http://dx.doi.org/10.1016/j.jaac.2017.07.191

33.1 THE INTERPLAY OF MATERNAL HISTORY OF MALTREATMENT, VIOLENCE-RELATED POSTTRAUMATIC STRESS DISORDER (PTSD), AND MENTALIZING CAPACITY AS PREDICTORS OF TODDLER EMOTIONAL DYSREGULATION: WHERE TO FOCUS TREATMENT? Daniel S. Schechter, MD, University of Geneva Hospitals and Faculty of Medicine, [email protected] Objectives: This presentation aims to 1) review original research on the interplay of mothers’ history of violence-related PTSD and mentalizing capacity as significant predictors of their toddlers’ emotional dysregulation; and 2) show clinical vignettes and accompanying videoclips to illustrate where intervention can most efficiently be targeted in high-risk populations. Methods: Psychological, physiologic, and neuroimaging findings that have contributed to the development of two evidence-based videofeedback therapies, Modified Interaction Guidance and Clinician-Assisted Videofeedback Exposure Session(s), will be reviewed with illustrative case examples involving mothers with violence-related PTSD, with and without childhood physical abuse by a primary attachment figure. Results: The severity of mothers’ violence-related PTSD and level of mentalizing capacity as measured by parental reflective functioning account for as much as 18 percent of the variance (F3,54 ¼ 5.92, P < 0.005), with respect to dysregulated child behavior, as reported in the Infant-Toddler Social and Emotional Assessment (ITSEA) and as observed during coded interactions using the CARE-Index. A history of early physical abuse by the mother’s own mother or equivalent poses added challenges to the treatment, which needs to support and model maternal mentalization and confront PTSD-related avoidance and hyperarousal that interferes with maternal appraisal of child emotional communication.


Supported by the National Center of Competence in Research, the Swiss National Science Foundation Grant n 51AU40_125759, the Gertrude von Meissner Foundation, the Oak Foundation, la Fondation Prim’Enfance, the Center for Biomedical Imaging of the Geneva–Lausanne Universities, Ecole polytechnique f ed erale de Lausanne, and the Geneva–Lausanne University Hospitals http://dx.doi.org/10.1016/j.jaac.2017.07.192

33.2 “PEOPLE WHO SAY THEY SLEEP LIKE A BABY USUALLY DON’T HAVE ONE”: ON DIAGNOSIS AND TREATMENT OF SLEEP ISSUES IN CHILDREN UNDER AGE FIVE Magdalena Romanowicz, MD, Mayo Clinic, romanowicz. [email protected] Objectives: Nearly 25 percent of parents with children under the age of 5 years report sleep issues. An understanding of the regulation of sleep and its effects on maternal and family well-being is important to help families with sleep difficulties. Methods: Sleep, following the transactional model of child development, is influenced by dynamic, bidirectional exchanges between infant characteristics, such as temperament and the caregiving environment. Disruptions in sleep are very frequent after the birth of a baby. Sleep fragmentation and deprivation are almost universal in postpartum period, and there are studies that suggest that such sleep disruptions are correlated with postpartum depression. Likewise, maternal depression predicts infant and toddler sleep difficulties and disruptions in the ability to form a secure bond. Sleep becomes more consolidated usually by ages 6–9 months, and by then, most infants sleep six to eight hours at night. Question regarding links between attachment style and infant’s quality of sleep remains largely unanswered. The challenge for counseling parents on ways to help with regulation of the sleep in their babies is to understand the contributions of the child and the parent and to facilitate the child’s internal regulation of sleeping. Transactional processes focus on goodness of fit in parent–child relationships, and sleep patterns between the mother and her child is an important aspect of the dyad’s behavior. Mothers who require less sleep before pregnancy seem to do better with infants whose sleep is more fragmented, whereas mothers who require more sleep are better fit for infants who sleep more. Results: Research has demonstrated that sleep problems, mostly nighttime awakening and problems with falling asleep, may lead to learning difficulties, irritability, behavioral problems, mood regulation, and obesity. Conclusions: Good sleep hygiene is important to promote health and facilitate bonding between young children and their parents.

EC, INF, SLP http://dx.doi.org/10.1016/j.jaac.2017.07.193

33.3 EXTERNAL VERSUS INTERNAL REGULATION OF EATING: DIAGNOSIS AND TREATMENT Irene Chatoor, MD, Children’s National Medical Center, [email protected] Objectives: The goals of this session are to underline the importance of understanding the mutual regulation of feeding in young children and to explain a transactional model by which both infant temperament and parental characteristics contribute to the young child’s successful self-regulation of eating.

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Methods: There are three developmental stages of a young child’s learning to regulate eating, and during each stage, feeding disorders can arise. After birth, infants need to transition from continuous feeding through the umbilical cord to being fed at intervals by their mother. To feed, they need to reach a state of calm alertness. Infants who are too sleepy or too excitable pose a special challenge to their caretakers, and feeding disorders of homeostasis arise. Next, infants and mothers need to understand each other’s signals and develop a rhythm of feeding and sleep, which can derail if the infant is highly aroused or if the mother is overwhelmed by her own needs. This will lead to a feeding disorder of reciprocity in the first months of life. Starting around nine months of age, infants become increasingly competent; they begin to walk and talk, and during each meal, mother and infant have to negotiate who is going to put the spoon into the infant’s mouth. This is a critical developmental period during which two major feeding disorders arise: infantile anorexia and sensory food aversions, which are captured under avoidant-restrictive food intake disorder (ARFID) in DSM-5. During the latter stage of development, parents need to facilitate the infant’s increasing self-regulation of eating. However, if infants have a poor appetite or reject increasing number of foods, the parents become anxious and resort to distractions or become short-order cooks to accommodate the infant’s food choices. This leads to increasing conflict between parent and child and results in the child’s external regulation of eating. The challenge for treating each of these feeding disorders is to understand the contributions of the child and the parent and to facilitate the child’s internal regulation of eating. Results: Research has demonstrated that, if untreated, the symptoms of AFRID will continue throughout childhood, and symptoms of emotional dysregulation and sleep disorders will emerge. Conclusions: Facilitating internal regulation of eating in young children is critical for their overall healthy development.

33.5 SELF-CONTROL AND THE DEVELOPING BRAIN

EC, EA, TEMP


Diane M. Misch, MD, University of Illinois at Chicago, [email protected] Objectives: The goals of this session are as follows: 1) to review the neuroanatomical regions relevant to self-control in the developing young brain; 2) to discuss the multidirectional interactions of genetics, neurochemistry, language skills, temperament, individual variation, environment, culture, and socioeconomic status on self-control and development of psychopathology; and 3) to highlight interventions for detection and treatment of at-risk young children and enhancement of resiliency. Methods: Neuroimaging, psychological assessments, physiologic measurements, language assessment, and identification of specific genes have identified specific risk and resiliency factors related to self-control. A summary of the information will be reviewed, as well as evidence-based interventions designed to improve control of attention, cognition, and the ability to suppress impulses. Results: A brain-based approach to self-control can shed light on the environmental, physiologic, and genetic contributions to individual differences; can suggest which children with certain environmental risk factors are more likely to develop self-control problems; and can guide the development of interventions designed to target brain regions, stress hormones, neurotransmitters, language capacity, and quality of interpersonal interactions involved in self-control. Conclusions: Integrating the body of evidence that links environmental, physiologic, and genetic contributions to individual differences can lead to enhancement of cognitive functioning early in life and significantly improve late life outcomes in multiple ways.

DEV, NEURODEV, RF


33.4 EARLY DYSREGULATION OF EMOTION AND BEHAVIOR: TWO PATHWAYS


Jean M. Thomas, MD, George Washington University School of Medicine, [email protected]

UPDATE ON EPILEPSY FOR CHILD PSYCHIATRISTS

Objectives: The goals of this session are as follows: 1) to describe two developmental patterns of early dysregulation of mood and behavior that distinguish children with similar disruptive symptoms but different combinations of risk factors; 2) to identify three measures that correlate with two distinctive patterns, neurodevelopmental/disruptive and not neurodevelopmental/disruptive; and 3) to compare the clinical advantages in identifying these two diagnostic patterns. Methods: To acquire self-regulation, infants need to transition from helplessness to competence, which involves the following steps: reaction and emotional and behavioral regulation. Of 82 children examined (ages 18–47 months) who presented consecutively with a chief concern of disruptive behavior, 34 were diagnosed with disorders of affect, 29 with neurodevelopmental disorders, and 19 with PTSD. A later study examined children (ages 24–42 months) with dysregulation of emotion and behavior using three of the following instruments: the Bayley Scales Infant Development II, the Brief Rating Inventory of Executive Function (BRIEF), and the Child Behavior Checklist (CBCL), to study correlations between the clinical diagnoses of these two developmental patterns and the findings on the three instruments. Results: The later study demonstrated significant correlations between the diagnoses of neurodevelopmental/disruptive and not neurodevelopmental/ disruptive on the three of the following measures: the Bayley, the BRIEF, and the CBCL. The Bayley was most helpful in differentiating the subtypes neurodevelopmental/disruptive and not neurodevelopmental/disruptive, i.e., affective disorder. Conclusions: These findings have important implications for treatment because behavioral dysregulation should not always be diagnosed as neurodevelopmental, i.e., an early stage of ADHD.

Sigita Plioplys, MD, Ann & Robert H. Lurie Children’s Hospital of Chicago, [email protected]; David W. Dunn, MD, Indiana University School of Medicine and Riley Children’s Hospital, [email protected]; Tatiana Falcone, MD, Cleveland Clinic, [email protected]; Jana E. Jones, PhD, University of Wisconsin School of Medicine and Public Health, jejones@ neurology.wisc.edu

DIAG, DBD, DMDD http://dx.doi.org/10.1016/j.jaac.2017.07.195

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Objectives: The goal of this session is to review the most frequent psychiatric comorbidities in youth with epilepsy, as well as the different forms of evidence-based treatment for the comorbidities. Methods: Speakers will discuss the most important psychiatric comorbidities in youth with epilepsy. Dr. Dunn will discuss ADHD and epilepsy, the important considerations of treating children with epilepsy with stimulant medications, review the most relevant treatment studies, and discuss the differences between treating children with ADHD and treating children with epilepsy. Dr. Falcone will review mood disorders in children with epilepsy and his experience in building a program for integrated care for youth with epilepsy. Dr. Jones will discuss anxiety disorders in epilepsy. The etiology of underlying anxiety disorders in epilepsy has been controversial, ranging from psychosocial to biologic to familial. The psychosocial view holds that seizures are unpredictable, frightening, and thus, a potentially significant factor precipitating anxiety. In addition, the psychological treatment for mood and anxiety disorders in children with epilepsy will be presented. Dr. Plioplys will be discussing all of these presentations during this workshop. Results: Participants will be able to use their knowledge from this presentation while treating youth with epilepsy. Attendees will have an active role during this workshop; a case will be discussed by each one of

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the presenters, illustrating important issues that patients with epilepsy face. Conclusions: At the end of this presentation, participants will feel empowered with the knowledge gained on evidence-based practice to manage mental health comorbidities in youth with epilepsy. A handout with all the presentations and take away points will be given to each of the participants.

EP, CM, TREAT Sponsored by AACAP's Physically Ill Child Committee http://dx.doi.org/10.1016/j.jaac.2017.07.198

CLINICAL PERSPECTIVES 35 WHEN PREVENTION IS NOT ENOUGH: TREATMENT AND EMPOWERMENT OF PREGNANT TEENS AND TEEN MOMS Liwei L. Hua, MD, PhD, Baltimore Catholic Charities, LLH228@ gmail.com; Lois T. Flaherty, MD, Cambridge Health Alliance, loisfl[email protected] Objectives: Although teenage pregnancy in the United States has declined for the most part since peaking in 1991, rates in the United States remain higher than in other Western developed nations. This clinical perspective seeks to educate clinicians on the incidence of teenage pregnancy; physical and psychiatric issues that these adolescents and their children face, as well as issues of consent and confidentiality; and programs that help pregnant and parenting teenagers break the cycle of dropping out of school and living in poverty. Methods: Literature searches will be performed, and data will be presented on important topics pertaining to pregnant and parenting teenagers. Clinical case examples will be used as necessary. Methods of instruction will include lecture, visual aids, and interactive discussion. Results: The audience will learn about the importance of engaging in frank discussions with adolescents about sexual activity and education on the choices of contraception; the incidence of teenage pregnancy and risk factors; somatic and mental health issues that pregnant teenagers and teenage mothers face, as well as applicable and safe forms of treatment; the role of consent and confidentiality in treating these patients; and resources that support and empower pregnant and parenting teenagers to complete school while learning to care for their own children. Conclusions: The CDC named teenage pregnancy prevention as a “Winnable Battle” in 2010, demonstrating the continued importance of this issue, despite recent declines. Prevention of adolescent pregnancy is the ultimate goal; however, until then, pediatricians and child and adolescent psychiatrists must coordinate care for pregnant teenagers and teenage mothers and become familiar with physical, emotional, and psychosocial issues that this vulnerable population faces and be able to diagnose and manage psychiatric disorders appropriately. Clinicians working with these pregnant and parenting teenagers must also become familiar with state and community programs that empower these adolescents to complete school and make healthy parenting choices.

ADOL, PRE, SEX Sponsored by AACAP's Adolescent Psychiatry Committee http://dx.doi.org/10.1016/j.jaac.2017.07.200

35.1 ADOLESCENT PREGNANCY: EPIDEMIOLOGY, CONSEQUENCES, AND PREVENTION Heather Burrows, MD, PhD, University of Michigan, armadill@ med.umich.edu Objectives: Racial and economic disparities strongly affect adolescent pregnancy rates in the United States. Pregnancy is associated with poor medical, social, and economic outcomes for both the teenager and her child. Overall, children of teenage moms have lower school achievement, more health problems, and higher rates of unemployment. Although talking with teenagers about sexual health and contraception requires time to develop a therapeutic relationship and the ability to have confidential conversations,


engaging in these discussions can decrease both initial and repeat pregnancy rates, thus improving the long-term outcomes for adolescents. Methods: Heather Burrows, MD, PhD, will discuss current data on teenage sexual activity, pregnancy, and contraception. Methods for talking with teenagers to promote safe sexual health and avoid pregnancy will be addressed. She will explore medical conditions associated with teenage pregnancy and the need for interactions with child and adolescent psychiatry. Methods of instruction will include lecture, slides, and discussion. Results: After participation, attendees will understand national trends for teenage sexual activity and pregnancy; they will learn techniques for discussing sexual health and contraception with teenagers, be able to explain methods of contraception and the advantages of long-term contraception for teenagers, recognize health issues prevalent in teenage moms and their children, and will understand ways that child and adolescent psychiatrists can be involved in prevention of initial and repeat teenage pregnancy. Conclusions: Although there has been a slight decrease in US teenage pregnancy in recent years, rates are still higher than other developed countries. Teenage pregnancy disproportionally affects minority and socially disadvantaged youth and leads to increased medical problems for these teenagers and their children. By the age of 18 years, 60 percent of US teenagers are sexually active. It is important that all physicians who care for adolescents are able to provide confidential and culturally appropriate services, such as counseling around sexual health and contraception, to help prevent teenage pregnancies. Coordination of medical care for teenagers when they do have children is important to optimize positive long-term outcomes for the teenagers and their children.

ADOL, COLST, FAM http://dx.doi.org/10.1016/j.jaac.2017.07.201

35.2 ADOLESCENT PREGNANCY: CONSENT, CONFIDENTIALITY, AND ISSUES OF ABUSE/ NEGLECT Sarah S. Mohiuddin, MD, University of Michigan, mohiudd@ med.umich.edu Objectives: Adolescent pregnancy is of great importance to child and adolescent psychiatrists as adolescents with major mental illness are at increased risk for pregnancy. Pregnant teenagers are at higher risk for intimate-partner violence, and 36 percent of pregnant adolescents report their sexual partner to be at least six years older. Reporting of abuse requires careful assessment of the adolescent and whether the capacity for consent to sexual activity is impacted by mental illness or coercion. Issues related to consent and confidentiality are also complex. Although most states allow minors to consent to prenatal care, many require parental notification for abortion. Pregnancy also impacts minor status as medical emancipation is often granted to married minors or minors with children. By use of a complex case of pregnancy in adolescence from the consult/liaison service as an example, we aim to illustrate issues of consent and confidentiality as they pertain to pregnant teenagers and learn how and when to address concerns of child neglect/abuse. Methods: Sarah Mohiuddin, MD, will discuss a case of teenage pregnancy on the consult service in which psychiatric comorbidity intersects with issues of consent, confidentiality, and childhood abuse/neglect. She will also discuss aspects of the minor’s status and how pregnancy impacts it, as well as definitions of consent, notification, and judicial bypass. Methods of instruction will include lecture, slides, and discussion. Results: Participants will be able to 1) describe minor status, consent, notification, judicial bypass, and the impact of pregnancy in adolescents on these issues; 2) explain adolescent confidentiality and how minor status in teenage pregnancy relates to confidentiality; 3) describe how child abuse and neglect are evaluated in adolescent pregnancy; and 4) explain ways in which clinicians can adequately evaluate pregnant teenagers while considering consent and confidentiality. Conclusions: Adolescent pregnancy raises complex issues related to consent, confidentiality, and childhood abuse/neglect. These issues often interplay with one another, and it is important to assess how mental illness and childhood abuse/neglect impact consent and confidentiality. Clinicians must have a thorough understanding of these issues to provide appropriate care for this vulnerable patient population.

ADOL, CON, ETH http://dx.doi.org/10.1016/j.jaac.2017.07.202

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35.3 MEDICATIONS IN PREGNANCY Allison Scott Baker, MD, Massachusetts General Hospital, [email protected] Objectives: Adolescent parenthood is associated with a range of adverse outcomes for young mothers, including mental health problems, such as depression, substance abuse, and PTSD. Teenage mothers are also more likely to be impoverished and reside in communities and families that are socially and economically disadvantaged. These circumstances can adversely affect maternal mental health, both antepartum and postpartum, as well as parenting and behavior outcomes for their children. In this clinical perspective, we provide an overview of the treatment approach for antepartum and postpartum mental health needs of adolescent women, including a review of medications used for the treatment of psychiatric disorders during pregnancy and in the postpartum. Methods: We conducted a literature search on multiple databases, focusing on the prevalence of mental health disorders in pregnant and postpartum adolescents. We used different combined keywords as teen pregnancy, teen mother, teenage parents, teenage childbearing, teenage mother depression, and medications in pregnancy. Our search included different types of journals to obtain different viewpoints (medical, psychological, epidemiological). Results: Teenage mothers are more at risk for antepartum, postnatal depression, school dropout, and bad socioeconomic status. The babies and children are more at risk for prematurity and low birth weight and later for developmental delays and behavior disorders. Conclusions: Postpartum depression (PPD) is relatively common, affecting between 10 and 15 percent of women after delivery. Although it is difficult to reliably predict which women in the general population will experience postpartum mood disturbance, it is possible to identify certain subgroups of women who are more vulnerable. One such group is teenage mothers, where the risk of PPD is approximately 25 percent. Given this finding, pregnancy in adolescence should be supported in an interdisciplinary way (gynecologist, psychologist, child and adolescent psychiatrist, midwives, pediatrician). An update on medications used during pregnancy, the postpartum plan to target those patients most at risk, and ways to personalize maximum support of these patients will be provided. This presenter will also give an overview of the risk analysis of medications used in pregnancy vs. risks of untreated mental health disorders in the pregnant teenager.

ADOL, DDD, PPC http://dx.doi.org/10.1016/j.jaac.2017.07.203

35.4 EMPOWERING PREGNANT AND PARENTING TEENS Liwei L. Hua, MD, PhD, Baltimore Catholic Charities, LLH228@ gmail.com Objectives: Pregnant and parenting adolescents would benefit from services that empower them to move toward self-sufficiency while balancing the demands of parenting. Such services support the development of healthy families, strengthen communities, and demonstrate respect for the rights and capabilities of adolescents. The audience will learn about two such empowerment programs as follows: 1) the Connecticut’s Supports for Pregnant and Parenting Teens (SPPT) school-based program funded through the Office of Adolescent Health Pregnancy Assistance Fund; and 2) the Massachusetts Alliance on Teen Pregnancy (MATP), a 501(c)(3) nonprofit organization supported by community members, private foundations, corporate sponsors, the United Way, and the Centers for Disease Control and Prevention. They will also become familiar with various services and resources that these programs offer. Methods: Liwei Hua, MD, PhD, will present data from the SPPT, whose main outcomes are the reduction of repeat pregnancy and increased chance of high school graduation. MATP’s role as an expert in Massachusetts on adolescent pregnancy, prevention, parenting, and healthy sexual development will also be discussed. Results: Since 2010, participants in the SPPT program have had 2–9 percent yearly reduction in repeat pregnancies and a 75–82 percent high school graduation rate (with 62 percent of graduates accepted to

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college). There has been increased education and support of pregnant and parenting teenagers (including fathers), as well as destigmatization via education of teachers and staff in schools. The Office of Administrative Hearings has named the SPPT a “model program” and has charged them with creating a “roadmap” of services for pregnant and parenting adolescents and keeping them in school. Since 2002, the MATP has provided tailored assistance to community coalitions, youth-serving nonprofits, schools, clinics, and family-planning agencies in communities in Massachusetts. Conclusions: The MATP program seeks to advocate statewide and mobilize communities to prevent teenage pregnancy, and both the Connecticut SPPT and MATP programs aim to increase opportunities for youth and young parents and empower them to make healthy decisions about parenting and life. This presentation will highlight these organizations to educate clinicians about the existence of such resources to better treat their pregnant and parenting adolescent patients and to improve their options as they face parenthood.

ADOL, DEV, PAT http://dx.doi.org/10.1016/j.jaac.2017.07.204

CLINICAL PERSPECTIVES 36 CHILD AND ADOLESCENT PSYCHIATRISTS AND ATTORNEYS: ADVOCATING TOGETHER FOR THE BEST INTERESTS OF CHILDREN Milangel T. Concepcion-Zayas, MD, Brattleboro Retreat, [email protected]; Eraka Bath, MD, University of California, Los Angeles Semel Institute for Neuroscience and Human Behavior, [email protected] Objectives: This Clinical Perspectives aims to 1) introduce the concept of advocacy as established within ACGME competencies; 2) provide a practical framework on how to develop collaboration and partnerships with nonmedical child-serving systems; and 3) illustrate how training programs can incorporate rotations that involve medico-legal partnerships and collaborations for advocacy to the benefit of children’s health. Methods: Child and adolescent psychiatrists and attorneys share their perspectives on how the participation from medico-legal collaborative consultation models broadened their view into the complexities of the welfare systems and educational and legal systems, understanding within the greater systems of care, and how understanding around mental health needs have improved advocacy efforts, respectively. Three medico-legal collaborative consultation models will be illustrated. Results: There is a dire need for increasing awareness and advocacy efforts of the mental health aspects of children among welfare, legal, and legislative stakeholders, as well as an urgent need to increase access to quality mental health services. Child and adolescent psychiatrists are in need of a broader understanding of child-serving systems and the legal nuances that have a direct effect on their practice so they can advocate for the children at different levels. By developing collaboration and partnerships among attorneys and academic centers where quality mental health services are available, these needs can potentially be fulfilled. Conclusions: The growing evidence of the high barriers to accessing quality mental health services in children is well documented. Children can benefit from advocacy efforts that medico-legal partnerships can offer. Child and adolescent psychiatrist training institutions can capitalize by developing special tracks around already established community services or resources providing legal care for children and vice versa. Despite the scarce resources in children’s mental health, there are opportunities awaiting expansion. In times of political uncertainties and as the health care system evolves to integration and collaborative models of care, these types of partnerships are instrumental in attaining good health outcomes in the pursuit of the best interest of children.

PUP, REST, CON http://dx.doi.org/10.1016/j.jaac.2017.07.206

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36.1 ADVOCACY FROM THE TRENCHES OF CHILD AND ADOLESCENT PSYCHIATRY PRACTICE: WHERE DO WE STAND? Milangel T. Concepcion-Zayas, MD, Brattleboro Retreat, [email protected] Objectives: The goals of this session are as follows: 1) to provide a framework of children’s need for protection of their basic rights in the pursuit of their best interest at the individual level and in reducing healthcare disparities at the population level; 2) to illustrate the importance of advocacy in the child and adolescent psychiatry field and to present some lessons learned while participating in a medico-legal partnership during fellowship training; and 3) to present current efforts in advocacy training from other medical specialties. Methods: The speaker will present a brief overview of the four guiding principles for children’s rights as they are applied to health in the international arena and how they contrast with the child protection system in the United States. A clinical case will be used to briefly illustrate how advocacy is important at all levels of mental healthcare. The case will be evaluated through the lens of the Model of Physician Responsibility in Relation to Influences on Health. Concrete examples on how child and adolescent psychiatry can play an active role in advocacy efforts will be provided. Results: Child and adolescent psychiatrists usually operate as part of a team in a changing system of care. Along with their knowledge and expert clinical care, they are expected to be information integrators and resource managers, to practice collaboratively in community-based settings, and to advocate for children and their families. Despite the importance of child and adolescent psychiatry advocacy and existing advocacy training curricula developed by other medical specialties, the child and adolescent psychiatry field in the United States still needs to develop rigorous education opportunities for advocacy during fellowship training. Conclusions: In a time of political instability and changes in the healthcare system, it is paramount that children’s basic rights are protected. Child and adolescent psychiatrists have the responsibility to actively advocate for and with the vulnerable population they serve. Developing a basic advocacy training curriculum that includes some legal terms, processes, and direct interface with the multiple child-serving systems can potentially result in better access to health and raise the children’s voices to a higher level in the policy arena.

AC, PUP, CON http://dx.doi.org/10.1016/j.jaac.2017.07.207

36.2 CHILD AND ADOLESCENT PSYCHIATRISTS AND ATTORNEYS: A PERFECT TRAINING OPPORTUNITY, HOW AND WHY IT WORKS SO WELL Lisa M. Cullins, MD, Children’s National Medical Center, [email protected]; Valentina Cimolai, MD, Children’s National Medical Center, [email protected] Objectives: The goal of this session is to explore the significant educational benefits that working in collaboration with attorneys has on the development of a child and adolescent psychiatrist. Methods: This presentation will explore the development, implementation, effectiveness, and sustainability of elective rotations in psychiatry and the law. The presenter will discuss the development of an elective rotation in which child psychiatry fellows work closely with attorneys in particular areas of interest, such as children in foster care, educational advocacy, and human rights. This presentation will include a second-year child psychiatry fellow who is currently completing an elective at Human Rights First, a nonprofit organization advocating for children’s basic rights. The fellow will share her experience, including the structure of the rotation, richness of the educational experience, expectations, and outcome. The bidirectional/ reciprocal benefits that evolve with this type of collaboration and partnership will be highlighted.


Results: This presentation will provide the participants with a greater understanding of opportunities and challenges in developing educational experiences for child psychiatry fellows in psychiatry and the law. This presentation will offer participants concrete strategies on ways to develop, implement, and integrate psychiatry and the law into graduate medical education. Conclusions: Developing and sharpening a child psychiatrist’s knowledge base in psychiatry and the law is extremely valuable. This educational learning experience is also highly valuable for the attorney as well. In child psychiatry training, refining one’s clinical skills is a priority and is strongly emphasized; however, as the world and society continue to change, it may be equally important to refine our skillsets as child advocates. This type of collaboration affords child fellows this rare but important opportunity.

AC, OTH, REST http://dx.doi.org/10.1016/j.jaac.2017.07.208

36.3 CHILDREN’S LAW CENTER - CHILDREN’S NATIONAL MEDICAL CENTER PSYCHIATRY ROTATION: WHAT HAVE WE LEARNED FROM THIS MEDICO-LEGAL COLLABORATION? Gabrielle Mulnick Majewski, JD, Children’s Law Center, [email protected]; Katherine PiggotTukke, JD, Children’s Law Center, Kpiggott-tooke@ childrenslawcenter.org Objectives: The goals of this session are indicated as follows: 1) to provide an overview of Children’s Law Center’s partnership with Children’s National Medical Center’s Division of Psychiatry and the ways in which the collaboration has better equipped Children’s Law Center staff to advocate around children’s mental health issues; 2) to illustrate the reciprocal benefits that attorneys obtain from having child and adolescent psychiatrist consultations as they prepare for court hearings and other engagements to advance clients’ interests; 3) to illustrate how attorneys’ advocacy is expanded with the clinical knowledge provided by child and adolescent psychiatrists through case consultations, inhouse didactics, and resource manuals created by child and adolescent psychiatrists; and 4) to describe how this medico-legal collaboration can be replicated by other legal services organizations and child and adolescent psychiatrists. Methods: Children’s Law Center fights so every child in Washington, DC, can grow up with a loving family, good health, and a quality education. An integral component of Children’s Law Center’s work centers on children’s mental health advocacy, both on behalf of individual clients and through recommendations to ensure citywide policies and programs that address the health and mental health needs of all District children. Two attorneys from Children’s Law Center who have supervised child and adolescent psychiatrist fellows will share the processes and outcomes of this collaboration. Through a case study and two years of qualitative data, the presenters will highlight how the partnership improved attorneys’ advocacy for children across various domains. Results: As attorneys consult with child and adolescent psychiatrists on a range of general medical and psychiatric-specific issues, they gain a deeper understanding of how to address clients’ mental health within the system of care; how to evaluate the appropriateness of assessments, medications, and therapeutic interventions; and how to navigate issues with client medical providers. Conclusions: Working with attorneys provides the child and adolescent psychiatrists with an in-depth view of child-serving systems. As a result, the participating psychiatrist gains a more comprehensive understanding of client populations and the range of child welfare, educational, and housing issues they encounter. In turn, the child and adolescent psychiatrist offers specialized knowledge that enables attorneys to advance the best interests of children in court and through formal and informal advocacy realms.

OTH, PUP, CON http://dx.doi.org/10.1016/j.jaac.2017.07.209

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36.4 CROSS-DISCIPLINE DIDACTIC PRESENTATIONS AND CASE CONSULTATIONS AS A MEANS OF CHILD ADVOCACY: EXPLORATION OF A PILOT PARTNERSHIP Jessica Yeatermayer, MD, Ann & Robert H. Lurie Children’s Hospital of Chicago, [email protected] Objectives: The goals of this session are as follows: 1) identify barriers that attorneys face in representing children with mental health needs in the child welfare system; 2) understand the role for education of attorneys on matters pertaining to mental health and of psychiatrists on matters pertaining to legal issues in access to care; and 3) recognize the opportunity for child psychiatrists and attorneys alike to use co-education and the sharing of their expertise for child advocacy. Methods: The speaker will discuss her experience in creating a partnership with the Cook County Office of the Public Guardian in Chicago, Illinois, with the goal of providing a multidisciplinary team approach to the pursuit of the best interests of the child. The speaker will highlight challenges faced by attorneys who represent child clients with severe mental health needs—often involving inpatient hospitalization and treatment with psychotropic medication—and the resources required by the attorneys to help ensure that these children’s mental health needs are being appropriately met by the Department of Child and Family Services. The speaker will outline the structure of the piloted partnership, which includes individual (anonymized) case consultation, roundtable discussions on systems issues pertinent to child welfare, and didactic presentations given by the child psychiatrist and counting as Continuing Legal Education credits for the attorneys in attendance. The speaker will also discuss the invaluable education she has received from the attorneys regarding legal issues pertinent to her patients and will speak to the gap in legal knowledge relating to child welfare among practicing child psychiatrists. Results: The speaker will share qualitative data regarding the impact of the pilot partnership, will speak to the project as a means of performing child advocacy work, and will identify future avenues of collaboration under this advocacy model. Conclusions: Medical and legal professionals play different but important parts in caring for and representing children involved in the welfare system. This project highlights the vital role that education and discourse across disciplines can play in working toward serving the best interests of a doubly vulnerable population—children in care with mental health needs.

CON, JJS, OTH http://dx.doi.org/10.1016/j.jaac.2017.07.210

CLINICAL PERSPECTIVES 37 CLINICAL AND RESEARCH INSIGHTS INTO THE ASSESSMENT AND TREATMENT OF ANXIETY AND OBSESSIVE-COMPULSIVE DISORDER IN YOUTH WITH AUTISM SPECTRUM DISORDER Brenna B. Maddox, PhD, University of Pennsylvania, [email protected]; Lawrence Scahill, MSN, PhD, Marcus Autism Center, [email protected] Objectives: Anxiety disorders and OCD are among the most common and impairing psychiatric comorbidities seen in children and adolescents with autism spectrum disorder (ASD). Unfortunately, these internalizing disorders often go unrecognized or misdiagnosed and, therefore, untreated in the context of ASD. Although a fair amount of ASD research has informed evidence-based assessment and treatment, this knowledge has not been well disseminated to clinicians. The objective of this Clinical Perspectives is to discuss practical, evidence-based recommendations for the assessment and treatment of anxiety and OCD in children and adolescents with ASD. Methods: Four presenters, Drs. Martin Franklin, Connor Kerns, Brenna Maddox, and Matthew Siegel, will discuss the assessment and treatment of anxiety and OCD in youth with ASD in both outpatient and

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inpatient clinical settings. By integrating research findings and their clinical expertise, they will highlight key points for differential and dual diagnostic decision making and discuss important considerations for intervention. As discussant, Dr. Lawrence Scahill will integrate and critique the individual presentations and summarize their clinical implications. Results: Dr. Kerns will focus on evidence-based approaches to diagnosing anxiety disorders in youth with ASD. Dr. Franklin will provide guidelines about the differential diagnosis of OCD and ASD, as well as CBT for OCD within ASD. Dr. Maddox will summarize recommendations for modifying CBT for youth with ASD and anxiety. Dr. Siegel will present best-practice guidelines on the psychopharmacological treatment of anxiety and OCD in youth with ASD, with a focus on the management and treatment of this population in the inpatient setting. Conclusions: Determining whether psychiatric symptoms in children and adolescents with ASD are part of core ASD features or whether they represent anxiety/OCD is a complex clinical issue. In addition, the cognitive-behavioral and pharmacological treatment of co-occurring anxiety disorders/OCD present various challenges to clinicians working with youth on the autism spectrum. The evidence-based recommendations provided here serve as a guide to clinicians caring for this unique population.

AD, ASD, OCD http://dx.doi.org/10.1016/j.jaac.2017.07.212

37.1 THE DIFFERENTIAL DIAGNOSIS OF ANXIETY DISORDERS IN CHILDREN AND ADOLESCENTS WITH AUTISM SPECTRUM DISORDER Connor M. Kerns, PhD, Drexel University, [email protected] Objectives: The goal of this session is to describe and discuss evidencebased approaches to diagnosing anxiety disorders in youth with autism spectrum disorder (ASD). This will include discussion of methods for differentiating shared and overlapping symptoms of ASD and anxiety, and also how ambiguous or idiosyncratic fears (e.g., fear of change, toilets) should be conceptualized. Methods: The presenter will draw on burgeoning literature on anxiety in ASD, including a systematic literature review, to illustrate the challenges inherent to assessing anxiety disorders in children with ASD and their implications for clinical practice and research. In addition, the presenter will describe recent efforts to overcome these challenges with the development of an adapted, semi-structured clinical interview for assessing anxiety in ASD called the Anxiety Disorders Interview Schedule/Autism Spectrum Addendum (ADIS/ASA). Results: Results of this recent body of work suggest that anxiety disorders are prevalent in youth with ASD and are likely to manifest in ways both similar and dissimilar to those seen in youth without ASD. Findings also indicate that existing anxiety measures may have limitations when used in youth with ASD, in part due to the overlapping and ambiguous quality of many symptoms. The ADIS/ASA, a tool designed to address these diagnostic challenges, has demonstrated strong inter-rater and retest reliability, as well as convergent and discriminant validity for assessing both comorbid anxiety disorders and more ambiguous symptoms in youth with ASD. Conclusions: Research supports the presence of the following: 1) comorbid anxiety disorders in children with ASD, similar in presentation to the anxiety disorders of children without ASD; and 2) ambiguous anxiety-like symptoms that appear more closely tied to ASD-related characteristics and deficits. Understanding the varied presentation of anxiety in ASD and the importance of tailored assessment and diagnostic approaches is critical for treatment planning and accurate clinical research.

AD, ASD, DIAG Supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development Grant K23 HD087472, Autism Science Foundation, Adelphi University, and the Pershing Charitable Trust http://dx.doi.org/10.1016/j.jaac.2017.07.213

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37.2 THE ASSESSMENT AND COGNITIVEBEHAVIORAL TREATMENT OF OBSESSIVECOMPULSIVE DISORDER IN YOUTH WITH AUTISM SPECTRUM DISORDER Martin E. Franklin, PhD, University of Pennsylvania, marty@ mail.med.upenn.edu Objectives: The goal of this session is to provide guidelines on the differential diagnosis of OCD and autism spectrum disorder (ASD) and the cognitivebehavioral treatment of OCD within ASD. Methods: The presenter will discuss evidence-based recommendations on distinguishing OCD and ASD, focusing on several key considerations as follows: 1) restricted interests in ASD vs. obsessions in OCD; 2) repetitive behaviors in ASD vs. compulsions in OCD; and 3) behavioral rigidity in ASD vs. “not just right” OCD. In addition, the presenter will describe how to harness restricted interests to improve the treatment of comorbid OCD in children with ASD. Throughout the presentation, he will provide case examples to highlight key points. Results: Individuals with ASD often present to the clinic with symptoms that are described colloquially as “obsessional,” yet careful assessment of these focused areas of interest do not reveal any fear or anxiety in the presence of relevant stimuli. Obsessions in OCD give rise to distress, whereas restricted interests in ASD are usually experienced as appetitive. Likewise, uncovering the affective function of repetitive behaviors is key to differentiate them from compulsions. Individuals with ASD may have to repeat behaviors to reduce discomfort, but the prompt for this kind of discomfort is often a deviation from usual routines (e.g., being picked up early or being late for school) that typically provide assurance about sameness. In clinical situations in which an individual suffers from both OCD and ASD, exposure-based treatments can be especially difficult to conduct. One way to enhance motivation to engage in exposures both in and between sessions is to link compliance with procedures with time spent in session discussing the patient’s restricted interest. Conclusions: OCD and ASD symptoms, although often similar on the surface level, typically serve different affective functions that can help differentiate them from one another and help the clinician to devise treatment strategies for each. Thus, it is imperative to perform a functional analysis to carefully identify the antecedents, exact behaviors, and consequences of OCD and ASD symptoms. Clinicians are also encouraged to make ample use of patients’ restricted interests during treatment as a way to help patients engage fully with the exposure procedures.

ASD, CBT, OCD http://dx.doi.org/10.1016/j.jaac.2017.07.214

37.3 COGNITIVE-BEHAVIORAL TREATMENT FOR ANXIETY DISORDERS IN CHILDREN AND ADOLESCENTS WITH AUTISM SPECTRUM DISORDER Brenna B. Maddox, PhD, University of Pennsylvania, [email protected] Objectives: The goal of this session is to provide evidence-based recommendations for the effective CBT of anxiety disorders in children and adolescents with autism spectrum disorder (ASD). This presentation will include a discussion of common challenges faced by clinicians working with this population, important modifications to CBT when applied to youth with ASD, and possible mechanisms of treatment effect. Methods: The presenter will draw from growing literature on CBT for anxiety in youth with ASD, along with her own clinical experience working with this population and training community clinicians to treat anxiety in individuals with ASD. She will briefly describe two case examples to highlight the treatment of social anxiety disorder (which has considerable phenotypic overlap with ASD) with an adolescent and specific phobia with a minimally verbal child. Results: The available research suggests that CBT strategies, demonstrated to be effective with youth who do not have ASD, are applicable to youth with ASD, with some modifications. Adapting the structure, content, and process


of traditional cognitive-behavioral approaches is important because of differences in learning styles between those with and without ASD, core ASD symptoms, such as social communication impairments that affect therapeutic rapport, and common difficulties with emotion recognition and executive function. Key modifications, as highlighted by the case presentations, include the following: an increased number of sessions with more frequent practice of cognitive restructuring and exposure exercises, emphasis on social skills training, additional information using concrete examples to enhance the client’s understanding of emotions, inclusion of visual aids and written materials, avoidance of colloquialisms or metaphors, reliance on a more directive (rather than Socratic) therapeutic style, and incorporation of the client’s circumscribed interests. Conclusions: For many youths with ASD, anxiety symptoms are often the impetus for psychiatric evaluation and treatment, so it is critical for clinicians to have a clear understanding of the effective treatment options available. Treatment modifications for clients with ASD and anxiety improve the acceptability and utility of CBT, along with the client’s engagement in treatment.

AD, ASD, CBT http://dx.doi.org/10.1016/j.jaac.2017.07.215

37.4 PHARMACOLOGIC TREATMENT OF ANXIETY DISORDERS AND OBSESSIVECOMPULSIVE DISORDER IN CHILDREN AND ADOLESCENTS WITH AUTISM SPECTRUM DISORDER Matthew Siegel, MD, Spring Harbor Hospital, SIEGEM@ MaineBehavioralHealthcare.org Objectives: The goal of this session is to draw from the limited evidence base on pharmacologic intervention for anxiety and OCD in youth with autism spectrum disorder (ASD) to facilitate evidence-informed decision making. Applications of pharmacology for typical and atypical anxiety in ASD will be addressed. Methods: The presenter will build upon a systematic literature review of pharmacologic trials in ASD and a best-practices expert consensus publication to elicit a rational approach to medication use for the amelioration of anxiety and associated features in ASD. Potential overlap and confusion of anxiety/OCD symptoms and other symptoms/behaviors will be considered in relation to the research literature. Treatment of comorbid conditions in the context of anxiety reduction will also be discussed. Results: Although anxiety disorders and OCD are prevalent in youth with ASD and present with both typical and atypical features, there is limited research evidence for pharmacologic treatment that can be drawn from clinical trials specific to ASD. Where there is an absence of controlled evidence, bestpractice approaches for the treatment of anxiety/OCD in youth with ASD, drawing from the established evidence base for treatment in neurotypical youth, can be considered. Conclusions: Pharmacologic treatment may play a role in the amelioration of impairing anxiety and OCD symptoms in ASD, although controlled evidence is mostly lacking. Best-practice approaches using related controlled evidence and the targeting of associated features, such as physiologic arousal and executive dysfunction, may be beneficial for some youth with ASD and impairing anxiety/OCD.

AD, ASD, OCD http://dx.doi.org/10.1016/j.jaac.2017.07.216

CLINICAL PERSPECTIVES 38 CREATIVE PSYCHOTHERAPIES IN CHILD AND ADOLESCENT PSYCHIATRY Jennifer S. Saul, MD, Child and Adolescent Psychiatry Consulting, LLC, [email protected]; Sergio Delgado, MD, Cincinnati Children’s Hospital Medical Center, [email protected]

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Objectives: The goals of this presentation are as follows: 1) to learn how creative experiences are integrated into psychotherapy to achieve mental health and behavioral treatment goals; 2) to understand the evidence for experiential psychotherapeutic modalities, including equine-assisted psychotherapy, art therapy, horticultural therapy, dance and movement therapy, and music therapy; 3) to identify which populations are likely to benefit from each modality; and 4) to become familiar with the role of metaphor in facilitating self-awareness, self-expression, and psychobehavioral change. Methods: Psychotherapies that integrate experiences with art, horticulture, dance and movement, music, and horses have been growing increasingly popular. The processes of creating art, moving one’s body in harmony, or interacting with nature can lead to the development of metaphors within a safe therapeutic environment; can encourage patients to explore different ways of thinking, doing, and being; and facilitate behavioral and emotional change. Presenters introduce psychotherapy modalities (art therapy, horticultural therapy, dance and movement therapy, music therapy, and equine assisted psychotherapy) and review evidence for its use in various child and adolescent populations. Cases from their own clinical experiences will illustrate how the modality facilitates connections between the symbolic and the actual to achieve treatment goals. Results: A wealth of new evidence examining the effectiveness of creative, integrative therapies for children and adolescents with various behavioral and emotional disturbances suggests that these interventions are effective across a broad range of psychological, developmental, and behavioral disturbances. These modalities show promise in facilitating a therapeutic alliance and engagement with treatment. Conclusions: A growing body of research provides evidence for these creative, integrative therapies as a viable therapeutic option for children and adolescents. The same evidence hierarchies applied to “typical” community-based psychotherapies can be used to examine the research and evaluate the efficacy of these “creative psychotherapies.” Child and adolescent psychiatrists should be familiar with the experiential therapies and the research on their use in various child and adolescent populations.

P, TREAT Sponsored by AACAP's Psychotherapy Committee, Complementary and Integrative Medicine Committee, and Art Committee http://dx.doi.org/10.1016/j.jaac.2017.07.218

psychotherapies complicates efforts to standardize treatment and compare outcomes. Conclusions: The acceleration of research on EAP in the past several years has provided an evidence base for EAP as a viable therapeutic option for children and adolescents. It is anticipated that future research will extend these findings and perhaps shed light on the components of EAPs that are most effective in identifiable subgroups of children with developmental and psychological disorders.

CAM, FAM, P http://dx.doi.org/10.1016/j.jaac.2017.07.219

38.2 NATURE AS CO-THERAPIST: HORTICULTURAL THERAPY IN CHILD MENTAL HEALTH Matthew J. Wichrowski, MSW, Rusk Institute NYU Langone Medical Center, [email protected] Objectives: Nature-based interventions such as horticultural therapy (HT) have become increasingly popular in a number of therapeutic settings. HT is defined as the use of nature-based environments and activities designed to meet the therapeutic goals of participants. HT is used in both indoor and outdoor programs and can assist in the treatment of a variety mental health issues. Methods: The underlying foundations of human response to nature are explored, providing an understanding of environmental elements that can positively impact the therapeutic process. Current research on passive and active benefits of nature is reviewed in the context of maximizing patient benefits. Case studies are used to exemplify techniques and program possibilities. Results: Information is provided, which enables the therapist to develop new techniques and approaches and enhance treatment settings. Treatment recommendations for psychiatric settings, including design recommendations for a therapeutic environment, the role of HT in the treatment milieu, strategies for rapport building, and use of nature as a form of therapy, are provided. Conclusions: The use of horticultural therapy activities and therapeutic garden design principles has great potential to provide a unique and effective array of benefits in the area of child mental health.

CAM, P, STRESS http://dx.doi.org/10.1016/j.jaac.2017.07.220

38.1 METAPHORS(E) BE WITH YOU: EQUINEASSISTED PSYCHOTHERAPY Jennifer S. Saul, MD, Child and Adolescent Psychiatry Consulting, LLC, [email protected] Objectives: Interest in equine assisted psychotherapy (EAP) continues to grow. According to a 2014 survey of 509 Equine Assisted Growth and Learning Association (EAGALA) programs, 338 children (ages 10–18 years) received EAP. EAGALA is one of many professional organizations whose members provide equine-assisted therapies. Methods: The various ways that horses are used therapeutically are discussed. A presentation that reviews the quality of evidence for EAP in various child and adolescent populations was conducted using PubMed and other resources and the search terms such as “equine assisted psychotherapy,” “children,” “adolescents,” and so on. Individual cases will be presented to enhance a practical understanding of relevant clinical themes. Results: Although a 2014 systematic review concluded that equine-related treatments for mental disorders lacked empirical support, seven quantitative studies suggesting efficacy of EAP have been published subsequently. A number of studies (n ¼ 34) on the efficacy of EAP in a total of 672 children and adolescents examined children with suicidal ideation, ADHD, anxiety, history of sexual abuse, PTSD, history of bereavement, and other social and behavioral problems. Improvements were noted in “warm emotion,” quality of life, empowerment, anxiety, depression, enthusiasm, and happiness. Two studies identified physiological correlations of cortisol and heart rate between human and/or horse pairs. The diversity of equine interventions used in

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38.3 THE DANCING DIALOGUE: THE ROLE OF THE UNSPOKEN AND THE CREATIVE ARTS IN THERAPEUTIC CHANGE WITH INFANTS, CHILDREN, AND THEIR FAMILIES Suzi Tortora, EdD, Memorial Sloan Kettering Cancer Center, [email protected] Objectives: The goals of this session are as follows: 1) understand the role of embodied, multisensory, and preverbal experience in early emotional development; 2) understand the role of nonverbal analysis for assessment and clinical intervention; 3) from felt-experience to metaphoric expression, explore the psychological role of interpersonal body and movement experiences as a means of communication; 4) learn how creative and interactive explorations using dance, movement, and music are used to support psychobehavioral change; and 5) learn how object relations theory and neuroscience research provide a foundation for dance/movement therapy theory and clinical practice. Methods: In dance/movement therapy, the body, mind, and emotions are regarded along a circular continuum rather than independently. Primary embodied experiences from a somatic, sensory, kinesthetic, and interpersonal perspective influence mental perceptions and each individual’s development. Analyzing body experiences through multisensory creative dance and movement facilitates psychobehavioral change. Results: A comprehensive review of research in trauma, chronic pain, adverse childhood experiences, implicit knowledge, intersubjective

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motivations, early infancy memory, and dyadic nonverbal therapeutic videoanalysis inform treatment. A concept described in 1972, “placing the self in the body,” during infancy highlights the essential relational basis of bodily experience. The infant’s experience occurring outside of verbal conscious awareness is studied to explain the development of self and other in attachment. Neuroscience research emphasizes that the development of our brain is dependent on the physical and experiential nature of relationships. Separation between action and perception, motor processes and sensory perception, motor functioning and sensory perception no longer exists. Conclusions: The role body/movement experience, nonverbal understanding, and nonverbal expression play in the development of self, and interpersonal relationship is discussed in the context of relevant research. Interventions that are experientially based using nonverbal analysis, and the creative process mobilize the psychotherapeutic experience when working with children and their parents.

ATTACH, DEV, P http://dx.doi.org/10.1016/j.jaac.2017.07.221

38.4 MUSIC THERAPY IN CHILD AND ADOLESCENT MENTAL HEALTH TREATMENT Olivia Yinger, PhD, University of Kentucky, olivia.yinger@ uky.edu Objectives: The American Music Therapy Association (AMTA) estimates that 1.5 million people received music therapy services in 2014. More board-certified music therapists work in mental health treatment than in any other single area of treatment. This presentation will discuss the use of music therapy in mental health treatment for children and adolescents, providing an overview of the research, as well as case examples. Methods: A review of research published in 2014 on music therapy for children and adolescents receiving mental health treatment revealed promising results but a need for further research. An updated systematic search of databases (including PubMed and PsycINFO) was conducted for articles published since 2012 using the search terms “music therapy,” “mental health,” “child,” “adolescent,” and “psychiatric.” Additionally, music therapy journals and arts in psychotherapy journals were hand-searched for relevant articles. Results: A total of 33 studies were retrieved, including systematic reviews (n ¼ 3), randomized controlled studies (n ¼ 4), pilot studies (n ¼ 9), and qualitative case studies (n ¼ 17). Many of the studies included children or adolescents with neurodevelopmental disorders (n ¼ 16), particularly those with autism spectrum disorder (ASD) (n ¼ 11). Other studies included groups of participants with various psychopathologies (n ¼ 6), such as psychotic disorders, bipolar and related disorders, and depressive disorders or other conditions that may be the focus of clinical attention (n ¼ 11), such as relational problems or abuse and neglect. A variety of music therapy approaches and interventions were used. Outcomes included improved mood, social engagement, and expression of feelings. Conclusions: The body of research on music therapy in child and adolescent mental health treatment is growing, with promising results. Because of the variety of music therapy approaches and interventions, as well as the heterogeneity of the populations with whom music therapists work, future controlled research should examine specific approaches and interventions with specific populations to determine best practices.

CAM, P, TREAT http://dx.doi.org/10.1016/j.jaac.2017.07.222

38.5 DRAWING OUT UNDERSTANDING: ART AS A WINDOW INTO THE WORLD OF CHILDREN AND ADOLESCENTS Megan McSwain Mann, LCSW, Peachtree Art Therapy and Counseling, [email protected]


Objectives: When working with children and adolescents, art therapists combine the evidence-based knowledge and skills of pediatric mental health counseling and psychotherapy with the specialized practice of the art-making process as it relates to self-regulatory needs and the emotional, physical, and cognitive development of the child. Because art is a natural language for most children, its use enables the mental health provider to literally see from the child’s perspective and approach the treatment of mental health in a child-centered manner. Methods: There are diverse applications of art therapy with children and adolescents, as both a validated assessment and clinical intervention, which will be discussed in this presentation. The evidence base of art therapy and its use with children will be reviewed, with particular focus on current research on child development as it pertains to art making, attachment and attunement in the art therapy process, and parentchild art therapy (dyadic therapy art). Clinical case material from an art therapist’s practice will be offered, including video and art examples that will illustrate these findings. Results: Findings support that art therapy offers a unique and childrencentered perspective into the emotional lives of children and teenagers, particularly in the cases of trauma, attachment, adjustment, and self-concept and self-esteem. Artwork made in the context of art therapy also provides critical development and cognitive information. Conclusions: The body of research on art therapy and children and adolescents is an expanding field that offers important information on effectively providing emotional support and relief from mental health issues effecting children and adolescents. Artwork and the art-making process offers a window into the world view of children and adolescents that allows mental health providers and parents to see from the child’s perspective and create child-centered and effective interventions and tools, as well as promote more collaborative therapeutic relationships.

CAM, P, TREAT http://dx.doi.org/10.1016/j.jaac.2017.07.223

CLINICAL PERSPECTIVES 39 IMPLEMENTING CLINICAL PATHWAYS FOR ACUTE BEHAVIORAL HEALTH ISSUES IN PEDIATRIC MEDICAL SETTINGS Vera Feuer, MD, Northwell Health - Long Island Jewish Medical Center, [email protected]; Laura M. Prager, MD, Massachusetts General Hospital, [email protected] Objectives: This clinical perspective will introduce the development and implementation of clinical care pathways in the evaluation and treatment of children and adolescents presenting with acute mental health complaints to various medical settings. Methods: After a brief introduction to clinical pathways and their literature, the first presentation in our clinical perspectives will introduce a care protocol developed for management of pediatric patients on the autism spectrum who present to an emergency department setting. We then will review the development of an easy-to-use, single source, concise protocol for the management of adolescents, with a variety of substance abuse and/or withdrawal complaints that was based on a comprehensive literature review and a survey of over 50 pediatric facilities. The third presentation will focus on developing best practices for the care of patients with acute mental health needs who are awaiting inpatient psychiatric admission in a medical facility. The fourth and last presentation will provide us an insight into a clinical pathway that was developed in Canada to guide and support the care of children and youth presenting to the emergency department with mental health and addictions issues and to ensure their seamless transition to follow-up services with relevant community mental health agencies and providers.

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Results: Clinical pathways and care protocols developed at four academic centers will be reviewed, including implementation, challenges, and outcome results. Conclusions: These pathways have been found helpful in streamlining processes, organizing available resources, providing guidance, and improving quality of care.

CON, TREAT, OTH Sponsored by AACAP's Emergency Child Psychiatry Committee and Physically Ill Child Committee http://dx.doi.org/10.1016/j.jaac.2017.07.225

39.1 IMPLEMENTATION OF AN ACUTE CARE PROTOCOL FOR MANAGEMENT OF PEDIATRIC PATIENTS WITH AUTISM SPECTRUM DISORDERS PRESENTING TO A MAJOR METROPOLITAN EMERGENCY DEPARTMENT Stephen Tourjee, MD, Massachusetts General Hospital, [email protected] Objectives: Emergency department (ED) visits among youth with autism spectrum disorder (ASD) has increased considerably with some findings reflecting three percent in 2005 to nearly 16 percent in 2013. Adolescents with ASD are nearly five times more likely to have had an ED visit than those without ASD. Outcomes, such as restraints, prolonged length of ED stay, and elopement, can likely be reduced through better training of staff and streamlining the management process of patients with ASD. There is a need for a concise protocol that is user-friendly, adaptable, and custom-tailored to the individualized needs of each patient with ASD. Methods: During the presentation, we will provide a review of the literature regarding youth with ASD in emergency department settings. We will introduce the development of a user-friendly protocol to identify comfort and safety considerations, unique sensory needs, and communication methods of youth with ASD in our ED where we have no dedicated child psychiatry area or easy access to an inpatient child psychiatry unit. We will describe how the development and implementation of this protocol, which utilizes a modified version of the Autism Care Questionnaire and is integrated to our electronic medical records (EMR) may be helpful in addressing prolonged lengths of stay and suboptimal care. We will then review characteristics and outcomes of those who have received the protocol, such as demographics, details of consultations, and possible impact on length of ED stay. Results: Emergency medical response and other logged data will be analyzed for use of the ASD protocol. We will discuss difficulties in implementation of the protocol, ongoing considerations for effective streamlining of the process, and demographics, disposition, impact on ED length of stay, and overall satisfaction with the protocol. Conclusions: Providing appropriate care to youth with ASD in the ED is a unique challenge that requires special considerations. A streamlined process that is easily embedded within the EMR for each patient with ASD to address unique sensitivities is ideal from a quality improvement perspective. This protocol will improve patient satisfaction, medical and psychiatric outcomes, and clinical care.

ASD, RI, TREAT http://dx.doi.org/10.1016/j.jaac.2017.07.226

39.2 DEVELOPMENT OF A PROTOCOL FOR ACUTE MANAGEMENT OF SUBSTANCE ABUSE AND/OR WITHDRAWAL IN THE PEDIATRIC MEDICAL SETTING Nadine Schwartz, MD, Nationwide Children’s Hospital, [email protected] Objectives: This presentation will describe the process of development and the resultant protocol for management of adolescents with a variety of substance abuse and/or withdrawal complaints who present acutely to the medical setting. Availability of an easy-to-use, single source, concise protocol

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should enable providers to better recognize and treat presentations of substance abuse and/or withdrawal. Methods: We conducted a literature review on the most recent evidence and all published guidelines concerning acute management of abuse and withdrawal of substances commonly used by adolescents. We also reached out to colleagues from over 50 pediatric facilities across the United States and Canada to ascertain whether nonpublished protocols for these presentations were in existence or use at any of these institutions. Results: We found no published formal and complete protocols for shortterm management of substance abuse and/or withdrawal in the pediatric medical setting. We found guidelines for use of supportive care and/or comfort medications and/or management strategies for single substances or substance categories and/or guidelines for ongoing long-term treatment. We did find some protocols for treatment of substance abuse and withdrawal for adults that mentioned management of adolescents. We consolidated and distilled the evidence we collected from all of the singlesubstance protocols obtained through our literature search into a single, streamlined, easy-to-use, concise, adoptable, and adaptable protocol for management of patients who presented with substance abuse and/or withdrawal complaints. Conclusions: The prognosis of adolescent patients presenting with acute substance abuse and/or withdrawal to medical settings is significantly improved with early recognition and initiation of appropriate medical treatment. This is true not only for the acute immediate needs but also for the probable long-term success of their substance abuse and/or dependence problems. From a quality improvement perspective, availability of a single source, user-friendly, adoptable, adaptable, pragmatic guideline should improve patient satisfaction outcomes, and medical and psychiatric outcomes and decrease medicolegal liability.

ALC, CON, SUD http://dx.doi.org/10.1016/j.jaac.2017.07.227

39.3 BEST PRACTICES FOR MANAGEMENT OF CHILDREN BOARDING FOR PSYCHIATRIC ADMISSION IN MEDICAL SETTINGS Negar Beheshti, MD, UMass Memorial Medical Center and UMass Medical School, [email protected] Objectives: Because of the shortage of child and adolescent psychiatric beds, it often takes prolonged periods of time for a patient to be placed in an appropriate mental health setting. During this period, children and adolescents often board in the emergency department or a pediatric medical unit. Although they are awaiting appropriate placement, these patients often present a risk to themselves or others and require care not ordinarily available in a medical setting. We describe how standardizing nonpharmacological and pharmacological approaches to agitation management, psychoeducation, and therapeutic and behavioral treatment approaches may benefit patients awaiting psychiatric hospitalization. Methods: We conducted a literature review to evaluate best practices for managing children and adolescents’ acute behavioral health and agitation symptoms in the medical setting. We also reviewed expert opinion from pediatric emergency medicine, pediatric hospitalist, and child and adolescent psychiatric physicians at our tertiary medical center. Results: There are no clear evidence-based guidelines for the management of agitation or standard boarding treatment in the medical setting, including the emergency department. To assist our own pediatric agitation care and ongoing treatment management of patients boarding for placement at University of Massachusetts Memorial Medical Center, we developed an approach and general guideline based on a review of the existing literature and a review of expert opinions from pediatric emergency medicine, pediatric hospitalist, and child and adolescent psychiatric physicians at our tertiary medical center.

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Conclusions: This presentation will highlight our recommendations for this patient population, with a strong focus on medication use, as we found this to be the area of greatest confusion and misunderstanding. We also describe steps to produce a creative treatment plan for children and adolescents who spend extended periods of time in settings that are suboptimal for their needs. These plans can involve, but are not limited to, collaboration among pediatrics, child and adolescent psychiatry, child life, social work, nursing, and occupational therapy.

caregivers’ aspect. Data are collected from an immigrant minority in the United States and the general population from Egypt and China. Results: By the end of this presentation, attendees will be able to 1) identify the role of stigma and shame as a barrier to mental health; 2) recognize the need for cultural awareness to provide accessible mental healthcare; and 3) review principles for countering stigmatization. Conclusions: Understanding the role of stigma in child and adolescent mental health is crucial for early recognition of high-risk population and prompt delivery of mental health services.

AGG, CON, ICP

EPI, CC, SP


Sponsored by AACAP's Diversity and Culture Committee http://dx.doi.org/10.1016/j.jaac.2017.07.231

39.4 THE CREATION OF AN EMERGENCY DEPARTMENT CLINICAL PATHWAY FOR CHILDREN AND YOUTH WITH MENTAL HEALTH AND ADDICTION ISSUES Clare Gray, MD, Children’s Hospital of Eastern Ontario, gray_ [email protected] Objectives: The goals of this session are as follows: 1) to create a clinical pathway to guide and support the care of children and youth presenting to the emergency department with mental health and addictions issues; and 2) to ensure seamless transition to follow-up services with relevant community mental health agencies and providers. Methods: An interdisciplinary expert working group was created, including representation from hospital and community agencies and mental health, emergency, and pediatrics departments, as well as the healthcare funders. This group completed a literature search and an environmental scan, which contributed to the recommendations for the clinical pathway. Results: The emergency department clinical pathway for children and youth with mental health and addictions issues contains three key components, including 1) the availability (24 hours a day/7 days a week) of a child and youth mental health clinician for the emergency department; 2) the use of standardized triage screening tools and assessment form, as well as a preprinted order set for the treatment of aggressive behavior; and 3) a memorandum of agreement between the emergency department and community agencies. Conclusions: The development of an emergency department clinical pathway for mental health and addictions issues will promote integrated services for children and youth with mental health concerns by ensuring a stabilization plan and timely follow-up. This will provide better patient care and reduce unnecessary use of costly emergency services.

ADMIN, CC, MDM http://dx.doi.org/10.1016/j.jaac.2017.07.229

CLINICAL PERSPECTIVES 40 SHAME, STIGMA, AND CHALLENGES FOR MENTAL HEALTH PROVIDERS: FOUNDATIONS FOR UNDERSTANDING THE BURDEN OF STIGMA IN CHILD AND ADOLESCENT PSYCHIATRY ACROSS THREE CONTINENTS Andres J. Pumariega, MD, Cooper Medical School of Rowan University and Cooper University Hospital, [email protected] Objectives: In this session, participants will 1) understand cultural conceptions of child mental health; 2) recognize the role of stigma and shame as a barrier to seeking early treatment from a caregivers’ perspective; and 3) learn the theoretical and social neuroscience models of stigma. Methods: Four academic psychiatrists will present original data from their novel research on stigma for child and adolescent mental health from a


40.1 CAREGIVER KNOWLEDGE AND ATTITUDE TOWARD MENTAL HEALTH PROBLEMS IN CHILDREN IN CHICAGO, ILLINOIS, AND WUHAN, CHINA Khalid Imran Afzal, MD, University of Chicago, [email protected] Objectives: The purpose of this study is to 1) review the University of Chicago Behavioral Health Questionnaire (UCBHQ); and 2) understand parental attitude toward seeking mental health (MH) services for children from Chicago’s immigrant population and the general population in Wuhan, China. Methods: A total of 93 participants in Chicago, Illinois were included. Results: Compared with Arab-Americans, Asian-Americans believed that ADHD was not a mental illness (P < 0.004) and that behavioral or mental health problems were present in the Western cultures and not Eastern cultures (P < 0.002). Males generally believed that anxiety and ADHD were not medical and/or mental illnesses (P < 0.03 and P < 0.017), respectively. Compared with their counterparts, female respondents believed that behavioral problems in children were a part of MH (P < 0.002); however, they were less likely to believe that behavioral issues were a part of MH in teenagers (P < 0.018). Men were more likely to believe that medications/therapy change brain chemistry (P < 0.001). Respondents who had been living in the United States for more than 15 years were more likely to believe that behavioral/MH conditions were caused by chemical imbalance in the brain (P < 0.035) and that medications/therapy change the chemistry of the brain (P < 0.02), compared with respondents who had been living in the United States for a fewer number of years. Southeast Asians were more likely to believe that behavioral or MH conditions are only present in the Western cultures and not Eastern cultures (P < 0.005), compared with their contemporaries who spent their youth in the United States. Conclusions: Addressing cultural influences on stigma empowers mental health providers to effectively deliver culturally sensitive services and to improve adherence.

ADOL, FAM, SP http://dx.doi.org/10.1016/j.jaac.2017.07.232

40.2 CAREGIVER KNOWLEDGE AND ATTITUDE TOWARD MENTAL HEALTH PROBLEMS IN CHILDHOOD AND ADOLESCENCE IN BENI SUEF GOVERNORATE, EGYPT Maha Emadeldin, MD, Beni Suef University, [email protected] Objectives: The goals of this session are as follows: 1) to assess the knowledge and attitude of caregivers about mental health (MH) problems in children and adolescents in Beni Suef, Egypt; and 2) to understand cultural influences on stigma toward MH. Methods: Participants (N ¼ 1,937), caregivers attending primary healthcare centers in Beni Suef, Egypt, completed the Arabic version of University of Chicago Behavior Health Questionnaire.

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Results: Sixty-five percent of participants were mothers, 66.2 percent lived in rural areas, 19 percent completed education in a university, and the mean age was 34.7 14.1 years. Twenty-five percent believed MH problems are caused by chemical imbalances in brain; 43.1 percent were concerned about medication use because of adverse effects; and 58.9 percent preferred natural remedies, whereas 46.8 percent preferred spiritual healing. “Having someone in the family with MH problems and previous attendance of a MH workshop” comprised the most significant data clusters related to the outcomes. Higher level of education increased the knowledge of etiology of MH problems in children and adolescents (P ¼ 0.03). Although 58.8 percent of children and adolescents agreed to seek help for MH problems, 31.6 percent did not know where to seek such help. Agreement by children and adolescents to seek MH help was positively correlated with higher level of education (P ¼ 0.002), understanding of etiology of MH problems (P < 0.001), beliefs about efficacy of treatment (medication and psychotherapy) (P < 0.001), and social and religious beliefs (P < 0.001). Higher education was significantly related to increased concern about risk and adverse effect of medications (P ¼ 0.02). Conclusions: This study highlighted the need for awareness campaigns targeting etiology and methods of treatment of MH problems in children and adolescents.

ADOL, FAM, SP http://dx.doi.org/10.1016/j.jaac.2017.07.233

40.3 THE CENTRALITY OF CULTURE IN MENTAL HEALTH TREATMENT ENGAGEMENT: INTERSECTING INFLUENCES OF EXPLANATORY MODELS OF ILLNESS, CULTURAL STIGMA, AND NETWORKS Miwa Yasui, PhD, University of Chicago, myasui@ uchicago.edu Objectives: By the end of this session, participants will be able to 1) understand the existence of higher severity of illness in Chinese Asians compared with other ethnic groups; 2) learn the factors contributing to poor treatment engagement for Asian immigrants; and 3) explore central influences of culture on mental health treatment engagement in this community. Methods: A total of 36 youth and 88 adults participated in 13 focus groups. Using an interpretive perspective, data derived from the focus groups were analyzed with NVivo v9 using thematic analysis to report patterns or themes in the data. Results: Findings from the thematic analysis illustrated the following central cultural influences on the beliefs and practices related to engaging in mental health treatment among Chinese immigrant families: 1) the role of explanatory models of illness in symptom recognition and attributed causes of the illness; 2) the role of explanatory models of illness in the seeking of cultural versus professional treatment services; 3) the influence of cultural stigma of mental health on help seeking; and 4) the influence of networks and self-construal on help-seeking behaviors. The data revealed that Chinese cultural models of illness regarding mental health significantly shaped their beliefs about causes of illness and, subsequently, how they conceptualized their symptoms of distress. Most striking was the role of cultural beliefs about mental illness in the distinction participants made between cultural idioms of distress versus “mental health,” which was attributed to severity and dysfunction. Conclusions: The current study addresses a critical gap in the literature in the treatment engagement of Chinese immigrant populations.

ETHN, R, SP Supported by the Agency for Healthcare Research and Quality Grant 5K12 HS023007 http://dx.doi.org/10.1016/j.jaac.2017.07.234

40.4 NEUROBIOLOGY OF STIGMA AND SHAME Karam Radwan, MD, University of Chicago, kradwan@bsd. uchicago.edu

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Objectives: The goals of this session are as follows: 1) to review the cognitive and neurobiology of stigma processes; 2) to appreciate the significant impact of stigma as a formidable obstacle in children and adolescents’ mental health; and 3) to review the latest research in Stigma Reduction Initiatives. Methods: 1) The session will highlight the cognitive process involved in the interactions between the perceivers and the stigmatized individuals, such as perceived dangerousness and avoidance. 2) We will provide a theoretical overview of the stigma concept and offer a useful taxonomy of four types of stigma (public stigma, self-stigma, stigma by association, and structural stigma). 3) There will be a brief overview of the detrimental consequences of stigma on individuals and families. 4) Perceptions of stigma by association and its relevance to the field of child and adolescent psychiatry will be discussed. 5) We outline new developments in the area of the neuroscience of stigma and stereotypes behaviors. 6) We will describe the challenges in stigma research and cultural factors. Results: By the end of this session, the attendees will 1) appreciate an overview of the stigma concept and offer a useful taxonomy of stigma (public stigma, self-stigma, stigma by association, and structural stigma); and 2) learn about strategies available to address stigma-related questions. Conclusions: Theoretical understanding is crucial to effectively managing stigma in clinical practice.

ADOL, EBP, NEURODEV http://dx.doi.org/10.1016/j.jaac.2017.07.235

CLINICAL PERSPECTIVES 41 SKILL BUILDING IN FAMILY-CENTERED PEDIATRIC INTEGRATED CARE Katherine E. Grimes, MD, MPH, Children’s Health Initiative, [email protected]; Gregory Hagan, MD, Cambridge Health Alliance, [email protected]; Cecil R. Webster, MD, Cambridge Health Alliance, mail@ cecilwebstermd.com; Karen Martinez, Cambridge Health Alliance, [email protected]; Gregory K. Fritz, MD, Bradley Hasbro Children’s Research Center, GFritz@ lifespan.org Objectives: The goal of this session is to teach effective strategies for developing a collaborative practice, including child psychiatrists, family support specialists, and pediatricians within community-based primary care settings. Methods: Process and experience will be described from the perspective of the child psychiatrist and pediatrician who developed the collaborative practice model in an urban primary care clinic near Boston and from the perspective of a trainee and the pioneering family support specialist (peer-topeer parent) who joined the clinical team and now participates in training and transport of the model to other clinics. Case examples will be used to illustrate differences in what the integrated team approach can offer providers, especially with regard to improving outcomes for highly vulnerable families. Handouts, with additional background material and resources, will be provided. Results: Questions from workshop participants and discussion of related experience will be encouraged throughout; workshop faculty remarks are intended to be brief to provide ample time for information exchange among participants and discovery of possible common elements among those who have worked within integrated settings, as well as resources for those for whom this blend of systems of care skills and consultation-liaison skills is a new undertaking. Conclusions: Networking will be encouraged among the participants, so that collaborative learning can continue after the conference, including dissemination of additional resources, which may arise in the discussion.

EBP, SP, CON http://dx.doi.org/10.1016/j.jaac.2017.07.237

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41.1 HEARING THE WHOLE STORY: PEER-TOPEER PARENT SUPPORT IN PRIMARY CARE Karen Martinez, Cambridge Health Alliance, [email protected] Objectives: The goals of this session are to teach effective strategies for strength-based listening to parents and to elicit “the rest of the story”— helping integrated primary care teams in community-based settings understand unique family barriers to care and culturally sensitive ways to work with parents and youth to overcome them. Methods: Ms. Karen Martinez will describe her role as an experienced family support specialist in the pediatric integrated model and curriculum that she had developed to train others. Case examples will be used to illustrate effective peer-to-peer support to parents and the varied ways that family support specialists function as key members of the provider team. Results: In our five-year study, what began as an unfamiliar “add-on” resource that required flexibility on the part of both pediatricians and family support specialists, along with many operational challenges about care being delivered by “nonclinicians,” quickly was perceived as an essential ingredient to integrated care. Primary care clinicians started out seeking mental health expertise, and the child psychiatrists would bring the family support specialist into the consultation. Within a year, based on the visible impact of peer-to-peer support for their most complex families, the pediatricians began to specifically seek out consultation from the family support specialist. Conclusions: Emerging research indicates that enhanced engagement is possible for at-risk youth with mental health needs and their families through the introduction of mental health treatment within their familiar pediatric clinic setting and facilitating follow-through with the help of parent-professionals.


41.2 PEDIATRIC PERSPECTIVE ON THE ROLE OF INTEGRATED CARE IN THE TREATMENT OF ADVERSE CHILDHOOD EXPERIENCES (ACES) Gregory Hagan, MD, Cambridge Health Alliance, ghagan@ challiance.org Objectives: There is growing recognition that a child’s family and social environment are critical determinants of long-term physical and mental health. The Adverse Childhood Experience (ACE) work of Filetti and Anda underscores the harmful effects of trauma risks, such as parental mental illness or substance use, food or housing insecurity, exposure to domestic violence, and child abuse/neglect. We recognize the importance of good screening instruments to help pediatricians identify children with, or at risk for, trauma, but we wanted to test out a new care delivery team approach to accompany enhanced screening, considering that, in the past, positive screens only sometimes led to treatment. Methods: We have changed to an improved screening tool (the Survey of Wellbeing of Young Children) that specifically looks for evidence of ACEs, but this project relied on a combination of our prior screening tools [Parents’ Evaluation of Developmental Status, Pediatric Symptom (PEDS) Checklist and Pediatric Symptom Checklist (PSC)], supplemented by clinical judgment of the primary care physicians. In addition to routine screening, we invited child psychiatrists directly into the pediatric clinic for one to two sessions a week. Results: We found that routine pediatric screeners did not identify new children for us to refer; however, “Peds worry” consistently identified children already affected by adverse experiences and showing symptoms of trauma. The presence of integrated care child psychiatrists supported us in recognizing those needs and gave us more tools to respond to the needs we found. When the primary care team included collaborative mental health (MH), we found that we were able to respond to children’s needs promptly with individualized interventions, ranging from “curbside consults,” real-time MH assessments, brief MH interventions, and expeditious referral for higher levels of care.


Conclusions: Integrating child psychiatrists as collaborative partners for the pediatric care team helped us identify needs, clarify mental health diagnoses, and create unified treatment plans. This, in turn, helped us to more efficiently get the right care for both children and parents. Having the ongoing collaboration also encourages pediatricians to do routine screening, knowing that the consultants are accessible. Combining this multidisciplinary team approach with the next generation of ACE surveillance screens should allow us to meet the needs of the overall population of children in our care more cost-effectively.


41.3 TRAINING STRATEGIES TO SUPPORT INTEGRATED CARE FOR CHILDREN Cecil Webster, MD, Cambridge Health Alliance, mail@ cecilwebstermd.com Objectives: The goal of this session is to describe a shared training initiative, which resulted in an innovative Collaborative Practice Training Model among the Cambridge Health Alliance (CHA) department of psychiatry child and adolescent psychiatry fellowship program, the CHA Department of Pediatrics, and the Massachusetts General Hospital Pediatric Residency program. Methods: Designed to provide training in highly integrated care in a community setting, child and adolescent psychiatry fellows and pediatric residents share “protected” time in a pediatrics continuity clinic, during which they respond to the naturalistically occurring patient flow. The child and adolescent fellows provide clinical consultation and informal didactics and gain experience in communicating with pediatricians across episodes of care, rather than a single consultative conversation. The pediatric residents acquire greater familiarity with the causes and presentations that accompany child and adolescent mental illness and become more comfortable with triage and shared treatment of such cases, including understanding family or school requests to give a child medication. Results: Despite barriers of space, time, and money, the enthusiasm for a collaborative practice training experience propelled the simple elective into a sustainable elective across two disciplines and three institutions and has influenced career directions for those who participated. Conclusions: Access to this level of collaborative training enhances the skills of both child and adolescent psychiatry fellows and pediatric residents and expands much-needed workforce capacity, which is necessary as service delivery systems become more integrated.


CLINICAL PERSPECTIVES 42 STIMULANTS: ISSUES IN CLINICAL AND ETHICAL USAGE Breck Borcherding, MD, Weill Cornell Medical College, [email protected]; Judith L. Rapoport, MD, National Institute of Mental Health, [email protected] Objectives: A wide range of stimulant actions in children and adults exist, including effects on motivation, energy, and mood beyond ADHD symptoms. The potential broad range of robust positive and negative effects of stimulants makes accurate identification of target symptoms in ADHD cases important. Cases that are in the range of mild to subclinical ADHD raise concerns about inappropriate medication use in enhancement of normal processing. Perspectives on these topics are reviewed in this presentation. Methods: We will explore subjective and objective effects of stimulants in a variety of clinical and nonclinical circumstances. Studies of young adult volunteers illuminate their motivation for stimulant use, psychological backgrounds of users, and perceived versus objective cognitive improvement on stimulants. Cases of child ADHD demonstrate how

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measures of impairment may assist diagnosis and treatment planning to avoid possible issues with overtreatment of normal developmental functioning. Results: Stimulants are used medically and nonmedically to target ADHD symptoms, but also mood, motivation, and energy. There is a disconnect between subjective impressions and objective measures of cognitive improvement in studies of young adults, with stimulants likely bringing about improvement in noncognitive areas but not demonstrating appreciable cognitive effects. With many cases of ADHD identified for treatment being mild in nature, measures of functional impairment probably add to symptom checklists in the diagnostic and treatment-planning process. Unless careful formulation is made, it is possible that treating some children falls in the category of neuroenhancement. Conclusions: Clinicians should be aware that, in treating ADHD symptoms, perceived improvement may be a result of improvement in other areas beyond standard ADHD symptomatology. In addition, measures of functional impairment and a careful formulation should inform ethical medication prescribing for ADHD.

ETH, ADHD, STIM

Results: Several methodologically rigorous double-blind, placebocontrolled studies and meta-analyses have revealed that, in healthy volunteers, stimulant effects on attention, executive function, memory, and standardized achievement tests are small at best, raising questions about the clinical significance of these effects. Despite the lack of improvement observed on cognitive measures, non–ADHD participants in double-blind research tend to view their performance as more enhanced by an active stimulant than by placebo. On self-report, nonmedical stimulant users perceive stimulants’ motivational effects to be at least as pronounced as the cognitive effects, including the effects on attention. Users report lower motivation for cognitively demanding tasks and describe their everyday work habits as poorer than control subjects with no history of stimulant use. Conclusions: Taken together, these data suggest that, in people without fullblown ADHD, stimulant use may benefit mood, energy, and motivation more than cognition per se.

ADHD, COG, STIM Supported by the Office of Naval Research Grant N000140710034 and the Scandinavia Foundation Netter Graduate Scholarship http://dx.doi.org/10.1016/j.jaac.2017.07.241


42.1 EXPLORING THE RANGE OF STIMULANT USAGE AND EFFECTS

42.3 DIAGNOSTIC DILEMMAS WITH SUBCLINICAL OR MILD ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER

Breck Borcherding, MD, Weill Cornell Medical College, [email protected]

Mark A. Stein, PhD, University of Washington, Mark.Stein@ seattlechildrens.org

Objectives: The goals of this session are to review the wide range of community usage of available stimulants and their reported effects in both children and adults and to demonstrate the wide range of cognitive, emotional, and motivational outcomes across clinical and nonclinical situations. Methods: Although stimulants are predominantly marketed for ADHD treatment, data from the literature are presented to review the broad usage of stimulants. Information on medical uses beyond ADHD are discussed, which include other reported psychiatric and neurologic indications, in addition to use medically for energy and wakefulness. Nonmedical use is also reviewed to include performance enhancement in sport and the military, and stimulant abuse. Each of these indications and/or usages could be linked to specific neurobiological mechanisms and psychological processes. Results: Stimulants have a variety of effects beyond those on basic attentional processes, which include actions on energy, motivation, wakefulness, and mood. As stimulants are increasingly prescribed and used, explanations and review of effectiveness should include consideration of multiple psychological effect domains. It is unclear whether patients with clinical syndromes may respond to medication in a similar way to, or differently than, nonpatients. In addition, side effects may undermine wanted effects through interfering actions on other systems. Conclusions: Prescribers should be aware of the multiple psychological processes affected by stimulants, and research into stimulant use should investigate these multiple domains in assessing their effectiveness.

Objectives: The goals of this study are to highlight clinical issues in treating mild or subclinical ADHD, along with pitfalls regarding ADHD assessments, and to provide a framework for making clinical decisions and treatment planning based upon the severity of impairment while balancing risks versus potential harms. Methods: Although mild ADHD is more common than severe ADHD, there is a paucity of clinical trials of mild or subclinical ADHD to guide clinical practice, yet such cases often present for care. To highlight diagnostic dilemmas, several case studies will be presented, including cases of ADHD symptoms and impairment in one setting, differences between parents and ADHD youth in treatment targets and preferences, and when subclinical ADHD becomes performance enhancement. The key concept of impairment is highlighted as a guide to treatment choice, with cases illustrating the relationship between context and capacity. The diagnostic process will be discussed, along with assessment strategies and review of several specific impairment measures (e.g., Impairment Rating Scale, Barkley Functional Impairment Rating Scale, Weiss Functional Impairment Rating Scale). Results: The diagnosis of ADHD is based on developmentally inappropriate symptoms and significant impairment. There are several tools to measure impairment that can help distinguish mild ADHD from performance enhancement based on impairment. Conclusions: Over-reliance on ADHD symptom counts can be misleading and result in over diagnosis. Identifying and measuring impairment can help distinguish mild ADHD from performance enhancement and guide treatment choices.

ADHD, COG, STIM http://dx.doi.org/10.1016/j.jaac.2017.07.240

ADHD, DIAG, IMP http://dx.doi.org/10.1016/j.jaac.2017.07.242

42.2 STIMULANT EFFECTS IN YOUNG ADULT USERS WITHOUT ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER Irena Ilieva, PhD, Weill Cornell Medical College, iri9005@ med.cornell.edu

42.4 PROBING THE BOUNDARIES OF THE ATTENTION-DEFICIT/HYPERACTIVITY DISORDER SPECTRUM AND REQUESTS FOR ITS TREATMENTS AS NEUROENHANCEMENT

Objectives: The goal of this session is to review research data on the perceived and objective effects of stimulants in stimulant users and normal young adults. Research on the effects and correlates of unprescribed stimulant use can inform the clinical approach to patients who complain of inattention, without otherwise meeting diagnostic criteria for ADHD. Methods: The current presentation will examine studies of stimulant cognitive effects in young, non–ADHD users, as well as the motives for unprescribed use, and the psychological profile of nonmedical stimulant users.

Objectives: The goal of this session is to review the variance in ADHD prevalence and demographics and the imperative of clinical guidelines in its diagnosis and treatment. Methods: We reviewed existing data on ADHD diagnostic prevalence and the striking discrepancies between medical specialties, cultures, geographical areas, and age groups. In addition, we reviewed recent

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William Graf, MD, University of Connecticut, WGraf@ connecticutchildrens.org

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data on current trends in stimulant medication prescription and diversion. We assessed the ADHD diagnosis as a neurodevelopmental “spectrum” disorder and compared its consequences to other spectrum disorder diagnostic constructs. We examined recent data on “smart drugs,” their markets, efficacy, potential harm, and user intent and discuss the ethical and legal responsibilities to patients with ambiguous ADHD complaints who are prescribed stimulants to enhance cognitive or affective functioning. Results: The nosological justification of behaviorally and dimensionally defined “spectrum disorders” is an inclusive classification scheme allowing overlapping heterogeneous conditions, regardless of severity or etiology. As a consequence, spectrum disorders lack strictly demarcated diagnostic boundaries. ADHD becomes a controversial diagnosis when its signs and symptoms are mild or ambiguous. Recent statistics indicate that almost half (46.7%) of US children diagnosed with ADHD have mild problems and that only about one in six children diagnosed with ADHD have severe impairment. Despite efforts to implement dimensionality, pragmatic coupling of any broad categorical diagnosis to its designated interventions is a continuing challenge. Conclusions: Neither the acknowledgement of ADHD dimensionality, nor the application of the impairment criterion is addressing the problem of appropriate diagnosis and management of ADHD symptoms and behaviors in various age groups. Current trends of stimulant drug use compel ongoing discussions about these topics.

ADHD, DIAG, ETH http://dx.doi.org/10.1016/j.jaac.2017.07.243

CLINICAL PERSPECTIVES 43 TELL ME ABOUT YOUR MOTHERBOARD: DIAGNOSING AND TREATING INTERNET GAMING DISORDER AND OTHER ONLINE ADDICTIONS Paul E. Weigle, MD, Natchaug Hospital, pweigle@ sbcglobal.net Objectives: Computer entertainment has rapidly become the pastime of choice for American youth. A significant minority engage in excessive, uncontrolled computer habits that represent a behavioral addiction, associated with impairment in academic, social, and familial functioning. The most common habit is pathological video game play, but others include compulsive engagement with pornography, social media, or smartphones. This problem is prevalent but frequently avoids diagnosis and treatment. Methods: Each presentation is based on extensive, ongoing reviews of the available scientific literature using extensive ongoing database searches. Studies were reviewed for relevance and summarized for presentation, incorporating the presenters’ own clinical experiences and cases as appropriate. Results: Specific internet use addictions are the consequence of interactions between predisposing factors (neurobiological and psychological make-ups), moderators (coping styles and cognitive biases), and mediators (affective and responses to triggers), as well as deficits in executive functioning. A large body of clinical research documents the pathological engagement with video games, online pornography, and social media, revealing characteristics of prevalence, epidemiology, and comorbidity and effects on parameters of psychological well-being such as academic achievement, sleep, and behavior. Video game playing involves similar neural mechanisms as drug abuse, with similar long-term effects on brain structure and function. Research and clinical experience reveal effective treatments for video game and internet addictions, including specific therapies and psychopharmacological interventions. Conclusions: Behavioral addictions to video games, online pornography, smartphones, and social media are common and impairing. Clinicians must correctly diagnose and treat these conditions to provide comprehensive care. A significant body of research and experience informs epidemiology, neurobiology, and comorbidity associated with behavioral addictions to computer entertainment. Practitioners have


multiple options for addressing internet use disorders. Research data on treatment approaches are considerable, but more research is required to provide definitive direction.

COMP, DIAG, TREAT Sponsored by AACAP's Media Committee http://dx.doi.org/10.1016/j.jaac.2017.07.245

43.1 WEB JUNKIES: THE DIAGNOSIS AND EPIDEMIOLOGY OF INTERNET ADDICTIONS Paul E. Weigle, MD, Natchaug Hospital, pweigle@ sbcglobal.net Objectives: The goal of this session is to provide the practitioner with a framework for understanding pathological internet habits, such as internet gaming disorder (IGD) and behavioral addictions to online pornography, social media, and smartphone use. This will include summaries of existing literature on diagnosis, prognosis, and clinical implications. Methods: An ongoing, exhaustive literature review has been conducted on IGD and other internet disorders. The resulting hundreds of studies are evaluated for relevancy and level of evidence. The most important and relevant information is consolidated for the presentation, incorporating lessons from the authors’ considerable clinical experiences. Results: The diagnosis of internet disorders requires a persistent, recurrent gaming habit leading to significant distress or impairment and a number of related symptoms similar to those of substance use disorders, but more strictly diagnosed. The most prevalent and well documented is IGD, included in the DSM-5 as a condition requiring further study. However, evidence and clinical experience also support the existence of uncontrolled, disordered engagement with online pornography, social media, and smartphones. Neurobiological changes in affected individuals are analogous to those affecting individuals with substance use and gambling disorders. A substantial body of literature documents the prevalence, characteristics, and effects of these phenomena in children and adolescents. Research indicates both similarities and distinctions in risk factors, prognosis, and clinical outcomes. Impairment is often considerable and is typically associated with psychiatric comorbidities in a complex association. Conclusions: Pathological, compulsive internet habits are both common and impairing, typically revolving around engagement with video games, pornography, social media, or smartphones. Clinicians must learn to correctly diagnose and treat internet disorders to provide the best care to the substantial number of children and adolescents who suffer from them. Scientific research and clinical experience describe the epidemiology, neurobiology, and comorbidity associated with behavioral addictions to computer entertainment, as well as resultant effects on academic functioning, sleep, and relationships.

COMP, DIAG, EPI http://dx.doi.org/10.1016/j.jaac.2017.07.246

43.2 VIRTUAL ADDICTION: ETIOLOGICAL AND NEUROBIOLOGICAL ASPECTS OF COMPULSIVE INTERNET USE David Greenfield, PhD, The Center for Internet and Technology Addiction and The University of Connecticut, School of Medicine, [email protected] Objectives: The goals of this session are as follows: 1) to provide clinicians with an etiological understanding of the addictive nature of the internet; 2) to examine the neurobiological basis for internet addiction; 3) to review the basic premise of variable ratio reinforcement and classical conditioned notifications with smartphone use/abuse; and 4) to compare and contrast other process and substance-based addictions with the neurophysiological and neurochemical features found in compulsive internet behavior. Methods: Addiction medicine has established many advances in the recent decade regarding the etiology and neurobiology of substance-

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based and behavioral/process addictions; recent criteria by the American Society of Addiction Medicine that all addictions, both process/behavioral and substance-based, share similar mesolimbic mechanisms of action and processing, support the validity of internet addiction as an emerging digital drug of choice. Clinical, anecdotal, and neuroimaging studies have demonstrated strong evidence for the psychoactive and addictive nature of internet and digital media behavior. Results: The diagnosis of internet use disorder seems to be based on the same diagnostic criteria found in substance-based and behavioral addictions as indicated as follows: 1) engaging in intoxicating/pleasurable behaviors that typically alter mood and consciousness; 2) developing repetitive patterns of excessive use (with compulsion); 3) negative consequences that impact a major sphere of living; 4) the presence of tolerance/ habituation; and 5) difficulty terminating use along with concomitant withdrawal symptoms. Conclusions: Compulsive and addictive use of the internet and other digital media technology has been well-established in the psychiatric and addiction medicine literature. It is critical for clinicians to recognize the brain-based markers, as well behavioral and neurobiological dynamics of this emerging addiction phenomenon.

NECHEM, PSP, SUD http://dx.doi.org/10.1016/j.jaac.2017.07.247

43.3 SHORTING THE CIRCUIT: EVIDENCE-BASED TREATMENT OPTIONS FOR ONLINE ADDICTIONS Clifford Sussman, MD, Clifford Sussman, MD, PLLC (Private Practice), [email protected] Objectives: The goal of this session is to review biological, psychological, and social treatments for internet gaming disorder (IGD) and online addictions, including prevention strategies. Methods: An ongoing literature review of the studies on IGD treatment is conducted. This data will be compared with those from studies on effective treatments for substance use disorders, emphasizing treatments that have been or can be adapted for online addictions. The author’s considerable clinical experience, providing individual therapy using motivational interviewing techniques for patients with online addictions, will be incorporated. Prevention strategies, as well as established treatment centers and psychoeducational media, will also be reviewed. Results: A significant contrast between the gold standards in substance abuse treatment and treating online addictions is that the end goal of abstinence in the treatment of online addiction may not be feasible, so a treatment goal of harm reduction through limited use is often preferable. Understanding the neurobiological mechanisms and symptomatology of digital technology withdrawal and the typical patterns of compulsive use can help to guide treatment decisions, such as how and when to perform a “digital detoxification.” Medication treatment may provide a supplement to psychotherapy and may be effectively used to treat commonly comorbid conditions but should not replace psychological and social treatments. Promising psychotherapeutic treatments include rehabilitation centers, such as “Restart” in Seattle, individual therapy, family therapy, and group therapy, including 12-step programs. Relevant therapy modalities include cognitive behavioral, psychodynamic, mindfulness, and motivational interviewing. Social treatments include psychoeducation of schools, parents, and children to complement the widespread use of prevention strategies. Conclusions: Just as the epidemiology and neuropathology of substance use disorders and IGD share many commonalities, so does their treatment. The most effective treatments for IGD and online addictions incorporate a regimen of group or individual psychotherapy. Effective treatments for IGD and online addiction are in great demand but are, as of yet, based on limited evidence. It is vital that providers understand the current evidence base to guide treatment until additional clinical studies are available.

ADHD, MED, SUD http://dx.doi.org/10.1016/j.jaac.2017.07.248

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43.4 THE BIG DISCONNECT: A CASE STUDY IN THE TREATMENT OF INTERNET GAMING DISORDER Edward Spector, PsyD, Edward Spector, PsyD, LLC, [email protected] Objectives: The goal of this session is to discuss the assessment and treatment of technology addiction in clinical practice, using a specific case example from the author’s own clinical experience in order to highlight common themes, challenges, comorbidities, and complexities common to such cases. Methods: The author treated a patient in clinical practice for 16 months for addiction to video games. This patient is fairly typical of the type of patients seen in the author’s clinical practice, which specializes in the treatment of patients suffering from addiction to technology. Results: The case will include a presentation and detailed discussion of symptoms, diagnosis, and course of treatment, including intervention and outcomes. Identifying information will be altered to protect the patient’s privacy. Descriptions will include background information on the patient, his family relationships, academic challenges, social/emotional functioning, and comorbid mental illness. Treatment will be described in detail, including assessment, creation of a treatment plan emphasizing harm reduction; level of care considerations; course of individual therapy; coordination with school, family, and psychopharmacology; and the technology used to monitor progress toward treatment goals. Ample opportunity will be given for audience questions and discussion. Conclusions: This case highlights some of the most common challenges found in helping an individual who is compulsively gaming. Patients often present with comorbid mental illness, interpersonal family conflict, academic problems, and social isolation. The patient often has far more skill and knowledge about technology than his or her parents who are trying to set limits. Removing all access to computer technology is a tempting solution but an impractical one, which would interfere with homework completion. Significant therapeutic work must be done to motivate such patients to embrace a lifestyle of moderation. With so many variables at play, effective treatment requires a multimodal treatment approach, including effective communication and coordination between psychiatrist, therapist, educators, and parents.

COMP, P, TREAT http://dx.doi.org/10.1016/j.jaac.2017.07.249

CLINICAL PERSPECTIVES 44 TREATING AVOIDANT RESTRICTIVE FOOD INTAKE DISORDER USING A MULTIDISCIPLINARY APPROACH: TALES FROM THE TRENCHES Jennifer L. Derenne, MD, Stanford University, jderenne@ stanford.edu Objectives: Avoidant/restrictive food intake disorder (ARFID) is a recent addition to the DSM-5, and increasing numbers of children and adolescents have been referred to child and adolescent psychiatrists as a result. The illness results in significant medical comorbidity, and a multidisciplinary team is often necessary to adequately target symptoms and insure safe renourishment. Participants will learn about the following: 1) diagnostic criteria for ARFID, a “new” feeding and eating disorder included in DSM-5, which often requires a multidisciplinary approach to treatment; 2) psychological, psychiatric, medical, and nutrition assessment and treatment approaches in both inpatient and outpatient settings, with a focus on evidence-based interventions where available; and 3) practical suggestions for how clinicians can collaborate most effectively with colleagues from other disciplines to provide excellent clinical care for a challenging set of patients. Methods: Presenters will use didactic lectures, PowerPoint presentation, and clinical case vignettes to illustrate principles of assessment, treatment, and care collaboration among members of a multidisciplinary treatment team. Results: By the end of the session, participants will 1) be more knowledgeable about ARFID, including medical and psychological symptoms; 2) will understand the assessment and treatment approaches for the different disciplines involved; and 3) be aware of strategies for working and communicating effectively in a multidisciplinary treatment team.

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Conclusions: With the recent inclusion of the ARFID diagnosis in DSM-5, child and adolescent psychiatrists are likely to receive increased referrals for assessment and treatment and will benefit from a comprehensive understanding of the services offered.

CON, TREAT, EA http://dx.doi.org/10.1016/j.jaac.2017.07.251

44.3 WORKING TOGETHER: NUTRITION AND OCCUPATIONAL THERAPY ROLES IN CARING FOR PATIENTS WITH AVOIDANT RESTRICTIVE FOOD INTAKE DISORDER Anne Sinha, OTR/L, Lucile Packard Children’s Hospital Stanford, [email protected]

Objectives: Psychological assessment of avoidant/restrictive food intake disorder (ARFID) is a vital part of a comprehensive evaluation. The evaluation of the etiology of the avoidant/restrictive behaviors, as well as the psychological consequences of this avoidance, directs the treatment approach. Participants will learn about the following: 1) types of fears and avoidant behaviors; 2) ways that these fears develop and factors that maintain their existence; and 3) therapeutic approaches that help the patient and family challenge the fears and decrease the avoidant/restrictive behaviors. These approaches will include assessment/teaching-alternative coping strategies, assessment of motivation to challenge fears, and creation of an exposure hierarchy. The treatment approach includes elements of CBT, exposure response prevention, and a modified family-based therapy approach to support families in helping the patient take on challenge foods/situations. Methods: Assessment protocols will be presented along with treatment plans and protocols. Clinical case vignettes will illustrate the use of these tools. Results: 1) Participants will have a greater understanding of how these fears and avoidant behaviors develop; 2) participants will be able to use the ARFID assessment tools in their practice to evaluate their patients; and 3) participants will be able to use the ARFID treatment plans/protocols to create individualized treatment plans for their patients. Conclusions: Although the presentation of ARFID can be quite varied, clinicians will be able to comprehensively assess their patients and create individualized treatment plans.

Objectives: Clinical nutrition and occupational therapy assessment of avoidant/ restrictive food intake disorder (ARFID) are vital parts of a comprehensive evaluation among team members in the treatment of ARFID patients. Participants will learn about the nutritional assessment, which includes an evaluation of current anthropometrics, growth history, assessment of biochemistry and clinical data, physical activity, nutrition history, and calculation of estimated nutrition needs. Occupational therapy evaluation includes the following: the feeding components of the avoidant/restrictive behaviors and physiological patterns during feeding, as well as the current way that it is impacting patient function and goals of the family and patient. Considerations of the following physical components may be present in ARFID patients by patient type: lifetime of picky eating, children with sensory issues, and patients who have experienced a fear-related episode. Participants will learn about the treatment approach, which includes a comprehensive and individualized nutritional plan of care, occupational therapy’s therapeutic use of self, feeding sessions, learning coping techniques to address fears and physiological patterns, behavior modification plan, and parent-feeding education. Participants will also learn about clinical nutrition, including the different types of meal planning with a probable need for calorie tracking, replacement protocols, various enteral nutrition plans, and parent nutrition education. Methods: Our team clinical dietitian and occupational therapist will share their method of assessment and treatment. Results: Participants will have a greater understanding of ways to help patients progress medically through systematic refeeding and the oral motor/ eating patterns that may impact these patients. Participants will have a clear sense of the step-by-step process of reintroducing food during repeated feeding sessions in a structured, reinforced pattern that progresses nutrition. Participants will understand physiological patterns that may arise in patients and methods of addressing them through physiological coping strategies. Conclusions: Through a team approach and treatment plan, ARFID patients can progress; parents are empowered in facilitating changes that support long-term health.

AD, CON, EA

EA, PAT, SP



44.2 AVOIDANT RESTRICTIVE FOOD INTAKE DISORDER: MEDICAL ASSESSMENT, MANAGEMENT, AND SAFE RENOURISHMENT

44.4 WORKING TOGETHER: DIETITIAN AND OCCUPATIONAL THERAPY ROLES IN CARING FOR PATIENTS WITH AVOIDANT RESTRICTIVE FOOD INTAKE DISORDER

44.1 PSYCHOLOGICAL ASSESSMENT AND TREATMENT OF CHILDREN AND ADOLESCENTS WITH AVOIDANT RESTRICTIVE FOOD INTAKE DISORDER Mary Sanders, PhD, Stanford University, maryjsand@ yahoo.com

Jennifer Carlson, MD, Stanford University, carlson2@ stanford.edu Objectives: Children and adolescents with avoidant/restrictive food intake disorder (ARFID) may present with medical issues that range in both scope and acuity. Participants will learn about the following: 1) the health issues that should be considered during initial evaluation; 2) the growth and health concerns specific to children versus adolescents with ARFID; and 3) the medical monitoring and treatment recommendations during renourishment. Methods: With the use of clinical case vignettes, medical issues and treatment recommendations will be reviewed. Medical management in both the inpatient and outpatient settings will be addressed, referenced to current literature, as well as expert practice models. Results: By the end of the session, participants will be able to do the following: 1) identify the key medical information to be obtained during an initial evaluation; 2) identify the medical complications of ARFID in both children and adolescents; and 3) have a greater understanding of the medical management during renourishment/treatment. Conclusions: The medical presentation of ARFID in children and adolescents can be quite varied. Identifying and understanding the potential medical complications of ARFID will allow for the safest management of this population.

ADOL, EA, MIC http://dx.doi.org/10.1016/j.jaac.2017.07.253


Allyson Sy, RD, Lucile Packard Childrens Hospital Stanford, [email protected] Objectives: Clinical nutrition and occupational therapy assessment of avoidant/ restrictive food intake disorder (ARFID) are vital parts of a comprehensive evaluation and team members in the treatment of patients with ARFID. Participants will learn about the nutritional assessment, which includes an evaluation of current anthropometrics, growth history, assessment of biochemistry and clinical data, physical activity, nutrition history, and calculation of estimated nutrition needs. Occupational therapy evaluation includes the feeding components of the avoidant/restrictive behaviors, physiological patterns during feeding, and the current way that it is impacting patient function and the goals of the family and the patient. Considerations of the physical components that may be present in patients with ARFID by patient type are as follows: lifetime of picky eating, children with sensory issues, and patients with a postfear-related episode. The treatment approach includes a comprehensive and individualized nutritional plan of care, occupational therapy’s therapeutic use of self, feeding sessions, information on coping techniques to address fears and physiological patterns, behavior modification plan, and parent-feeding education. Clinical nutrition information covers different types of meal planning, with a probable need for calorie tracking, replacement protocols, various enteral nutrition plans, and parent nutrition education.

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Methods: Our team clinical dietitian and occupational therapist will share their method of assessment and treatment. Results: 1) Participants will have a greater understanding of ways to help patients progress medically through systematic refeeding and the oral motor/eating patterns that may impact these patients; 2) participants will have a clear sense of the step-by-step process of reintroducing food during repeated feeding sessions in a structured, reinforced pattern that progresses nutrition; and 3) participants will understand physiological patterns that may arise in patients and methods of addressing them through physiological coping strategies. Conclusions: Through a team approach and treatment plan, patients with ARFID can progress, and parents are empowered in facilitating changes that support long-term health.

PAT, SP, TREAT http://dx.doi.org/10.1016/j.jaac.2017.07.255

nature (with autism spectrum disorder and psychosis), although all four prove to have characteristics of both, directly impacting treatment and prognosis. Results: Regardless of the severity of congenital heart disease, psychiatric symptoms can develop in any age group, and multiple studies have indicated the need for regular screening and early identification. Although there is limited research into the assessment of medically unexplained pain, there are suggested guidelines and approaches that can serve as models for psychiatrists caring for these patients. Guidelines for treatment of children with autism spectrum disorder and comorbid medical illness aim to prevent initial or escalated agitation and improve early assessment, thus preemptively decreasing resource utilization in the longer term. Growing recognition of autoimmune encephalitis and comprehensive clinical approaches to diagnosis can decrease the time to accurately identify the disorder and start appropriate treatment. Conclusions: Despite the subtleties and consequent challenges, a thorough assessment of medical- and psychiatric-presenting symptoms is essential to a comprehensive evaluation, diagnostic clarification, and proper treatment approach throughout the field of child and adolescent psychiatry.

44.5 CHILD AND ADOLESCENT PSYCHIATRISTS IN AVOIDANT RESTRICTIVE FOOD INTAKE DISORDER: PSYCHOTROPIC MEDICATION USES AND UNIQUE PRESENTATIONS

PYI, SP, TREAT

Emily Fu, MD, Stanford University, [email protected]; Gillian Reierson, MD, PhD, Stanford University, greierso@ stanford.edu

45.1 HEART OF THE MATTER

Objectives: There is a lack of empirical evidence to guide the use of psychotropic medications in the treatment of avoidant/restrictive food intake disorder (ARFID) in children and adolescents. Participants will learn about the following: 1) what is currently known about psychiatric medications in ARFID; 2) when to consider using pharmacotherapy; 3) types of medications used to target comorbid symptoms, including a discussion of benefits and risks; and 4) case presentations highlighting medication trials in ARFID. Methods: Review of the literature about target symptoms and psychiatric medication use in ARFID will be presented. Three clinical vignettes demonstrating psychotropic medication use in classic, acute onset, and complex ARFID cases in the inpatient setting will be discussed. Results: By the end of this session, participants will have 1) increased awareness of indications for psychiatric medication in the treatment of ARFID; and 2) increased knowledge of possible benefits and risks of medication use in this population. Conclusions: Despite the paucity of research about medication use in ARFID, there is growing clinical evidence that supports the consideration of psychotropic medications in the clinical treatment approach in ARFID.

AD, CON, EA http://dx.doi.org/10.1016/j.jaac.2017.07.256

CLINICAL PERSPECTIVES 45 COMMON MEDICAL COMORBID CLINICAL CONUNDRUMS: DIAGNOSTIC CLARIFICATION AND TREATMENT IMPLICATIONS Susan Samuels, MD, NewYork Presbyterian Hospital- Weill Cornell Medical Center, [email protected]; Maalobeeka Gangopadhyay, MD, NewYork-Presbyterian/ Columbia University Medical Center, [email protected]. edu; Jonathan Slater, MD, NewYork-Presbyterian/Columbia University Medical Center, [email protected] Objectives: The goal of this clinical perspectives will be to gain tools and updated knowledge for diagnostic clarification and management of common comorbid clinical conundrums encountered throughout the field of child and adolescent psychiatry, including inpatient settings, outpatient settings, the emergency department, and the consultation-liaison service. Methods: Four distinct cases will be presented by four different clinicians, each focusing on the report of initial symptoms, the evolution of the diagnostic clarification, and management of the clinical conundrum; two of these cases seem to be of primary medical nature (with cardiac disease and inflammatory bowel disease), and two of them seem to be of primary psychiatric

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Sponsored by AACAP's Physically Ill Child Committee http://dx.doi.org/10.1016/j.jaac.2017.07.258

Maalobeeka Gangopadhyay, MD, NewYork-Presbyterian/ Columbia University Medical Center, mg3569@cumc. columbia.edu Objectives: Children with congenital heart disease (CHD) may undergo numerous procedures and go through times of intensive management interspersed with other periods of relative calm. Their adjustment and quality of life are affected by the experience of procedures, their expectations, and their development, both cognitively and emotionally through the process. Psychiatrists in inpatient medical settings can be called to address emotional difficulties in the setting of interventions and distinguish the contributions of medical pathology and psychopathology in the presentation. The goal of this presentation is to present a review of the literature of CHD and psychiatric comorbidities in pediatric patients in the context of an illustrative case. Methods: This presentation will review a case of CHD and cardioversion that led to the development of acute stress disorder and multiple subsequent medical evaluations with the involvement of the child psychiatry service on the medical floor in the emergency room and in the outpatient clinic. A review of the literature was conducted to identify the recent evidence about psychopathology in the pediatric CHD population and treatment strategies to address accompanying social, behavioral, and academic dysfunction. Results: Lower emotional, social, and school functioning was found in both prepubertal children and adolescents with CHD compared with children and adolescents without chronic illness. Regardless of severity of CHD, psychiatric symptoms can develop in any age group, and multiple studies have indicated the need for regular screening and early identification. The risk factors to predict psychopathology in children with CHD will be discussed. Conclusions: Although the American Heart Association recommends increased behavioral screening for developmental delays and surveillance of functioning, there is limited research to suggest what are effectively preventive and interventional strategies to address psychopathology in children with CHD. Assessing children with CHD for psychiatric symptoms in the setting of medical confounders can be a challenge for psychiatrists. Psychiatrists should keep in mind conditions and medications that can mimic psychiatric symptoms, as well as the developmental trajectory of the individual case when designing interventions.

CON, PYI, SOM http://dx.doi.org/10.1016/j.jaac.2017.07.259

45.2 PAIN OUT OF PROPORTION Lisa Hutchison, MD, NewYork-Presbyterian/Columbia University Medical Center, [email protected] Objectives: Pain that seems to be out of proportion to medical illness is one of the most common reasons for psychiatric consultation in the hospital, yet many psychiatrists do not consider themselves experts in pain management. Psychosomatic pain presents unique challenges in pain treatment. This

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presentation provides an updated review of the literature concerning the assessment and treatment of psychosomatic pain and chronic pain syndromes in the context of an illustrative case. Methods: A case of somatic symptom disorder comorbid with inflammatory bowel disease will be used to exemplify the challenges associated with the assessment and treatment of psychosomatic pain. A review of the literature was conducted to identify the most recent evidence concerning the assessment of medically unexplained symptoms and nonopioid treatments of pain. The search included focus on both pharmacological and nonpharmacological interventions, including psychoeducation, psychotherapy, mind/body techniques, and integrative modalities, such as hypnosis, yoga, acupuncture, and massage. Results: Although there is limited research into the assessment of medically unexplained pain, there are suggested guidelines and approaches that can serve as models for consult-liaison psychiatrists. In children and adolescents, evidence provides the greatest support for nonpharmacological interventions, including relaxation, CBT, and models that promote return to functioning. Involvement of the family is essential, especially when addressing the function of the presenting pain symptom. When pharmacological interventions are warranted, a number of nonopioid agents can be considered. This evidence will be discussed, as well as the application of these medications in the pediatric population. Conclusions: The assessment and treatment of pain can be a daunting task for any physician, and typically, this role falls to psychiatrists only when other specialists are stumped. Although there is limited evidence for any interventions for pain in children and adolescents, the greatest support is for nonpharmacological treatments that focus on return to functioning. When necessary, there are a number of nonopioid pharmacological agents that can be considered in specific situations, but these agents should be used with care.


45.3 ACUTE ABDOMEN AND ABRUPT AGITATION ARE AKIN IN AUTISM Nadine Schwartz, MD, Nationwide Children’s Hospital, [email protected] Objectives: Physicians caring for children with autism spectrum disorder (ASD) may face challenges in diagnosis that can negatively impact quality of care, especially in the context of agitation and/or acute or occult medical illness. Psychiatrists working in co-located outpatient, emergency, or inpatient medical settings either may be asked to manage aggressive symptoms that arise while patients undergo evaluation or may be called on to manage the entirety of the clinical situation if early medical evaluation attempts prove fruitless. This presentation will provide an updated review of the literature concerning the acute assessment of patients with ASD with an illustrative case. Methods: A review of the literature was conducted by studying the most recent evidence and guidelines concerning the challenges associated with assessing patients with ASD in the context of agitation and/or acute or occult medical illness. The presentation will focus on a case that illustrates the pragmatic difficulties in such evaluations and discussion of approaches to manage these disorders. Results: Recently, there has been increasing development and publication of suggested guidelines and approaches to assessment of potential acute or occult medical illness in children and adolescents with ASD. The goals of these guidelines include increased provider awareness of the relationship between underlying medical processes and agitation, decreased likelihood of provoking or escalating patients in the process of assessing for medical concerns, and improved efficacy and efficiency in systems of care leading to improved experiences and outcomes for the patients and the providers who assess and treat them. These guidelines have in common bidirectional education between family/caregivers and medical providers, staff training, capacity building, and workflow process development, with goals of preventing initial or escalated agitation and improving early assessment, thus preemptively decreasing resource utilization in the longer term. Conclusions: The assessment of patients with ASD is often labor- and resourceconsuming, and the demands can quickly become overwhelming when agitation and/or aggression develop or escalate. An educational and preemptive approach can improve safety and outcomes for the patient and providers.

ASD, CON, DIAG http://dx.doi.org/10.1016/j.jaac.2017.07.261


45.4 ALTERED MENTAL STATUS Shanti Lila Gooden, MD, University of California, San Francisco Benioff Children’s Hospital, [email protected] Objectives: Anti-N-methyl-D-aspartate receptor (anti–NMDAR) encephalitis is an autoimmune disease that presents with a variety of neurological and psychiatric symptoms. In general, patients present with a nonspecific clinical exam that may create a delay in diagnosis and treatment. Patients may be admitted to psychiatric hospitals when preliminary neurologic workups are inconclusive. Psychiatrists working in an inpatient medical setting are often asked to manage aggressive symptoms that occur while patients undergo treatment. The goal of this presentation is to present a review of the literature on anti–NMDAR encephalitis diagnosis, treatment, and management of aggression in pediatric patients with a case presentation. Methods: The presentation will review the case of a teenage boy who had multiple admissions, including to a psychiatric unit, before being diagnosed with anti–NMDAR encephalitis. A review of the literature was done, examining recent evidence on the diagnosis and treatment strategies for patients presenting with behavioral changes in the setting of anti–NMDAR encephalitis. Results: Growing recognition of autoimmune encephalitis and comprehensive clinical approaches to diagnosis can decrease the time to accurately identify the disorder and start treatment. There is limited evidence supporting specific psychotropic medications to manage associated behavioral disturbance, including insomnia and aggression. Conclusions: Rapid diagnosis and treatment of anti–NMDAR encephalitis leads to a better outcome for the patient. An interdisciplinary approach can aid in this process. A thoughtful approach to medication management of behavioral symptoms can improve safety for the patient and staff while avoiding confusing the clinical picture with undesired iatrogenic complications.

PYI, PPC, PSY http://dx.doi.org/10.1016/j.jaac.2017.07.262

CLINICAL PERSPECTIVES 46 SUICIDE PREVENTION AND RESILIENCE AT CHILDREN’S (SPARC) PROGRAM: AN INNOVATIVE PROGRAM AIMED TO REDUCE SUICIDE EVENTS IN ADOLESCENTS WITH SUICIDAL BEHAVIORS Graham J. Emslie, MD, University of Texas Southwestern Medical Center, [email protected]; Ankit Parmar, MD, University of Texas Southwestern Medical Center, [email protected]; Paul E. Croarkin, DO, Mayo Clinic, [email protected] Objectives: This presentation will discuss how Suicide Prevention and Resilience at Children’s (SPARC) program was developed, various psychotherapeutic modules used during program, and several outcome measures used to evaluate acceptability and effectiveness of the program. Steps taken to modify the program to expand its outreach to communities with limited resources will also be discussed. Perspectives of the trainees involved with the program will also be provided. Methods: Five speakers will present on different aspects of the program as follows: background and development, implementation, clinical data and outcome measures, dissemination to communities with limited resources, and impact on the trainees involved in the program. Results: The first presenter will talk about available literature on youth suicide and provide an evidence-based approach used to develop the SPARC program. The second presenter will discuss the implementation process and several psychotherapeutic modules used during the program. The third presenter will discuss outcome measures using different assessment tools and one-month and six-month follow-up data. The fourth presenter will highlight modifications that were made to disseminate the program in underserved and culturally diverse communities. The fifth presenter will provide insights into the psychiatry and psychology trainees’ perspectives while rotating through the program.

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Conclusions: Findings of this project suggest that the SPARC program was effective in improving adherence to follow-up treatment and reducing future suicide attempts among high-risk suicidal youth by providing evidence-based care that was widely accepted by patients and families.

EBP, PRE, S http://dx.doi.org/10.1016/j.jaac.2017.07.264

46.1 SPARC PROGRAM: BACKGROUND AND DEVELOPMENT Betsy D. Kennard, PsyD, University of Texas Southwestern Medical Center, [email protected] Objectives: The presentation will provide information on current evidencebased treatment approaches for suicidal youth and the development of an intensive outpatient program. Methods: Outcome data on adolescent treatment programs will be discussed, along with the development and implementation methods used to develop an intensive outpatient program. Results: Outcomes suggest that an intensive outpatient program for adolescents with suicidal behaviors is acceptable and feasible to implement with positive patient and parent satisfaction outcomes. Conclusions: Suicide-focused intensive outpatient programs providing specialized care fill an important gap in the treatment of suicidal youth and families.


46.2 SPARC PROGRAM: IMPLEMENTATION Brooke Castillo, MA, Children’s Health System of Texas, [email protected] Objectives: This segment will discuss the implementation of the program and various modules used during the treatment. Methods: Treatment includes an initial assessment and three hours of group therapy sessions twice weekly for four to six weeks. Individual and family therapy sessions are provided as needed. Parents and teenagers attend a three-hour multifamily group therapy once a week during the first two weeks of treatment. Consultation to a child and adolescent psychiatrist is provided as needed. After discharge from the program, families are contacted at one and six months by phone to assess subsequent suicidal behaviors, service utilization, and adherence to ongoing psychiatric and psychosocial treatment recommendations. Results: The intervention approach primarily consists of 11 modules that uses several skills of CBT, DBT, mindfulness CBT, and relapse prevention CBT. The effectiveness of the modules will also be discussed during this section. Conclusions: The program was successfully implemented to 427 youth over the span of three years.


46.3 SPARC PROGRAM: OUTCOMES Graham J. Emslie, MD, University of Texas Southwestern Medical Center, [email protected] Objectives: This presentation will present data on changes in depression, suicidality, and patient satisfaction before and after treatment and at one and six months after treatment. Methods: Patients and families completed measures of depression [Quick Inventory of Depressive SymptomatologyAdolescents (QIDS-A)], Suicidality [Concise Health Risk Tracking (CHRT)], and client satisfaction [Client Satisfaction Questionnaire (CSQ-8)] at beginning and end of treatment. Clinicians completed the Columbia Suicide Severity Rating Scales for suicidality. At one and six months, patients were interviewed for reattempt, readmission, and ongoing treatment. Results: Between 2014 and 2016, 474 youth were evaluated and 427 completed at least one session. The majority were female (79.4%), and the

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mean age was 14.9 + 1.4 years. Of the participants, 81.5 percent completed the program. There was a significant improvement in depression (QIDS-A 14.1–7.2) and suicide propensity (CHRT 26.2–15.1). More than 80 percent of patients were contactable at six months, and more than 90 percent were receiving outpatient treatment. Data on reattempt and readmission rates will be presented. Conclusions: The program was effective in reducing symptoms and improving continuity of care between inpatient and outpatient treatment.


46.4 SPARC PROGRAM: DISSEMINATION Alexandra Moorehead, BS, Children’s Health System of Texas, [email protected] Objectives: This presentation will discuss various challenges and dissemination strategies to implement Suicide Prevention and Resilience at Children’s (SPARC) program to serve underserved and low-income culturally diverse population. Methods: Qualitative interviews were conducted with suicidal teenagers (n ¼ 6), their parents (n ¼ 6), and community clinicians (n ¼ 8) to perform needs assessment. Results: Findings of the qualitative interviews will be discussed. This information is being used to make specific changes in the structure and implementation of the program to cater to the needs of such communities. Conclusions: This discussion shows the ways in which the outreach of the SPARC program will be expanded to target culturally diverse populations. This will further help in expanding the program to other groups that currently lack such treatment.

EBP, PRE, S Supported by the University of Texas Southwestern Medical Center http://dx.doi.org/10.1016/j.jaac.2017.07.268

46.5 SPARC PROGRAM: IMPACT ON THE TRAINEES Ankit Parmar, MD, University of Texas Southwestern Medical Center, [email protected] Objectives: The goal of this session is to discuss psychiatry and psychology trainees’ perspectives while they rotated through the program. Methods: Personal experience and findings of an anonymous survey will be discussed here. Results: Approximately five to seven psychiatry and psychology trainees are involved with the Suicide Prevention and Resilience at Children’s (SPARC) program each year. The survey (n ¼ 10) suggested that more than 90 percent of the trainees “agreed” or “strongly agreed” that the program made them feel more comfortable in working with suicidal patients and performing safety planning. Almost all the trainees felt that this was a valuable experience during their training and that they would recommend it to the incoming trainees. Several trainees also conducted research projects during this rotation. Conclusions: In addition to helping suicidal adolescents, the SPARC program helped train future care providers in learning different aspects of psychotherapeutic techniques and safety planning and potentially motivated them to work with this population in the future.


CLINICAL PERSPECTIVES 47 DEVELOPING A COMMUNITY-BASED CONTINUUM OF CARE FOR CHILDREN WITH DEVELOPMENTAL DISABILITIES Robert L. Klaehn, MD, Anthem Insurance Companies, Inc., [email protected]; Kathleen Koth, DO, Medical College of Wisconsin and Children’s Hospital of Wisconsin, kkoth@chw.

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org; Jeremy Veenstra-VanderWeele, MD, Columbia University, [email protected] Objectives: Because of the administrative separation of services for persons with developmental disabilities and for persons with mental health and substance use disorders at the federal level, services for children and adolescents with autism spectrum disorders (ASD) or intellectual disability are often separate and not well coordinated at the state and local levels. This Clinical Perspective session will highlight efforts to more highly coordinated services for this population, discussing model programs that emphasize accurate diagnosis and evidencebased treatment interventions. Methods: The presenters will discuss the current state of integration of services for children and adolescents with developmental disabilities into federally funded community-based systems of care. Other presenters will describe current efforts to develop collaborative models (uniting developmental disabilities and mental health services) at the state or local levels to provide expertise in the diagnosis and treatment of children and adolescents with ASD or intellectual disability. Best practices for the care of children and adolescent with developmental disabilities in community-based systems of care will also be reviewed. Results: The attendee will learn about the current state of inclusion of children and adolescents into community-based systems of care and efforts to improve inclusion and collaboration. Models for increased integration of mental health and developmental disabilities services will also be presented. Conclusions: The development of strong linkages between programs for federal, state, and local developmental disabilities programs with community-based systems of care and with child psychiatrists in private practice will result in better care for children and adolescents with ASD and intellectual disability.

ASD, ID, CC Sponsored by AACAP's Community-Based Systems of Care Committee and Autism and Intellectual Disability Committee http://dx.doi.org/10.1016/j.jaac.2017.07.271

47.1 INCLUSION OF CHILDREN AND ADOLESCENTS WITH DEVELOPMENTAL DISABILITIES IN COMMUNITY-BASED SYSTEMS OF CARE Robert L. Klaehn, MD, Anthem Insurance Companies, Inc., [email protected] Objectives: This presentation will discuss the current organization of services at the federal and state levels for children and adolescent with developmental disabilities. Best practices for the community-based treatment of children and adolescents with developmental disabilities will also be described. The administrative separation of services for children and adolescents with developmental disabilities and mental health at the federal level reflects the common separation of these services at the state and county levels as well. This separation has placed services for children and adolescents with developmental disabilities, for the most part, outside SAMHSA’s efforts to develop community-based systems of care for children and adolescents with serious emotional disturbances. This lack of inclusion often creates difficulties for families trying to access needed services for their children with developmental disabilities in their communities. Methods: This presentation will briefly describe the federal Administration on Intellectual and Developmental Disabilities and the Center for Mental Health Services in the Substance Abuse and Mental Health Services Administration and several state models for developmental disability and mental health services. Best practices for the inclusion of children and adolescents within community-based systems of care will also be described. Results: The learner will have a clearer understanding of the organizational structure of services for children and adolescents with developmental disabilities at the federal, state, and local levels. The attendee will also learn best


practices for greater inclusion of these children and adolescents in their local systems of care. Conclusions: Greater inclusion of children and adolescents with autism spectrum disorder and intellectual disability into community-based systems of care will result in greater access to needed wraparound and other evidencebased services.

ASD, CC, ID http://dx.doi.org/10.1016/j.jaac.2017.07.272

47.2 ENHANCING THE PUBLIC SECTOR CONTINUUM OF CARE FOR CHILDREN WITH AUTISM IN PHILADELPHIA Kamilah Jackson, MD, MPH, Community Behavioral Health, [email protected] Objectives: This presentation will discuss the current efforts to expand the continuum of services within Medicaid for children and adolescents with autism spectrum disorder (ASD) in the Philadelphia area. Special emphasis will be made on addressing the rise in crisis presentations of this population and efforts to increase access to acute care services while strengthening the community-based continuum. The services available to children and adolescents with developmental disabilities who are eligible for Medicaid are often limited to case management and medication management in community-based settings. Access to other services, such as home-based care, and evidence-based treatments, such as applied behavioral analysis and specialized acute care, is often quite limited. Methods: The services available to children and adolescents with developmental disabilities who are eligible for Medicaid are often limited to case management and medication management in community-based settings. Access to other services, such as home-based care, and evidence-based treatments, such as applied behavioral analysis and specialized acute care, is often quite limited. Results: The attendee will learn how the public sector continuum of care for children and adolescents with ASD has been expanded in Philadelphia County, Pennsylvania. Conclusions: Enhancement of the continuum of care in the public sector and increased access to evidence-based treatments, such as applied behavior analysis, will improve the outcomes for children and adolescents with ASD and other developmental disabilities.

ASD, CC, ID http://dx.doi.org/10.1016/j.jaac.2017.07.273

47.3 FRACTURED TREATMENT OF CHILDREN AND ADOLESCENTS WITH MENTAL HEALTH DISORDERS AND CO-EXISTING AUTISM SPECTRUM DISORDER DEVELOPMENTAL DISABILITIES AND AN EFFORT TO DEVELOP A SPECIALIZED INPATIENT PSYCHIATRIC UNIT Matthew Perkins, MD, MBA, MPH, New York State Office of Mental Health, [email protected] Objectives: This presentation will discuss the fractured nature of having two agency licensing services for mental health and developmental disabilities in New York state. It will include a description of the collaborative efforts of the two agencies to develop a specialized inpatient psychiatric unit for children and adolescents with autism spectrum disorder (ASD)/developmental disabilities (DD). Methods: In New York state, two state agencies oversee and license programs for individuals with mental health concerns and individuals with DD. The Office for People with Developmental Disabilities (OPWDD) provides services if the individual’s disability occurs before age 22 years, is expected to continue indefinitely or permanently, and causes a “substantial handicap.” OPWDD services have not increased at a rate commensurate with increased identification and the current need. The Office of Mental Health (OMH) licenses programs that treat individuals with ASD/DD only if they also have a

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co-occurring mental health diagnosis. The result is limited programs in New York state providing focused treatment to children and adolescents with mental health disorders and ASD/DD. Results: This presentation will discuss the administrative structure that has resulted in difficulty accessing services in New York state. In addition, the partnership between OMH and OPWDD to develop an inpatient psychiatric unit with residential step down will be a primary focus of the discussion. This collaborative program will also be a key training and education resource for New York. Conclusions: The learner will understand the organizational and administrative barriers of services for children and adolescents with mental health disorders and co-occurring ASD/DD, which exist and identify new strategies for collaborative and evidence-based treatment options across a continuum of care.

ASD, ICP, ID http://dx.doi.org/10.1016/j.jaac.2017.07.274

47.4 DEVELOPING A MULTIDISCIPLINARY CONTINUUM OF CARE FOR CHILDREN WITH AUTISM, INTELLECTUAL DISABILITY, AND SIGNIFICANT BEHAVIORAL CHALLENGES Matthew Siegel, MD, Center for Autism and Developmental Disorders, [email protected] Objectives: The etiology of significant behavioral challenges in youth with autism spectrum disorder (ASD) or intellectual disability (ID) is frequently multifactorial, potentially including psychiatric, medical, occupational, communicative, family-reinforced, and environmentally reinforced components, among others. Child psychiatrists are uniquely positioned to oversee a multidisciplinary treatment plan for this population but may not have experience in building programs that draw on other disciplines. Methods: The presenter will build upon recent research evidence and bestpractice publications to illustrate the evidence for approaches to complex behavior in youth with developmental disabilities. The process of developing a multilevel system of care for this population will be discussed, and risks and benefits will be identified. Results: From inpatient to outpatient levels of care, a multidisciplinary culture of care can be used to address refractory behavioral challenges in youth with developmental disabilities. Access to specialists in communication, occupational therapy, family systems, case management, applied behavioral analysis, and other disciplines can be aligned to produce improved outcomes. Conclusions: Youth with ASD and ID can develop serious behavioral challenges that are refractory to approaches from a single discipline. Developing a continuum of care for this population, including inpatient, day treatment, outpatient, phone consultation, and other services, will be discussed and avenues for success identified.

ASD, ICP, ID http://dx.doi.org/10.1016/j.jaac.2017.07.275

CLINICAL PERSPECTIVES 48 FAILURE TO LAUNCH: WHAT EVERY CHILD AND ADOLESCENT PSYCHIATRIST NEEDS TO KNOW TO HELP FACILITATE SUCCESSFUL COLLEGE TRANSITION Jennifer L. Derenne, MD, Stanford University, jderenne@ stanford.edu Objectives: Participants will 1) identify best practices for helping families navigate the transition from high school to college; 2) learn about ethical and legal principles impacting college student privacy and effective communication with clinicians and administrators; and 3) learn about transition issues unique to specific diagnoses (eating disorders, mood disorders, anxiety disorders, substance use disorders, autism spectrum disorders, and attention-deficit/hyperactivity disorder), using clinical case vignettes to stimulate discussion.

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Methods: Best-practice guidelines for transitioning adolescents to college will be reviewed using a combination of didactic presentations, clinical case vignettes, and an interactive question-and-answer panel session. Results: Participants will be able to 1) encourage children and adolescents to gradually take on increased responsibilities for self-care and health care decisions in an age- and diagnosis-appropriate way; 2) serve as an informed liaison for patients and families to systems of higher education; 3) standardize the transfer of care to new providers in the college system; and 4) prepare parents and students for possible difficulties with the separation process. Conclusions: Early identification, planning, and knowledge of laws and campus resources will help child and adolescent psychiatrists become better advocates and guides for families navigating the transition to college and more independent management of mental health needs.

ETH, COLST, TREAT Sponsored by AACAP's Transitional Age Youth and College Student Mental Health Committee http://dx.doi.org/10.1016/j.jaac.2017.07.277

48.1 ARE YOU READY? TRANSITION PREPARATION AND PLANNING WITH OUR COLLEGE-BOUND PATIENTS AND THEIR FAMILIES Adele L. Martel, MD, PhD, Northwestern University Feinberg School of Medicine, [email protected] Objectives: In this session, participants will learn the following: 1) the value of transition planning and preparation in the context of heading to college with a mental illness; 2) therapeutic strategies to assist patients and families in understanding the patient’s strengths and vulnerabilities and readiness for transition to college; 3) domains of late adolescent/ young adult functioning essential for postsecondary education success; and 4) salient anticipatory guidance topics to discuss with college-bound patients and their families. Methods: The speaker discusses the following: 1) definitions of healthcare transition, transition preparation/planning, and transfer of care as derived from special education and pediatrics; 2) characteristics of comprehensive, successful transition plans, and barriers to optimal transition; 3) the functional domains of self-advocacy, independent living skills, academic skills/executive functioning, independent management of mental health condition, and psychosocial milestones (peer and family relationships, identity formation, self-awareness); 4) the use of transition readiness assessments in routine practice; and 5) a timeline of transition-related tasks/ activities for clinicians, patients, and families to promote readiness in multiple domains. Results: Participants will be better able to do the following: 1) identify components of a solid, well-rounded transition plan; 2) use therapeutic strategies to assess, monitor, and move patients forward in their readiness for transition to college; 3) engage patients and families in thoughtful discussion of postsecondary options based on the mental health status and ongoing treatment needs of the patient; 4) collaboratively develop transfer of care plans, which promote patient autonomy, provide continuity of care, and include plans for crisis management; and 5) offer anticipatory guidance to patients and families on the possible impact of the college environment on mental wellness and stability. Conclusions: Child and adolescent psychiatrists are in a unique position to assist patients and their parents through the often-difficult transition from high school to college. Proactive, developmentally informed, intentional, and explicit transition preparation and planning on a foundation of a well-thought-out diagnostic and biopsychosocial formulation can promote wellness, build resilience, and improve transition outcomes.

DEV, PRE, SP http://dx.doi.org/10.1016/j.jaac.2017.07.278

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48.2 LEGAL AND ETHICAL ISSUES IN COLLEGE MENTAL HEALTH Laura Braider, PhD, Northwell Health and Hofstra University Northwell School of Medicine, [email protected] Objectives: Given that more students are attending college with psychiatric diagnoses and are seeking treatment, the need for collaboration between psychiatric treatment providers and academic institutions has become more common and necessary. Participants will learn about ethical and legal principles impacting college student privacy and ways in which providers can effectively communicate with family, college clinicians, and administration. The speaker will discuss the following: 1) principles of the Family Educational Rights and Privacy Act (FERPA) and HIPAA in emergency psychiatric assessment, hospitalization, and outpatient care; 2) weighting both parent and school collateral in the assessment and treatment of college students; 3) negotiating balance of autonomy, advocacy, and privacy within school environment with parents and students; and 4) school reentry processes with consideration of the Americans with Disabilities Act (ADA). Methods: Principles of FERPA, HIPAA, and ADA relevant to treatment of college students will be presented. Discussion will cover clinical situations where collaboration with schools is preferred and illustrate case study examples. Snares or pitfalls to avoid school communication breaches of confidentiality or work contrary to the student’s best interest will be highlighted. Results: Participants will have learned the following: 1) principles of HIPAA and FERPA in the context of treating college students during emergency assessment, psychiatric hospitalization, and outpatient care; 2) importance of weighting both parent and school collateral in the assessment and treatment of college students; 3) considerations in balancing student autonomy, privacy, and advocacy with schools and parents; and 4) ways to navigate school reentry processes and ADA, including proper personnel/ departments to collaborate with and what information requests are appropriate. Conclusions: A better understanding of ethical and legal principles impacting student privacy and ways to best collaborate with colleges can lead to more informed and improved treatment of college students.

COLST, EDUC, ETH http://dx.doi.org/10.1016/j.jaac.2017.07.279

48.3 DIAGNOSIS-SPECIFIC CONSIDERATIONS: SUBSTANCE USE DISORDERS AND MOOD DISORDERS Zhanna Elberg, MD, University at Buffalo, zelberg@ buffalo.edu Objectives: Mood disorders and substance use disorders (SUDs) are highly prevalent among college students but pose several treatment challenges for transitioning and matriculated students. Students with untreated mental health disorders are at increased risk for suicide, which is already the second leading cause of death in college students. Participants will learn about the following: 1) assessment and treatment of mood disorders and SUDs in the college-age population; 2) treatment challenges, as well effective strategies, and available resources available to college students with these diagnoses; and 3) risk factors for suicide in this population and available prevention strategies. Methods: Evidence-based literature on the prevention, diagnosis, and treatment of mood disorders and SUDs will be presented. Challenges to treatment, including management of suicidality risk, will be described. Available resources and limitations of treatments of these disorders on college campuses will be outlined. Practical applications to the college-age population and case examples will be offered. Results: Participants will do the following: 1) improve their knowledge of evidence-based practice in the diagnosis and treatment of mood disorders and SUDs in the college-age population; 2) appreciate the various treatment challenges in working with college students with mood disorders and SUDs; and 3) recognize the significant suicide risk in this population and be able to describe prevention strategies.


Conclusions: After learning about the treatment approach for mood disorders and SUDs in college students, participants will be equipped with the tools to effectively manage and advocate for this population.

COLST, SUD, S http://dx.doi.org/10.1016/j.jaac.2017.07.280

48.4 DIAGNOSIS-SPECIFIC CONSIDERATIONS: ATTENTION-DEFICIT/HYPERACTIVITY DISORDER AND AUTISM SPECTRUM DISORDER Nnenna Kalaya Okereke, MD, Carilion Clinic, nkokereke@ yahoo.com Objectives: Students with ADHD and autism spectrum disorder (ASD) are increasingly entering college in higher numbers, and many seek psychiatric treatment by providers. The assessment and treatment of these students pose unique challenges in the college setting. Participants will learn about the following: 1) appropriate assessment and management of particular, more prominent developmental issues in college students with ADHD and ASD; 2) effective treatment planning for college students with ADHD and ASD; and 3) pertinent education and disability laws and disability services commonly available on college campuses for students with these diagnoses. Methods: Evidenced-based literature on the assessment, diagnosis, and treatment for ADHD and ASD will be presented. Developmental issues, particularly in college students with ADHD and ASD, will be described. Disability services commonly available on college campuses will be discussed specifically. Practical applications to college students with ADHD and ASD will be offered and illustrated with case examples. Results: By the end of the session, participants will have 1) increased knowledge of the assessment and management of pertinent developmental issues in college students with ADHD and ASD; 2) increased awareness of treatment options for college students with ADHD and ASD; and 3) further specific knowledge of disability services commonly available on college campuses and ways to use these resources for students with ADHD and ASD. Conclusions: Increasing the knowledge of specific developmental issues, assessment, and evidence-based treatment of college students with ADHD and ASD will further equip providers to better manage these conditions in the college setting.

ADHD, ASD, COLST http://dx.doi.org/10.1016/j.jaac.2017.07.281

48.5 DIAGNOSIS-SPECIFIC CONSIDERATIONS: EATING DISORDERS AND ANXIETY DISORDERS Jennifer L. Derenne, MD, Stanford University, jderenne@ stanford.edu Objectives: Treatment of disordered eating behavior and anxiety, although challenging in any setting, can be more complex in the college-age population because of many factors. Participants will learn about the following: 1) expectations of university administration and unique challenges in providing treatment to the college-age patient with eating disorders and anxiety; 2) effective outreach, prevention, and treatment of eating disorders and anxiety disorders; and 3) ethical principles and legal dilemmas specific college patients with these diagnoses. Methods: Evidence-based literature on prevention, diagnosis, and treatment for eating disorders and anxiety will be presented. Challenges to treatment will be described in the context of ethical principles and legal regulations; mandated assessment and treatment will be discussed specifically. Practical applications to the college-age patient and case examples will be offered. Results: Participants will have 1) increased knowledge of best-practice treatment and prevention and advocacy tools for eating disorders and anxiety; and 2) an increased awareness of treatment dilemmas specific to college students with anxiety and eating disorders in the university setting, including ethical challenges and legal quandaries. Conclusions: Armed with more information on unique treatment challenges specific to diagnoses common in college-aged patients, practitioners can be more effective advocates and agents of change.

COLST, EA, TREAT http://dx.doi.org/10.1016/j.jaac.2017.07.282

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CLINICAL PERSPECTIVES 49 IMPACT ON CAREGIVERS WORKING WITH REFUGEE POPULATIONS Joshua D. Feder, MD, Senior Consultant, International Network for Peace Building with Young Children, jdfeder@ mac.com Objectives: We are overdue in our duty to support child and adolescent psychiatrists to better withstand the rigors of work with refugee populations. The experiences of these families are among the most unimaginable, eroding our usual means of managing the fact of violence and armed conflict in the world. The messages clinicians hear repeatedly include “we didn’t think it could happen to us” or “neighbor killing neighbor.” Horrific reports of unimaginable violence and suffering must impact us as clinicians, and yet, we need to help and even recruit others to help these suffering children and families. Therefore, it is our responsibility to offer support and guidance and to press for research on how to best support our colleagues in this work. Methods: This set of talks uses the experiences of child psychiatrists to delineate the challenges and responses of clinicians to work with refugee populations. Results: Participants will learn about the impact of working with refugees and receive practical guidance on how to withstand and even grow from this work. Conclusions: Research is limited in this area, and although we seek to study the impact on clinicians working with refugees, it is both valuable and necessary to share and discuss clinical experience as part of our duty to support clinicians working with refugees.

PTSD, CC, SP Sponsored by AACAP's International Relations Committee and Disaster and Trauma Issues Committee http://dx.doi.org/10.1016/j.jaac.2017.07.284

49.1 PROVIDERS OF DISPLACED SYRIAN ADOLESCENTS IN THE JORDANIAN REFUGEE CAMPS Suzan Song, MD, MPH, PhD, George Washington University Hospital, [email protected] Objectives: Youth affected by war often have severe experiences, such as flight from their home country, displacement in a refugee camp, separation from their families, and multiple types of trauma that can create adverse mental health issues. Often humanitarian workers and clinicians are overwhelmed by the mental health needs of youth and families in areas of conflict. This presentation will discuss the needs of clinicians working with Syrian adolescent refugees in the camps and present interventions to assist these clinicians. Methods: Mixed qualitative and quantitative methods were used on longitudinal data from the Health of the Nation Outcomes Scales, Client and Family Satisfaction Surveys, Client Functioning Scales, and in-depth structured interviews with case managers in the mental health and protection sectors, as well as psychiatry and medical fields from participants (N ¼ 271) from four clinics in Jordan. Results: The majority of child patients had enuresis (3%), intellectual disability (3%), and epilepsy (2%), clearly showing the difficulty of mental health diagnoses in this context. Qualitative interviews revealed that case managers overwhelmingly felt under-trained in mental health assessment and requested more training. Case managers (83%) felt that documentation was a burden and stress that detracted from direct client care. Staff also reported gratitude for having a meaningful job but feeling “unhappy” because of being overworked, without support, and unappreciated. Conclusions: Those who work with the mental health of displaced Syrian youth face personal and professional difficulties, which can lead to burnout and secondary trauma. Assisting case workers with better mental health assessment and basic therapeutic skills can help the case worker feel more

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competent, productive, and supported. The majority of workers engage in this work engage in meaningful work, and adequate appreciation can help combat stress, along with assisting in individualized professional development.

PTSD, SP, TREAT http://dx.doi.org/10.1016/j.jaac.2017.07.285

49.2 LEARNING TO COMPARTMENTALIZE: THE CHALLENGES OF WORKING WITH TRAUMATIZED FAMILIES FOR THE PROVIDER Gabrielle L. Shapiro, MD, Icahn School of Medicine at Mount Sinai, [email protected] Objectives: This clinical presentation will review a series of clinical cases and address the problem of how providing treatment and addressing the complex psychosocial needs of these children and families can have profound psychological impacts on the providers. A discussion of how this was manifested in working with these specific cases and how the provider processed these issues will be presented. Methods: Meetings/discussions with colleagues, who work with this patient cohort, on the impact on the providers of working with these special patients, were initiated over a three-month period. Ideas were shared about how to identify possible symptoms of countertransference stress symptoms in the providers. Ideas were shared with regard to providing support and utilization of support to assist with fostering coping strategies for providers. Results: The consensus was that the formation of informal support/supervision groups with periodic informal meetings in a relaxed setting would be a means to support providers working with this special population. Additionally, a phone list was formulated and distributed for providers to contact each other when they needed support. Conclusions: Working with children and families fleeing violence and trauma is often challenging and draining for providers. Dealing with new challenges to the refugee/asylum children and families in our country is challenging and often frustrating to providers of care. However, there are efficient ways to support clinicians in this process.

SP, STRESS, TREAT http://dx.doi.org/10.1016/j.jaac.2017.07.286

49.3 WORKING WITH CLINICIANS WHO WORK WITH PARENTS OF TERRORISTS Ayesha I. Mian, MD, Aga Khan University, ayesha.mian@ aku.edu Objectives: At the end of the session, participants will be able to discuss the context of multiple terror attacks in Pakistan, especially those relating to children and families; appreciate the psychological impact of working with disaster-torn families on frontline workers; and differentiate interventions designed for violence-based disasters versus natural ones. Methods: The work of frontline workers, including child psychiatrists and others after the Army Public School (APS) massacre, will be discussed as an example of extremist attacks that have occurred since 2001. Discussion will focus on how terrorism-based trauma interventions differ from those following natural disasters. Results: The impact of mass shootings extends beyond primary victims to encompass the community. Community members resent the media and blame the violence on outsiders. Mental health planners should proceed carefully, as counseling was often resented. Those exposed to the shootings often displayed many psychological symptoms. Similar reactions were noted after the APS massacre in Peshawar, Pakistan. At the Aga Khan University, we offer peer mentoring services for the immediate caregivers, and psychiatry residents seek supervision from faculty and also use “huddle” groups to process their burnout and emotional turmoil. Balint groups are planned for psychiatry faculty, trainees, and emergency department and pediatric health personnel. A formal disaster response network has been established, an active arm of which is to develop support programs for the caregivers.

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Conclusions: Terror attacks are a sad reality of our current scenario globally. They occur in different contexts and thus must vary in the intervention process. Frontline workers find themselves dealing with horror stories of loss and disaster. It is important to equip them with training in psychological first aid, as well as peer and expert groups, to prevent caregiver burnout.


49.4 BUILDING RESILIENCE IN HUMANITARIAN WORKERS RESPONDING TO THE REFUGEE CRISIS IN GREECE Allen Dyer, MD, PhD, George Washington University, adyer@ mfa.gwu.edu Objectives: The goals of this session are as follows: 1) to learn about the biopsycho-social impact of population displacement; and 2) to learn a specific skill set for strengthening coping for aide workers and for refugees. Methods: This talk will describe how the George Washington (GW) University program in Global Mental Health organized two teams to respond to the different phases of the population displacement during the 2015– 2016 refugee migration from Turkey to Greece and the subsequent closure of the Greece–Macedonian border. At the request of the US Embassy in Athens, with the support of the Greek nongovernmental organization, Metadrasi, GW provided a resilience workshop to help participants strengthen their own skills to help their colleagues help the refugees. The workshop focused on mindfulness training, psychological first aid, and hope modules. Results: Humanitarian workers began to experience vicarious trauma and burnout as they witnessed suffering and tried to help refugees struggle with new frustrations and dashed hopes. Specific resilientbuilding skills assisted workers in decreasing burnout, increasing productivity, and improving a sense of efficacy in their work. A multimodal approach that incorporates mindfulness, psychological first aid, and the skills of hope building were helpful to humanitarian workers and their clients. Conclusions: Clinicians working with those who have endured extreme trauma, migration, and human rights abuses are subject to burnout, despair, poor self-care, and more emotional stress. A specific skill set that incorporates mindfulness, psychological first aid, and hope building can assist in building resilience for both clinicians and their clients.


CLINICAL PERSPECTIVES 50 LIFE MEMBERS WISDOM CLINICAL PERSPECTIVES: CARE INTEGRATION FOR CHILDHOOD SEXUAL ABUSE: POSTTRAUMATIC STRESS DISORDER, HEROIN, AND OTHER ADVERSE OUTCOMES Douglas A. Kramer, MD, MS, University of Wisconsin School of Medicine and Public Health, [email protected]; Allan Mark Josephson, MD, Bingham Clinic, University of Louisville, [email protected] Objectives: A major and always underreported and underestimated problem in this country and elsewhere is child maltreatment, basically abuse and neglect, with multiple subdivisions of type within the overall category. The human cost, in terms of mental illness, physical illness, drug and alcohol abuse and dependence, education, poverty, and relationship difficulties (in other words, all areas of human functioning), is far more than ever imaginable. Methods: Dr. Kramer will describe his experience working in a women’s prison in Wisconsin treating young and middle-aged women who were


once little girls and subjected to childhood sexual, physical, and/or emotional abuse, and/or neglect. Most have undiagnosed and untreated PTSD. Dr. Bath will discuss the sexual abuse and trauma trajectories of girls in the juvenile justice system, drawing on her work as a forensic psychiatric consultant to the Los Angeles County Juvenile Court. Dr. Amaya-Jackson will provide an overview of the impact of childhood trauma and adverse experiences, and illustrates current research. She will emphasize that childhood trauma and adversity can be positively impacted by using evidence-based interventions. Dr. Keeshin will describe an evidence-based care process model for pediatric traumatic stress that determines the right trauma-based treatment for the child, with key indicators to identify children best suited for various trauma-specific treatment(s). Dr. Josephson will share his unique perspective as the Director of Child and Adolescent Psychiatry within a department of pediatrics, i.e., integrated care in operation. Results: Within the medical community, more awareness of this hidden disorder is needed, with more active screening, assessment, and referral to appropriate services. Active cooperation in the context of a seamless partnership between pediatrics and child psychiatry is crucial, as is the development of seamless relationships with other medical specialties and those involved with this population. Conclusions: As child abuse and neglect are hidden problems right out in the open, there is an important public policy role for physicians with respect to local, state, and national funding for education, awareness, treatment, and diversion programs from the corrections arena to the treatment arena.

PTSD, JJS, CAN Sponsored by AACAP's Life Members Committee, Family Committee, and Child Maltreatment and Violence Committee http://dx.doi.org/10.1016/j.jaac.2017.07.290

50.1 “COMING HERE SAVED MY LIFE”: A CHILD PSYCHIATRIST’S EXPERIENCE IN A WOMEN’S PRISON Douglas A. Kramer, MD, MS, University of Wisconsin School of Medicine and Public Health, [email protected] Objectives: After practicing psychiatry for 42 years, I had no idea how rewarding working in a women’s prison would be. I found it not only rewarding clinically, as I believe child psychiatry is the perfect background for this population, but personally and interpersonally as well. I find myself experiencing deep respect, even admiration, every day for the vast majority of my patients. Methods: I will describe my clinical experience over two years in a women’s prison in Wisconsin. I will review both the demographic diversity of my patients in contrast to the lack of diversity of the clinical presentation. Although every story is different, the path from dysfunctional family to adverse childhood experience, primarily severe sexual abuse over an extended period of time, resulting in longstanding PTSD, with the only safety net being running away at age 14 years, thus leading to additional abusive relationships, and finally, discovering that opiates, especially heroin, give absolute relief from the symptoms of PTSD or they cause death. Results: The vast majority of the women, and a high percentage of men, in prison fit the paradigm described above. When a psychiatrist “actually listens . . . acts like a real person . . . and not like a psychiatrist,” women who have had no reason in their lives to trust anyone have the capacity to be trusting, engage in treatment, and provide useful feedback. They pay exquisite attention to the therapeutic relationship, “You didn’t look at the clock even once,” as I believe that most patients do at some level, an important reminder for all of us in all clinical settings. As discharge approaches, it is not uncommon to be told, “Coming here saved my life,” referring to the entire rehabilitation experience, although the psychiatric and psychological treatment likely makes the rest possible. Conclusions: Child psychiatrists have the ideal training and experience to provide good care to the majority of patients in a prison environment.

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Training in developmental psychopathology results in a high probability of accurate diagnoses. Prior experience in treating children, adolescents, and young adults is helpful in understanding the experience of early childhood adversity. Both of the above components facilitate empathy for the patient by thinking developmentally and understanding nontheoretically what happened when they were little girls.

50.3 CONSEQUENCES OF CHILDHOOD TRAUMA AND ADVERSITY: AWARENESS AND INTERVENTION POINTS

SUD, PTSD, CAN

Objectives: Childhood trauma and adversity are prevalent and often occur via multiple exposures that offer a dose-response risk in the child’s normal development that may be disrupted by traumatic stress and neurobehavioral and functional problems. Traumatized youth at all ages may present with behavioral and emotional manifestations, which may be hard to recognize as secondary to trauma by their caregivers, educators, and healthcare providers (including mental health clinicians), thus making it difficult to intervene appropriately within the many service systems with which these youths may interface. Methods: The author will provide a brief overview of the impact of child trauma and adverse experiences and illustrate current research as well as insights from high-impact organizations such as the AAP and the National Child Traumatic Stress Network (NCTSN) to guide participants in conceptualizing how awareness of exposure to childhood trauma and adversity can be positively impacted by use of proven, evidence-based treatments and interventions. Results: Child psychiatrists and other mental health professionals attend to adverse childhood experiences and other traumatic life events in their work and face the need to not only become aware and understand this impact on the developing child, but, per the NCTSN, “take awareness to action” to intervene appropriately—whether through screening, assessment, referral, or providing access to appropriate evidence-based treatment. Conclusions: Practitioners must be able to integrate awareness and understanding of trauma while providing children and their families options regarding evidence-based treatments and interventions that have demonstrated effectiveness in mitigating the negative outcomes associated with childhood exposure to trauma and adversity.


50.2 GIRLS AND THE JUVENILE JUSTICE SYSTEM: SPECIALTY COURTS AND APPROACHES TO WORK WITH COMMERCIALLY SEXUALLY EXPLOITED YOUTH IN THE LOS ANGELES COUNTY JUVENILE COURT SYSTEM Eraka Bath, MD, University of California, Los Angeles Semel Institute for Neuroscience and Human Behavior, ebath@ mednet.ucla.edu Objectives: Commercially sexually exploited youth (CSEY) represent a high-need, high-risk, and underserved subset of the female juvenile delinquency population. Both CSEY and non–CSEY, which judicially include girls who have high rates of substance use disorders (SUDs) and non–CSEY girls with SUDs, are at risk for future exploitation. Several studies demonstrate that girls in the juvenile justice system have high rates of sexual victimization and the greatest mental health needs among their peer groups. Approximately 74 percent of delinquent girls have at least one psychiatric disorder. Furthermore, studies have shown that 75-95 percent of arrested girls have histories of childhood maltreatment and that close to 50 percent meet the criteria for SUDs. Compared with both nonoffending females and their male-offending counterparts, offending girls are at significantly greater risk for the development of SUDs, psychiatric symptoms, and negative health outcomes, such as HUV infection/AIDS or other sexually transmitted infections (STIs). Methods: The goal of this study is to determine type and severity of past substance use and psychiatric diagnoses and examine how service engagement varies by demographic and clinical characteristics (i.e., substance use, mental health) using a retrospective cohort of 200 CSEY served in a specialty court [Succeed Through Achievement and Resilience Court (STAR Court)] for CSEY in Los Angeles County (Los Angeles, CA). Results: Preliminary review of 100 case files of STAR Court participants from 2012 to 2014 reveals that all participants were female and that the majority were African American (75%), whereas 18 percent were Hispanic. The average age was 17 years (ranging from age 13 to 23 years), and average length of stay under STAR Court supervision was 12–18 months. In addition, 10 percent had a history of pregnancy, 81 percent used alcohol or drugs, and 69 percent had a mental health diagnosis, with 25 percent having three or more such diagnoses. The CSEY in the STAR Court are disproportionately females of racial/ ethnic minority, with high levels of substance use and mental health problems. Conclusions: Research suggests that developmental pathways to drug use, initial legal involvement, and co-occurring negative health outcomes may be different for girls, thus supporting the importance of testing gender-specific juvenile justice interventions. Empirically supported interventions to decrease substance abuse and improve mental health and/or legal outcomes among CSEY in the juvenile justice system are lacking.

FCP, JJS, PTSD Supported by NIH Grant P20MD000182; the Los Angeles County Department of Probation; and the AACAP Physician Scientist Program in Substance Abuse, supported by the National Institute on Drug Abuse http://dx.doi.org/10.1016/j.jaac.2017.07.292

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Lisa Amaya-Jackson, MD, MPH, Duke University Hospital, [email protected]

CAN, EBP, PTSD http://dx.doi.org/10.1016/j.jaac.2017.07.293

50.4 INTEGRATED CARE AND TRAUMA: CHOOSING THE RIGHT TREATMENT FOR THE RIGHT CHILD AT THE RIGHT TIME Brooks R. Keeshin, MD, University of Utah School of Medicine, [email protected] Objectives: Children with histories of abuse are regularly cared for by pediatric providers in both medical and mental health settings. With support from networks such as the National Child Traumatic Stress Network (NCTSN), there has been a significant increase in the development and dissemination of effective interventions to treat abused children with significant trauma. Much of the gains in trauma treatment have focused on training providers in a specific psychotherapeutic, traumafocused modality to be delivered in a community mental health setting. However, for the child psychiatrist or pediatrician in integrated care settings, less is known about the effective incorporation of evidence-based psychotherapies into a comprehensive treatment plan and the potential use of adjunct pharmacotherapy among children with prominent trauma symptoms. Methods: To address this system gap within the NCTSN, our center has begun to develop an evidence-based care process model for pediatric traumatic stress that will 1) use evidence to decide on the right trauma-based treatment for the child, with key indicators to identify children best suited for various trauma-specific treatment(s); and 2) the appropriate role of medication in children with PTSD, with or without psychiatric comorbidity. Results: We will present data that support both the under- and overutilization of resources for trauma-exposed children and key aspects of our traumainformed approach to treating traumatized children in our trauma clinic. In addition, we identify practical trauma assessment steps, feasible in integrated care settings that may increase the capacity of the pediatrician in the initial

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detection and assessment of trauma in abused children. Last, we present data on the use of specific pharmacologic agents in PTSD and potential pharmacologic treatment strategies in conjunction with evidence-based psychotherapies. Conclusions: Effective interventions have been developed to address childhood trauma, yet many traumatized children do not receive these interventions. Integrated care approaches that recognize the unique role of pediatricians and child psychiatrists in the treatment of childhood trauma may improve the appropriate utilization of evidence-based, trauma-specific practices among abused children.

CAN, EBP, PTSD Supported by SAMHSA Grant 1U79SM080000-01 http://dx.doi.org/10.1016/j.jaac.2017.07.294

CLINICAL PERSPECTIVES 51 MICROAGGRESSIONS, MACROAGGRESSIONS, INJURY, AND HEALING: AN UPDATE Cheryl S. Al-Mateen, MD, Virginia Commonwealth University School of Medicine, [email protected]; Melvin D. Oatis, MD, Private Practice, [email protected] Objectives: The participant will explore the relationship of historical trauma and recent events on diverse youth from varying perspectives and reflect on the impact of these events on his/her patient population. Methods: “Historical trauma” describes a collective experience of complex trauma inflicted upon a group with a specific group identity (i.e., ethnicity, religious affiliation) and includes cumulative wounding across generations. Social determinants of health are conditions in the places where people live, learn, work, and play that affect a wide range of health risks and outcomes. Two key areas of social determinants of health are 1) social and community context and 2) neighborhood and built environment. Multiple groups experience racism and discrimination in similar forms. These are harmful to health and predict future psychological distress. Overt racial-ethnic discrimination and margination in years past have become latent, institutional, and unconscious bias, which is harder to challenge and address. Interactions with law enforcement can be a significant aspect of day-to-day experience for youth in these populations. The Federal Bureau of Investigation reported a 67 percent increase in anti–Muslim hate crimes from 2014 to 2015. There was also an increase in crimes against Jews, African Americans, and lesbian, gay, bisexual, and transgender individuals. Living in these environments is difficult and a significant stressor that is often not overtly addressed in therapeutic encounters. This experience has, however, been frequently discussed in all forms of the media in our current environment. We will inform the child and adolescent psychiatrist about aspects of these issues that are useful in understanding important perspectives that may impact clinical presentation and the clinician–patient relationship. Opportunities for advocacy in working with families and various community organizations will be discussed. Results: We will discuss the impact of trauma for various members of the community. The effects on youth, families, and law enforcement personnel will be discussed, with recommendations for healing that the child and adolescent psychiatrist will be able to use in practice. Conclusions: One answer to changing the current dynamic is to have authentic dialogue about multiple factors that contribute to our situation and community solutions that the child and adolescent psychiatrist can incorporate into practice and, perhaps, advocacy.

ETHN, SP, STRESS Sponsored by AACAP's Diversity and Culture Committee http://dx.doi.org/10.1016/j.jaac.2017.07.296

51.1 THE REACTION TO HISTORICAL TRAUMA AMONG MINORITY YOUTH Andres J. Pumariega, MD, Cooper Medical School of Rowan University and Cooper University Hospital, [email protected]


Objectives: This session seeks to draw a linkage among the current youth protest movements (Black Lives Matter, Latino Dreamers, the Resistance) and the continuing re-living of historical trauma among minority youth in the United States. In recent years, discrimination has shifted from latent to overt (particularly against Muslim, Latinos, and African Americans). This has been a result of socioeconomic challenges and fears of globalization and terrorism among white ethnic populations. Re-emphasis on “Melting Pot” assimilation has resulted in rejection of the value of diversity and addressing disparities. This has resulted in higher levels of tension between mainstream and minority populations. However, minority youth continue to experience the chronic consequences of historical trauma (unemployment, incarceration, community violence). Methods: The history of historical trauma for underserved minority groups is reviewed. The recent context of socioeconomic stress and its impact on already stressed communities is presented, both for minority and white ethnic populations, as well as ways recent violent incidents have served to reactivate historical trauma. The beneficial role of agency in addressing the impact of personal and historical trauma is then discussed, as well as the evidence behind this approach. Results: The current youth movements (Black Lives Matter, Latino Dreamers, the Resistance) can be seen as “agentistic” movements. They offer youth an opportunity to develop an agency in the midst of an adverse climate and find proactive personal and societal solutions to continuing adversities that result from historical trauma. Youth agency is an adaptive, constructive approach for self-advocacy, which has evidence in addressing adverse health and mental health consequences. In addition to the benefits from agentistic movements, the risks of backlash to strident protests and of not reaching out to other disenfranchised populations (such as rural white youth) are discussed. Conclusions: Child and adolescent psychiatrists should be sensitive to the adverse impact of historical trauma and their current manifestations, incorporate validating and agentistic approaches to address the impact of historical cultural trauma, and support participation by diverse youth in proactive social movements.

ETHN, OTH, SP http://dx.doi.org/10.1016/j.jaac.2017.07.297

51.2 HOW AN UNDERSTANDING OF TRAUMA AND THE IMPLEMENTATION OF TRAUMAINFORMED CARE CAN ASSIST IN THE HEALING OF MEMBERS OF LAW ENFORCEMENT AND ADVANCE COMMUNITY POLICING Robert K. Reed, JD, Department of Justice, Robert.Reed2@ usdoj.gov Objectives: The goal of this session is to discuss the impact of traumatic experiences on the work of law enforcement and criminal justice (LECJ) professionals. Methods: The day-to-day exposure to crime and violence impacts members of law enforcement as it does the community they serve. Members of LECJ—police, probation, parole, and corrections—are no less immune from trauma than members of the armed forces. Yet, until recently, most of these LECJ officials had little or no understanding of what trauma is and the impact that their work has on their emotional and mental health. In Philadelphia, members of the health community and law enforcement have partnered to create and implement training programs to educate law enforcement about how their jobs impact their health and undermine their ability to effectively serve. These types of training reveal, not surprisingly, that some members of law enforcement actually suffer from PTSD and that others suffer from elevated levels of stress that impact their lives and their ability to serve the public effectively. These types of training and their results will be described. Results: The training also provides an opportunity to bridge the huge chasm of misunderstanding and mistrust that exists between law enforcement and the communities they serve by allowing both to gain an understanding (empathy) of the experiences and challenges of the other. It follows that such efforts should substantially enhance existing community-policing strategies. A review of various programs that have been implemented to enhance

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relationships between the LECJ and diverse community members of all kinds will be presented. Conclusions: It may be said that the relationship between police departments and the African American and Latino communities requires substantial improvement. One answer to changing the current dynamic is to have authentic dialogue about the issues facing police who work in high-crime communities and the community members.

JJS, OTH, SP http://dx.doi.org/10.1016/j.jaac.2017.07.298

51.3 RECOMMENDATIONS AND PATHWAYS FOR HEALING Jonathan J. Shepherd, MD, Black Mental Health Alliance, Inc., [email protected] Objectives: The participant will explore various solutions that can promote healing among the members of the groups affected by micro- and macroaggressions. From these recommendations, the child and adolescent psychiatrist may choose to implement them in his/her practice. Microaggressions, or routine slights, can trigger psychological stress, distress, and trauma. “It’s not the incident that causes stress, distress, or trauma; it’s the helplessness in the face of the incident.” One of the most common coping mechanisms is anger, which fuels riots, vandalism, and other destructive behaviors. Other more adaptive coping methods include prayer, peaceful protests, and increasing the awareness and understanding of the forces behind the insults and injuries. Methods: The presenter will share various recommendations, ideas, and instituted programs that have been implemented in communities with some measure of success. Two examples are the Baltimore Rising: Summoning the Village-Call to Action Educational series, which is a monthly forum, and Emotional Emancipation Circles, which are more frequent support groups organized by local leaders. Both of these groups help the community manage traumatic experiences. Results: The participant will learn about selected programs, techniques, and coping mechanisms that promote healing within damaged communities. Conclusions: The child and adolescent psychiatrist will be able to use these recommendations in his/her practice or advocacy, thereby impacting the surrounding community.

ETHN, SP, STRESS http://dx.doi.org/10.1016/j.jaac.2017.07.299

51.4 UNCONSCIOUS BIAS, MICROAGGRESSIONS, AND HEALTH Cheryl S. Al-Mateen, MD, Virginia Commonwealth University School of Medicine, [email protected] Objectives: At the conclusion of this activity, participants will 1) discuss the impact of unconscious bias in patient care; 2) discuss the relationship between racism, unconscious bias, and microaggression; and 3) understand the relationship between microaggressions, mental health, and mental health disparities. Methods: A microaggression is a “brief and commonplace daily verbal, behavioral, and environmental indignity, whether intentional or unintentional, that communicates hostile, derogatory, or negative racial slights and insults to the target person or group.” As human beings, we all have unconscious attitudes or implicit cognitions, which are shaped by life experiences and may be favorable or unfavorable. At times, our implicit beliefs may not be the same as those explicitly endorsed. The social psychology literature suggests that implicit biases impact physician– patient communication. The psychiatrist or mental health professional may have negative thoughts or feelings that are explicitly rejected in relation to a patient’s race, ethnicity, gender, sexual orientation, or other

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characteristics that may impact diagnosis and treatment. These unconscious biases may be expressed through microaggressions, which negatively impact the clinician–patient relationship (from both perspectives). Long-term exposure to racial microaggressions have been related to increased rates of heart disease, diabetes, hypertension, and use of illicit drugs and alcohol dependence. Social determinants of health are “conditions in the places where people live, learn, work, and play that affect a wide range of health risks and outcomes.” Microaggressions and recent events have had an impact on a variety of children, youth, and families, including an increase in hate crimes from 2014 to 2015. These numbers speak to the impact of social determinants. Results: This presentation will discuss the process of allopathic load and its implications for physical and mental health, providing examples of microaggressions and potential implications for practice for child and adolescent psychiatrists. Conclusions: The child and adolescent psychiatrist must be familiar with ways to assess this aspect of the patient and family’s life to develop an accurate understanding of psychosocial factors and needed interventions.

ETHN, SP, STRESS http://dx.doi.org/10.1016/j.jaac.2017.07.300

CLINICAL PERSPECTIVES 52 MOODINESS IN ADOLESCENTS AND ADULTS WITH ATTENTION-DEFICIT/HYPERACTIVITY DISORDER: STRATEGIES FOR ASSESSMENT AND TREATMENT W. Burleson Daviss, MD, Dartmouth College Geisel School of Medicine and Dartmouth-Hitchcock Medical Center, william. [email protected]; Boris Birmaher, MD, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, [email protected] Objectives: Participants will learn practical strategies for accurately assessing various psychiatric causes of moodiness/irritability in childhood ADHD, including comorbid autism spectrum disorder (Dr. McLaren), anxiety and obsessive-compulsive disorder (Dr. Spaniardi), PTSD (Dr. Daviss), and disruptive behavioral disorders, including oppositional defiant, conduct, and disruptive mood dysregulation disorders (Dr. Blader). Participants will also learn potentially effective strategies for pharmacological and psychosocial treatments of such mood and behavioral problems in children with ADHD. Methods: Each of the above speakers will review practical ways to assess such children, including interview tips and use of rating scales. They will also summarize the literature regarding pharmacological and psychosocial treatments for these comorbid mood problems, including recommendations from consensus panels of experts when available. Handouts of the PowerPoint slides and other helpful materials will also be made available to participants online. Dr. John Walkup, an internationally recognized child and adolescent psychiatrist researcher, will serve as a Discussant, highlighting key points of the other presenters and their potential relevance to clinicians and clinical researchers alike. Results: Through these presentations and the subsequent discussions and period of questions and answers, participants will improve their working knowledge of how to assess and treat these various types of mood problems in children with ADHD. Conclusions: Attendees of this clinical presentation will feel more capable in diagnosing and treating young patients with ADHD with these comorbid mood and behavioral problems and be aware of the knowledge gaps in field that will necessitate future research.

ADHD, IMD, SUD http://dx.doi.org/10.1016/j.jaac.2017.07.774

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52.1 DEPRESSIVE DISORDERS IN ADOLESCENTS WITH ATTENTION-DEFICIT/HYPERACTIVITY DISORDER: STRATEGIES FOR ASSESSMENT AND TREATMENT W. Burleson Daviss, MD, Dartmouth College Geisel School of Medicine and Dartmouth-Hitchcock Medical Center, william. [email protected] Objectives: Participants will learn practical and empirically supported strategies when available for accurately assessing depressive disorders among their moody patients with ADHD. Participants will also learn ways to improve their pharmacological and psychosocial treatments of such comorbid problems in their patients with ADHD. Methods: Dr. Daviss will review the potential risk factors and strategies for assessing comorbid depression in patients with ADHD. He will also summarize the literature that supports pharmacological and psychosocial treatments for comorbid depression, including recommendations from a consensus panel of experts. Case presentations, handouts, and other potentially helpful materials, such as rating scales and treatment algorithms, will be provided to participants and reviewed during the presentation. Results: Through this presentation and group discussion spurred by it, participants will improve their working knowledge of how to assess and treat such depressive disorders occurring in youth with ADHD. Conclusions: Ultimately, participants will be more informed on how to diagnose and treat patients with ADHD who have comorbid mood problems in their clinical practice and identify continuing knowledge gaps in our field that necessitate further research.

ADHD, DDD, IMD

longitudinal outcomes, and future studies evaluating possible preventative strategies for youth with ADHD and at high risk for BD are indicated.

ADHD, BD, IMD http://dx.doi.org/10.1016/j.jaac.2017.07.776

52.3 ATTENTION-DEFICIT/HYPERACTIVITY DISORDER, SUBSTANCE USE DISORDERS, AND MOOD Oscar Gary Bukstein, MD, MPH, Boston Children’s Hospital, [email protected] Objectives: Participants will learn about the relationship between ADHD and substance use disorders (SUDs) in adolescents and young adults, with an emphasis on co- or preexisting mood disorders and the evidence base supporting assessment and treatment of these comorbid disorders. Methods: Literature review and case examples will be used. Results: Participants will 1) understand the risk for the development of SUDs in youth with ADHD and mood problems; 2) understand elements of screening and assessment in such youth; and 3) be able to identify principles of intervention and the evidence-based specific treatment modalities in this comorbid population. Conclusions: Pre- and coexisting ADHD and mood problems may have a substantial influence in the development and course of substance use disorders and require special consideration in formulation of an effective treatment plan.

ADHD, IMD, SUD http://dx.doi.org/10.1016/j.jaac.2017.07.777


52.2 PEDIATRIC BIPOLAR DISORDERS AND ATTENTION-DEFICIT/HYPERACTIVITY DISORDER

52.4 MOOD DYSREGULATION AND MOOD DISORDERS IN ADULT ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER

Rasim Somer Diler, MD, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, dilerrs@ yahoo.com

Lenard Adler, MD, New York University School of Medicine, [email protected]; Michael J. Silverstein, BA, New York University School of Medicine, [email protected]

Objectives: Studies identified significant comorbidity of ADHD in youth with bipolar disorder (BD). Early recognition and treatment of mania is of vital importance to ameliorate ongoing syndromal and subsyndromal symptomatology and to reduce psychosocial morbidity and risk for suicide. We aim to characterize a clinical picture of manic presentations and longitudinal course in youth with ADHD that can help improve correct diagnoses and treatment interventions. Methods: Clinical characteristics of mania and depression in youth with BD and without ADHD and longitudinal trajectories of ADHD and BD will be reviewed. Baseline and repeated assessments at inpatient and outpatient settings will be reviewed, focusing on symptoms that help improve discriminating BD. Results: Recent studies have shown that BD is mainly manifested by recovery and recurrences, but ongoing fluctuating mood symptomatology, especially subsyndromal depressive and mixed symptoms, is also very common. Clinicians must be cautious about attributing symptoms to mania or hypomania unless they show a clear temporal association with the abnormally elevated, expansive, and/or irritable mood (plus increased activity/energy levels). The requirement of change in energy/activity levels in the DSM-5 for diagnosis of mania has important clinical implications in youth with ADHD. Symptoms of irritability, inattentiveness, and hyperactivity should be carefully assessed, with longitudinal follow-up to ascertain whether these symptoms are indeed manifestations of BD (e.g., clustering of other manic symptoms, change from baseline, and functional impairment). Presence of ADHD in youth with bipolar spectrum disorders is associated with worse mood swings during follow-up. Treatment of ADHD may benefit from stimulants after stabilizing the mood first. Conclusions: Careful clinical assessment can help improve identification of BD in youth with ADHD, which has significant treatment implications. We know very little about mixed mood presentations and medication effect on

Objectives: This talk will review the clinical significance of symptoms of mood (emotional) dysregulation versus frank co-occurring mood disorders in adults with ADHD and examine evidence for the potential treatment of co-occurring mood disorders or symptoms of emotional dysregulation in adults with ADHD. Methods: Studies on co-occurring mood disorders and emotional dysregulation symptoms in adults with ADHD were surveyed and reviewed via PubMed search and cross-referencing from review articles/chapters. Results: Mood dysregulation has been shown to be a commonly occurring symptom in adults with ADHD and exists as a separate, unique factor compared with symptoms of inattention, hyperactivity/impulsivity, and executive dysfunction. The same factor analysis found that emotional dysregulation symptoms loaded highly on the combined subtype of ADHD or in cases that did not meet full ADHD criteria. Treatment studies have found that emotional dysregulation symptoms do generally respond to treatment with stimulants or with the nonstimulant, atomoxetine, but at approximately half the effect size of stimulants. Studies have shown high rates of mood disorders of bipolar disorder (10–15%), major depression (15–20%), and dysthymia (20%) in adults with ADHD. Furthermore, rates of ADHD are quite high in individuals with mood disorders. The available literature on treating ADHD and comorbid mood disorders is surprisingly scant. Bupropion has an extensive history of use as an antidepressant, and several studies have shown it to be an effective nonstimulant in ADHD, but studies have not systematically assessed its use when mood disorders or mood dysregulation co-occur with ADHD. A handful of studies have examined the addition of stimulant medications to patients with major depression treated with antidepressants. Conclusions: Clinicians should be aware of high rates of co-occurring mood disorders in adults with ADHD, and the reverse, as not identifying one of the comorbidities may result in incomplete treatment or negative outcomes. High


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rates of mood dysregulation symptoms have been reported in adults with ADHD, even though they are not part of the core ADHD symptoms in DSM-5.

ADHD, CM, IMD http://dx.doi.org/10.1016/j.jaac.2017.07.778

Conclusions: Providing education to clinicians about alcohol use among college students will increase awareness of these disorders, which is crucial to leading a pathway for patient recovery.

ALC, COLST, SUD http://dx.doi.org/10.1016/j.jaac.2017.07.304

CLINICAL PERSPECTIVES 53 RISKY BUSINESS: CLINICAL MANAGEMENT OF PROBLEMATIC SUBSTANCE USE IN COLLEGE-AGED YOUTH Scott Krakower, DO, Northwell Health - Zucker Hillside Hospital - Long Island Jewish Medical Center, skrakowe@ northwell.edu Objectives: There have been rising concerns of substance abuse in the college-aged population. Substance use disorders have been associated with risky behaviors, academic difficulties, and legal dilemmas. Providers often have limited resources and may be challenged with how to treat these conditions. In this presentation, participants will be 1) educated on the common features of substance use disorders in the college-aged population; 2) understand how to effectively screen for substance abuse; and 3) learn effective strategies to help treat these conditions. Methods: Evidence-based literature will be reviewed on prevention, diagnosis, and treatment of substance use disorders. Practical applications to the college-aged population will be reviewed. Results: Upon completing this clinical review, participants will be able to effectively screen, diagnosis, and treat these disorders in the college-aged population and describe unique challenges in providing treatment to them on college campuses. Conclusions: Clinicians are faced with complex challenges when treating substance use disorders in the college-aged population. Through education and awareness of the conditions, clinicians can be better equipped on how to effectively manage them.

COLST, SUD Sponsored by AACAP's Substance Use Committee http://dx.doi.org/10.1016/j.jaac.2017.07.303

53.1 MANAGING ALCOHOL ABUSE IN COLLEGEAGED YOUTH Scott Krakower, DO, Northwell Health - Zucker Hillside Hospital - Long Island Jewish Medical Center, skrakowe@ northwell.edu Objectives: Alcohol use on college campuses places students at increased risk for dangerous behaviors and may have academic, medical, and legal consequences. It is critical to address this dilemma on college campuses. In this presentation, participants will 1) learn about the prevalence of alcohol on college campuses; 2) be presented with effective screening tools to identify high-risk individuals; and 3) understand specific treatments to help this population. Methods: Participants will receive a broad overview of alcohol use disorders and their impact on college campuses. The audience will be provided with effective tools to treat these conditions. Clinicians will be given case examples to apply this clinically. Results: Students have expressed a variety of reasons for drinking alcohol, such as decreasing inhibition and improving social relationships. They may be less motivated to seek help for their drinking and may not recognize that they have a drinking problem. Despite efforts to control binge drinking on college campuses, statistics relatively remain unchanged. Additionally, a large number of students continue to engage in heavy drinking. Through effective environmental and individual strategies, providers may be able to address these problems on college campuses. Upon completion of this lecture, participants will become familiar with these disorders and learn ways to evoke change.

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53.2 CANNABIS USE AMONGST COLLEGE-AGED STUDENTS Kara Simone Bagot, MD, University of California, San Diego, [email protected] Objectives: Recent data demonstrate decreased perception of harm and increased cannabis use among youth, especially among those residing in states that have enacted medical and recreational marijuana use laws. Given this finding and support of current government initiatives highlighting the reduction of adolescent substance use as a priority, it is of great importance to address cannabis use disorders in transitional aged youth. We aim to describe symptoms of, treatment for, and potential legal implications of cannabis use disorders. Methods: We review the literature for efficacy of cannabis use interventions in transitional aged youth and present data on the changing legal climate for cannabis use. Results: Randomized controlled trials of behavioral interventions for cannabis use in youth demonstrate moderate effect sizes post treatment, with few maintaining abstinence through follow-up. Data on use of technology-based interventions for secondary and tertiary prevention among college aged populations appear promising and warrant further study. Although there are no FDA-approved medications for cannabis use disorders, promising data exist for the use of cannabinoid 1 receptor agonist medications and medications that modulate alternate neurotransmitter systems. There are significant challenges in regulation of alternate forms of cannabis, such as edibles and other high-potency formulations, and cannabis legalization can have economic as well individual and public health effects. Conclusions: Study of treatment interventions aimed at reduction or cessation of cannabis use in youth range from rigorous psychotherapeutic treatment trials to novel, emerging strategies with less robust evidence such as mobile health and pharmacotherapeutic interventions. Efficacious treatment modalities have become of greater concern with increasing legalization of cannabis.

COLST, SUD, TREAT http://dx.doi.org/10.1016/j.jaac.2017.07.305

53.3 DEALING WITH THE OPIOID EPIDEMIC IN COLLEGE STUDENTS Patrice Malone, MD, Columbia University, College of Physicians and Surgeons and the New York State Psychiatric Institute, [email protected] Objectives: The use of opiates by college students has risen dramatically over the past two decades, resulting in increased accidental overdose among other things; thus making the quest for identifying strategies to address this public health crisis essential. For this presentation, we aim to explore the prevalence, risk factors, and interventions for college students suffering from opiate use disorders. Methods: This presentation provides a comprehensive review of the literature focusing on the rise of opiate use among college students, challenges in treating this population, and possible interventions. Results: Between 1993 and 2005, the use of certain prescription opioids (e.g., Vicodin, Oxycontin, and Percocet) among colleges students increased by 343 percent. One in every four colleges or universities has an annual prevalence of 10 percent or higher for prescription opioid use. It has been found that college students who engage in nonmedical use of prescription opiates are more likely to use other drugs, engage in other risky behaviors, and put themselves at risk for unintentional overdose. Studies show that

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nonmedical use of prescription opioid analgesics was higher among college students who were white and residents of fraternity/sorority houses and offcampus houses, had lower grade-point averages, and attended more competitive colleges. Because of the aforementioned risk factors, a more recent trend on college campuses is the creation of substance-free housing; however, there are no data to support the efficacy of such initiatives. The psychopharmacological treatment of college-age individuals with opiate use disorder has proven challenging because of their high rates of dropout and relapse. Conclusions: Nonmedical use of prescription opiates is second only to marijuana as the most common form of drug use among college students in the United States and is associated with lower school performance and increased risky behavior. Therefore, it is essential to continue developing prevention and treatment strategies aimed at reducing prescription drug abuse and possible escalation to more dangerous forms of opiates (i.e., heroin), which increases morbidity and mortality.

COLST, OTH, SUD http://dx.doi.org/10.1016/j.jaac.2017.07.306

53.4 PRESCRIPTION STIMULANT ABUSE ON COLLEGE CAMPUSES David Louis Atkinson, MD, University of Texas Southwestern Medical Center, [email protected] Objectives: The goals of this session are to inform readers of the extent of stimulant abuse on college campuses, identify individuals at particular risk for diversion, and discuss strategies for mitigation of the problem. Methods: We will review the literature regarding stimulants and describe how they have been effective in individuals with ADHD. We will review the neurobiology of ADHD and discuss the handful of studies that have examined diversion and misuse in the college-aged population. Results: Stimulant medications are the most effective forms of pharmacologic treatment for any psychiatric disorder, and they are the gold standard for ADHD treatment. Stimulant abuse is very common in the college-aged population, with the rate being a surprising 17 percent of college students. Individuals who belong to Greek organizations; students who have problems with alcohol, cannabis, and other drugs; and individuals who are desiring academic enhancement are at risk for diversion. There is a strong indication that the effects on individuals with ADHD may be sustainable over time, in part, because they normalize brain structures. In an individual without ADHD, there is concern that the medications may have initial beneficial effects but trigger long-term brain adaptations to down-regulate monoamine transmission in the brain. Conclusions: Stimulant diversion is commonly associated with substance use and may indicate a decline in academic performance as opposed to the desired improvement in academic outcomes. There needs to be more research on the effect on eating disorders and the development of other psychiatric disorders. The prevalence of stimulant diversion affecting one of six college students indicates that this is a greatly under-researched topic.

AC, ADHD, STIM http://dx.doi.org/10.1016/j.jaac.2017.07.307

53.5 TREATING SEDATIVE AND BENZODIAZEPINE ABUSE IN COLLEGE STUDENTS Gregory Tau, MD, PhD, Columbia University and the New York State Psychiatric Institute, [email protected] Objectives: Prescription benzodiazepines and sleep aids are available on college campuses through illicit means. Misuse of this class of prescription medications can quickly lead to substance use disorder and its dangerous sequelae. In this presentation, participants will 1) learn the epidemiology of problem sedative-hypnotic use on college campuses; 2) understand the ways that this class of prescription medication is used alone and in combination with other substances; 3) be given strategies to identify and assess


high-risk individuals; and 4) understand specific treatment approaches to population. Methods: The epidemiology and clinical literature on sedative-hypnotic use in transitional youth will be reviewed. This will include the literature on the use of sedative-hypnotics in combination with other substances and problem sedative-hypnotic use in individuals with psychiatric comorbidities. Results: Benzodiazepines are coveted by a population of college-aged transitional youth, which sustains a black market for diverted prescriptions and “street press” or home-made benzodiazepine tablets. Specific jargon has been developed to describe the medications and their use. College students may use these substances to alleviate stress or anxiety, experience euphoria, enhance or alter the intoxicating effects of other substances, or treat withdrawal symptoms from other drugs of abuse. Benzodiazepine misuse alone, and especially in combination, can easily lead to morbidity, which includes accidents, victimization, and extreme sedation leading to emergency department visits. Nevertheless, the dangers of illicit use of this class of medications are minimized by college students, and because benzodiazepines are reinforcing drugs, their use persists despite repeated untoward sequelae. Conclusions: Although sedative-hypnotic use disorder is not one of the most common addictive problems in college-aged transitional youth, it is one that is associated with higher morbidity and mortality than most. Furthermore, benzodiazepine-involved students are particularly challenging for treatment because their illness is more severe than their peers. It is crucial for child and adolescent psychiatrists to be familiar with the nature of this substance use disorder on college campuses and be able to identify, assess, engage, and treat this vulnerable and challenging population.

AXX, COLST, SUD http://dx.doi.org/10.1016/j.jaac.2017.07.308

CLINICAL PERSPECTIVES 54 SEXTING AND SOCIAL MEDIA: RISK-TAKING BEHAVIOR IN THE 21ST CENTURY Corinne R. Catarozoli, PhD, NewYork-Presbyterian/Weill Cornell Medical Center, [email protected]; Renae Beaumont, PhD, University of Queensland, [email protected] Objectives: This Clinical Perspectives panel aims to describe various approaches to conceptualizing sexting and risky social media use in adolescents, as well as provide practical guidelines for clinicians on how to manage these behaviors. Methods: Four different Clinical Perspectives for the conceptualization of and approach to teenage sexting and risky social media use will be presented and discussed. An emphasis will be placed on understanding sexting in the context of the current digital environment and distinguishing behaviors associated with normative sexual development from those that pose greater risk and warrant clinical intervention. Results: Hayley McMahon will describe the prevalence, correlates, and outcomes associated with sexting, as well as various motivations and functions it serves. Jacqueline Nesi will provide a broad overview of social media features, ways that these features differ from traditional communication and thus impact teen interactions, peer influence, and sexual risktaking behavior. Dr. Theodore Shapiro will comment on sexting from a developmental perspective and discuss how it relates to teenage sexual development. Dr. Jodi Gold will speak about parent involvement in monitoring and safeguarding teenagers’ social media use and practical tips and strategies for parents and providers. The presentations will be followed by a discussion led by Dr. Renae Beaumont to summarize, compare, and contrast the perspectives offered by panelists and promote further discussion on teenage sexting and when and how to intervene clinically. Conclusions: Sexting is a prevalent behavior that poses significant consequences for teenage development. Clinicians and parents play an important

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role in helping teenagers to mitigate the risks associated with this normative adolescent behavior.

ADOL, MED, COMP http://dx.doi.org/10.1016/j.jaac.2017.07.310

54.1 TEEN SEXTING: WHAT WE KNOW Hayley McMahon, MRCPsych, University of Queensland, [email protected]; Kim Halford, PhD, University of Queensland, [email protected]; Fiona Barlow, PhD, University of Queensland, f.barlow@psy. uq.edu; Brendan Zietsch, PhD, University of Queensland, [email protected] Objectives: This presentation topic will provide an overview of current research-informed knowledge regarding adolescent sexting, including prevalence, correlates, motivations, and associated outcomes. Methods: An applied literature review will be presented, incorporating both quantitative and qualitative research. Four studies that have been conducted by the authors will also be referenced, which investigated qualitative perspectives on sexting, the relationship between sexting behaviors and couple relationship qualities, and gender differences in how sexts and sexters are evaluated. Results: Sexting is a common (with prevalence rates ranging 4–35%), yet varied behavior, with many potential positive and negative outcomes. Sexting is often used for showing and/or developing romantic and/or sexual interest and has links with positive relationship qualities, including sexual satisfaction and positive sexual communication, yet it can also facilitate victimization through nonconsensual participation and/or sharing of messages. Adolescent sexting has been linked with risk-taking behaviors (such as problematic alcohol use and unprotected sex) and psychological distress. However, as most sexting research is correlational, caution is warranted when drawing conclusions about how sexting relates to other constructs. Gender seems to influence teenage attitudes about sexting, as well as participation in, response to, and consequences of sexting, with women experiencing more victim blaming if messages are released. Conclusions: Sexting is common among adolescents, with varying motivations, functions, and outcomes. It is important for clinicians who are working with adolescents to be aware that consensual sexting is a potentially normal process in adolescent sexual development. Recommendations on how clinicians can help teenagers to be mindful of and safeguard themselves against the risks associated with sexting will be briefly discussed, focusing on a harm minimization approach.

ADOL, COMP, MED http://dx.doi.org/10.1016/j.jaac.2017.07.311

54.2 SOCIAL MEDIA AS A UNIQUE CONTEXT FOR ADOLESCENT SEXUAL BEHAVIOR Jacqueline L. Nesi, MA, University of North Carolina, nesi@ email.unc.edu Objectives: Social media provides a novel context for adolescents’ social interactions and risk behavior engagement. Recent statistics suggest that 92 percent of adolescents go online daily, 89 percent belong to at least one social networking site, and at least 88 percent engage in text messaging. Indeed, many adolescents report that most of their social interactions take place via social media, rather than in person. Given the proliferation of social media and text messaging among adolescents, it is critical to examine the ways in which this environment differs from traditional social contexts. This presentation will provide an overview of the features that define social media as a discrete context and will discuss the implications of these features for adolescents’ engagement in sexual risk behaviors, both online and offline. Methods: Findings from relevant theoretical and empirical work will be reviewed and summarized. Results: Drawing on prior work from computer-mediated communication, media effects, and developmental psychology fields, we present numerous

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features of social media that are important to understanding this digital environment. Key features include the following: 1) permanence or the length of time that content remains accessible; 2) publicness or the degree to which content is accessible to large audiences; 3) availability or the ease and speed with which content can be accessed and shared; 4) cue presence or the degree to which interpersonal cues are available; and 5) visualness or the extent to which photos and videos are emphasized. These features may have a transformative impact on traditional interpersonal processes, including peer influence and social status, which play a role in adolescents’ sexual behavior. “Sexting” and its associated risks, for example, may result from the disinhibiting effect of reduced cue presence, the permanence with which images remain available, and the speed with which content may be shared. Conclusions: Adolescents’ social environments play a key role in their sexual decision making and behavior. Social media represents a novel context with features that may transform the ways these behaviors occur.


54.3 DEVELOPMENTAL CONSIDERATIONS OF SEXTING Theodore Shapiro, MD, NewYork-Presbyterian/Weill Cornell Medical Center, [email protected] Objectives: This presentation will comment on sexting from a developmental perspective, including how it relates to adolescent sexuality and sexual identity development. An additional aim is to determine how cyber-communication helps and hinders the integration of fantasies of sexual desire and the need for intimacy that Erikson describes as a goal of adolescent maturation. Historically documented conditions of Madonna–Prostitute and love–desire splits will be revisited. Methods: A review of the historical use of various media in preparing adolescents for mature sexuality will be presented. Traditional media such as the novel, pornography, and sexually explicit magazines will be explored as they relate to masturbation fantasies to discover differences from cyber-communication in their effect on later mature aims. Results: Nonsystematic clinical data will be used to validate effects on development of adolescents’ capacity to engage sexually and feel intimacy and identify a threshold for determining what can be considered normative teenage sexual exploration versus potentially dangerous and pathological behavior. Conclusions: As technology progressed, electronic media has increasingly become the platform used to explore sexuality not only through passive consumption of sexual content but also through the active creation, exchange, and participation in it. Clinicians should be aware of the psychological functions served by sexting, photo sharing, and other risky social media use, including anxiety tolerance, cultivation of desire, and sexual splitting.


54.4 MANAGING TEEN TECHNOLOGY USE: TECH-SAVVY TIPS FOR PARENTS AND PROVIDERS Jodi Gold, MD, NewYork-Presbyterian/Weill Cornell Medical Center, [email protected] Objectives: Technology is changing the way teenagers communicate, socialize, express themselves, date, and attend school. In 2017, kids are spending more time on devices than ever before, and parents face new and constantly evolving challenges of how to best manage this technology. Children now also develop their identity and sense of self both offline and online. Clinicians and parents must move away from restricting and setting time limits and move toward embracing the digital world as another platform where children grow up. The existing research offers very limited assistance in charting a course for the future. Methods: Data gathered through hundreds of interviews for Dr. Gold’s recently published book, Screen Smart Parenting: How to Find Balance and

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Benefit in Your Child’s Use of Social Media, Apps and Digital Devices, will be presented to provide an overview of the research and the digital landscape. Results: We provide recommendations on how to ensure that children use the digital world in an age-appropriate way. Only a few evidence-based conclusions can be made about healthy use. Parent screen time directly affects child screen time, and parents who are “media mentors” and who engage with their children are more effective than restrictors at cultivating healthy outcomes. The research consistently demonstrates that selective self-presentation can lead to greater self-esteem. There is a pattern that the “rich get richer” in the social and emotional world of digital technology. Unfortunately, the opposite is true as well. Adolescents who seek excessive reassurance online or postprovocatively to get “friends” and attention are more vulnerable to rejection, bullying, and worsening depression. Conclusions: The goal in parenting through the digital era is to cultivate digital citizenship and online resilience and to encourage strong identity development. Clinicians should assess their patient’s relationship with digital technology and guide parents in managing it at home by encouraging them to co-engage with their children and have frank conversations about privacy, friendship, body image, addiction, and healthy sexuality online and offline.


CLINICAL PERSPECTIVES 55 SOCIAL MEDIA USE IN DISASTER RESPONSE: WHAT HELPS AND WHAT HARMS Manuel D. Reich, DO, Private Practice, dr.manuel.reich@ gmail.com; Frederick J. Stoddard, Jr., MD, Massachusetts General Hospital, [email protected] Objectives: The goals of this session are as follows: 1) to learn how social media impacts the public and professionals during and after a disaster; 2) to learn how social media is used during a major disaster response in the context of recent disasters; 3) to learn what social media has been able to accomplish in positive and negative ways in recent disaster response; and 4) to appreciate the impact of social media on families and children affected by disaster, directly as consumers but also indirectly through disaster responders who use social media as a tool in their work. Methods: Didactic presentations are given by child and adolescent psychiatrists involved in disaster response work, as well as from an experienced disaster systems administrator on the subject of social media and its uses in disaster work. Results: Attendees will be apprised of the latest applications of social media in disaster mental health work with families and children affected by disasters. Conclusions: Social media has tremendous potential for benefit in rapid disaster response to communities who are impacted; however, it can also further create distress. Recommendations will be made for child and adolescent psychiatrists based on lessons learned from a variety of described experiences.

QA, MED, DS Sponsored by AACAP's Disaster and Trauma Issues Committee http://dx.doi.org/10.1016/j.jaac.2017.07.316

55.1 SOCIAL MEDIA AND DISASTERS: A LITERATURE REVIEW Ranjan Avasthi, MD, Morehouse School of Medicine, [email protected] Objectives: In this session, the participant will learn via an events-based disaster review about the impact of social media on emergency response, expression of public sentiments around peri-disaster experiences, and mental health effects on both survivors and responders engaging in social media use during disasters. Methods: The presenter will provide a review of the existing literature regarding social media and disasters, including organizational, consumer, and research perspectives.


Results: The audience will be better informed on the wide range of social media uses before, during, and after disaster events and the effects that social media had on responders, families, and children. Conclusions: Social media allows for a variety of basic and more complex tasks and experiences around disaster work and disaster survival.

COPI, DS, MED http://dx.doi.org/10.1016/j.jaac.2017.07.317

55.2 THE PHYSICIAN VOLUNTEER’S EXPERIENCE WITH SOCIAL MEDIA IN DISASTER RESPONSE WITH HURRICANE MATTHEW AND THE 2016 FLOODS IN BATON ROUGE Allan K. Chrisman, MD, Duke University School of Medicine, [email protected] Objectives: This presentation instructs the participant on how large organizations apply social media to disaster response efforts. The participant will also be educated on the various types of social media presence encountered during recent disaster events. Methods: Dr. Chrisman will present his experiences as a physician volunteer with the American Red Cross (ARC) when deployed to assist with the 2016 floods in Baton Rouge, Louisiana, as well as with Hurricane Matthew in North Carolina. Results: The audience will learn about the variety of ways that social media is used in monitoring, public health messaging, and notification of up-to-date developments of hazards and resources. Conclusions: Large organizations, such as the ARC, have developed a wide array of social media applications in disaster response, and responders, as well as survivors, will need to know about these developments.

DS, MED, STRESS http://dx.doi.org/10.1016/j.jaac.2017.07.318

55.3 DISASTER RESPONSE: SOCIAL MEDIA AS A MECHANISM TO FOSTER RESILIENCY Heather M. Hilliard, MBA, R. Roan Enterprises, LLC, heather. [email protected] Objectives: The speaker will discuss the different ways in which social media impacts the public and professionals during different phases of disasters using the emergency management disaster cycle framework via event-based review of social media’s impact on emergency response. She will illustrate how resilience and repeated traumatization can been seen among responders, as well as the communities they serve. Review of social media accomplishments in positive and negative ways will show success metrics and strategic messaging tactics with social media’s user demographics (Facebook, Twitter, Snapchat) that promote assistance rather than disaster tourism. Methods: Speaker Ms. Heather Hilliard, a Certified Emergency Manager and Adjunct Professor of homeland security at Tulane University Department of Emergency and Security Studies, will review the emergency management cycle’s incident-related stressors. She will describe actual examples of what works in various disaster situations (depending on the social media’s user demographics of particularly high-index platforms, such as Facebook, Twitter, Snapchat) to promote assistance rather than disaster tourism. The nuances of local first responders versus those who “self-deploy” to disaster areas will also be addressed. In addition, resiliency and vulnerability among community members who are impacted repeatedly by the barrage of information displayed by them or received by them through the various social media outlets will be addressed. Statistics on social media proliferation, application demographics, methodology of public information dissemination, rationale for social media accelerants, mobile news audiences, and variations with real-time live streaming versus prepared media releases will be reviewed. Results: Attendees will be apprised of the latest applications of social media in disaster mental health work with families and children affected by disasters.

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Conclusions: After attending this perspectives session, participants will be able to more effectively select self-monitored social media outlets for appropriate information dissemination before, during, and after large-scale, high-profile events.

DS, MED, QA http://dx.doi.org/10.1016/j.jaac.2017.07.319

CLINICAL PERSPECTIVES 56 A TALE OF TWO DEPARTMENTS: HOW IMPLICIT BIAS DIVIDES US AND CAN UNITE US Anita Kishore, MD, Stanford University, anitaRkishore@gmail. com; Melissa A. Silverman, MD, Stanford University, silver77@ stanford.edu; Shirley D. Alleyne, MBBS, University of Florida, [email protected]fl.edu; Marilyn B. Benoit, MD, Devereux Advanced Behavioral Health, [email protected]; John Leikauf, MD, Stanford University, [email protected]; Andr es Martin, MD, MPH, Yale Child Study Center, andres. [email protected]; Linda C. Mayes, MD, Yale Child Study Center, [email protected]; Susan Milam Miller, MD, Sonoma County Behavioral Health, susan.milam@ stanfordalumni.org; Marina Post, MD, Stanford University, [email protected]; Dorothy E. Stubbe, MD, Yale Child Study Center, [email protected]; Isheeta Zalpuri, MD, Stanford University, [email protected] Objectives: This presentation for all child and adolescent psychiatrists working within academic or other healthcare organizations will provide a primer in principles of implicit bias and bias interrupters that are directly applicable to attaining greater gender parity within child psychiatry. Gender equality at all faculty levels has long been a top priority for institutional leaders and visionaries, and yet, the percentage of women at higher faculty ranks continues to lag, which is striking given that women have comprised at least 40 percent of medical school classes over the past two decades, suggesting that the dearth of women leaders is not a “pipeline” problem. There have been enough women in medical school classes to translate to equal numbers at the top. Women physicians face barriers to career progression and are under-represented at senior levels. Although there have undoubtedly been a myriad of stubborn factors driving that persistent disparity, in this presentation, we will focus on implicit bias and bias interrupters, a burgeoning area of research. Methods: The program will begin with a summary of current research on the presence of implicit bias, with a focus on the studies that are most relevant to work in child psychiatry (20 min). The opening discussing will be followed by a panel discussion with four senior child psychiatrists (30 min), followed by four small working groups (30 min each) in which each facilitator will use vignettes to encourage participants to be thoughtful about how implicit bias may have impacted their own career development and then engage in a brainstorming activity regarding ideas that each individual could implement within their own workplace to interrupt such bias. We will conclude with a large group discussion to share ideas generated in each small group (10 min). Results: Participants will gain exposure to the principles of implicit bias and bias interrupters, specifically with regards to its impact on the careers of women and men in child psychiatry. Conclusions: Participants will learn advantages of a model in which decisions are made less reflexively with regard to increasing gender parity in child psychiatry, especially for the most senior positions in our field. Feedback from this interactive session will be used in planning future programs in this area, furthering AACAP’s mission to support gender equality in the field.

ADMIN, CAD, OTH Sponsored by AACAP's Diversity and Culture Committee and Training and Education Committee

CLINICAL PERSPECTIVES 57 GETTING CHILDREN TO ACCEPT LIMITS: DEVELOPMENTAL AND FAMILY PERSPECTIVES ON THE REGULATION OF BEHAVIOR AND EMOTION Allan Mark Josephson, MD, Bingham Clinic, University of Louisville, [email protected]; Martin J. Drell, MD, Louisiana State University School of Medicine, mdrell@ lsuhsc.edu Objectives: The disruptive, impulsive, noncompliant child is the most common problem encountered by child and adolescent psychiatrists. Although biological vulnerabilities are clearly in play, what often matters most is the shaping effects of early environments. The objective of this session is to explore different psychosocial aspects of dysregulation and offer solutions. Methods: Speakers will present relevant clinical research data, offer critiques of diagnostic methods, elaborate a nuanced perspective of developmental psychopathology, propose a comprehensive view of family intervention, and offer specific treatment insights for the younger child and the adolescent. Results: Dr. Kramer will describe the sciences of interaction, defined by gene environment interaction and brain environment interaction. The family is the environment that interacts with the genome and the brain. These sciences of interaction will be illustrated by a case example. Dr. Cook will describe a unique program that helps adolescents regulate their emotions through changes in their parents’ attitude, behavior, and demeanor. The session will include the offering of essential steps for parental and teenage skills building, with a practical emphasis on teaching these skills. Dr. Thompson will review the transactional processes of young children and caregivers in the development of behavioral and emotional regulation. Practical interventions are offered, considering the child’s temperament, the quality of primary relationships, and the caregiver’s ability to support the child’s regulation efforts. Dr. Josephson will describe emotional and behavioral dysregulation in the context of family function. He will offer a critique of current diagnostic practices and propose a diagnostic approach that incorporates an understanding of the how the family is the key-regulating principle for children. He offers a six-stage treatment model to illustrate how regulation takes place. Conclusions: Problems in a child’s regulation of behavior and emotions arise in the context of the family. The overarching goal of the clinician’s work is to equip families to raise children who can self-regulate.

FAM, PSP, DEV Sponsored by AACAP's Family Committee http://dx.doi.org/10.1016/j.jaac.2017.07.323

57.1 COMPREHENSIVE BIOLOGICAL TREATMENT: EMPLOYING THE SCIENCES OF INTERACTION IN THE REGULATION OF BEHAVIOR AND EMOTION Douglas A. Kramer, MD, MS, University of Wisconsin School of Medicine and Public Health, [email protected] Objectives: Developmental psychopathology and its treatment are dynamic processes occurring within the framework of normal development, as defined in the context of family, group, neighborhood, culture, religion, community, nation, and era. For example, behavior that is pathological in one developmental context might be resilient in another. Developmental psychopathology and its healing are impossible to discuss without significant attention to the context within which the child is developing—primarily the family in the early years. The “sciences of interaction” are likely to render specific DSM-5 diagnoses less relevant in favor of conditions that are defined


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by gene environment interaction (GxE), and brain environment interaction (BxE). Methods: I will briefly review the science behind epigenetics (modern definition) and nonlinear brain dynamics, the most well-known examples of GxE and BxE. These interactional processes are the biological foundation of developmental psychopathology and its corollary, developmentally mediated healing. Families and family delegates, purposeful and accidental, are the “environment” that interacts with the genome and the brain during the operation of the sciences of interaction. A reductionistic aspect to child psychiatric treatment (e.g., a focus on modifying the activity of a receptor site) must occur in the context of an overall comprehensive biological treatment (i.e., involving the biopsychosocial context within which treatment enhances development). Results: Case examples are described that illustrate ways to translate the sciences of interaction into clinical experience. These include the following: 1) the words used to educate parents and whole families on the developmental importance of family participation in treatment; 2) examples of how interactions involving dysregulated affect, dysregulated behavior, and power dynamics enter into treatment interactions; and 3) the integration of pharmacotherapy, individual psychotherapy, parent counseling, and family group relationship treatment into clinical practice. Conclusions: A child psychiatric treatment model is described based on the principles of family psychiatry.

DEV, FAM, FT http://dx.doi.org/10.1016/j.jaac.2017.07.324

57.2 HELPING TEENS REGULATE EMOTIONS AND BEHAVIOR BY HELPING THEIR PARENTS Mary N. Cook, MD, Empower Centers of Excellence in Family Behavioral Health, [email protected] Objectives: It is accepted that neglecting to involve parents in treatment is a recipe for failure. Yet many child and adolescent specialty behavioral programs have minimal parent participation. When parents are involved, there is a need for standardized treatments that target the special concerns of families. Methods: This presentation provides an overview of a novel, familybased program that effected rapid, positive changes across households. When even just one parent masters the ability to regulate emotions, resolve conflict, and assert themselves, there is a ripple effect in the family. The relationship-building strategies are inherently reinforcing to the parents who can drastically change a teenager’s attitude, behavior, and demeanor by changing their own. The essential steps for skills building include parent-, teenager-, and family-directed 1) psychoeducation; 2) tools and models; 3) expert demonstration; 4) family rehearsal; 5) family homework; and 6) trouble shooting. Effective novel program techniques include the following: 1) memorable acronyms and formulas; 2) before and after tests; 3) video; 4) peer mentoring; and 5) wallet-sized cards. Results: The program population ranged between ages 12 and 18 years and presented with a broad array of primary psychiatric diagnoses. The program was associated with a significant reduction in problems (P < 0.001) and improvement in functioning (P < 0.001), effectiveness (P < 0.001), and hopefulness (P < 0.001) on the Parent and Teen-rated Ohio Youth Scales. It demonstrated a high rate of retention (85 percent), along with favorable compliance; families attended an average of 87 percent of recommended sessions. Conclusions: The Transforming Teen Behavior program was developed to meet a growing need for best practice, family-based programs. The program was sustainable through third party collections and effective in serving a diagnostically broad patient population.

ADOL, DMDD, FAM http://dx.doi.org/10.1016/j.jaac.2017.07.325


57.3 EMOTIONAL AND BEHAVIORAL DYSREGULATION OF THE YOUNG CHILD Kym Spring Thompson, PsyD, Empower Centers of Excellence in Family Behavioral Health, kym@ empowerscenters.net Objectives: This presentation reviews the transactional process of young children and caregivers in the development of emotional regulation. Successful interventions require a relational approach that targets the child, the parent, and the relationship. Methods: Factors important to emotional regulation include a child’s temperament, the quality of primary relationships, and the caregiver’s ability to support the child’s regulation. Interventions target the child, the caregiver, and their relationship to promote the development of selfregulation. In “Power Kids,” parents are taught the importance of their own self-regulation and learn parenting and behavior management strategies appropriate for the young child’s developmental level. Children learn and practice strategies for emotion regulation within the context of their caregiving relationships. Such exercises encourage positive coregulation and attachment patterns. Coordinating with schools, pediatricians and other supports in the community help promote the use of the skills across settings. Results: Parents learn to internalize a developmentally appropriate perspective for their child’s behavior and a “tool box” for de-escalation. Parents learn to manage behavior while also fostering self-esteem, problem-solving, communication, and social skills. Children learn to calm themselves, identify and communicate feelings, and learn to make positive choices. Conclusions: Although this curriculum is in the program development stage, initial qualitative data showed that after its use parents endorsed improvements in their child’s self-regulation, developed increased confidence in their parenting, and improved the quality of their relationship with their child.

DEV, FAM, PSP http://dx.doi.org/10.1016/j.jaac.2017.07.326

57.4 BEYOND DIAGNOSIS: UNDERSTANDING THE FAMILY’S ROLE IN THE REGULATION OF EMOTION AND BEHAVIOR Allan Mark Josephson, MD, Bingham Clinic, University of Louisville, [email protected] Objectives: The most common problem encountered by child and adolescent psychiatrists is the disruptive, impulsive child who does not accept limits. DSM diagnostic statements of ADHD, ODD, conduct disorder (CD), and disruptive mood dysregulation disorder do not cover the essence of this problem. Dysregulation of affect and behavior is the core process cutting across each of these diagnoses. This presentation will review dysregulation not as a disease process but as a biologically influenced adaptation, embedded in family interactional experience. Methods: Dr. Josephson will draw on the conceptual work to look beyond a DSM diagnosis and see more than mere labels. Diseases, the dimensional/ developmental perspective, behavioral syndromes, and family beliefs all convey an element of diagnosis. This presentation will discuss the process of development associated with specific regulatory patterns, such as appropriate regulation (attunement); over-regulation; under-regulation, inappropriate regulation, irregular regulation, and chaotic regulation. These various interactional experiences, influenced by parental mental set and parental relationship, shape the mind of the child, and this cognitive template determines her capacity to self-regulate. Dr. Josephson will describe how these concepts of regulation are incorporated into a six-stage model of integrated individual and family psychotherapy. Results: Recognizing the processes of regulation equips the clinician to understand the developmental meaning of behavior, a core necessity for an effective case formulation. The child’s biological nature (e.g., temperament) requires regulation, and it is primarily the family that regulates the child’s

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emotions and behavior, giving rise to the development of cognitive schema. Children who do not have their basic needs met and those whose basic needs have been excessively met can both become entitled, full of rage, and dyscontrolled. Examples of these family constellations will be offered. Conclusions: Why can parents not set limits on out-of-control behavior and emotion? This presentation will attempt to answer this question through the delineation of family interaction, which gives rise to dyscontrol syndromes. Practical, nonpharmacologic solutions are offered.

FAM, FT, PSP http://dx.doi.org/10.1016/j.jaac.2017.07.327

CLINICAL PERSPECTIVES 58 GLOBAL PERSPECTIVES ON CHILD AND ADOLESCENT MENTAL HEALTH SERVICES Norbert Skokauskas, MD, PhD, Norwegian University of Science and Technology, [email protected]; Gregory K. Fritz, MD, Bradley Hasbro Children’s Research Center, [email protected] Objectives: The main objective of this session is to provide an overview of child and youth mental health services around the globe. An additional objective is to highlight a rationale for youth mental healthcare reform as a very important investment for transformational change in mental health care. Finally, this session aims to initiate global collaborations around child and youth mental health services. Methods: Speakers will review the scientific literature, analyze and synthesize key data, and share the perspective of their countries on the optimal ways to meet child and youth mental health needs. Results: Despite the general consensus on the importance of child and youth mental health, the scarcity of child and youth mental health services is prominent all over the world, with some exceptions. With increasing urbanization and industrialization, the demands on children, adolescents, and youth are increasing. There is a growing need for education and more sophisticated levels of adaptation to succeed in our ever more challenging world. Conclusions: The challenges outlined above are not attributed to a lack of research evidence on treatment. On the contrary, the last decade has seen a plethora of new studies on effective mental health interventions for children and youth. The critical problem lies with inadequate implementation of effective evidence-based interventions working synergistically across multiple settings. There is a clear recognition that better services for children and youth are urgently needed.

EBP, MC, TREAT Sponsored by AACAP's International Relations Committee and Training and Education Committee http://dx.doi.org/10.1016/j.jaac.2017.07.329

58.1 INTRODUCTION TO GLOBAL CHILD AND ADOLESCENT MENTAL HEALTH Norbert Skokauskas, MD, PhD, Norwegian University of Science and Technology, [email protected] Objectives: The goals of this session are 1) to receive information and knowledge about global opportunities for leadership and collaboration examples in child and adolescent psychiatry; 2) to become more sensitized and reinforce positive attitudes and behaviour in relation to collaborative approach in global child mental health; and 3) to take action to promote and lead collaborative approach in the course of attendees professional duties. Methods: In this session, the presenters will demonstrate successful leadership and provide collaboration examples in child and adolescent psychiatry; promote global child mental health; and highlight World Psychiatric Association, Child and Adolescent Psychiatry section activities.

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Results: According to the World Health Organization, the world has made substantial progress in turning around the epidemics of human immunodeficiency virus, malaria, and tuberculosis. Unfortunately, health systems and societies have not yet adequately responded to the burden of mental disorders. In low- and middle-income countries, between 76 and 85 percent of people with mental disorders receive no treatment for their disorders. Within these percentages, it is unknown how many are children or adolescents. However, it is known that there are around 2.2 billion children in the world, and most of them live in suboptimal conditions. Among these children, one in four will develop a mental health disorder; approximately half of all mental disorders begin before the age of 14 years. Many low- and middle-income countries have only one child psychiatrist for every one to four million people; wars, refugee crises, terror attacks, and other disasters have a large impact on children’s mental health and psychological well-being. There are likely many reasons why this need has been neglected, but we can identify a few as follows: a lack of understanding about child and adolescent mental health, stigma, challenges in workforce supply and distribution, and inadequacy of resources for training. In this session, we discuss our strategies and efforts to overcome these challenges, including international networking and advocacy, application of developing technologies, antistigma programs, collaboration with primary care and other professionals, and global training initiatives. Conclusions: We can avoid the tragic and costly consequences of unidentified and untreated mental illness in youth by taking timely evidence-based actions in partnership with others.

EBP, MC, MDM http://dx.doi.org/10.1016/j.jaac.2017.07.330

58.2 CHILD AND ADOLESCENT MENTAL HEALTH SERVICES IN QATAR: PAST, PRESENT, AND FUTURE Muhammad Waqar Azeem, MD, DFAACAP, DFAPA, Sidra Medical & Research Center, [email protected] Objectives: The objective of this presentation is to provide historical perspective of child and adolescent mental health services in Qatar. An overview of the current situation and future plans for improving the services for children and families in Qatar will be discussed. Methods: The presenter will review the current literature and information from key stakeholders in Qatar regarding pediatric mental health services in the country. Results: Qatar is a small country with a population of approximately 2.3 million. The approximate population of children and youth is 350,000. Qatar is part of the Gulf Cooperation Council (GCC) coalition, which includes Saudi Arabia, Bahrain, Oman, United Arab Emirates, Kuwait, and Qatar. Qatar boosts the highest population growth among GCC (approximately three times in 10 years), with the local Qatari population representing only 14 percent of the total population. Worldwide, up to 20 percent of youth experience mental health issues. In the past, GCC and Middle East always had very limited mental health services, especially for youth. Currently, there are only a couple of child psychiatrists, no child and adolescent psychiatry inpatient beds, and limited resources in the country. There is no formal child and adolescent psychiatry training program in the region. The Department of Health in Qatar developed National Mental Health Strategy in 2013 for the period of 2013 to 2018, with the main goals of providing the right care at the right time and at the right place. Sidra Medical and Research Center (SMRC), which has 400 beds in a general pediatric and women’s hospital, is currently in a construction phase, with outpatient being planned to open in 2016. SMRC is planning to provide a wide array of child, adolescent, and women’s mental health services to meet the needs of the country. Conclusions: Interventions at the national level in a small country, with a vision of improving the mental health of children and families, potentially can have a huge impact on the creation and service delivery for children and families in most need.

MC, MDM, RTX http://dx.doi.org/10.1016/j.jaac.2017.07.331

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58.3 NATIONAL SERVICE MODELS FOR CHILD AND ADOLESCENT MENTAL HEALTH SERVICES IN ENGLAND Gordana Milavic, MD, The South London and Maudsley NHS Foundation Trust, [email protected] Objectives: The goal of this study is to provide an overview of existing services and set out the strategy for the transformation and development of national child mental health services in England. Methods: Despite a number of successful programs aimed at improving mental health services for children over the past five years, persisting challenges led to the then Minister for Care and Support to set up a Children’s Mental Health and Well-being Task Force in 2014. The resultant government publication proposing a comprehensive model of services—with a systems approach across health, social care, education, and voluntary agencies—remains to be one of the most important child mental health policies in decades and continues to serve as a basis for the transformation plans and their implementation. Results: The Task Force recommendations for improving outcomes in mental health by 2020/2021 center upon the promotion of resilience, early intervention, and care for the most vulnerable and continued investment in building up a highly skilled cadre. Specific examples of some of the proposals influenced by the recommendations include prevention programs starting with expectant mothers, the provision of mental health care to 70,000 more children and young people, and continued training. Conclusions: The combination of public mental health prevention services (available at the primary care level, in schools, nurseries, and social care institutions), early intervention, and recovery in highly specialized mental health services for the most severely ill are most likely to have far reaching benefits and improved outcomes. It is imperative that these plans are underpinned by a culture of continuous evidence–based service improvement.

ADMIN, DIAG, EBP http://dx.doi.org/10.1016/j.jaac.2017.07.332

58.4 CHILD AND ADOLESCENT MENTAL HEALTH SERVICES IN PAKISTAN Sana Younus, MBBS, Aga Khan University, sana.younus@ aku.edu Objectives: The objective of this presentation is to provide an overview of child and adolescent mental health services in Pakistan. Pakistan is the world’s sixth most populous country with an estimated population of 191 million. Individuals under the age of 18 years constitute approximately 43 percent of the population. There are only four child and adolescent psychiatrists in Pakistan, which makes up a ratio of one child psychiatrist to a population of 20 million under the age of 18 years. Methods: The presenter will review the current literature and information from key stakeholders in Pakistan. Results: The College of Physicians and Surgeons (CPSP), the ACGME counterpart, has recently agreed to the proposal of initiating child and adolescent psychiatry as a specialty. With this advent, it will be possible for three major cities in Pakistan to host pilot projects of the fellowship under the auspices of CPSP. The Aga Khan University (Karachi) initiated a fellowship in child and adolescent psychiatry in 2016 and is working toward increasing the number of fellows trained each term. In the same year, Aga Khan University hosted a research symposium on neurosciences and dedicated a day and half to activities related to child and adolescent mental health. Another important development has been by a group of child psychiatrists of Pakistani origin practicing abroad. They have established a modified curriculum that is disseminated virtually in a select few university programs that provide training and supervision to trainees in psychiatry. These endeavors highlight the milestones achieved in the domain of mental health education and training. An important landmark in services development domain is the establishment of an inpatient unit for child and adolescent psychiatry at the King Edward Medical University (Lahore), which is the one and only of its kind. Important work is also being done in the field of research as professionals from Pakistan have been actively participating


and presenting at various prestigious conferences worldwide and publishing in international peer-reviewed journals. Conclusions: With no official child and adolescent mental health policy or plan in place, these interventions are an important step toward developing and integrating mental health services into general health services and providing specialized training in child and adolescent psychiatry.

DIAG, MC, MDM http://dx.doi.org/10.1016/j.jaac.2017.07.333

58.5 SHARED EXPERIENCE OF DEVELOPING PEDIATRIC CONSULTATION LIAISON PSYCHIATRY IN SINGAPORE Say How Ong, MD, Institute of Mental Health, say_how_ [email protected] Objectives: In Singapore, the development of Pediatric Consultation Liaison Psychiatry (PCLP) has historically been limited by the health organizational structure and availability of child and adolescent psychiatry services. This study explores the mental health needs of children and adolescents admitted into the country’s largest pediatric hospital, Kerbang Kerbau Women’s and Children’s Hospital (KKWCH), and the development of a child and adolescent mental wellness service (CAMWS) since 2010. Methods: A review of the PCLP caseload and psychiatric diagnoses was performed from 2010 to 2013. Common challenges and problems faced by CAMWS and patients monitoring and treatment by the PCLP team were highlighted. Results: CAMWS serves both inpatients and outpatients referred by other doctors within the hospital. Common diagnoses included adjustment and stress-related disorders, ADHD, depression, and anxiety disorders. Although there was adequate corroboration among different health professionals, some common problems faced by the PCLP team included the lack of adequate knowledge and training in pediatric mental health among the nursing and medical staff, especially with regard to the management of agitated, psychiatrically unwell, or suicidal patients. Process workflows and treatment algorithms for common psychiatric conditions in children and adolescents were also lacking. Conclusions: To achieve the best clinical outcomes for medically ill children and adolescents, the PCLP clinician and his/her team must possess adequate understanding of medical illnesses, as well as a general knowledge of procedures, medications, hospital routines, and medical outcomes for this group of patients. They must take an imitative approach to engage pediatric colleagues through regular training sessions and case discussions with the medical and surgical teams. As psychological needs often coexist with physical symptoms or complicate clinical presentations, the PCLP team must work collaboratively with and support their pediatric colleagues more effectively.

ADMIN, MC, MDM http://dx.doi.org/10.1016/j.jaac.2017.07.334

CLINICAL PERSPECTIVES 59 HEALING ARTS: CULTURAL SYMBOLISM IN CHILDREN’S ART IN CHINESE, ISLAMIC, MIDDLE EASTERN, NATIVE AMERICAN, AND AFRICAN AMERICAN CULTURES Rebecca Susan Daily, MD, Family and Children’s Services of Oklahoma, [email protected] Objectives: Art is an essential expression of life. Humans strive to bring sense and form to emotions and experiences. As one of the earliest forms of expression and communication, who is not fascinated by the cave drawings of our distant ancestors pouring out their fears, wishes, feats, and aspirations using the materials at hand? Art therapy is a vital tool for the child psychiatrist, and with our ever-evolving cultural diaspora, we have an ever-growing need

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to understand the vast variations in the symbolism of cultures around the world. Methods: Symbolism within art in several cultures (Chinese, Middle Eastern, Islamic, Native American, African American) will be defined. Participants will be introduced to symbolism within these cultures and will be exposed to clinical cases and examples of art symbolism applications. Participants will learn about diverse ways in which different cultural groups use symbolism within art across a range of settings, which interface with or are part of clinical practice. Active engagement of those present will be elicited. Results: Art therapy uses the expression of inner emotions through myriad media, allowing the individual to explore their own emotions and internal conflicts while improving self-awareness and understanding of issues. Cultural symbolism must be understood by the therapist to assist the individual in their exploration. Cultural definitions and variations of symbols are extremely important to the individual’s expression in their art. Misinterpretation of symbolism within art can inhibit the therapeutic process, frustrate or alienate the individual producing the art, and potentially disrupt the therapeutic process. Conclusions: This presentation will provide an appetizing primer for the child and adolescent psychiatrist on the use of symbolism in art within some of the cultures of our world. Artistic symbolic expression provides a vital outlet while promoting health at the physiological, individual, and community levels— both for the creators and those who view the art. There is an anticipation that further interest will be sparked so that participants will want to remain abreast of this culturally rich field with regard to its practice and applications.

ETHN, OTH Sponsored by AACAP's Art Committee, Native American Child Committee, and Diversity and Culture Committee http://dx.doi.org/10.1016/j.jaac.2017.07.336

59.1 HEALING THROUGH THE ARTS: AN ISLAMIC PERSPECTIVE

Balkozar S. Adam, MD, University of Missouri – Columbia, [email protected] Objectives: The goals of this session are 1) to identify ways Muslims use Islamic art as a way of expression and 2) to focus on the use of Islamic art in the treatment process. Methods: Muslim youth in America are under unprecedented stress following the new administration’s ban on Muslims and refugees. They have been singled out at school and in the community, becoming the victims of bullying, hate crimes, and attacks. Many mental health professionals have not been able to keep up with the changing landscape. Many Muslim youths have grown up with Islamic art in their daily lives, yet few clinicians are aware of the impact it has had on them. Even fewer have incorporated it into treatment. Dr. Adam will discuss the history of Islamic art and its key characteristics. She will describe the centuries-old practice of calligraphy and its vital role in Islamic art. Abstraction, modular structure, successive combinations, and repetition are some of the characteristics of Islamic art. Ornamentation in the Islamic arts is not a mere filling of space. The presenter will review the literature and demonstrate the use of Islamic art as a treatment modality while helping Muslim youth. Results: With the growing stress facing Muslim youth, it is imperative for clinicians to explore additional therapeutic modalities. Islamic art has both reflective and interactive applications. Children and adolescents can view common works of arts and discuss their symbolism and impact. In addition, they can express themselves by creating their own pieces, reducing the need for verbal communication particularly during challenging times. Participants will learn why patterns are preferred over figures in Islamic art. In addition, the presenter will discuss the presence of repeated geometric and botanical designs, known as Arabesque, and how they are often used to symbolize the transcendent, invisible, and infinite nature of God. Dr. Adam will also discuss the modern applications of Islamic art and its impact on today’s Muslim youth. Conclusions: Because of the increased stress faced by Muslim youth, it is imperative to find different tools to help them deal with the various pressures,

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as well as a means of self-expression. The incorporation of Islamic art in the therapy process is an avenue to explore.

RF, SP, STRESS http://dx.doi.org/10.1016/j.jaac.2017.07.337

59.2 CHINESE CALLIGRAPHY: A COMPLEMENTARY THERAPEUTIC ROLE Zheya Jenny Yu, MD, PhD, University of Pennsylvania, zheya. [email protected] Objectives: Calligraphy is an abstract form of art in Chinese culture and is a mental exercise that involves the coordination of mind and body. This presentation will demonstrate the therapeutic value of calligraphy as a form of art therapy that may complement traditional psychotherapies. Methods: This presentation will examine the current available literature on the therapeutic role of Chinese calligraphy in children with ADHD, autism spectrum disorder (ASD), and intellectual disability, as well as in children who have survived natural disasters. Results: The practice of Chinese calligraphy handwriting can help a person with physical relaxation, emotional stability, visual perception, motor coordination, and cognitive activation. Chinese calligraphy training has also helped the attention and social communication in children with ADHD; negative behaviors and communication with the family and peers in children with ASD; and attention, judgment, cognition, and motor control in children with intellectual disability. Calligraphy writing has also improved hyperarousal symptoms and reduced salivary cortisol level in the experimental group compared with the control group of child survivors from the 2008 China earthquakes. In addition, Chinese calligraphy has also demonstrated more positive effects compared with biofeedback and meditation. Conclusions: Similar to the effect of relaxation training, Chinese calligraphy writing demonstrates a gradual build-up of physiological slowdown and is associated with heightened cognition, improved mood and behavior, and communication in children with certain neurocognitive disorders, as well as certain PTSD symptoms in children who have suffered from natural disasters.

COG, COPI, DBD http://dx.doi.org/10.1016/j.jaac.2017.07.338

59.3 MIDDLE EASTERN ART: A WAY FOR EMOTIONAL EXPRESSION AND THERAPY Fatten Elkomy, ARNP, Arthur Center Community Health, [email protected] Objectives: The goals of this session are as follows: 1) to identify the importance of art in the Middle Eastern culture and its key characteristics; 2) to understand the use of art as a medium of self-expression in the light of the different religions and the changing environment in the Middle East; and 3) to explain how art can be used as a healing and expressive tool when treating Middle Eastern patients, who were exposed to the trauma of existing wars, immigration, and loss. Methods: Dr. Elkomy will discuss the history of Middle Eastern art and its key characteristics. She will describe the historic drawings and symbolism of the ancient history and different religions of the Middle East. The current political conflicts and wars led to increased immigration from this area to the United States. Art is a common language tool that mediates expressional and communicational aspects of the treatment process. Children and adolescents can use art as a tool to express themselves across the language barrier and can discuss the meaning of artwork of others. Participants will learn how art is used in different areas of the Middle East to express emotions and ideas. The presenter will discuss the different symbols, colors, figures, and geometry in the Middle East culture and presentation of religions. Results: The youth of Middle Eastern origin face enormous challenges. These challenges include handling the traumatic events before and

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throughout the immigration process, as well as adjusting to the US culture in the face of the current political atmosphere of rejection following the recent terrorist attacks. They are at risk of being victims of physical violence, isolation, or despair. Clinicians have to be mindful of these risks and its impact on this population. Conclusions: This presentation will help participants learn how to use art as a therapeutic tool to express emotions and to promote healing for Middle Eastern children. Art has always been a part of their culture; drawings are used to tell a story, reflect deep feelings, and create a medium for self-recognition and determination. However, art is rarely used while dealing with this population.

ADOL, AD, PSP http://dx.doi.org/10.1016/j.jaac.2017.07.339

59.4 HEALING THROUGH THE ARTS: NATIVE AMERICAN SYMBOLISM Rebecca Susan Daily, MD, Oklahoma State University School of Osteopathy, [email protected] Objectives: Participants will be able to identify some of the key symbolic characteristics of Native American art, including weaving, painting, sand painting, and pottery while gaining some understanding of aspects of Native American culture. This knowledge will help clinicians’ understanding and treatment of Native American patients. Methods: Native American youth in America have suffered under generations of historical trauma and faced chronic poverty, racism, and the highest suicide rate of any cultural group in the United States. Many Native American youths have grown up with symbolism in their daily lives, with many families producing beadwork or other art forms as a way of supplementing their income, yet few clinicians are aware of the symbolism within the artwork. Results: A review of literature regarding Native art and culture along with discussions with various Native artists and with staff at a Native American museum inform the presentation. Conclusions: The history of symbolism within Native American art will be presented. There will be description of a variety of art forms used within Native American culture and discussion of the perpetuation of cultural symbolism within art. Within Native culture, it is very common for verbal expression of emotions to be at a minimum; therefore, it is imperative for clinicians to explore additional therapeutic modalities, allowing nonverbal expression. Native American art has both reflective and interactive applications. In group sessions, children can share works of arts, produce group artwork, and discuss their symbolism and impact. In addition, they can express themselves by creating their own pieces. Participants will learn some of the differences between tribes in symbolic expression.

CAM, ETHN, OTH http://dx.doi.org/10.1016/j.jaac.2017.07.340

have grown up with African American art in their daily lives, yet few clinicians are aware of the impact it has had on them. Even fewer have incorporated it into treatment. Results: Dr. Young-Walker will discuss African American art throughout time, and how African American art has addressed relevant cultural issues at critical moments in African American history. The symbolism present in African American art and its impact on culture will be discussed. Dr. YoungWalker will also discuss the impact of modern art on African American youth. Conclusions: Because of the continued issues of racism and prejudice faced by African American youth, it is imperative to find different tools to help them to cope and to have a method of self-expression. The incorporation of African American art in the therapy process is a valuable resource for youth.

ETHN, MED, OTH http://dx.doi.org/10.1016/j.jaac.2017.07.341

CLINICAL PERSPECTIVES 60 INTEGRATING CHILD MALTREATMENT EXPOSURE AND IMPACT IN COMPREHENSIVE ASSESSMENT, DIAGNOSIS, AND TREATMENT IN CHILD PSYCHIATRY Jeanette M. Scheid, MD, PhD, Michigan State University, [email protected]; Gabrielle A. Carlson, MD, SUNY at Stony Brook, [email protected] Objectives: Child maltreatment is prevalent. Children who are exposed to maltreatment are at elevated risk for a variety of mental health disorders; however, such exposures can also complicate the process of diagnosis and treatment. An understanding of the relationship between maltreatment and diagnosis of psychosis, mood, anxiety, and disruptive behavior is critical to providing accurate diagnostic formulation and treatment. Methods: Presenters will focus on each of the following diagnostic clusters: 1) psychosis; 2) mood dysregulation disorder; 3) anxiety; and 4) disruptive/antisocial behavior. Each presentation will discuss screening and assessment of maltreatment and ways maltreatment exposure impacts the diagnostic and treatment process. Results: Participants will gain skills and knowledge needed to integrate screening and assessment of child maltreatment and its impact on the mental health diagnostic and treatment process. Conclusions: Achieving comprehensive assessment, accurate diagnostic formulation, and appropriate treatment recommendations require consideration of the impact of child maltreatment on emotions, thinking, and behavior. The integration of these relationships is critical to the mental health care of children and adolescents.

CAN, DIAG, TREAT

59.5 HEALING THROUGH THE ARTS: AFRICAN AMERICAN PERSPECTIVE Laine Young-Walker, MD, University of Missouri Hospital and Clinics, [email protected] Objectives: The goals of this session are as follows: 1) to identify ways that African American art was used as a form of expression during the Harlem Renaissance and Civil Rights Movement; and 2) focus on the use of African American art in the treatment process. Methods: African American art has been used symbolically to address relevant cultural issues of the time. Historically, this importance in the Harlem Renaissance and the Civil Rights Movement has been portrayed. Currently, African American plays a critical role in symbolically addressing racial issues and tension. Mental health professionals have not been able to keep up with the changing landscape. Many African American youth


Sponsored by AACAP's Child Maltreatment and Violence Committee http://dx.doi.org/10.1016/j.jaac.2017.07.343

60.1 IMPACT OF CHILD MALTREATMENT ON ASSESSMENT AND TREATMENT OF PSYCHOSIS Linmarie Sikich, MD, Duke University, linmarie.sikich@ duke.edu Objectives: This talk aims to improve attendees’ understanding of the complex interplay between childhood maltreatment and psychotic symptoms so that affected youth are diagnosed more accurately and treated effectively using disorder-specific treatments. Methods: This presentation will review literature on the prevalence and characteristics of symptoms that appear psychotic among maltreated youth and on increased rates of primary psychotic illnesses in individuals

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who were previously abused. Strategies to screen for maltreatment, psychotic symptoms, mood disorders, and schizophrenia across the pediatric population will be reviewed. Clinical vignettes will illustrate ways in which treatment needs may differ in youth who 1) are reexperiencing prior maltreatment; 2) have been maltreated and have mood disorders with psychotic features; 3) have been maltreated and have symptoms of schizophrenia; and 4) have psychotic symptoms but have not been previously maltreated. Results: Childhood maltreatment may present with apparent hallucinations and delusions short-term or long-term. Likewise, individuals with psychosis may have delusions of having been abused. However, childhood trauma increases the risk for the development of primary psychotic disorders. Furthermore, ongoing or subsequent maltreatment may exacerbate psychotic symptoms. Treatment is likely to be much less effective if clinicians fail to recognize and specifically treat either maltreatment or psychosis. Conclusions: Careful screening for child maltreatment and its sequelae and for mood and schizophrenia symptoms is critical in youth presenting with psychotic symptoms or unsubstantiated reports of abuse. Distinguishing between symptoms related to past maltreatment, mood disorders with psychotic features, and primary psychotic disorders is key to effective treatment.

CM, PSY, TREAT Supported by NIMH Grant 1K23 MH01802-02A http://dx.doi.org/10.1016/j.jaac.2017.07.344

60.2 CHILDHOOD MALTREATMENT AND DIAGNOSIS AND TREATMENT OF MOOD DYSREGULATION Yael Dvir, MD, UMass Medical School, yael.dvir@ umassmed.edu Objectives: Exposure to traumatic events and interpersonal trauma in childhood is associated with a wide range of impairments in children and adults, including affect dysregulation. Affect dysregulation, defined as the impaired ability to regulate and/or tolerate negative emotional states, also plays a role in many other psychiatric conditions, including anxiety disorders and mood disorders, specifically MDD in children and adolescents and bipolar disorder (BD) throughout the lifespan. Additionally, there is a high prevalence of childhood maltreatment in youth and adults with BD. Given that negative alterations in mood and reactivity (including irritable behavior and angry outbursts) are among the DSM-5 criteria for PTSD, it is not surprising that there is confusion when it comes to identifying and diagnosing BD in traumatized youth. Mood dysregulation in traumatized children often is misdiagnosed as BD, and conversely, the diagnosis of BD is often overlooked. This presents a diagnostic quagmire that is challenging to clinicians. Methods: This presentation will review the following: 1) emotional regulation and its development; 2) the effects of early life adversity and childhood maltreatment on emotion regulation and the development of mood disorders, including review of available literature and pilot research; and 3) guiding principles for clinical assessment, diagnosis, and treatment of those complex youth. Results: At the conclusion of this presentation, participants will be informed of the diagnostic challenges associated with identifying comorbid mood disorders in youth with histories of childhood maltreatment and will be aware of the links between these comorbid conditions and be able to apply the use of diagnostic instruments and principles of evidence-based interventions in clinical practice. Conclusions: There is a complex and bidirectional relationship between childhood trauma and emotional dysregulation, especially in youth with mood disorders, including BD. This has significant implications for the clinician faced with diagnosing and treating children and adolescents with such complex biopsycho-social presentations.

BD, CAN, IMD http://dx.doi.org/10.1016/j.jaac.2017.07.345

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60.3 ASSESSMENT AND TREATMENT OF ANXIETY DISORDERS IN CHILDREN WITH A HISTORY OF MALTREATMENT Jeffrey R. Strawn, MD, University of Cincinnati, strawnjr@ uc.edu Objectives: The goals of this session are to review the adversity-related risk factors of non–OCD anxiety disorders in pediatric patients and to describe the potential impact of adversity on “fear circuitry” (i.e., prefrontal-amygdala circuits) that is pathoetiologically implicated in these disorders. Methods: This presentation will review the literature related to the risk, epidemiology, and phenomenology of anxiety disorders in the pediatric population and will highlight the importance of screening for adversity using several evidence-based instruments. Additionally, Dr. Strawn will review the neurocircuitry of fear processing and threat perception, which is fundamentally dysregulated in adolescents with anxiety disorders and is affected by exposure to adversity and trauma. Multimodal imaging studies of adolescents with anxiety disorders and traumaexposed youth demonstrating increased activity in the amygdala, anterior cingulate chemistry, and ventrolateral prefrontal cortex activity will be presented. Results: Anxiety disorders are common in youth with exposure to adversity, and four epidemiologic studies of children and adolescents suggest that adversity (including parental separation, abuse, and negative, threat-related life events) represents a unique risk factor for the development of anxiety. Additionally, the extant neuroimaging data suggest impairment in prefrontal-amygdala modulatory systems and dysregulation of glutamate in both adolescent anxiety disorders and in youth who have been exposed to trauma. Conclusions: Adversity, including parental separation, abuse, and negative, threat-related life events, uniquely increases the risk for anxiety disorders, and this increased risk appears to be specific for fear-based anxiety disorders (e.g., separation anxiety, and social and generalized anxiety disorders). Moreover, exposure to trauma is associated with a distinct neurobiological fingerprint in regions that subserve fear processing and are implicated in the pathogenesis of anxiety disorders. Finally, anxiety disorders appear to represent a borderland between trauma exposure and the subsequent development of mood disorders; as such, they may reflect a distinct target for secondary prevention strategies.

AD, ATTACH, CAN http://dx.doi.org/10.1016/j.jaac.2017.07.346

60.4 IMPACT OF CHILD MALTREATMENT ON CLINICAL PRESENTATION AND TREATMENT OF DISRUPTIVE BEHAVIOR Niranjan S. Karnik, MD, PhD, Rush University Medical Center, [email protected] Objectives: The goals of this session are to examine the ways that maltreatment frames and feeds aggressive and disruptive conditions and to understand the implications for treatment. Methods: Several studies have been completed that examine the psychiatric epidemiology of homeless youth and young offenders. These studies have used validated structured and semistructured instruments to assess youth with a high degree of validity and reliability. These studies will be synthesized and presented during this talk. Results: This presentation will review the research literature on maltreatment and trauma among young offenders and homeless youth. Special focus will be made on a series of studies that examined the wards of the California Youth Authority. In addition, data will be presented from studies in San Francisco, Los Angeles, and Chicago examining the psychiatric epidemiology of homeless youth in these cities. Finally, the presentation will transition to a discussion of the implications of maltreatment in planning interventions.

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Conclusions: Maltreatment should be a major focus for providers who care for patients with aggressive or disruptive disorders. The existence of a history of maltreatment can markedly change the intervention selected.

AGG, CAN, DBD Supported by Hedge Funds Care, SAMHSA-Transformation Transfer Initiative/State of Illinois, and Rush University http://dx.doi.org/10.1016/j.jaac.2017.07.347

CLINICAL PERSPECTIVES 61 INTERVENTIONS FOR CHILD PSYCHIATRISTS TO SUPPORT CHILDREN, ADOLESCENTS, AND THEIR FAMILIES IN THE MIDST OF THE OPIOID EPIDEMIC Amy Yule, MD, Massachusetts General Hospital, ayule@ partners.org; Geetha Subramaniam, MD, National Institute on Drug Abuse, [email protected] Objectives: The United States is currently in the midst of a public health crisis because of the opioid epidemic, which is impacting the population at all points across the developmental lifespan. This symposium will help child psychiatrists understand the scope of the epidemic and the ways that they can be involved in prevention, early intervention, and treatment for youth, infants exposed to opioids in pregnancy, and women with opioid use disorders during pregnancy. Methods: A systematic review of the literature has been undertaken to provide a comprehensive review. Results: The latest literature on the following topics will be reviewed: the epidemiology of opioid use in youth and pregnancy; trends in opioid overdoses; recommended interventions to decrease misuse of prescription opioids; strategies to decrease mortality associated with opioid overdoses; evidence-based screening tools, assessment, and treatment interventions (medication and behavioral therapy) for youth with opioid use disorders; evidence-based treatment for women with opioid use disorders in pregnancy; treatment of neonatal abstinence syndrome; and considerations for working with families in the postpartum period. Conclusions: Child psychiatrists will be more prepared to help prevent the onset of prescription opioid misuse, intervene earlier to identify youth at risk for developing an opioid use disorder, treat youth with opioid use disorders, and work with families with a parent with an opioid use disorder.

PRE, SUD, TREAT Sponsored by AACAP's Substance Use Committee http://dx.doi.org/10.1016/j.jaac.2017.07.349

61.1 INTRODUCTION TO THE OPIOID EPIDEMIC Timothy E. Wilens, MD, Massachusetts General Hospital, [email protected] Objectives: The United States is currently in the midst of a public health crisis because of the opioid epidemic, which is impacting the population at all points across the developmental life span. Child and adolescent psychiatrists need to be aware of the basic pharmacology of opioids, prevalence of opioid use in youth and during pregnancy, and neonatal abstinence syndrome in infants exposed to opioids in utero. Child and adolescent psychiatrists need to understand the basic pharmacology of opioids, the history of opioid use in the United States, recent trends in prescribing opioids, and the prevalence of nonfatal and fatal overdose in youth. Methods: A selective review of the literature has been undertaken. Information from the CDC; Substance Abuse Mental Health Services Administration (SAMHSA); the Monitoring of the Future survey; and state public health reports on the prevalence of use, overdose, and demographics associated with overdose has also been reviewed. Results: Despite reductions in most substance use in adolescents and young adults, there has been an increase in both synthetic and


nonsynthetic opioid analog use. Much of the increase in opioid use has paralleled an increase in prescription opioid medication administration. However, most recently synthetic opioids have been decreasing, whereas nonsynthetic opioids have been increasing. Likewise, there has been a steady increase in opioid-related drug overdose poisonings over the past decade, with young people represented as one of the highest risk groups. The majority of young people misuse opioids that have been diverted from friends and family. Conclusions: Children, youth, and families are all being impacted by the opioid epidemic. Child and adolescent psychiatrists need to have a better understanding of the pharmacology and origins of the epidemic of opioid use and use disorders.

ADOL, EPI, SUD http://dx.doi.org/10.1016/j.jaac.2017.07.350

61.2 ASSESSMENT AND TREATMENT OF YOUTH WITH OPIOID USE DISORDERS Amy Yule, MD, Massachusetts General Hospital, ayule@ partners.org Objectives: Child and adolescent psychiatrists work with youth with mental illnesses who are at increased risk of developing a co-occurring opioid use disorder. Child and adolescent psychiatrists need to be familiar with screening tools to assess for opioid use. When opioid use is endorsed, child and adolescent psychiatrists also need to be comfortable in evaluating high-risk behaviors associated with opioid use and cooccurring medical illnesses. Child and adolescent psychiatrists need to understand evidence-based therapies for substance use disorders in youth, medication-assisted treatment, and differences in the levels of care for treatment. Methods: A systematic review of the literature on screening for opioid use in youth, assessment, and treatment of opioid use disorders (behavioral and pharmacologic) has been undertaken to provide a comprehensive review. Results: Child and adolescent psychiatrist attendees will understand how to assess for opioid use in youth with screening tools and toxicology testing. Child and adolescent psychiatrists will understand the health risks associated with different methods of opioid use and be prepared to screen for common medical comorbidities. Child and adolescent psychiatrists will understand the differences between existing evidencebased behavioral therapies for substance use disorders. Child and adolescent psychiatrists will also understand the differences between medication-assisted treatments and the current literature on the use of these medications in youth. They will be guided on how to access mentoring and further education on how to incorporate these treatments into their practice. Finally, child and adolescent psychiatrists will understand indications for different levels of care based on the severity of the opioid use disorder. Conclusions: Child and adolescent psychiatrists need to be involved in screening for opioid use and the treatment of opioid use disorders in youth to decrease the morbidity and mortality associated with the current opioid epidemic. Child and adolescent psychiatrists will be more prepared to do this after attending this portion of the clinical perspective.

ADOL, SUD, TREAT http://dx.doi.org/10.1016/j.jaac.2017.07.351

61.3 TREATMENT OF OPIOID USE DISORDER IN PREGNANCY Davida Schiff, MD, Massachusetts General Hospital, Davida. [email protected] Objectives: Opioid use disorder is at an all-time high prevalence in the United States. One population at particular risk is young women of reproductive age. Infants of these young women are at increased risk of neonatal abstinence syndrome, the numbers of which have risen exponentially with the rise of

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opioid use disorder in the perinatal population. Child and adolescent psychiatrists need to understand the role of current therapies for opioid use disorder in the pregnant and early parenting population and how this impacts their neonates. Methods: A systematic review of the literature has been undertaken to provide a comprehensive review of evidence-based treatment of opioid use disorders during pregnancy. Results: Child and adolescent psychiatrist attendees will understand the epidemiology of opioid use disorder in pregnancy and the risks of uncontrolled, illicit opioid use in pregnancy. Attendees will understand the evidence-based treatment for women with opioid use disorders in pregnancy, including the risks and benefits of medication-assisted treatment versus detoxification in pregnancy. In addition, attendees will understand the diagnosis and treatment of neonatal abstinence syndrome, including pharmacologic and nonpharmacologic methods. Conclusions: Participants will learn evidence-based treatments for women with opioid use disorders during pregnancy and the role that these treatments play in the health of both mothers and their infants.

EC, EBP, SUD http://dx.doi.org/10.1016/j.jaac.2017.07.352

61.4 WHAT’S IN YOUR MEDICINE CABINET? HOUSEHOLD OPIATE SAFETY Catherine A. Martin, MD, University of Kentucky College of Medicine, [email protected] Objectives: This lecture reviews the importance of household opiate safety, with a focus on adolescents and their families. Poisoning from consumption of pharmaceuticals is a leading cause of accidental death in children and adolescents. The rate of increase for opioid poisoning is greatest in youth (ages 1–17 years), particularly in youth age 16 years who are likely to experiment with prescriptions of opioids if available in the immediate household. A number of opioid harm reduction strategies have been proposed, but in spite of these efforts, the adverse consequences of exposure to opioids continue. An evolving intervention is enhancing family access to naloxone (narcotic antagonist) for one or more residents at risk of opioid overdose. Methods: This presentation will review efforts toward harm reduction in households, including increased monitoring of opiates in the household and household delivery of naloxone. A pilot clinical program for adolescents that provided education on the risks of opiate overdose partnered with education and actual delivery of naloxone to adolescents, who are concerned about opiate overdose in their families, will be reviewed. Results: We have partnered in a rollout of naloxone to families at risk for opiate overdose. This paired with family and adolescent education on opiate household safety is feasible, despite some barriers (e.g., administrators’ concerns about families’ fears of social service backlash). Conclusions: Child and adolescent psychiatrists are in an important position to address the administration of naloxone, given that they see the child and adolescent population at risk for opioid exposure either through the household or peers. Possible guidelines for this effort will be discussed along with potential strategies to address barriers.

ADOL, PRE, SUD Supported by NIH Center for Clinical and Translational Science http://dx.doi.org/10.1016/j.jaac.2017.07.353

CLINICAL PERSPECTIVES 62 #NOFILTER: SOCIAL MEDIA TIPS FROM THE AACAP YOUTH CONNECTION AND MEDIA COMMITTEE Nicholas Carson, MD, FRCPC, Cambridge Health Alliance, [email protected]; Otema Alice Adade, MD, The Ross

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Center for Anxiety and Related Disorders DC, otema.adade@ gmail.com Objectives: The purpose of this presentation is to educate psychiatrists about adolescent and young adult use of online social media through a unique collaboration with members of AACAP’s Youth Council (AYC), who are transitional-age youth with lived mental health experience. Attendees will hear reflections from AYC members about the important role that online social media play for youth. These reflections will be followed by more academic presentations on clinical research relevant to the AYC experience Methods: The topics for this panel were suggested by members of the AYC as salient for youth with mental health difficulties. Topic areas include the general benefits and risks of social media use, fear of missing out (FOMO), and the normative struggle to be authentic online; websites promoting selfharm and eating disorders; and new perspectives on social problems online that go beyond “cyberbullying.” Members of AYC will discuss each presentation topic from their perspective. Their academic partner will summarize relevant survey research, psychodynamic studies on developmental theory, and neurobiological research on the developing brain. Results: National surveys consistently show near ubiquitous and near constant use of social media by youth. Socialization among adolescents is increasingly happening via social media sites and applications (apps). Youth may be vulnerable to the “fear of missing out” online because of the effects of oxytocin on the adolescent brain and related demands of identity development. Social problems online continue to evolve beyond traditional cyberbullying, and adult assumptions about digital dangers do not often agree with teenagers’ assessments. Potential benefits of social media use include wellness and recovery communities. Areas of risk include active online spaces promoting eating disorders and self-injury. Conclusions: Educational sessions on media use at AACAP meetings rarely include voices of transitional-age youth with lived mental health experience. This talk opens a dialogue that values the youth perspective, leading to innovative and original perspectives on the important role that social media plays in the lives of youth with mental health difficulties.

ADOL, MED, COLST Sponsored by AACAP's Media Committee http://dx.doi.org/10.1016/j.jaac.2017.07.355

62.1 WHEN YOU’RE NOT INVITED TO THE PARTY: FEAR OF MISSING OUT AND AUTHENTICITY FOR YOUTH ONLINE Nicholas Carson, MD, FRCPC, Cambridge Health Alliance, [email protected] Objectives: The purpose of this session is to review research on the “fear of missing out” (FOMO) as a new concept in adolescent use of online social networks as it impacts their mental health. We consider how the competing pressures of needing to keep up appearances with the desire to be authentic can affect youth with mental health difficulties. Methods: This is an innovative collaboration with AACAP’s Youth Council (AYC), where an AYC member will present her lived experience with FOMO in the context of her own mental health difficulties and treatment. A PubMed search was performed for research on the phrases “internet,” “adolescence,” “fear of missing out,” and “authenticity.” Relevant psychodynamic writing (Erikson’s developmental theory) and neurobiological research on the developing adolescent brain (salience of peer influence on risk-taking behavior) were reviewed. Results: FOMO has been operationalized in a 10-item self-report measure, such that it can be measured and studied for associations with related mental health symptoms and emotional states. A nationally representative survey suggested that transitional-age youth with high levels of FOMO showed low mood and low life satisfaction, with higher levels of social media use, even in class and while driving. This phenomenon can also be understood within the Eriksonian stage of “identity versus isolation.” Online engagement can support identity development, but equally, online absence can be experienced as isolating. Finally, the developing brain appears particularly vulnerable to making risky decisions in the presence of peers. Research shows that

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increases in oxytocin lead to an increase in the salience of peer relations; this likely applies to online interactions as well. This phenomenon might influence how youth present themselves online in ways that feel inauthentic or inappropriate. Conclusions: Educational sessions on new media use at AACAP annual meetings have rarely included the voice of transitional-age youth with mental health experience. This talk opens a new avenue of clinical assessment that psychiatrists can use to understand how the fear of missing out online affects the psychological and emotional well-being of patients. The concept can be explained using both psychodynamic and neurobiological frameworks to aid our understanding.

ADOL, COLST, MED http://dx.doi.org/10.1016/j.jaac.2017.07.356

62.2 SOCIAL MEDIA SEX: EXPLOITATION OR EVERLASTING LOVE? Elizabeth Englander, PhD, Bridgewater State University, [email protected] Objectives: This research seeks to examine the different circumstances under which “sexting,” or sending nude or sexual photos, occurs. Sexting with positive and negative outcomes will be compared. Methods: A study of 500 adolescents was conducted in 2016–2017 through an anonymous survey. Subjects were asked about their sexting behaviors and the circumstances surrounding these behaviors, as well as their mental health, dating behaviors, and peer relationships (both online and offline). Data were also gathered on how youth manage their perceived risks regarding sexting behaviors, and key factors (such as frequency of reported sexting) were compared between this study in 2016 and similar studies conducted in 2012–2015. Results: According to recent research findings, most sexters reported no outcomes or consequences after sexting. This includes both positive outcomes (such as achieving a new relationship, becoming more popular, or being admired) and negative outcomes (such as depression, social rejection or humiliation, harassment or bullying, or problems with adults). Yet most subjects reported being warned about dire consequences during high school programs about sexting. Still, whereas most sexting did not appear to be either high-risk or with negative outcomes, it is important to note the exceptions. First, many sexters reported regret or “feeling worse” after having sexted. Second, some sexters did engage in high-risk sexting (sexting with individuals whom they did not know well). These sexters were far more likely to regret sexting with negative outcomes. Sexters who sent photos within already-established relationships were far less likely to report any negative outcomes. Some social norms, such as the specific social media platform used for different types of sexting, did emerge in the data. Conclusions: Sexting appears to be a behavior that is linked to adolescent sexual behaviors. It may be safer than in-person sex in some ways, although it may carry higher risks in other ways. The possibility that photos will later impact one’s life is always possible, although the risk of that happening is also unknown. It is important to understand the factors that lead youth to engage in high-risk types of sexting.

ADOL, R, SEX http://dx.doi.org/10.1016/j.jaac.2017.07.357

62.3 BENEFITS AND CONSEQUENCES OF SOCIAL MEDIA: TALKING TO YOUTH ABOUT THEIR SOCIAL MEDIA HABITS Erin L. Belfort, MD, Maine Medical Center, erin.belfort@ gmail.com Objectives: The goals of this session are as follows: 1) to review the potential benefits and consequences of social media use; and 2) to discuss the


importance of taking a social media history of patients as part of routine clinical practice. Methods: This presentation is an innovative collaboration with AACAP’s Youth Council (AYC), where an AYC member will present her lived experience with the presentation topic in the context of her own mental health difficulties and treatment. A literature search on the benefits and consequences of social media use was performed. Results: Pew data suggest that the average adolescent engages in over seven and a half hours per day of media use. Socialization among adolescents is increasingly happening via social media sites and applications. There have been a number of publications in the pediatrics and child psychiatry literature on both concerns about social media use and about potentially positive aspects of social media. Much of the literature focuses on the potential downsides of excessive social media use, including normalization and glorification of risky behaviors, such as selfinjury, pro-suicide sites, or pro-eating disorder sites and online communities. Other concerns include applications (apps) that are used widely for cyberbullying and sexting. There are also potential benefits to social media use, including wellness and recovery communities online and positive social connections through social media. Social media is an outlet for creative expression for many youths who share photographs, artwork, or writing, as well as a platform to develop and express individual identity. Conclusions: Social media use is ubiquitous among youth today. We emphasize that mental health providers must have some basic knowledge of social media platforms and engage with their patients in a curious way by taking a media history as a routine part of clinical work. An awareness of both the safety concerns and positive aspects related to use of social media is important.

ADOL, MED, RF http://dx.doi.org/10.1016/j.jaac.2017.07.358

62.4 SELF-HARM AND PRO-EATING DISORDER WEBSITES: WHAT’S BEHIND THE GLORIFIED SUFFERING? Hyun Jung Kim, MD, Yale University School of Medicine, [email protected] Objectives: The purpose of this talk is to understand the nature and scope of self-harm and pro-eating disorder (pro-ED) websites and to describe research informed clinical guidelines on how to approach adolescents and young adults’ online self-harm and pro-ED activities. Methods: This presentation is an innovative collaboration with AACAP’s Youth Council (AYC). A member of AYC will discuss self-harm and pro-ED websites from the youth perspective. A PubMed search was conducted for articles printed between 1991 and 2016 in English. The following terms were (in various combinations) as follows: ”self-harm,” “self-injury,” “eating disorder,” “pro-eating disorder,” “pro-ana,” “pro-anorexia,” “pro-mia,” “probulimia,” “social media,” “social network,” ”internet,” “adolescents,” “young adults,” and “youth.” Results: Adolescents and young adults who suffer from self-harm or eating disorder often make use of the internet. Self-harm or pro-ED messages are no longer limited to websites that can be easily monitored but instead have been transplanted to more volatile and constantly changing media, such as Snapchat, Twitter, Facebook, Instagram, Pinterest, Tumblr, and many others. Although these websites may offer interactive online communities in which young people who suffer from self-harm or eating disorders gain mutual emotional support without being socially stigmatized, they may exert negative influences, such as normalizing and reinforcing self-harm or disordered eating, discouraging disclosure, and preventing professional help seeking and recovery. A number of recommendations are proposed for clinicians who work with this population. Conclusions: The internet is a popular tool for information dissemination and community building, serving many purposes from social networking

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to support seeking. However, there may be a downside to using some online support communities. Although there may be some benefits associated with some online self-harm or pro-ED activity, there are a number of risks meriting the attention of mental health professionals who work with young people who suffer from self-harm or disordered eating. Because of the nature of these risks, mental health professionals need to know about these risks and how to effectively address young people’s online activities.

ADOL, EA, SIB http://dx.doi.org/10.1016/j.jaac.2017.07.359

CLINICAL PERSPECTIVES 63 PATHWAYS AND PROTOCOLS IN SOMATIC SYMPTOM AND RELATED DISORDERS: PUTTING THE FUNCTIONAL IN FUNCTIONAL DISORDERS Khyati Brahmbhatt, MD, University of California, San Francisco, [email protected]; Tyler Pirlot, MD, Alberta Health Services, [email protected]; Patricia I. Ibeziako, MD, Boston Children’s Hospital and Harvard Medical School, [email protected] Objectives: We aim to present standardized approaches to working with patients with somatic symptom and related disorders (SSRD). We will review ways to assess needs and design interventions for care providers and families, which align with systems’ changes in working with this vulnerable and challenging population Methods: A brief review of SSRD will be followed by two examples of conducting systematic needs assessment within different systems. We will share experiences in engaging various care providers and families in assessing and addressing SSRD in a systematic way in two hospital systems. The next speaker will describe a standardized method and tools to assess and intervene with families using a clinical example. Next, we will highlight a successful four-phase, systems level intervention that can be key to stakeholder buy-in. Finally, our discussant will describe the opportunities and challenges inherent in the presented models and share future directions in the care of SSRD. Results: A significant percentage of children experience somatic complaints. Some experience functional impairment leading to the diagnosis of SSRD. The presence of SSRD is associated with increased morbidity, care utilization, and poor experiences of care. These factors contribute to poor outcomes and present a significant challenge in an accountable care environment. Learning from examples of care standardization and improved quality of care and outcomes within pediatrics can help us address this issue. Standardizing care for SSRD requires a systematic assessment of needs within the local system. Furthermore, standards of care in SSRD can be applied systematically by involving care teams and families early in the assessment and intervention process. An organized approach to changing the focus on a systems level is important in facilitating the interventions discussed so far. Our experiences in attempting these steps provide examples of programs that can help change the narrative on outcomes and provider satisfaction in SSRD. Conclusions: Improving the outcomes of patients with SSRD across the continuum of care is the need of the hour. Through collaboration with care providers, families, and systems of care and a systematic approach, we may be able to create care pathways and programs that address this need.

RI, CON, SOM Sponsored by AACAP's Physically Ill Child Committee http://dx.doi.org/10.1016/j.jaac.2017.07.361

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63.1 GATHERING INPUT FROM PRIMARY CARE TO INFORM STRATEGY FOR SOMATIC SYMPTOM AND RELATED DISORDERS - 1 Nasuh Malas, MD, MPH, University of Michigan, nmalas@ med.umich.edu Objectives: Patients with somatic symptom and related disorders (SSRDs) pose a unique challenge for the healthcare system. Primary care providers (PCPs) are at the frontlines of SSRD care yet lack the resources and training. We describe the process of understanding current perceptions and needs to inform a strategy for systematically addressing SSRD care. Methods: We describe the needs assessment process at two large academic pediatric hospitals. At C.S. Mott Children’s Hospital of the University of Michigan Health System, data were collected through a statewide survey of PCPs to assess knowledge, attitudes, and practices, and a convenience sample group of inpatients with SSRD was reviewed. The Lean methodology was implemented. At SickKids in Toronto, an open forum of hospital staff was convened to discuss challenges and solutions for SSRD management. The hospital staff were surveyed on their knowledge, skills, and attitudes regarding the population. Input was gathered from families participating in group therapy for SSRD. Results: At the University of Michigan, 82 PCPs who responded to the survey cited challenges with lack of education and training, discomfort in making and communicating the diagnosis, time constraints, and struggles with mental health referral. With regard to training, most preferred online webinars and an SSRD hotline. The chart review of 36 inpatients reflected highly varied approaches, length of stay, and interventions. Mental health consultation during the first 24 hours of admission and diagnosis documentation were rare. At SickKids, an open forum of 40 interdisciplinary staff noted challenges with the clinician–patient interaction, communication, language, system navigation, healthcare utilization, and varied approaches. Solutions included the need for common language, consistent approach, improved system navigation, and communication, enhanced system capacity, education, research, and advocacy. Through the staff survey, 140 interdisciplinary staff reflected similar struggles and solutions. Families also shared consistent feedback for the healthcare system. Conclusions: SSRDs are prevalent, costly, and challenging for patients, families, and PCPs. Systematically identifying the need and problem areas in the evaluation and management of SSRDs can help to inform system-wide strategies.

CON, QA, SOM http://dx.doi.org/10.1016/j.jaac.2017.07.362

63.2 GATHERING INPUT FROM PRIMARY CARE TO INFORM STRATEGY FOR SOMATIC SYMPTOM AND RELATED DISORDERS - 2 Claire M. De Souza, MD, FRCPC, Hospital for Sick Children, [email protected] Objectives: Patients with somatic symptom and related disorders (SSRD) pose a unique challenge for the healthcare system. Primary care providers (PCPs) are at the frontlines of SSRD care yet lack the resources and training. We describe the process of understanding current perceptions and needs to inform a strategy for systematically addressing SSRD care. Methods: We describe the needs assessment process at two large academic pediatric hospitals. At C.S. Mott Children’s Hospital of the University of Michigan Health System, data were collected through a statewide survey of PCPs to assess knowledge, attitudes, and practices, and a convenience sample group of inpatients with SSRD was reviewed. The Lean methodology was implemented. At SickKids in Toronto, an open forum of the hospital staff

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was convened to discuss challenges and solutions for SSRD management. The hospital staff was surveyed about their knowledge, skills, and attitudes regarding the population. Input was gathered from families participating in group therapy for SSRD. Results: At the University of Michigan, 82 PCPs who responded to the survey cited challenges with a lack of education and training, discomfort in making and communicating the diagnosis, time constraints, and struggles with mental health referral. With regard to training, most preferred online webinars and an SSRD hotline. The chart review of 36 inpatients reflected highly varied approaches, length of stay, and interventions. Mental health consultation during the first 24 hours of admission and diagnosis documentation were rare. At SickKids, an open forum of 40 interdisciplinary staff noted challenges with the clinician– patient interaction, communication, language, system navigation, healthcare utilization, and varied approaches. Solutions included the need for common language, consistent approach, improved system navigation and communication, enhanced system capacity, education, research, and advocacy. Through the staff survey, 140 interdisciplinary staff reflected similar struggles and solutions. Families also shared consistent feedback for the healthcare system. Conclusions: SSRDs are prevalent, costly, and challenging for patients, families, and PCPs. Systematically identifying the needs and problem areas in the evaluation and management of SSRDs can help to inform system-wide strategies.

CON, EBP, SOM Supported by the Medical Psychiatry Alliance http://dx.doi.org/10.1016/j.jaac.2017.07.363

63.3 STANDARDIZING A FRAMEWORK AND CLINICAL PATHWAY APPROACH TO SOMATIC SYMPTOM AND RELATED DISORDERS: A TALE OF TWO CITIES - 1 Lisa B. Namerow, MD, Institute of Living at Hartford Hospital, [email protected] Objectives: This presentation will provide two models on how to structure the clinical approach to patients who present with medically unexplained physical symptoms to promote a consistent clinical approach and diagnostic understanding of this complex patient population. Methods: This presentation will focus on the approach of two different institutions using the framework of medically unexplained physical symptoms as the entry point for standardizing the clinical approach to patients admitted with probable somatic symptom disorders. In addition to illustrating the interventions developed to aid both families and providers, this presentation will also discuss the process of bringing together key stakeholders, logistically creating a clinical pathway, and identifying quality assurance measures to determine effectiveness. Results: Participants will become familiar with the process of standardizing the approach to somatic symptom disorders. These standardized approaches target patients presenting with medically unexplained physical symptoms, structuring a clinical approach that aims to clarify not only the diagnosis but also the contributing factors to the presentation. As a result of these approaches, patients, families, and providers move from feeling that symptoms are “unexplained” to feeling that symptoms are “explained.” This is accomplished not just by clarifying diagnosis but also by presenting a model of a possible etiology that can change the journey from continued illness to promoting recovery.


Conclusions: Patients presenting with somatic symptom disorders, especially to an inpatient pediatric hospital, can use many physician resources and hours. In addition, depending upon the physicians involved, there can be much variability in the approach in terms of workup, diagnosis, and treatment recommended. Often, both providers and families describe feeling frustrated by the lack of clarity around diagnosis and appropriate treatment. The use of a clinical pathway and a standardized approach to formulation can help to more clearly set expectations for patients and providers, leading to improvements in satisfaction with the medical care, increased collaboration, communication, and symptom reduction.


63.4 STANDARDIZING A FRAMEWORK AND CLINICAL PATHWAY APPROACH TO SOMATIC SYMPTOM AND RELATED DISORDERS: A TALE OF TWO CITIES - 2 Lisa Lloyd Giles, MD, University of Utah School of Medicine, [email protected] Objectives: This presentation will provide two models on how to structure the clinical approach to patients presenting with medically unexplained physical symptoms to promote a consistent clinical approach and diagnostic understanding of this complex patient population. Methods: This presentation will focus on the approach of two different institutions using the framework of medically unexplained physical symptoms as the entry point for standardizing the clinical approach to patients admitted with probable somatic symptom disorders. In addition to illustrating the interventions developed to aid both families and providers, this presentation will also discuss the process of bringing together key stakeholders, logistically creating a clinical pathway, and identifying quality assurance measures to determine effectiveness. Results: Participants will become familiar with the process of standardizing the approach to somatic symptoms disorders. These standardized approaches target patients presenting with medically unexplained physical symptoms, structuring a clinical approach that aims to clarify not only the diagnosis but also the contributing factors to the presentation. As a result of these approaches, patients, families, and providers move from feeling that symptoms are “unexplained” to feeling that symptoms are “explained.” This is accomplished not just by clarifying diagnosis but also by presenting a model of possible etiology, which can change the journey from continued illness to promoting recovery. Conclusions: Patients presenting with somatic symptom disorders, especially to an inpatient pediatric hospital, can use many physician resources and hours. In addition, depending on the physicians involved, there can be much variability in the approach in terms of workup, diagnosis, and treatment recommended. Often, both providers and families describe feeling frustrated with the lack of clarity around diagnosis and appropriate treatment. The use of a clinical pathway and a standardized approach to formulation can help to more clearly set expectations for patients and providers, leading to improvements in satisfaction with the medical care and increased collaboration, communication, and symptom reduction.


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63.5 STANDARDIZING FAMILIES ASSESSMENTS AND INTERVENTIONS: PATHWAYS IN CARE OF SOMATIC SYMPTOM AND RELATED DISORDERS Khyati Brahmbhatt, MD, University of California, San Francisco, [email protected] Objectives: AACAP’s practice parameters for working with medically ill children recognize the important role of family stressors and coping in determining outcomes for these children. This is also true for children with somatic symptom and related disorders (SSRDs). This presentation will describe a systematic approach to bedside practice of family engagement in these patients. Methods: A family-centered approach to working with children with SSRD starts with a systematic family assessment. Various models for conducting family assessments build upon family illness narratives. A discussion of illness narratives and the Calgary Family Assessment Method (CFAM) will be conducted. Various scales that can be used to support this work will be reviewed followed by a case example. The case will demonstrate the use of ecomaps and genograms in conducting family assessment, intervention, and outcomes assessment. Results: Historically, families have been tasked with caring for children with SSRDs, even as they were seen as contributing to the illness itself. As noted by the pediatric task force on family, no one type of family is universally pathogenic. A family-centered approach helps us see families as partners. A systematic approach, such as CFAM, can help operationalize this within inpatient pediatric settings. The audience will learn more about CFAM, which focuses on three major dimensions: structural, developmental, and functional. These dimensions can be used in a modular fashion to individualize care for each patient. There are various tools that can be used to assess these dimensions, including scales, ecomaps, and genograms. These can be used to elicit information as well as intervention tools to reframe behaviors and interactional patterns to build a partnership with the family. The audience will learn to use these tools with the help of a case example. Conclusions: Children and families who are experiencing SSRDs can be evaluated for various structural, developmental, and functional domains using a systematic approach such as the CFAM. The information is obtained within a framework of collaboration and can also be used for intervention and outcomes assessment. This systematic approach can empower providers to work with children with SSRDs and their families in a family-centered model of care.

CON, FAM, SOM http://dx.doi.org/10.1016/j.jaac.2017.07.366

63.6 FOUR-PHASE SYSTEMS APPROACH TO SOMATIC SYMPTOM AND RELATED DISORDERS Tyler Pirlot, MD, Alberta Health Services, [email protected] Objectives: Practice parameters for addressing somatic symptom and related disorders (SSRD) indicate that collaborative care is required, yet most institutions are not yet practicing in this way. This presentation will describe a systematic approach to SSRD using four phases, authored by Drs. Pirlot, Chapman, and De Souza in a new multidisciplinary integrated clinical pilot. Methods: Dr. Pirlot will present a new structured four-phase program for addressing SSRD that include an integrated clinical team consisting of a physiatrist, pediatrician, psychiatrist, physiotherapist, education consultant, and psychologist. We will work through a case example after describing the phases: confusion; mind body connections; integrated treatment; and finally, recovery and relapse prevention. Results: The four-phase integrated somatization clinic is shown to improve engagement and delays in diagnosis, and resulted in sharing the burden of

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costs with pediatrics, rehabilitation medicine, and mental health. Co-management by rehabilitation and mental health improves role clarity between specialists, creates more rewarding work experience in working with SSRD, and highlights the point that this population is best served by a multidisciplinary integrated clinical team. Across the continuum of care, a systematic approach can help mobilize treatment resources and recovery. Rehabilitation medicine and mental health also benefit because the structured approach clarifies potential family complaints, protects professionals from diffusion, and builds optimism in treating this population. The audience will hear about a case example to understand how to use the four phases. Conclusions: Individualized treatment planning through provider role clarity and phased treatment improves family engagement and moves providers and families from confusion to clarity about diagnosis and treatment. Although families move to and from phase 1 of confusion and families and patients may be in different phases of treatment, these can provide opportunities for family-centered care where each family member’s insight is considered and validated to correctly pace treatment interventions.


CLINICAL PERSPECTIVES 64 PREADOLESCENT MOODINESS AND ATTENTION-DEFICIT/HYPERACTIVITY DISORDER: EFFECTIVE STRATEGIES FOR ASSESSMENT AND TREATMENT W. Burleson Daviss, MD, Dartmouth College Geisel School of Medicine and Dartmouth-Hitchcock Medical Center, william. [email protected]; John T. Walkup, MD, Ann and Robert H. Lurie Children’s Hospital of Chicago, jwalkup@ luriechildrens.org Objectives: Participants will learn practical strategies for accurately assessing various psychiatric causes of moodiness/irritability in childhood ADHD, including comorbid autism spectrum disorder (Dr. McLaren), anxiety and OCD (Dr. Spaniardi), PTSD (Dr. Daviss), and disruptive behavioral disorders, including ODD, conduct, and disruptive mood dysregulation disorders (Dr. Blader). Participants will also learn potentially effective strategies for pharmacological and psychosocial treatments of such mood and behavioral problems in children with ADHD Methods: Each of the above speakers will review practical ways to assess such children, including interview tips and use of rating scales. They will also summarize the literature regarding pharmacological and psychosocial treatments for these comorbid mood problems, including recommendations from consensus panels of experts when available. Handouts of the PowerPoint slides and other helpful materials will also be made available to participants on-line. Dr. John Walkup, an internationally recognized child and adolescent psychiatrist researcher, will serve as a discussant, highlighting key points of the other presenters, and their potential relevance to clinicians and clinical researchers alike. Results: Through these presentations and subsequent discussions, participants will improve their working knowledge of how to assess and treat these various causes of moodiness or irritability in their child patients with ADHD. Conclusions: Attendees of this clinical presentation will feel more capable in diagnosing and treating children with ADHD and these other mood and behavioral problems and also will be aware of the knowledge gaps in this field that future research will need to fill.

ADHD, IMD, CM http://dx.doi.org/10.1016/j.jaac.2017.07.369

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64.1 MOODINESS IN CHILDHOOD AUTISM SPECTRUM DISORDERS AND ATTENTIONDEFICIT/HYPERACTIVITY DISORDER Jennifer McLaren, MD, Dartmouth College Geisel School of Medicine and Dartmouth-Hitchcock Medical Center, jennifer. [email protected] Objectives: There is significant comorbidity between autism spectrum disorder (ASD) and ADHD. For children with ASD, their functional impairment becomes more pronounced when ADHD is present. Children with this comorbidity experience greater impairment in adaptive skills and poorer quality of life. Children with ASD and ADHD can be more challenging to assess and treat as they struggle with negative mood, mood lability, self-control, and cognitive shifting. Participants will learn assessment and treatment strategies for children with ASD and comorbid ADHD. Methods: Dr. McLaren will review how to assess for ADHD in children with ASD. The evidence base of pharmacologic treatments for comorbid ADHD in children with ASD will be reviewed. Results: Participants will improve their knowledge on how to assess and treat ADHD in children with ASD. Overall, children with ASD are more vulnerable to the side effects of psychotropic medications compared with their typically developing peers. This is concerning as communication impairments in children with ASD make it difficult at times to detect the side effects. Thus, it is important for prescribers to have a good understanding of how to carefully assess symptoms and to determine an appropriate target for the psychotropic intervention. Conclusions: There is significant comorbidity between ASD and ADHD. Participants will be more informed regarding assessment and management of these disorders. Participants will have a greater understanding of literature and treatment strategies when caring for children with ASD and ADHD.

ADHD, ASD, IMD http://dx.doi.org/10.1016/j.jaac.2017.07.370

64.2 MOODINESS RELATED TO ANXIETY AND OBSESSIVE-COMPULSIVE DISORDERS IN CHILDREN WITH ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER Alma Spaniardi, MD, NewYork-Presbyterian/Weill Cornell Medical Center, [email protected] Objectives: ADHD and anxiety disorders are the most common mental health disorders found in children and can often co-occur. OCD is also frequently comorbid with ADHD. Both anxiety disorders and OCD can present with ADHD-like symptoms, which makes a correct diagnosis more challenging. Participants in this talk will learn rational approaches to distinguishing these complex symptoms in the evaluation of children with ADHD and comorbid anxiety or OCD. Participants will also be able to describe our current knowledge about the implementation of therapy and pharmacology in patients with ADHD and these comorbidities. Methods: This presentation will review and discuss the literature on biology, diagnosis, and treatment of children with ADHD and comorbid OCD or anxiety disorders. The neurobiology, correlates, and risk factors of these disorders will be discussed. Information from this presentation will be drawn from a literature review of randomized controlled trials, case studies, and meta-analyses. Results: Evidence shows that the presence of anxiety or OCD comorbid with ADHD can alter the etiology, correlates, and response to medications and therapy. There is increasingly strong evidence for the role of pharmacotherapy, psychosocial treatments, and the combination of these forms of treatment in comorbid patients with ADHD. Through this presentation, participants will gain in knowledge and improve their management of these comorbidities with ADHD. Conclusions: Participants will be better able to use strategies for the evaluation of children with ADHD with comorbid anxiety disorders and OCD.


Participants will also learn evidence-based strategies for treating such patients with ADHD and these comorbidities in their clinical practice.

AD, ADHD, OCD http://dx.doi.org/10.1016/j.jaac.2017.07.371

64.3 TRAUMA-RELATED MOODINESS IN CHILDREN WITH ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER W. Burleson Daviss, MD, Dartmouth College Geisel School of Medicine and Dartmouth-Hitchcock Medical Center, william. [email protected] Objectives: Patients with ADHD of all ages often experience traumatic events and may display moodiness as a result, even without having fullblown PTSD. Participants will learn practical strategies to screen for traumatic exposure and trauma-related symptoms in children with ADHD and potential strategies for using psychosocial and pharmacological treatments in such patients. Methods: Based on a review of the PTSD and ADHD literature, the speaker will discuss risks related to traumatic exposure and PTSD in children with ADHD and the biological basis of pediatric stress responses. He will then review practical strategies for identifying trauma exposure and its signs and symptoms in patients with ADHD. Finally, he will review the literature supporting pharmacological and especially psychosocial treatments for trauma-related psychopathology and how such treatments can be applied to traumatized children with ADHD. Results: There are many shared risk factors for ADHD and trauma exposure. Symptoms related to trauma exposure, including re-experiencing, avoidance, depressive, and hyperarousal symptoms, are easily confused with the symptoms of ADHD and its comorbidities. Traumarelated symptoms may alter such children’s neurobiology and impair their ability to function or respond to standard treatments for ADHD. There is strong evidence in children supporting pharmacological treatments for ADHD and trauma-focused CBT (TF-CBT) for PTSD. Evidence for PTSD pharmacotherapy (including SSRIs, a agonists, atypical antipsychotic drugs, and Prazosin) is more limited and mostly from studies in adults. Conclusions: Based on the available evidence, clinicians should generally first offer psychosocial treatments for the PTSD, such as TF-CBT and/or pharmacological treatment of the ADHD, and then consider adding other pharmacotherapy for more refractory or severe cases of PTSD symptoms in such patients.

ADHD, IMD, PTSD http://dx.doi.org/10.1016/j.jaac.2017.07.372

64.4 OPPOSITIONAL/CONDUCT AND DISRUPTIVE MOOD DYSREGULATION DISORDERS AND ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER Joseph C. Blader, PhD, University of Texas Health Science Center at San Antonio, [email protected] Objectives: Childhood ADHD with affective disturbances that lead to harmful behavior is highly prevalent, but uncertainties in its understanding and treatment persist. This presentation focuses on three common interacting pathogenic factors: generalized impulse control deficits; several affective processes that require careful assessment; and social and environmental factors that affect symptom expression and impairment. Dyscontrolled behavior driven by extreme emotional states is common among children with ADHD. However, key aspects have long eluded consensus, including the underlying psychopathology, diagnostic approaches, and optimal treatment. The controversies

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are largely reducible to differences in attributing these behaviors primarily to global self-control problems or to an identifiable mood disorder. Methods: We start with a brief historical review of diagnostic approaches to impulsive youth with high emotional lability. Case vignettes will illustrate common clinical uncertainties. Drawing on recent studies, we will present the rationale for a suggested algorithm for assessment and treatment. Factors that may hamper optimal treatment in community clinical settings will be discussed. Results: This presentation converges on three main points. First, weak self-regulatory processes emblematic of ADHD often lead to high negative emotional reactivity without invoking a separate mood disorder. Second, avid pursuit of first-line treatments that could alleviate these problems for most affected youth seem underutilized in practice, and there are some external barriers to doing so. Third, our current diagnostic schema has not kept pace with scientific developments in emotion and its regulation. Conclusions: The interface between impulse control and emotional processes is complex, but current tools make the resulting impairments tractable in many clinical situations. Obstacles to using them in a timely fashion need to be addressed.

ADHD, DBD, DMDD http://dx.doi.org/10.1016/j.jaac.2017.07.373

CLINICAL PERSPECTIVES 65 THE FUTURE OF TRAINING: INTERNATIONAL OPPORTUNITIES AND PARTNERSHIPS IN CHILD AND ADOLESCENT PSYCHIATRY Matthew G. Biel, MD, MSc, Medstar Georgetown University Hospital, [email protected]; Hector J. Parada, MD, Georgetown University School of Medicine, [email protected]; Paramjit Toor Joshi, MD, UC Irvine Medical Center, [email protected] Objectives: This presentation describes an exchange program in child and adolescent psychiatry between Valparaiso, Chile and Washington DC, USA. The session will describe these partnerships and illuminate how international exchanges can diversify trainees’ understanding of the cultural factors influencing mental health in an increasingly globalized world. Methods: This session describes the exchange programs between the University of Valparaiso (UV), Children’s National Medical Center (CNMC), and Georgetown University (GU) School of Medicine. We review the structure of the programs and discuss how this experience impacts trainees across programs. Findings from qualitative interviews with trainees are presented. Results: From 2012 to 2016, seven trainees and three faculty members from UV traveled to Washington for an average of 1.5 months. During the same period, five trainees from CNMC and GU traveled to UV for an average of two weeks. Trainees from UV have rotated through inpatient and outpatient clinical settings. Faculty from Washington and UV have visited their counterpart institutions and presented at academic conferences. UV implemented a collaboration with primary care based on similar programs in the United States and launched an inpatient unit inspired by units in Washington. CNMC and GU Medical School programs are supporting the exchange with UV with goals of helping trainees develop a global perspective, improve Spanish skills, and observe mental health interventions applicable to immigrants and Latino populations in Washington, DC. Conclusions: This collaborative experience enriches training by creating unique learning opportunities, providing exposure to different health systems, and fostering cross-cultural curiosity and understanding.

AC, PUP, REST http://dx.doi.org/10.1016/j.jaac.2017.07.375

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65.1 SHARING PROFESSIONAL PARADIGMS IN TWO DISTANT CITIES: WASHINGTON AND VALPARAISO Hector J. Parada, MD, Georgetown University School of Medicine, [email protected] Objectives: This presentation contrasts the realities of child and adolescent mental health in the two cities and explains how international partnerships can build capacity to meet global mental health demands. Methods: In 2010, the University of Valparaiso (UV) opened the first child psychiatry training program to confront the growing demand for pediatric mental health services in the greater Valparaiso region. Valparaiso has a population of more than 1.5 million but fewer than 10 child and adolescent psychiatrists. The per capita number is low compared with Washington, DC (DC), but similar to many states in the Midwest and southern United States. A recent epidemiological study of pediatric mental health in Chile shows that the prevalence of psychiatric disorders is 22.5 percent, but 62 percent of patients do not have access to mental health care. The numbers are similar to those reported in studies of the United States. Results: Since 2012, seven trainees from Valparaiso have rotated for two months in the DC institutions. They have spent time in inpatient units, consultliaison programs, school and residential programs, outpatient services, and specific programs treating mood disorders, autism spectrum disorder, ADHD, gender variance, and immigrant populations. Faculty from DC and Valparaiso have visited their counterpart institutions and have given talks. A dynamic dialogue about new initiatives has developed. UV implemented a collaboration with primary care institutions based on similar programs in the United States. It launched an inpatient unit inspired by units in DC. Children’s National Medical Center and Georgetown University programs are promoting the rotation of their trainees in Valparaiso, with the goal of helping trainees develop a global perspective, learn Spanish, and observe mental health interventions applicable in specific populations, such as immigrants and Hispanics in DC. UV and state agencies in Valparaiso are interested in the model of John L. Gildner Regional Institute for Children and Adolescents. Conclusions: International partnerships in child psychiatry have the potential through bidirectional influences to expand professional training and build mental health initiatives despite different realities and resources.

AC, REST, PUP http://dx.doi.org/10.1016/j.jaac.2017.07.376

65.2 PROFESSIONAL GROWTH THROUGH INTERNATIONAL COLLABORATION: THE EXPERIENCES OF TRAINEES AND FACULTY William Cohen, MD, Georgetown University School of Medicine, [email protected]; Beatriz Ortega, MD, University of Valparaiso, beaortega@ gmail.com Objectives: International exchange programs expose trainees and faculty to differences in the practice of medicine and broaden the understanding of sociocultural factors impacting health and illness. The University of Valparaiso, Chile has formed exchange programs with two child and adolescent psychiatry training programs in Washington, DC, USA. Methods: Descriptive qualitative methodology was deployed during the first four years of the exchange program (2012–2016). The characteristics of the participants are described. In addition, a qualitative assessment was applied during the period 2012–2015, using the SWOT (Strengths, Weaknesses, Opportunities, and Threats) matrix. Results: During the four-year period, seven trainees and three faculty members from the University of Valparaiso traveled to the Washington, DC region for an average stay of 1.5 months. During the same period, five trainees and four faculty members from the Children’s National Medical Center and

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Georgetown University School of Medicine traveled to Valparaiso for an average stay of two weeks. Participating clinical sites in Washington were Children’s National Medical Center, the John L. Gildner Regional Institute for Children and Adolescents, and MedStar Georgetown University Hospital. Participating clinical centers in Chile were Salvador Hospital and Carlos Van Buren Hospital. Clinical experiences will be described in detail. Based upon SWOT Matrix methodology, identified strengths included the following: strong relationships among faculty members on both sides of the exchange; motivation on the part of residents to participate; and the existence of a formal agreement between the different centers. Opportunities to improve second language skills, to develop a local project based on foreign experience, and to meet leading researchers were identified. The primary weakness and threat to the program was identified as the lack of financial resources to support participants’ travel and lodging. Conclusions: This collaborative training experience enriches learning in child and adolescent psychiatry by creating unique learning opportunities, providing exposure to different health systems, and fostering cross-cultural curiosity and understanding. The experience has the opportunity to improve trainees’ work within and across health systems, as well as to enhance clinical skills. The early success of our collaborations should inspire other teaching hospitals to pursue international collaborative training efforts in child and adolescent psychiatry.


65.3 TRAINING CHILD AND ADOLESCENT PSYCHIATRISTS FOR CHILE: LOCAL MISSION AND GLOBAL VISION Luis Alberto Duenas, MD, University of Valparaiso, [email protected] Objectives: Child and adolescent psychiatrist training in Chile began in the 1970s, but its development has been highly centralized at universities in Santiago, the nation’s capital. This prevented the development of programs for child and adolescent mental health in other areas of Chile. The lack of child and adolescent psychiatrists outside Santiago has become more evident in recent decades as a result of the increasing prevalence of child and adolescent mental health pathologies confirmed by recent epidemiological studies. At the same time, access to mental health treatment remains scarce. The greater Valparaiso region, with a population of more than 1.5 million, has fewer than 10 child and adolescent psychiatrists. Methods: In 2008, the University of Valparaiso opened the first child psychiatry training program outside Santiago to confront the growing demand for pediatric mental health services in the greater Valparaiso region. The training program was accredited by the national regulatory agency. The clinical sites for the program are in hospitals and ambulatory centers of the National Health Service. The University of Valparaiso started an international partnership with National Children’s Center, Georgetown University, and John L. Gildner Regional Institute for Children and Adolescents in the United States. Results: The University of Valparaiso training program has trained four child and adolescent psychiatrists who are practicing in the region of Valparaiso, and there are currently six trainees in different stages of training. The new professional resources have facilitated the expansion of outpatient services, the creation of an inpatient unit, and the development of novel collaborations with primary care services. An exchange program with the institutions in the United States has allowed the establishment of international rotations for trainees and faculty from Valparaiso and Washington. Comparing notes between international institutions resulted in new ideas regarding how to build capacity in global mental health. Conclusions: The implementation of a training program for child and adolescent psychiatry in Valparaiso has successfully resulted in increased numbers of child and adolescent psychiatrists in the region, the building and


expansion of new mental health services, and initiatives in the Valparaiso region.


65.4 THE DEVELOPMENT OF A CHILD PSYCHIATRIST: WHY IS CROSS-CULTURAL, BIDIRECTIONAL TRAINING SO IMPORTANT? Lisa M. Cullins, MD, Children’s National Medical Center, [email protected] Objectives: Mental disorders account for 7.4 percent of the world’s burden of health conditions, in terms of disability—adjusted life years and nearly a quarter of all years lived with a disability—more than cardiovascular diseases or cancer. Access and quality of mental healthcare are global issues. A global workforce shortage is one of the major contributors to poor access to mental healthcare for children and adolescents. In the United States alone, it is estimated that 30,000 child psychiatrists are required to meet the needs of children and adolescents and their families, but we currently have fewer than 9,000. In most countries in the world, 9,000 child psychiatrists would certainly be a luxury or may seem even to be an overabundance. The goal of this international training experience is to enhance and enrich the skillset of the psychiatrist, with the hopes that the clinician can share and integrate these clinical pearls in their country of origin. The enhancement and enrichment processes are bidirectional. Methods: This presentation will provide a historical perspective of the development of the International Exchange Program at the Children’s Hospital, review the structure and clinical experience that the international trainees receive, and discuss how this bidirectional learning experience impacts both the international and host program trainees and their respective training programs. Results: This International Exchange Program has been very well received by both the international and host program trainees and their respective training programs. Conclusions: The magnitude of the impact of emotional health and wellbeing of children and adolescents on their life trajectories cannot be understated. Developing International Exchange Training programs can sharpen the clinical acumen of clinicians across the globe. These highly skilled clinicians, in turn, can integrate their knowledge learned into effective, sustainable mental health service delivery models and treatment approaches for children and adolescents in their country of origin.


CLINICAL PERSPECTIVES 66 THE SIBLING EFFECT Neha Sharma, MD, Tufts Medical Center, nsharma@ tuftsmedicalcenter.org; John Sargent, MD, Tufts Medical Center, [email protected]; Eric Goepfert, MD, Child and Adolescent Consultation Liaison Service, Department of Psychiatry, [email protected]; Lee Carlisle, MD, Child Study and Treatment Center, carlill@ dshs.wa.gov Objectives: This Clinical Perspectives session aims to inform child and adolescent psychiatrists of the role that siblings play in each other’s social emotional development. When a life-changing event occurs in a child’s life, this can impact a sibling’s social-emotional development and mental health. Thus, our goal is to highlight how siblings are affected when his/her brother/sister experiences chronic medical

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illness or has a life-long developmental disorder. We will discuss how a sibling’s behavior may impact the clinical situation of the identified patient Methods: The presentation is based on a literature review of how siblings impact each other’s development. Additionally, the literature review includes how the sibling relationship changes when bullying is involved and how the sibling is affected when his/her brother/sister has chronic medical illness or a developmental disorder. The search in PubMed of these terms identified numerous publications. The high-quality articles will be shared during this presentation. Results: Siblings of medically ill, psychiatrically ill, children with developmental disorders, and aggressive children are at increased risk for externalizing and internalizing symptoms because of shared genetic and environmental factors. Overall, the loss of parental attention and supervision, change in one’s role in the family, disruption in the day-to-day routine, and the unpredictability of the course of the illness are all the factors that impact the sibling’s mental health. The experts in each subtopic—chronic medical illness, developmental disorder, aggressive children—will share the latest publications on the topic and clinically relevant strategies to address the families’ struggles. In addition, a model of sibling groups, from ethnically diverse families, that was conducted on an inpatient unit will be shared. Conclusions: Siblings of medically ill, psychiatrically ill, children with developmental disorders, and aggressive children experience variety of struggles as their role in the family changes. These siblings are at increased risk of experiencing externalizing and internalizing behaviors as a result of genetic and environmental factors. Clinicians are in a unique position to identify and address these risk factors, with the hope of preventing mental illness in siblings.

FAM, PRE, DEV Sponsored by AACAP's Diversity and Culture Committee, Early Career Psychiatrist Committee, and Family Committee http://dx.doi.org/10.1016/j.jaac.2017.07.381

66.1 SIBLINGS OF MEDICALLY ILL CHILDREN John Sargent, MD, Tufts Medical Center, jsargent@ tuftsmedicalcenter.org Objectives: Chronic health conditions affect approximately 20 percent of American children under the age of 18 years. Whereas professionals frequently address developmental, emotional, and behavioral challenges in these youth, the needs of the siblings are rarely addressed directly, and negative effects in siblings are often overlooked. This presentation will review current knowledge of the impact on siblings living with a child with a chronic health condition. It will also review factors that increase the deleterious effects for specific siblings and factors that may be protective for siblings. The impact of circumstances, such as sibling’s age, birth order, parental cohesion and support, and the nature and severity of the sibling’s illness will be discussed. Methods: A literature review of sibling adaptation was conducted. Meta-analytic review articles are presented highlighting the frequency of significant internalizing and externalizing problems in siblings of chronically ill children and teenagers. Several articles identifying family characteristics that promote sibling functioning are also discussed. Results: A previous study in 2012 reported a small increase in both internalizing and externalizing disorders in siblings of children with chronic health conditions compared with siblings of healthy children. Siblings of chronically ill youth also have fewer positive self-attributes. Younger siblings are less frequently affected; males and females are equally affected, and siblings of children with serious or life-threatening illness are more likely to be impacted negatively. A similar meta-analysis reported in 2002 showed very similar results. A study of youth with siblings afflicted with sickle-cell disease indicated that family expressiveness, family support, and low levels of family conflict were associated with enhanced psychosocial adjustment of these siblings. Conclusions: A sibling living with a child with a chronic health condition is at risk for internalizing and externalizing disorders and poor self-image. Family

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factors can promote sibling well-being. Clinical attention to the well-being of siblings is warranted. Further research to identify who is at greatest risk and what interventions can prevent negative effects is necessary.

CON, FAM, MDM http://dx.doi.org/10.1016/j.jaac.2017.07.382

66.2 SIBLINGS OF INDIVIDUALS WITH DEVELOPMENTAL DISORDERS Eric Goepfert, MD, Child and Adolescent Consultation Liaison Service, Department of Psychiatry, egoepfert@ tuftsmedicalcenter.org Objectives: The purpose of this session is to identify and treat psychopathology in siblings of children with autism spectrum disorder (ASD) and typical patterns in their families. Methods: We will discuss the literature review and experience working in a clinic. Results: Children with ASD have many helpers involved in their lives, and their siblings are always an integral part but seldom attended to by clinical care. Children with ASD differ in how they think, feel, and behave. Their siblings suffer from a number of expectable disorders. First, siblings and their parents share a genetic background of ASD, with its concomitant neurodevelopmental differences, so that their own neurobiological makeups may cause them to make sense of their world in certain, predictable ways. Second, siblings also have increased rates of psychiatric disorders. If a sibling’s difficulties are externalizing (conduct, oppositionality, or ADHD), an appropriate intervention should take place, regardless of the sibling’s ASD; however, the presence of ASD in the family necessitates a specifically different approach. The parents in such a family are certainly quite busy and distracted. If the sibling’s difficulties are internalizing (depression, anxiety, or learning disability), simply noticing such an elusive problem must be commended because having another child with ASD absorbs so much parental and clinical attention. When the sibling of the child with ASD does not have a disorder, they are certainly involved in the care of and affected by their sibling with ASD. In addition to trying not to add burden to the family’s plight, siblings may behave in ways that inadvertently affect the system and may even exacerbate a problem. Given the demands of providing care and the likely focus on the individual, rather than the rest of a family, practitioners do not often attend to siblings of children with ASD. Conclusions: Practitioners should invite parents to seek counsel on how to help siblings that may be struggling. They should certainly know how to get rapid assessment of siblings, with an attention to the impact of having a sibling with ASD. Child psychiatrists should be versed in the typical impact on family systems of having a child with ASD. Some treatments will include how a sibling’s role and behavior affect the family and, conversely, how the family affects the sibling.

ASD, DEV, FAM http://dx.doi.org/10.1016/j.jaac.2017.07.383

66.3 SIBLING GROUP Lee Carlisle, MD, Child Study and Treatment Center, [email protected] Objectives: In this session, we will describe a unique sibling psychoeducational group developed at a long-term 47-bed inpatient hospital designed to serve the most severely psychiatrically ill youth in the State of Washington. Those who attend will learn the implementation process, funding challenges, facilitator-training expectations, and ongoing supports needed to sustain the program. The goal of the group is to support the participating siblings and to deepen the understanding of the hospitalized sibling. Methods: A log was maintained throughout the last seven years since the program was developed that recorded descriptive data and ethnicity of

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participants, and the facilitators were interviewed for feedback regarding the program. This involved 90-minute sessions (monthly drop-in groups) of data gathering and feedback for seven years. Results: The basic structure of the group is to first discuss confidentiality of the group discussions, and then, the participating siblings play a game designed to promote getting to know each other better. For the next 20 minutes, psychoeducational true-or-false flash cards are used to stimulate discussion about mental illness and roles of siblings. The following activity is a group art project that is meant to enhance expression of thoughts and feelings about family interactions. Lastly, the youth is engaged in gross motor play before reuniting with parents. The sibling psychoeducational group runs concurrently with the multifamily group treatment, a psychoeducational group provided for the parents of the hospitalized children. This group has been successful in supporting adopted youth, foster youth, and underrepresented minorities in the following order: African American, Hispanic American, Asian American, and Native Americans. Conclusions: Investment in promoting enhancement of resilience in siblings of seriously mentally ill, hospitalized youth through a psychoeducational, cognitive-behavioral group is financially feasible and effective. The added benefits found were the advantages the youth experienced through receiving the intervention in an ethnically diverse group who had similar experiences, including the experience of an ethnically diverse and adoptive family background.

FAM, ICP, PRE http://dx.doi.org/10.1016/j.jaac.2017.07.384

66.4 SIBLINGS: FRIEND OR FOE Neha Sharma, MD, Tufts Medical Center, nsharma@ tuftsmedicalcenter.org Objectives: In the United States, more than 80 percent of Americans have siblings. Sibling aggression is common but often dismissed as benign. There is rising data that shows that sibling bullying is associated with increased mental health distress in the victim. The goal of this presentation is to inform clinicians of up-to-date information on sibling bullying and to make suggestions on interventions to minimize it. Additionally, strategies to avoid pitfalls of increased defensiveness when discussing sibling bullying will be presented. Methods: Literature review was done using terms such as “sibling” and “bullying” in search engines like PubMed. Results: According to a recent review, the prevalence of sibling bullying varies from 15 to 50 percent. In general, these prevalence rates are significantly higher than prevalence for peer bullying (5–20%). Boys are more likely to be the perpetrators than girls. Sibling victimization and bullying perpetration appear to decline with age. Additionally, the risk factors for sibling bullying include male–male sibling dyad, younger children, and siblings who are close in age. It was also noted that the bullying is more likely if there is a higher number of children in the household. Some of the family factors that impact sibling bullying include structural factors, socioeconomic factors, and caretaker behavior. Sibling bullying independently doubles the risk of clinical depression and self-harm. Lastly, being victimized by a sibling increases the odds of being victimized by a peer. Conclusions: Sibling bullying is more prevalent than peer bullying; yet, it is frequently dismissed by families and clinicians. Sibling bullying significantly increases the risk of psychopathology and risk of being a victim of peer bullying. Thus, it is imperative that families and clinicians address sibling aggression as a preventative measure for child mental health.

AGG, BLY, FAM http://dx.doi.org/10.1016/j.jaac.2017.07.385


CLINICAL PERSPECTIVES 67 TED TALKS MEETS PERSPECTIVES: (CLINICAL) IDEAS WORTH SPREADING Andr es Martin, MD, MPH, Yale Child Study Center, andres. [email protected]; Laura M. Prager, MD, Massachusetts General Hospital, [email protected]; Schuyler W. Henderson, MD, MPH, New York University Child Study Center, [email protected]; Amy Yule, MD, Massachusetts General Hospital, ayule@ partners.org; Jack L. Turban, MD, Massachusetts General Hospital, [email protected]; Jennifer S. Saul, MD, Child and Adolescent Psychiatry Consulting, LLC, saul.jenna@ gmail.com; Julie Chilton, MD, Yale University, julie.chilton@ yale.edu Objectives: The goal of this session is to bring Clinical Perspectives and the eponymous JAACAP column “into life” by casting content from recent and forthcoming installments of the series into the popular “TED Talk” (Technology, Education, and Design Talk) format. Methods: Following the format first established at the 2014 Annual Meeting, this will be a 180-minute session co-moderated by JAACAP Editor-in-Chief Andr es Martin and Assistant Editor for Clinical Perspectives Laura Prager. The session will start with a brief introduction providing the background, context, and “ground rules” for an effective TED Talk, including adherence to tight time limits and minimal use of audiovisual supports. The authors of five published or forthcoming Clinical Perspectives will then each present a 15-minute TED Talk of their respective articles. Each presentation will be followed by five minutes of interactive and moderated discussion. There will be a short break between speakers, allowing for a brief introduction. The session will end with overarching concluding remarks, time for discussion, and an invitation for new submissions. Results: All five presentations will discuss child psychiatric takes on topics of acute public health relevance and social concern that have been featured prominently in the lay media. Conclusions: Child and adolescent psychiatry is grounded in solid clinical practice, and it is from this clinical substrate that important research questions and hypotheses first arise. Clinical Perspectives provides a forum to consider and revisit clinical phenomena anew, a platform from which to reclaim the excitement that first drew us into our chosen field. The TED Talk format, which has been so successful in the global dissemination of Technology, Education, and Design ideas, can be successfully borrowed to reveal that child and adolescent psychiatry does indeed have (clinical) “ideas worth spreading.”

SEX, SUD, OBE http://dx.doi.org/10.1016/j.jaac.2017.07.387

CLINICAL PERSPECTIVES 68 WORKING WITH VULNERABLE YOUTH AND FAMILIES Roya Ijadi-Maghsoodi, MD, MS, University of California, Los Angeles, [email protected]; Patricia Lester, MD, University of California, Los Angeles Semel Institute of Neuroscience and Human Behavior, plester@mednet. ucla.edu

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Objectives: High-risk youth and families—including homeless youth and families and foster care youth—represent a significant public health challenge in the United States. Although these youth and families are at risk for poor health, mental health, and social outcomes, there are innovative approaches and psychosocial interventions for these populations that can improve care Methods: Five perspectives on providing care to high-risk youth and families will be presented, including adapting interventions to meet the distinct needs of these populations, findings from unique individual and family-based interventions, and practical skills for providers. Results: Dr. Roya Ijadi-Maghsoodi from University of California, Los Angeles (UCLA) will present the perspectives of homeless veteran families and lessons from partnering with recently homeless parents to adopt a family resilience intervention. Dr. Niranjan Karnik from Rush University will describe a novel mobile health intervention delivered to homeless youth in Chicago. Dr. Norweeta Milburn from UCLA will discuss a brief family-based approach for recently homeless youth, the STRIVE (Support to Reunite, Involve, and Value Each Other) intervention, and implications for providers working with newly homeless adolescents. Dr. Lauren Marlotte from UCLA will deliver an overview of working with foster care families and foster youth in college and tools for providers. Dr. Jeanne Miranda of UCLA will discuss her work developing a manualized Adoption-Specific Intervention (ADAPT), an intervention for families adopting older youth from foster care, and results from a recent randomized trial. Dr. Patricia Lester of UCLA, an expert in familycentered interventions, will serve as a discussant. Conclusions: There are emerging interventions and approaches to reaching and improving care for high-risk youth and families. Child psychiatrists and mental health clinicians working on the frontlines can use these approaches and tools to improve care for these important populations.

FOC, CC, SP http://dx.doi.org/10.1016/j.jaac.2017.07.389

68.1 COMING HOME: HELPING HOMELESS VETERAN FAMILIES WITH COMMUNITY INTEGRATION Roya Ijadi-Maghsoodi, MD, MS, University of California, Los Angeles, [email protected]; Sophie Feller, MD, University of California, Los Angeles Center for Health Services and Society, [email protected]; Gery Ryan, PhD, RAND Health, [email protected]; Sheryl Kataoka, MD, University of California, Los Angeles Child and Adolescent Psychiatry Training Program, [email protected]; Lillian Gelberg, MD, MSPH, University of California, Los Angeles David Geffen School of Medicine, [email protected] Objectives: Although there is a national effort to house homeless veteran families, little is known about what stressors families encounter during this process and how to best help veteran families integrate into the community after experiencing homelessness. This presentation will describe the perspectives of homeless/recently homeless parents and providers on the experiences and stressors of integrating into the community. We will share key findings from a participatory workgroup formed with recently homeless veteran parents to adopt a skills-based family resilience intervention. Methods: Semi-structured interviews were conducted with 18 homeless/ recently homeless parents and seven providers and recorded and transcribed. Interviews were coded for themes of community integration and barriers to integrating into the community. Additionally, a parent workgroup was developed in a participatory process with recently homeless veteran parents

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to tailor a family resilience intervention to improve community integration among recently homeless families. Results: Our findings revealed that many families tended to isolate after transitioning from homelessness into housing and lacked important social connections. Families described barriers to integrating, including adjusting to the transition out of homelessness, dealing with trauma, needing to focus on their own basic necessities, and structural barriers, such as lack of a school bus for their children to attend school. Families wanted more social activities and recommended ongoing family therapy services. The participatory parent workgroup revealed issues important to families when exiting homelessness and integrating into the community and ways to adapt a family intervention to best help the process. Conclusions: Services beyond providing housing, especially family-based interventions, and ways to enhance social connections are needed for recently homeless families. Child mental health providers can use the lessons voiced from these families to lead the way in delivering care that can best improve outcomes for the entire family.

FAM, SP, CC Supported by the VA Greater Los Angeles Health Services Research & Development Locally Initiated Project Award, Greater Los Angeles VA Research Enhancement Award Program on Enhancing Community Integration for Homeless Veterans, and the AACAP Physician Scientist Program in Substance Abuse, supported by NIDA http://dx.doi.org/10.1016/j.jaac.2017.07.390

68.2 SMARTPHONE-BASED INTERVENTION FOR HOMELESS YOUTH Niranjan S. Karnik, MD, PhD, Rush University Medical Center, [email protected]; Angela Glover, BA, Rush University, [email protected]; Randy Boley, BA, Rush University, [email protected]; Stephen Schueller, PhD, Northwestern University, [email protected]; Alyson Zalta, PhD, Rush University, [email protected] Objectives: Homeless youth experience high rates of mental health problems, including depression, substance use, anxiety, and PTSD. Furthermore, a significant number of homeless youth experience traumatic events both in childhood and during periods of homelessness. Despite mental health need, there are significant barriers to receiving mental health care within this population. Mobile health technologies are an emerging way to deliver care to high-risk youth populations that may otherwise go untreated. This presentation will describe the results of a smartphone intervention implemented among homeless youth in Chicago, with key lessons for child mental health providers. Methods: For this pilot study, 20 youth (ages 18–23 years) were recruited from two homeless shelters in Chicago. Participants were 70 percent female, 25 percent male, and five percent transgender. They consented to participating in the study and gave the providers their Nexus 5 smartphones with six months of voice and data. No restrictions were placed on their use of the devices. Subjects were informed as part of the consent process that an app called Purple Robot was installed on the devices and would passively send use data (GPS, use of apps, measurements of light and motion) to the research team. In addition, youth were offered up to four brief CBT sessions via phone, with a postdoctoral psychologist in the first month of their inclusion in the study. Baseline and follow-up measures were completed using the Posttraumatic Checklist for DSM-5 (PCL-5), Patient Health Questionnaire (PHQ-9), and State-Trait Anxiety Inventory (STAI). Results: Subjects in this study reported very high baseline rates of trauma exposure, with several of them meeting the threshold for PTSD. Likewise, depression and anxiety symptoms were high. Retention was high at the one-month end point of the study, with greater than 95 percent completing their participation. Only one phone was lost by a

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participant. Analysis of phone-based data is pending. Subjects reported overall satisfaction with the telephone format used for the CBT treatment intervention. Conclusions: Use of smartphones is a feasible approach for treatment of homeless and unstably housed youth. The use of these devices allows for an array of data-gathering approaches and provides a useful tool through which homeless youth can search for resources. The devices also enable homeless youth to remain connected to important social and supportive individuals in their lives.

CAN, CC, PTSD Supported by Hedge Funds Care, Sparrow Mobile, and Rush University http://dx.doi.org/10.1016/j.jaac.2017.07.391

68.3 A FAMILY INTERVENTION FOR RECENTLY HOMELESS YOUTH Norweeta Milburn, PhD, University of California, Los Angeles Semel Institute for Neuroscience and Human Behavior, [email protected] Objectives: Newly homeless youth are at increased risk for engaging in risky behaviors, including risky substance use and sexual behaviors. However, family-based interventions can be effective among this population. This presentation will discuss the components of the Support to Reunite, Involve, and Value Each Other (STRIVE) intervention, a family-based intervention for recently homeless youth, implementing the intervention among high-risk populations, and will highlight the implications for clinicians working with diverse high-risk youth. Methods: The STRIVE intervention is a brief five-session family intervention program provided to recently homeless youth and guardians, usually in their home. The sessions consist of skills that involve repeated feedback and practice by the families and focus on improving family climate, enhancing family functioning, and improving problem solving and conflict resolution among the families. The STRIVE intervention was delivered to recently homeless youth in Southern California and was found to significantly decrease alcohol and substance use and sexual risk behaviors as well and is being implemented among other high-risk populations. Results: STRIVE is now being used among other high-risk populations, including formerly incarcerated youth. This presentation will describe the components of the STRIVE intervention and implementing this intervention among high-risk youth. Presenters will discuss important lessons from taking a family-based approach to newly homeless youth and provide practical implications for the child psychiatrist and mental health provider working with this high-risk population. Conclusions: Newly homeless youth can be a challenging population for child mental health clinicians given the risk of youth engaging in substance use and risky behaviors and traditional lack of family involvement. However, engaging early with a family-based intervention can decrease the risky behaviors and may be an important point of intervention to prevent future homelessness.

ADOL, CC, SP Supported by National Institute on Minority Health and Health Disparities and NIDA http://dx.doi.org/10.1016/j.jaac.2017.07.392

68.4 BOUNCING BACK: RESILIENCE-BUILDING IN FOSTER FAMILIES AND YOUTH Lauren Marlotte, PsyD, University of California, Los Angeles Semel Institute for Neuroscience and Human Behavior, [email protected] Objectives: Given the high level of stress, transition, and trauma experienced by many foster youth, this population is at risk for challenges with mental and physical health, educational attainment, and maintaining secure housing. There is a strong need for prevention and intervention programs for foster


and adoptive youth, former foster young adults, and their families to promote emotional well-being. The Families OverComing Under Stress (FOCUS) model strengthens family functioning, reduces mental health symptoms in caregivers and children, and improves child social skills. This talk will explore the adaptation of FOCUS, an evidence-based, skill-building preventive intervention, for foster families and foster youth in college and provide clinical adaptations. Methods: FOCUS was created to support family resilience during times of stress, transition, and loss. FOCUS has been adapted for use with foster families and young adults attending college who are in foster care or who have recently transitioned out of foster care. Results: A clinical application of the FOCUS resilience-building model with foster youth and families will be presented. By using the core elements of FOCUS (the family assessment tool, psychoeducation, the five resilience skills, and the narrative timeline), FOCUS has been implemented with various groups, including foster families and youth. This talk will highlight how the family model has helped foster families communicate and appreciate one another’s experiences, understand the foster child’s reactions to stress, integrate developmentally appropriate ways to support a foster child, identify and reinforce family roles and customs, and establish clear routines and the importance of consistency in the lives of foster youth and young adults. The adaptation for college students was informed by feedback from students about their stressors as a foster youth or former foster youth in college. The program was implemented as a group skillbuilding workshop to promote social support and self-efficacy among former foster youth in college. Conclusions: As a trauma-informed, evidence-based program, FOCUS is a manualized model that is flexible and can be used by clinicians to promote well-being among diverse populations. FOCUS has been successfully adapted to meet the unique needs of foster families and foster youth in college.

FOC, PTSD, STRESS http://dx.doi.org/10.1016/j.jaac.2017.07.393

68.5 IMPROVING OUTCOMES FOR OLDER YOUTH ADOPTED FROM FOSTER CARE Jeanne Miranda, PhD, University of California, Los Angeles Center for Health Services and Society, JMMiranda@mednet. ucla.edu Objectives: There are increasing efforts to adopt older youth from foster care, given that youth who “age out” of the foster care system are at increased risk for homelessness, incarceration, and poor academic outcomes, yet research demonstrates that older foster care youth often have histories of trauma, substance exposure in utero, and risk of multiple placements, which can affect behavioral and adoption outcomes. Furthermore, there are few evidence-based interventions designed for families adopting older youth from foster care. The goal of this presentation is to describe a unique manualized Adoption-Specific Intervention (ADAPT) intervention, developed specifically for families adopting older foster care youth. Important lessons for mental health clinicians working with families of adopted youth will be discussed. Methods: We present early results from a small open and recently initiated the randomized trial of ADAPT versus care as usual for older children (ages 5–16 years) adopted from the foster care system. Outcomes include child symptomatology, parent stress, and progress on parent-defined behavioral goals. Results: Early results show that children assigned to the ADAPT intervention improve in terms of symptomatology and parent-defined behavioral goals. Parental stress does not appear to improve following the intervention. Implications of this intervention and early findings will be provided for clinicians working with this population in the community. Conclusions: The ADAPT intervention holds promise for improving outcomes for older children adopted from foster care.

ADOL, FAM, FOC Supported by the Annie E. Casey Foundation http://dx.doi.org/10.1016/j.jaac.2017.07.394

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CLINICAL PERSPECTIVES 69 CHILDREN OF INCARCERATED PARENTS Carol L. Kessler, MD, Astor Services for Children and Families, [email protected]; William Arroyo, MD, Los Angeles County Department of Mental Health, [email protected] Objectives: More than two million US children have an incarcerated parent. This traumatic separation impacts African and Latino families, in particular. Studies demonstrate increased prevalence of mood, behavioral, and attachment disorders in children of incarcerated parents. This presentation reviews the literature of the effect of mass incarceration on families. It also provides evidence for the positive impact of innovative programs that strengthen parenting from behind bars while supporting children in the community Methods: The Osborne Association is a pioneer in developing programs to meet the needs of families affected by incarceration. A New York initiative sparked by the 2005 Bill of Rights for the Children of Incarcerated Parents led to programs supporting latency age children, facilitating visits among children who are a flight away from incarcerated mothers, and teaching skills for older youth to advocate for themselves in the state legislature. Review of the literature, coupled with narratives of affected youth and formerly incarcerated parents, will demonstrate methods for strengthening attachment despite considerable obstacles. Results: Programs that maintain the parent-child connection in the face of incarceration have been demonstrated to decrease re-offenses by incarcerated parents and to increase the resilience of their children. Conclusions: Traumatic separation impacts more than two million US children in this era of mass incarceration. Maintenance of attachment through innovative programs that bridge the community-prison divide has been shown to nurture resilience in parent, child, and community. Child psychiatrists are in a unique position to detect the impact of parental incarceration and to connect impacted children to available resources developed for this special population.

CC, SP, PAT Sponsored by AACAP's Children and the Law Committee http://dx.doi.org/10.1016/j.jaac.2017.07.396

69.1 CHILDREN OF INCARCERATED PARENTS: A REVIEW OF THE LITERATURE Carol L. Kessler, MD, Astor Services for Children and Families, [email protected] Objectives: The goal of this session is to provide a review of existing literature regarding the impact of incarceration upon children, parents, and the community. Methods: A literature search will be conducted to detect relevant recent literature in the fields of mental health and social services. Relevant public policy will be reviewed. Outcomes of programs developed to address the needs of incarcerated children will be reviewed. Results: An overview of literature addressing the needs of incarcerated children will provide a foundation for the presentation of relevant programs. Conclusions: Review of available studies is a vital component of becoming aware of the more than two million US children that face the traumatic separation from their incarcerated parents.

ATTACH, CC, SP http://dx.doi.org/10.1016/j.jaac.2017.07.397

69.2 STRONGER TOGETHER: MAINTAINING THE PARENT–CHILD BOND IN THE FACE OF INCARCERATION Tanya Krupat, MSW, The Osborne Association, tkrupat@ osborneny.org Objectives: The goal of this session is to present the programs developed by the Osborne Association based on the premise that children and their incarcerated parents are “Stronger Together.”

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Methods: The Stronger Together handbook developed by the Osborne Foundation will be presented to convey the evidence that children cope better when their bond with their incarcerated parent is maintained. Innovative programs will be presented that strengthen parenting from behind bars and provide community-based support to children. Children’s shame and isolation are decreased as they meet peers in a similar situation. Older youth learn to advocate for themselves. Mothers exiled to prisons miles from their home are prepared to welcome their children, who fly accompanied by volunteers. Results: Innovative community-based programs maintain the parent–child relationship. Conclusions: The adverse childhood experience of parental incarceration has been demonstrated to place children at risk for poor health and mental health outcomes. Nurturing resilience by developing parenting skills and coping skills in a strengths-based community provides the possibility of healthy family ties.

ATTACH, COPI, PAT http://dx.doi.org/10.1016/j.jaac.2017.07.398

69.3 THE RIGHTS OF INCARCERATED CHILDREN Elizabeth Gaynes, JD, The Osborne Association, egaynes@ osborneny.org Objectives: The goal of this session is to outline the rights of incarcerated children and how their empowerment improves their self-esteem. Methods: The legal development of incarcerated children’s rights will be presented. The presenter’s experience parenting children with an incarcerated father sparked her passion to direct the Osborne Association’s development of parenting programs in New York state prisons. Her commitment was recognized when she was named the Champion of Change on Behalf of Children with Incarcerated Parents at the White House. Results: Crisis can be transformed into opportunity when the traumatic separation of incarceration is met with creative opportunities for parent and child. Conclusions: When incarcerated parents are not shed of their role and when children’s rights are respected, families and communities benefit.

PUP, SELE, SP http://dx.doi.org/10.1016/j.jaac.2017.07.399

69.4 DOCUMENTING MY RELATIONSHIP WITH MY INCARCERATED FATHER Kharon Benson, Echoes of Incarceration, Kharonbk718@ yahoo.com Objectives: The goal of this session is to share the power of video in giving youth with incarcerated parents a voice. Methods: Echoes of Incarceration is “a documentary initiative produced by youth with incarcerated parents.” It has partnered with Sesame Street to create a film-giving voice to youth, parents, and creators of programs that maintain the parent-child connection. A young man shares his shock of discovering that his father was not in the military, but instead serving a 25-year sentence in Sing Sing Correctional Facility. Video production is a tool to rise from shame as the narrative of a father-son relationship unfolds. Results: Videos provide a means for children of incarcerated parents to create meaningful narrative that becomes an agent of change. Conclusions: With the support of innovative programs, children of incarcerated parents are empowered. Shameful stories are transformed into courageous voices. Risk is transformed into resilience.

ATTACH, COPI, SP http://dx.doi.org/10.1016/j.jaac.2017.07.400

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CLINICAL PERSPECTIVES 70 ELECTROCONVULSIVE THERAPY IN YOUTH WITH SERIOUS MENTAL ILLNESS: INDICATIONS, EFFICACY, AND ETHICAL CONSIDERATIONS, AND A CASE STUDY IN CATATONIA Kristina Sowar, MD, University of New Mexico, ksowar@salud. unm.edu; Sandra B. Sexson, MD, Medical College of Georgia at Augusta University, [email protected] Objectives: This Clinical Perspectives provides an overview of ECT relevant to child and adolescent psychiatrists, with information on indications, benefits, and risk assessment. Potential legal, financial, and logistical barriers to referral are discussed. Catatonia is a complex neuropsychiatric disorder that can be effectively treated with ECT; epidemiology, evaluation, and treatment of the disorder are highlighted. Other indications for ECT, including treatment-resistant mood, psychotic, and self-harming behaviors, are also reviewed. Through this collaboration, participants may consider ways to make ECT a more accessible form of treatment for youth Methods: This presentation includes case reports, clinical studies, literature review, practice parameters, and federal and state laws and statutes regarding ECT, catatonia, and other severe mental health conditions in youth. Results: ECT is generally safe and well tolerated, without evidence of negative impact on neuronal development. Understanding of the procedure and associated risk assessment improves patient selection and consent processes. Certain disorders are especially responsive to ECT, including catatonia. Survey of symptoms and certain assessment tools can assist providers in diagnosing catatonia; ECT can be a valuable treatment in severe cases or when benzodiazepines are not effective. ECT is also indicated for some treatment-resistant affective and psychotic conditions. However, ECT is not an option for youth in all states, and access and logistical concerns may pose a barrier to treatment. Child and adolescent psychiatrists who are trained or educated in ECT can help increase access to this treatment for the pediatric population. Conclusions: ECT has been demonstrated as a safe and efficacious treatment option for severe mental health conditions; however, it has been less used and studied in youth. Improved provider familiarity with ECT may increase consideration of this as a treatment option for the pediatric population, especially for disorders such as catatonia, which can cause severe impairment and health risks. Further research is needed to examine long-term benefits and risks of ECT in youth, particularly in recurrence prevention and cognitive development.

PSP, ASD, NM http://dx.doi.org/10.1016/j.jaac.2017.07.402

70.1 ELECTROCONVULSIVE THERAPY IN YOUTH: PHYSIOLOGICAL, SAFETY, AND EFFICACY CONSIDERATIONS Eugene Grudnikoff, MD, South Oaks Hospital, egrudnikof@ northwell.edu Objectives: The presentation will review the following: 1) literature on indications and efficacy of ECT in youth; 2) physiology and safety of a wellstudied treatment that involves general anesthesia, electric stimulus, and a generalized seizure; and 3) conducting a risk assessment before ECT. Methods: Relevant peer-reviewed publications were reviewed. Results: ECT should be considered in youth with severe, life-threatening affective and psychotic disorders who do not respond to two adequate trials of pharmacological treatments. Likewise, ECT is indicated for catatonia and neuroleptic malignant syndrome. Studies of ECT in youth are limited to retrospective series. Nonetheless, ECT has a robust record of efficacy, particularly in catatonia (80–100% response rate), followed by mood disorders


(63–92% response rate), and psychotic illness (48–78%). ECT risk assessment and safety optimization require understanding of the multiple physiological changes that occur during ECT. These involve the stimulation of both the sympathetic and parasympathetic divisions of the autonomic nervous system and the effect of seizure on the neurovascular system. Additionally, effects on the cardiopulmonary function must be considered, because ECT treatment involves low-dose general anesthesia and muscle paralysis, with a consequent decrease in respiratory drive. Short-term side effects are benign; however, retrograde amnesia is a persistent safety concern, partly modifiable through varying ECT parameters. There is no evidence that ECT negatively impacts neuronal development in youth. There are no absolute medical contraindications to ECT. Child psychiatrists may avoid or delay recommending ECT because of a lack of familiarity with the treatment, reluctance to recommend a treatment for which there is an inadequate understanding of mechanism of action, or because of obstacles in the systems of care, such as limited access to ECT providers and insurance issues. Parents and caregivers are faced with these as well as many other challenges. Conclusions: ECT has a strong evidence base as an effective treatment in treatment-resistant affective disorders and catatonia. Because the risks and side effects of ECT are known and modifiable, care should be taken to minimize patient discomfort and undesired outcomes.

EBP, NM, TREAT http://dx.doi.org/10.1016/j.jaac.2017.07.403

70.2 PRESENTATION OF CATATONIA IN A CLINICALLY DIAGNOSED GROUP Neera Ghaziuddin, MD, University of Michigan, neerag@ umich.edu Objectives: The goal of this session is to describe catatonia in a group of predominantly developmentally delayed (DD) youth with autism spectrum disorder (ASD) and/or Down syndrome (DS). Catatonia is a neuropsychiatric syndrome, which includes a variety of motor, speech, and behavioral symptoms. There is growing awareness that individuals with DD may experience this disorder at a relatively high rate. Early and accurate diagnosis is important. Methods: Participants were diagnosed with catatonia during standard clinical care using DSM-5 and Bush-Francis Catatonia rating scale. After institutional review board approval, data were extracted and entered in a statistical program called SPSS. Results: Characteristics of participants are as follows: N ¼ 31; mean age SD ¼ 16.2 6.7; males ¼ 64 percent (20/31); intellectual disability ¼ 58 percent (18/31); ASD ¼ 73 percent (22/30), DS only ¼ 7 percent (2/30); commonest time interval between suspected onset and diagnosis ¼ >1 year in 39 percent. Motor symptoms were present in the entire sample group: increased activity ¼ 43 percent (15/31); reduced activity ¼ 23 percent (7/31), or mixed ¼ 26 percent (8/31). Change in overall motor activity was followed by stereotypies ¼ 87 percent (26/30), staring ¼ 73 percent (22/30), unprovoked/relatively unprovoked aggression ¼ 53 percent (16/30). Grimacing, self-injury, ambitendency, exaggerated response to touch, or increased motor tone was less common. Reduced speech ¼ 77 percent (23/30) and perseveration of words or phrases ¼ 79 percent (23/29) were noted. Decline in function in multiple areas was common in 97 percent (30/31). Additional symptom were changes in mood in 93 percent (28/29), followed by obsessions in 70 percent (21/29), reduced sleep in 69 percent (20/29), and psychosis/psychotic-like symptoms in 37 percent (13/30). Deterioration or a lack of response to antipsychotic drugs was common, if documented (25/25; 100 percent) and antidepressants (19/21; 90 percent). After diagnosis, a benzodiazepine trial in 27/28 resulted in partial response in 57 percent (16/26). ECT was necessary in 60% (18/30), with maintenance ECT in 30 percent (5/16). Conclusions: Youth with catatonia are usually males with change in motor behavior, speech, decline in function, and mood symptoms. Response to benzodiazepines is less robust than previously believed. ECT may be needed in a proportion of cases.

NM, PSP, TREAT http://dx.doi.org/10.1016/j.jaac.2017.07.404

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70.3 CATATONIA IN ADOLESCENTS WITH NEURODEVELOPMENTAL DISORDERS: DIAGNOSTIC AND TREATMENT CHALLENGES Eva C. Ihle, MD, PhD, University of California, San Francisco Benioff Children’s Hospital, [email protected] Objectives: Diagnosing catatonia in children and adolescents remains a challenge, especially when these patients have neurodevelopmental disorders (NDD). A review of the process of diagnosing catatonia in individuals with NDD will be presented, along with a discussion of the obstacles to providing ECT when indicated. Methods: Research studies that have investigated the epidemiology of pediatric catatonia will be discussed. A review of the literature on the legal constraints that limit the delivery of ECT to adolescents with catatonia and comorbid conditions will be conducted. Case examples will be presented. Results: Pediatric catatonia often goes undiagnosed. A high index of suspicion is necessary to avoid missing this syndrome, particularly given the high morbidity and mortality associated with delayed diagnosis. Despite a low overall incidence, certain pediatric populations are at much greater risk for catatonia, including patients with NDDs, such as autism spectrum disorder and developmental delay. Although rating scales, such as the Bush-Francis Catatonia Rating Scale, can be helpful in making the diagnosis, the approach needs to be modified in NDD because many patients could meet criteria at baseline as a result of their NDD. Once a diagnosis is made and the first-line intervention (lorazepam) has not been proven to be effective, ECT is indicated. However, clinicians may encounter legal obstacles with this intervention. Statutory requirements are even more stringent for adolescents than those for adults. In California, for example, a court order is necessary for patients younger than age 16 years. Furthermore, a hearing to determine whether patients have the capacity to give and withhold consent must be done in the county where they are legal residents. The court may also need to determine whether their parent(s) meets the statutory requirement to give and withhold consent for ECT. Conclusions: Pediatric catatonia is not often recognized, especially in the setting of NDD. Once clinicians adjust their perspective on catatonia, the diagnosis can be readily made and treatment can be provided. However, it can be a challenge to obtain ECT, the other effective treatment after lorazepam, for this age group. Legal obstacles can get in the way of this treatment but can be surmounted when these hurdles are anticipated.

ASD, ETH, NM http://dx.doi.org/10.1016/j.jaac.2017.07.405

70.4 ACUTE AND MAINTENANCE ELECTROCONVULSIVE THERAPY FOR CATATONIA IN AUTISM SPECTRUM DISORDERS Lee Wachtel, MD, Kennedy Krieger Institute, wachtel@ kennedykrieger.org Objectives: This presentation aims to present data on 22 patients with autism spectrum disorder (ASD) who received short-term and maintenance ECT (mECT) for catatonia. Methods: This presentation includes a retrospective review of psychiatric, behavioral, and ECT records. Results: Catatonic patients with ASD (N ¼ 22) ranging in age from 8 to 25 years at the start time of ECT were treated from 2006 to 2016. There were six females and 16 males. All patients had ASD and presented at neurobehavioral assessment for catatonic regression and challenging behaviors. Of these patients, 18 met the Bush–Francis Catatonia Rating Scale (BFCRS) criteria with symptoms of immobility, rigidity, staring, posturing, mutism, echophenomena, withdrawal, and negativism. Patients (n ¼ 15 of 18) presented with additional BFCRS criteria of psychomotor excitement, stereotypy, and combativeness in the form of devastating, repetitive self-injury. The four remaining patients met BFCRS criteria based solely on excitement, stereotypy, and combativeness, with the repetitive, self-injurious acts that occurred thousands of times daily and required ongoing physical restraint for safety. All patients underwent short-term courses of ECT three times weekly. Two patients were started with right unilateral ECT; the remainder received bilateral

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treatment. All patients experienced a marked reduction in catatonic symptoms. A total of 18 of 19 patients with self-injurious behavior experienced similar acute reduction of such symptoms; 16 of 19 patients with self-injurious behavior experienced sustained behavioral reduction, with ongoing m-ECT. Patients continued with m-ECT ranging from once to twice weekly, with total duration ranging from 3 to 118 months and total ECT from 12 to 700 months. Conclusions: Multiple symptoms of catatonia are found in patients with ASD; some of the most devastating presentations involve psychomotor excitement in the form of repetitive self-injury. New experience regarding the usage of short-term and maintenance ECT is highly relevant for current care and future research with regard to these extremely ill and vulnerable patients.

ASD, NM, SIB http://dx.doi.org/10.1016/j.jaac.2017.07.406

70.5 IMPROVING ACCESS TO ELECTROCONVULSIVE THERAPY FOR YOUTH THROUGH EDUCATION AND TRAINING FOR CHILD PSYCHIATRISTS, AND REVIEW OF TREATMENT INDICATIONS Kristina Sowar, MD, University of New Mexico, ksowar@salud. unm.edu Objectives: This presentation will review treatment indications for ECT in youth, including severe or treatment-resistant, affective and psychotic disorders. It will also explore how increased education and training for child psychiatrists can improve access to ECT as a treatment option for youth. Methods: Literature review and case studies will be presented. Clinical experience of providing ECT treatments and working with other ECT providers will also be shared. Results: ECT has been better studied in adults with severe affective and psychotic disorders; however, case studies have demonstrated efficacy and safety of ECT in pediatric patients with mood disorders, schizophrenia, catatonia, suicidality, nonsuicidal self-injury, and status epilepticus. Results from these studies indicate that mood disorders have a relatively high rate of response to ECT (75–100%) and that psychotic disorders have a response rate of 50–60 percent to ECT. The uncertainty about effects of ECT on the developing brain and cognitive functioning persists and contributes to limited use of ECT in pediatric populations. In considering ECT as a treatment option for youth, gaining further education and training as a child psychiatrist can decrease barriers in patient selection and referral. At University of New Mexico, six adolescents with severe mood, psychotic, and catatonic disorders have been successfully treated by our two practicing child and adolescent ECT psychiatrists, as part of the larger ECT team. More trainees have since pursued further education in ECT, and outside referrals have also increased. Conclusions: ECT has been demonstrated as a safe and effective option for severe and treatment-resistant disorders; small studies in youth demonstrate significant improvement in mood and psychotic disorders. Encouraging further education and training for child psychiatrists in ECT can improve access and decrease barriers to this as an available treatment for youth.

AC, NM, PSP http://dx.doi.org/10.1016/j.jaac.2017.07.407

CLINICAL PERSPECTIVES 71 FROM THE BEDSIDE TO STATE-WIDE: A TOUR OF INTEGRATED CARE MODELS ACROSS THE COUNTRY Lisa Lloyd Giles, MD, University of Utah School of Medicine, [email protected]; Gary Maslow, MD, MPH, Duke University, [email protected]; D. Richard Martini, MD, Primary Children’s Hospital and the University of Utah School of Medicine, [email protected] Objectives: Although there is increasing evidence that integrating approaches to mental health are of great importance to providing child

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psychiatry services to all children, there are many challenges to implementing these models. Our objective is to examine real-world applications of integrated care to provide inspiration and examples so that child and adolescent psychiatrists can apply these techniques in their own practice, health system, or state. Methods: Each presenter will describe a real-world application of integrated care from across the United States. Dr. Gleason will describe an integrated approach to consultation to primary care and early intervention programs for young children in Louisiana. Dr. Rackley will describe an approach to adolescent depression from Mayo Clinic. Dr. Giles will present data regarding the system-wide approach to integrated care in a large state-wide health system from Utah. Dr. Malas will describe a state-wide child psychiatry telephone and video consultation program in Michigan. Dr. Jacobson from Pittsburgh will describe integrated programs in their health system with a particular focus on training. Results: Presenters will describe a number of different strategies for integrated care, from single clinics to large health care systems to state-wide initiatives. Hearing from a variety of presenters across the country will allow participants to consider different strategies for achieving the ideal integrated care. Because each of the presenters will be describing the evolution of their program, common themes will emerge regarding the barriers to integrated care and strategies for overcoming them. Conclusions: The approach to implementing integrated care in a single clinic may be quite different from implementing a state-wide initiative. However, regardless of the system of care or region of the country, there are common themes and barriers. The real-world development of integrated programs requires the expertise and leadership of current and future child and adolescent psychiatrists.

PYI, CON Sponsored by AACAP's Physically Ill Child Committee, Triple Board and Post Pediatric Portal Programs Committee, and Committee on Collaboration with Medical Professions and Training and Education Committee http://dx.doi.org/10.1016/j.jaac.2017.07.409

71.1 GOING WHERE THE CHILDREN ARE: EARLY CHILDHOOD CONSULTATION IN LOUISIANA

Conclusions: Consultation to child-serving professionals offers substantial access to early childhood mental health providers.

CON, EC, PSC http://dx.doi.org/10.1016/j.jaac.2017.07.410

71.2 COLLABORATIVE CARE FOR ADOLESCENT DEPRESSION: THE MAYO CLINIC EXPERIENCE Sandra J. Rackley, MD, Mayo Clinic, rackley.sandra@ mayo.edu Objectives: The collaborative care model for depression management in the primary care setting has been shown to both improve outcomes and reduce the overall cost of care in adults with depressive disorders. Limited information is available to guide implementation of this model with pediatric populations. Methods: This presentation will describe the implementation of a collaborative care model for the care of adolescents with depressive disorders in three primary care clinics. The presentation will introduce the model, describe modifications to the adult protocol that support more developmentally appropriate implementation with adolescent patients, and review quality and outcomes data received thus far. Results: The intervention has been well received by patients, parents, and primary care providers. Patients enrolled in the collaborative care program overall had higher rates of remission than patients receiving the usual care. Predictors of poorer response to interventions include comorbid anxiety or substance use disorders. Differences implementing the program compared with adult-centered models have included the additional time per patient required to coordinate with parents, schools, and other key adults in the child’s life; difficulties clarifying the differential diagnosis in the setting of social stressors and potential psychiatric comorbidities; inclusion of empirically validated psychotherapies (rather than pharmacotherapy alone) in the management of adolescent depression; and the strong preference of many adolescents to eschew telephone calls in favor of text messaging. Conclusions: Collaborative care is a feasible and effective intervention for primary care management of adolescents with depression. Modifications to the standard protocol help the program be more developmentally appropriate and efficacious with adolescents.

CON, DDD, TREAT

Mary-Margaret Gleason, MD, Tulane University School of Medicine, [email protected]


Objectives: The goal of this session is to present implementation and outcomes of a community-focused, multidisciplinary early childhood mental health (ECMH) consultation program. Young children experience mental health problems at similar rates as older children, with substantial functional impairment and family burdens. ECMH problems often are associated with ongoing disorders in school age. Access to evidencebased treatments for these children is limited, and often the professionals who serve them in other contexts provide mental health support as a default, often without sufficient training in early childhood psychopathology. This is particularly true in underserved health care regions, especially in rural areas. Methods: Louisiana Project Linking Actions for Unmet Needs in Children’s Health (LAUNCH) offers consultation to child-serving providers in three domains: primary care (PC), early intervention (EI), and child care. This presentation will discuss the model in the two clinical domains, PC and EI. Consultation in all domains focuses on strengths, parent-child relationships, validated screening tools, and attention to adversity exposure. Consultation in PC is offered through on-site consultation as well as off-site consultation evaluations and didactics. EI consultation is provided to EI professionals and the leadership in family homes or separate from the home visits by phone, face-to-face meetings, or scheduled team meetings. Results: In the first 21 months of active consultation, more than 564 consultations were provided in primary care, focusing on the mental health needs of children ages 0–8 months. In early intervention, in the first 18 months, 553 consults were provided to children ages 0–3 months. Characteristics of consultants and providers will be described.

71.3 MENTAL HEALTH INTEGRATION: THE INTERMOUNTAIN EXPERIENCE


Lisa Lloyd Giles, MD, University of Utah School of Medicine, [email protected] Objectives: The majority of children and adolescents with behavioral and mental health concerns present to their primary care physicians (PCPs). However, pediatricians and family practice physicians often feel undertrained, overwhelmed, and ill-equipped to handle mental health concerns in a primary care setting. Over the past 15 years, Intermountain Healthcare (IH) has developed a team-based approach known as mental health integration (MHI) to care for these children and their families. The team includes the pediatricians (or other PCPs) and their staff integrated with mental health professionals, community resources, care management, and families. The MHI team care process model operationalizes a standard system in which the key focus is on the efforts by the PCPs to provide appropriate levels of mental health care within a high-functioning team. Methods: This presentation will discuss the design and implementation of Intermoutain’s MHI Program. We will review the quality and value data that have been collected and the ongoing improvement process. Results: MHI is a standardized team-based care process that includes mental health as a normal part of the routine medical encounter. Pediatric and family practice clinics (N ¼ 64) that provide care for children have adopted this model across the state of Utah. Providers in MHI clinics report improved satisfaction and feel more confident in addressing the mental health needs of patients. Patients treated in MHI clinics show improved satisfaction, lower costs, better quality outcomes, and decreased use of emergency services.

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Conclusions: There are a growing number of models across the country to improve access to mental health care treatment for children and adolescents. Intermountain has a care process model that goes far beyond colocation in its approach to operationalize team-based care. The MHI program seems to be a successful approach to improving care for children and adolescents within the medical home.

CON, EBP, MC http://dx.doi.org/10.1016/j.jaac.2017.07.412

71.4 BUILDING BRIDGES WITH PRIMARY CARE PROVIDERS ACROSS THE STATE: THE MICHIGAN CHILD COLLABORATIVE CARE PROGRAM (MC3) Nasuh Malas, MD, MPH, University of Michigan, nmalas@ med.umich.edu Objectives: There is a profound shortage of child and adolescent psychiatrists throughout the United States. This shortage has resulted in poor access to pediatric mental health services. Telepsychiatry provides a feasible, costeffective means of enhancing collaboration and communication between child and adolescent psychiatrists and primary care physicians (PCPs) and can result in significant improvements in the quality of care, and efficiency of practice, as well as PCP, patient, and family satisfaction. Methods: The Michigan Child Collaborative Care Program (MC3) is a model of collaborative care jointly developed by the state of Michigan, PCPs, and the University of Michigan Department of Psychiatry. MC3 provides phone and video psychiatric consultations to PCPs of patients ages 0–26 years. Unique to MC3 is a strong partnership between PCPs and community mental health (CMH) offices and the use of behavioral health consultants (BHCs) to provide local expertise to facilitate referrals and offer embedded support to a catchment of practices. The MC3 program launched in May 2012. Demographic data through September 2016 have been analyzed. Additional data have been collected on PCP satisfaction, services provided, number of patients accessing mental health care without previous access, nonpharmacologic services recommended, evaluation recommendations, psychotherapy recommendations, psychotropic recommendations, and referrals provided. Results: MC3 has enrolled more than 1,100 primary care providers representing nearly 300 practices in 40 Michigan counties to address this gap in care, providing more than 3,035 consultations and contacts from May 2012 to September 2016. PCPs who use MC3 identify the service as timely, accessible, and helpful, with strong measures of PCP satisfaction. PCP perceptions and practices have changed with the use of MC3, including screening practices; diagnostic evaluation; engagement of local resources; use of nonpharmacologic interventions, including psychotherapy; and use of diagnostically focused pharmacotherapy. Conclusions: Telepsychiatry offers a convenient, feasible, and cost-effective approach to enhance access to child psychiatric consultation. MC3 serves as one successful model of the tremendous use of telepsychiatry to enhance collaboration with primary care and improve access to timely psychiatric consultation.

CC, CON, TVM http://dx.doi.org/10.1016/j.jaac.2017.07.413

71.5 PREPARING OUR GRADUATES: PITTSBURGH’S APPROACH TO TRAINING IN INTEGRATED CARE Sansea L. Jacobson, MD, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, jacobsonsl@ upmc.edu Objectives: Integrated care models use limited resources smartly to address the shortage of specialist medical providers across the United States. The next generation of child and adolescent psychiatrists will require a new skillset outside of what has traditionally been taught in residency and fellowship programs. In recognition of these training needs, a new set of Child and Adolescent Psychiatry Competencies and Program Requirements have

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already been proposed. In anticipation of these changes, we must learn how to adjust training to prepare our graduates to be effective in the diverse roles of child and adolescent psychiatrists in integrated care systems. Methods: In Pittsburgh, delivery of high-quality, evidence-based integrated care models have flourished in the last 20 years, growing exponentially over the past decade. Determining ways to involve medical students, residents, and fellows in new and expanding settings can be a challenge, especially with changing reimbursement models that directly influence the potential role of the child and adolescent psychiatrist. Recognition of these complexities has resulted in a training model that includes clinical opportunities with multiple members of the primary care-based team as well as required didactic/interactive sessions to discuss the implementation of evolving models of treatment. Through the ongoing development of integrated care curricula, with its roots in AACAP’s systems-based practice curriculum, the implementation of novel clinical rotations in specialty care and community-based settings, Pittsburgh trainees are now receiving an earlier exposure to, and firmer foundation in, integrated care. Results: Each year, a larger proportion of our child and adolescent psychiatry graduates from Pittsburgh are being recruited into integrated care settings. The graduates who choose to work in integrated care upon graduation tend to be those trainees who were exposed to integrated clinical electives and received more robust education and mentorship in integrated care. Conclusions: To meet the growing health care needs of our nation, we must prepare our physicians-in-training to provide leadership and thrive in integrated care systems. The Pittsburgh integrated training model provides one such example of ways we can begin to address these needs.

CC, MC, REST http://dx.doi.org/10.1016/j.jaac.2017.07.414

CLINICAL PERSPECTIVES 72 IMPLEMENTING AND OPERATING PEDIATRIC TELEPSYCHIATRY PROGRAMS Vera Feuer, MD, Northwell Health, [email protected] Objectives: Telepsychiatry is a much needed service that provides mental health care to the underserved. We describe the history, evidence base, current practice, and educational efforts in telepsychiatry. The experience of three academic centers with implementation of clinical care and training of psychiatry residents and fellows is detailed. Methods: During the presentation, we will provide a review of the literature of telepsychiatry as it relates to clinical practice, practice guidelines, implementation in various clinical settings, and postgraduate education. We will then review the design and implementation of the telepsychiatry program at Rhode Island Hospital, a pediatric emergency telepsychiatry program at the Children’s Hospital of Colorado, and a school-based telepsychiatry program at New York University. We will examine the current state of graduate medical education in telepsychiatry, providing an overview of various residency program curricula and current training approaches. Practical training tips will be emphasized, and future directions will be explored. Results: The literature on the clinical utility of telepsychiatry is growing. There are clinical services and hospital systems that have successfully integrated this modality into their practice. Although psychiatrists in training recognize the critical importance of this service to underserved populations, postgraduate medical education programs have not kept the pace with the need for and interest in telepsychiatry. Conclusions: Telepsychiatry can and should be incorporated into clinical services across various settings, as well as into curricula of postgraduate medical education programs. The evidence base for the feasibility of and satisfaction with telepsychiatry is well established. Outcome data are growing. Implementation of this critical service is lagging and can be significantly enhanced through thoughtful exposure during psychiatry residency and fellowship programs.

ADMIN, REST, TVM Sponsored by AACAP's Telepsychiatry Committee http://dx.doi.org/10.1016/j.jaac.2017.07.416

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72.1 STARTING A TELEPSYCHIATRY PROGRAM FROM SCRATCH

72.3 NEW YORK UNIVERSITY SCHOOL-BASED TELEPSYCHIATRY

Pamela E. Hoffman, MD, Hasbro Children’s Hospital, pamela. [email protected]

Rahil Jummani, MD, New York University School of Medicine, [email protected]

Objectives: Despite its increasingly widespread use and availability, there are only a few documented descriptions of how one implements a telepsychiatry program. The presentation will describe one example of starting telepsychiatry for a health system in Rhode Island. Methods: We will delineate the various steps that it has taken to initiate and implement a new telepsychiatry program into a health system, with no prior experience with telehealth. We will describe essential regulatory and legislative hurdles to program implementation and operation. We will describe system-specific changes put in place. Results: We will provide an overview of clinical and operational issues that organizations should consider when designing their programs, using the Rhode Island Hospital system’s telepsychiatry program as an example. Conclusions: Discussion of the initiation and implementation of telepsychiatry in a state with new legislation supporting the modality will offer guidance and a framework for other programs wishing to start a new telepsychiatry program.

Objectives: Schools have long been recognized as major centers for provision of almost universally available health education and services. Seventy to 80 percent of children and adolescents who do receive mental healthcare do so in the school setting. School-based telepsychiatry is an underutilized modality to mitigate the limited access to mental health services for many youth, especially in rural communities. Methods: During the presentation, we will provide a review of the literature regarding use of school-based telepsychiatry. We will then review the design and implementation of the New York University (NYU) school-based telepsychiatry program in partnership with the New York State Office of Mental Health, highlighting key features. Results: We will report on the characteristics of the schools and patients participating in the NYU school-based telepsychiatry program. We will describe the experience of patients and trainees with school-based telepsychiatry, including impediments and successes with assessment and treatment. Data will be provided for school-based telepsychiatry services completed since the program was piloted. We will discuss demographics, diagnostic composition, and treatments conducted, as well as clinician and patient/family satisfaction with the modality. Conclusions: Schools are an ideal location for healthcare education and provision. Follow-up for mental health services in schools is much higher than in traditional community mental health facilities. School-based telepsychiatry is a modality that can be successfully implemented in underserved areas to significantly enhance the availability of needed mental health services for children and adolescents. Focus on education for psychiatric trainees in the modality and development of formal curricula is of outmost importance as the modality continues to gain increased utilization.

ADMIN, RP, TVM http://dx.doi.org/10.1016/j.jaac.2017.07.417

72.2 TELEPSYCHIATRY FOR PEDIATRIC PSYCHIATRIC EMERGENCIES AS HIGH-VALUE CARE Douglas K. Novins, MD, University of Colorado Denver, [email protected]

EDUC, SC, TVM

Objectives: The goal of this session is to evaluate a videoconferenceconducted psychiatric emergency consultation service implemented at geographically dispersed “network of care” sites of an academic children’s hospital compared with treatment as usual that involved ambulance transport to the main hospital for in-person psychiatric emergency consultation before disposition to inpatient care or discharge to home. Methods: This presentation included a cross-sectional, pre-post design within five network sites before and after implementation of telepsychiatry consultation for 494 pediatric psychiatric emergencies during the calendar year of 2015. Data were obtained from clinical records abstracted on service encounters (emergency department length of stay, disposition/discharge, hospital and physician charges) and satisfaction surveys to providers and patient/caregiver (acceptability, effectiveness, efficiency) of telepsychiatry consultation. Results: Telepsychiatric consultations had significantly shorter median lengths of stay during the emergency visit (5.5 hours telepsychiatry vs. 8.3 hours transport to in-person consultation, P < 0.01) and lower cost ($3,493 telepsychiatry vs. $8,611 in-person transfer, P < 0.01). Satisfaction surveys indicated that provider and patient caregivers were satisfied with the overall acceptability, effectiveness, and efficiency of the care provided via videoconference. No safety concerns were indicated based on readmissions within 72 hours in either treatment condition. Conclusions: Videoconference-conducted consultations for child and adolescent psychiatric emergencies were cost effective compared with usual ambulance transport to main campus academic children’s hospital. Parents and network emergency providers found it both acceptable and efficient. Videoconference-conducted consultations for psychiatric emergencies improved clinical and operational efficiency and improved the patient and family experience.


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72.4 TELEPSYCHIATRY EDUCATION AND CURRICULUM DEVELOPMENT Jonathan Merson, MD, Northwell Health, jmerson@ northwell.edu Objectives: There is a worldwide shortage of child and adolescent psychiatrists to provide the necessary care to all children affected with mental illness. Telepsychiatry is a modality of service that helps to increase access to care for patients who otherwise may not receive psychiatric care. Despite its widespread use and availability, many clinicians have minimal to no exposure to telepsychiatry as a modality. Little or no training is provided in residency programs. The presentation will describe various clinical settings in which the modality may be used as well as how it may be integrated into curricula within residency programs. Methods: We will investigate and summarize current opportunities in telepsychiatry for treatment of children and adolescents. We will also describe an overview of various residency program curricula and current training approaches. We will discuss practical tips for training and future steps in curriculum development. Results: The various settings for telepsychiatry include, but are not limited to, inpatient, outpatient, crisis stabilization, emergency department, schoolbased, and consultative services. Although many academic centers have a form of telepsychiatry used in their settings, few residency programs have structured training and opportunities for residents to participate, despite expressed interest and need. Conclusions: Although it is gaining exposure and momentum, telepsychiatry is not yet ubiquitous, and further education is needed. Dissemination and discussion of current curricula may help to bridge the gap for programs while awaiting a standardized curriculum recommendation.

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CLINICAL PERSPECTIVES 73 THE HIDDEN MESSAGE: HOW IMPLICIT BIAS IMPACTS GIRLS AND HOW CLINICIANS CAN HELP THEM Anne Frederickson, MD, Newark Beth Israel Medical Center, [email protected]; Mariam Rahmani, MD, University of Florida, rahmanim@ufl.edu; Cynthia J. Telingator, MD, Cambridge Health Alliance and Harvard Medical School, [email protected] Objectives: Child and adolescent psychiatrists have a unique understanding of development and use this understanding to help their patients grow and develop to the best of their abilities. However, many practitioners fail to identify and address the role that gender stereotypes and biases play in the development of their female patients. The purpose of this clinical perspective is to examine the different mechanisms by which girls learn and internalize gender biases and ways clinicians can help girls move past stereotypes to reach their full potential. Methods: A combination of social science research into gender bias during development and clinical cases are presented to illustrate the ways that different attitudes about gender affect girls. Results: Children are exposed to so many influences as they grow and develop. Families impart their values, belief systems, and biases to their children. How a family views their female children can both positively and negatively impact girls’ development and mental health. As children move beyond the family and into the outside world, they are faced with more messages of what it means to be a girl. How girls navigate the constant bombardment of messages from television, books, magazines, the internet, and even the evening news can predict how she will view herself and her future. For some youth, gender and other forms of bias, such as race and sexuality, become intertwined and amplified. This becomes a complex set of issues for young girls and adolescents to negotiate. However, there are ways in which practitioners, families, and communities can work to counteract these stereotypes and biases to promote healthy development of girls. Conclusions: In the end, these different perspectives of the gender stereotypes and bias that girls experience are woven together to guide the clinician on how best to work with girls to promote healthy self-image and to not unwittingly perpetuate these biases.

ADOL, SELE, DEV Sponsored by AACAP's Women in Child and Adolescent Psychiatry Committee http://dx.doi.org/10.1016/j.jaac.2017.07.422

73.1 FAMILY GENDER BIAS AND INFLUENCE ON GIRLS’ MENTAL HEALTH VULNERABILITIES Mariam Rahmani, MD, University of Florida, rahmanim@ ufl.edu Objectives: This session will examine the implicit bias that girls receive from their families and how this affects their self-image, contributing to their sense of wellness and/or pathology. Methods: We will share the latest literature on the effects of families’ implicit bias on girls’ developmental trajectories and how family acceptance can lead to positive outcomes in girls. Two clinical examples of the presenter’s patients will be discussed to emphasize the effects of families’ biases and acceptance on mental health vulnerabilities. Results: It is well documented that girls are subject to implicit bias from their families from infancy. For example, a study showed that mothers of 11-monthold girls underestimated their motor development compared with boys of the same age. Results of long-lasting effects of the family’s implicit bias on girls are now being documented. A retrospective study of women enrolled in psychotherapy found that the gender bias that girls experience from their families of origin, including devaluation and deprivation, is correlated to

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clinical depression in adult women. In underdeveloped countries, families often choose to allocate more resources, such as schooling, to sons while assigning more responsibilities, such as housework, to girls. A study of women in the information technology workforce showed that the majority of them attributed their career choice to influence from their fathers. There is limited research available on how positive messages from families are protective for girls’ mental well-being. For example, a recent US study found that daughters’ perceptions of strong mother–daughter relationships are associated with healthy child body image. Two clinical examples will be shared: one where perceived family bias was contributing to depression in a teenage girl and her family’s acceptance contributed to a reduction in her depressive symptoms, and a second example where a family’s implicit beliefs contributed to the isolation of a teenage girl. Conclusions: Families’ implicit biases have important and extremely enduring effects on girls’ development. Recognizing the existence of these biases, bringing them into awareness, and encouraging family’s acceptance of their children’s choices may play a significant role in girls’ mental health and selfesteem.

DEV, FAM, SELE http://dx.doi.org/10.1016/j.jaac.2017.07.423

73.2 SUGAR AND SPICE AND EVERYTHING NICE: GENDER REPRESENTATION IN MEDIA Anne Frederickson, MD, Newark Beth Israel Medical Center, [email protected] Objectives: It is well-known that media exposure has an impact on the developing child. The goal of this session is to examine the messages that children receive about gender and gender roles from various media sources. Methods: Recent research and examples of media representations of gender stereotypes and gendered messages will be presented. Participants will be better able to critically examine the media that youth consume and help girls and families recognize and combat negative messages. Results: Children are growing up with increasing exposure to various forms of media from television, movies, books, and now from online sources. Embedded within many of these media are messages about what it means to be a boy or a girl. In stories and movies, male characters are cast in the active, intelligent, and problem-solving roles, whereas female characters are cast in more helpless roles, with beauty being valued over brains. Even children’s television focuses more on male exploits, leaving female characters out of stories at rates unchanged since the 1950s. Girls are learning at an early age about stereotyped ideals of femininity and internalizing these ideals. When they do so, they are found to have lower ambition in school, lower career achievement, and higher rates of depression. They are also at risk for developing unhealthy ideas about their bodies, leading to disordered eating and other attempts to obtain ideal beauty. Conclusions: Media can create a biased image of gender that children, specifically girls, internalize. We as clinicians have a role to help girls and families recognize and correct these biases to promote the healthy development of young girls.

MED, OTH, PRE http://dx.doi.org/10.1016/j.jaac.2017.07.424

73.3 SURVIVAL: HOW CULTURE, FAMILY, AND ENVIRONMENT INTERFACE AND IMPACT THE DEVELOPMENT OF AN AFRICAN AMERICAN GIRL Lisa M. Cullins, MD, Children’s National Health System, [email protected] Objectives: This session will examine the significant impact of culture, family, and environment on gender identity development in an African American girl. It will also explore the intersection of gender bias and identity development given the aforementioned factors. Methods: The presenter will discuss a case of a girl who experienced multiple traumas, separation, and loss at a young age. This young girl’s formative years

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were wrought with violence—the murder of her mother, severe domestic violence by her maternal grandmother, the emergence of maternal grandmother’s mental illness, and her own sexual assault while living on the streets. After multiple stints in juvenile detention centers, this girl was ultimately placed in a residential treatment center. This presentation will explore how these life events and cultural, societal, and familial influences shaped and molded her development of gender and sense of self. Results: There is a limited body of literature on gender identity development in children and adolescents. The scientific knowledge base of the interplay of culture and socioenvironmental factors on gender development in youth is even more restricted. African American youth, in particular, have one of the highest rates of polyvictimization. This presentation will 1) illustrate how early life adverse events influence gender development; 2) explore how institutional care (i.e., detention centers, residential treatment facilities) may impact gender development; and 3) provide practitioners therapeutic strategies on how to assist young African American girls in developing their sense of self amidst the challenges they confront each day. Conclusions: Developing one’s sense of self is complex and multifactorial for all children and adolescents, but especially in ethnic minority youth. The impact that early life adverse events, culture, family, and environment have on gender identity development is not fully understood. As more research emerges regarding this topic, it is important that practitioners use a patientcentered approach and integrate culture and socioenvironmental factors in their patient formulations and treatment interventions. It is also important for practitioners to understand the interplay of implicit gender bias and identity development as they are so intricately intertwined.

ETHN, IDD, GID http://dx.doi.org/10.1016/j.jaac.2017.07.425

73.4 EXPANDING THE DIALOGUE: HOW CLINICIANS CAN FOSTER COMMUNICATION AND SUPPORT FOR GENDER-NONCONFORMING AND SEXUAL MINORITY YOUTHS Natalie Ramos, MD, MPH, University of California, Los Angeles Semel Institute for Neuroscience and Human Behavior, [email protected] Objectives: This session aims to improve clinicians’ understanding of the role of gender and sexual identity in social and emotional development. Participants will learn how to provide more comprehensive and sensitive care to gender nonconforming and sexual minority youths and explore ways in which clinicians can foster open communication with patients and help families build support. Methods: Gender and sexual identity development has become increasingly relevant to the field of child and adolescent psychiatry because clinicians are increasingly tasked with helping children and parents navigate complex, politicized systems. The presenter will discuss the impact of gender and sexuality in social and emotional development throughout childhood and adolescence and help clinicians develop tools to effectively address these topics in clinical practice. Results: Existing research, although limited, suggests the presence of wide disparities in both mental and physical health outcomes for gender and sexual minorities, with these groups experiencing elevated levels of violence, victimization, and harassment, as well as high levels of discrimination. There is evidence that family support is protective against suicidal behaviors in these youths, although family rejection is a strong risk factor for depression, suicidality, substance use, and other risk behaviors. Even rejecting families can become more accepting over time; thus, providing accurate information and resources can help families better support their children. Child psychiatrists can play a critical role in the safe exploration of gender and sexuality. This presentation will specifically help clinicians build the tools to 1) assess gender identity and sexual orientation across the lifespan; 2) improve communication regarding these topics among youths and their families; and 3) provide support and resources for gender nonconforming and sexual minority youths. Conclusions: The development of gender and sexual identity is complex and nuanced, and there is a general lack of awareness about how to approach gender nonconforming and sexual minority youths in health care settings.


Clinicians can play a key role in fostering communication and support for youths, which is likely to improve physical and mental health outcomes over time.

SEX, FAM, GID http://dx.doi.org/10.1016/j.jaac.2017.07.426

73.5 OUT-OF-SCHOOL TIME: A CRITICAL SPACE IN THE HEALTHY DEVELOPMENT OF GIRLS Denese Lombardi, MA, Girls, Inc. DC, denese.girlsincdc@ gmail.com Objectives: The session will provide information on the value of out-of-school time programs in support of the healthy development of girls; explore The Girls Incorporated (Inc.) Experience, a model of the national program Girls Inc., whose mission is to inspire all girls to be strong, smart, and bold; and provide practical ways that we can all support the healthy development of girls at home, in schools, and in our communities. Methods: The speaker brings direct experiences, success stories, and the voices of girls from her 30-year career with youth in both education and mental health settings, and particularly from her most recent 12 years as a founding board member and subsequently as executive director of Girls Inc., of the Washington, DC Metropolitan Area, providing the Girls Inc. Experience to girls in the Washington, DC region. Results: Girls who have the benefit of strength-based, affirming programs that are compensatory and intentional for girls’ development are likely to demonstrate confidence in their abilities. They are more apt to do well in school, community, and in life. Conclusions: Girls’ experiences growing up and their treatment at home, at school, and in their communities, all contribute to their social-emotional growth, educational attainment, and ultimately to their health and wellness as adult women. A girl’s ability to confidently meet the many challenges that she will inevitably face along her journey to adulthood is critical to her becoming a healthy, educated, independent woman, ready to make her own contributions to society. By supporting single gender out-of-school time programs, being mindful of unhealthy messages girls receive in the marketplace, as well as our own implicit biases regarding girls’ abilities, practitioners commit to ensuring that their communication and behavior affirm every girl’s fundamental rights and celebrate her unique abilities.

OTH, PUP, SELE http://dx.doi.org/10.1016/j.jaac.2017.07.427

CLINICAL PERSPECTIVES 74 UNWANTED YOUTH: UNACCOMPANIED MINORS AND FAMILY DETENTION IN THE UNITED STATES Suzan Song, MD, MPH, PhD, George Washington University Hospital, [email protected] Objectives: The goals of this study are as follows: 1) to gain a better understanding of the impact of geopolitical violence on youth and families; 2) to describe the mental health dimensions of the traumas of separation from family, reunification with estranged family, flight from one’s home country to the United States, and the needs in the United States; and 3) to learn how to use clinical and family therapy clinical techniques in a coordinated and interdisciplinary system of care. Methods: Policy, research, and clinical care will be presented as follows: 1) push and pull factors, “Strengths and Needs: An overview of unaccompanied minors (UM) into the U.S.” (Suzan Song, MD, MPH, PhD); 2) family detention (Andres Pumariega, MD); 3) reunification to a forgotten family (Saara Amri, LCP); and 4) treating families facing and dealing with reunification with unaccompanied minors (UM) (John Sargent, MD). Results: 1) Dr. Song first provides the research on the mental health of UM and then discusses their experiences and clinical care available here in the United States through her work with the Office of Refugee Resettlement; 2) Dr. Pumariega will discuss the experiences of fragmented families through his

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role on the Federal Advisory Committee for Family Reunification Centers; 3) Saara Amri will discuss how a community-based agency responds to the needs of UM and mediates barriers to successful family reunification through the presentation of a case example; and 4) Dr. Sargent will discuss culturally appropriate therapeutic ways to clinically engage UM and families using family techniques. Conclusions: The mental health dimensions of migration, separation from families, along with multidimensional exposure to trauma, and living in an age of political upheaval present challenges to children and to professionals concerned with their health and development. There are a growing number of UMs, with the demands of mental health needs more than the supply of child and adolescent psychiatrists experienced to work with this population.

FT, FOC, STRESS Sponsored by AACAP's Family Committee, International Relations Committee, and Diversity and Culture Committee http://dx.doi.org/10.1016/j.jaac.2017.07.429

74.1 PUSH AND PULL: AN OVERVIEW OF UNACCOMPANIED MINORS INTO THE UNITED STATES Suzan Song, MD, MPH, PhD, George Washington University Hospital, [email protected] Objectives: The number of youth who migrate alone to the United States is growing at an alarming rate, with the highest number of minors arriving in 2016 in the past decade. Unaccompanied minors (UMs) are separate from the refugee process and continue to arrive, despite the government’s allocation of refugees into the United States. The majority of youth crosses the border from Guatemala, Honduras, and El Salvador, and many experience physical, sexual, and emotional abuse during migration. Knowledge on the traumas that this hidden, although expanding, group of youth experience, as well as the interventions, clinical services, and policies that can benefit these youth, will be discussed. Methods: 1) A systematic review of 22 qualitative and quantitative studies pertaining to the mental health of UMs will be presented; and 2) data regarding the interventions and services of the Office of Refugee Resettlement (ORR) will be discussed to provide an overview of the systems of care and interventions currently in place for unaccompanied minors. Results: Current research involving this population includes an emphasis on the assessment of PTSD, showing a higher level of PTSD symptoms compared with accompanied refugee minors. Studies also showed that age and female gender influence PTSD symptoms. The ORR is mandated with providing mental health services, case management, housing, and family reunification services for these youths and has difficulty managing the high mental health needs of UMs and the shortage of child and adolescent psychiatrists who are experienced with the unique needs of this population. Conclusions: UMs are a growing population of the US youth, who are difficult to access and engage in research. Therefore, additional research is needed that includes the analysis of mental health issues besides PTSD, longitudinal or long-term outcomes, as well as coping skills and resilient mechanisms at the individual and community/policy levels. Moreover, culturally appropriate methods and approaches will assist in better understanding the true experience of these youth. Child and adolescent psychiatrists who are experienced and comfortable working with this population are greatly needed at the national level.

CC, ETHN, FAM http://dx.doi.org/10.1016/j.jaac.2017.07.430

74.2 FAMILY DETENTION OF IMMIGRANT YOUTH IN THE UNITED STATES Andres J. Pumariega, MD, Cooper Medical School of Rowan University and Cooper University Hospital, [email protected] Objectives: The goals of this session are to outline the background for family detention for immigrant youth, psychosocial needs and mental health

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challenges faced by the families in detention, and efforts by advocates and an advisory committee to the federal government to better address these issues. The process of detention, extent of available services, and proposed service model for detained children and families will be presented. Methods: Review of the literature covers experiences in Texas centers and by advocates and key recommendations of the report as they pertain to the mental health needs of detained children and parents. Personal clinical experience on the Federal Advisory Committee on Family Detention Centers, appointed under the Obama administration, to provide consultation to the US Immigration and Customer Enforcement (ICE) and US Department of Homeland Security (DHS) on how to best serve Central American families detained in the centers will also be used. This includes visits to centers, reviews of policies, and construction of a recommendations, and the report for improvement in the services provided to detained children and parents. Results: Centers are run in correctional facilities, with close monitoring and isolation. After legal and health screening, families’ average length of stay was 14 days. In combination of the strict conditions of the centers and the previous traumatic experiences, uncertainty about future lives contributed to depressed mood and chronic anxiety. The Advisory Committee developed a report to the US ICE/DHS, which comprised 165 pages, with 284 recommendations spanning legal rights, health, mental health, trauma-informed care, cultural competence, educational/developmental services, postrelease case management, and oversight and monitoring of the centers. AACAP practice parameters were very useful in constructing many recommendations. Conclusions: The future of how this population will be dealt with by US authorities is uncertain. Current popular reaction and government policies and actions regarding even previously recognized refugee groups bring even more uncertainty and negative outlook to this as-yet unrecognized refugee group, and advocacy will be critical in addressing the challenges faced by this and all refugee groups in the United States, including mental health challenges. The recent advocacy statements by AACAP and APA leadership on where psychiatry stands on these issues are encouraging.

CC, PRE, SP http://dx.doi.org/10.1016/j.jaac.2017.07.431

74.3 FAMILY REUNIFICATION WITH AN UNKNOWN FAMILY Saara Amri, Northern Virginia Family Services, [email protected] Objectives: The objective of this presentation is to highlight, through the presentation of a clinical case example, how a community-based social services agency, such as Northern Virginia Family Service (NVFS), responds to the psychosocial needs of unaccompanied minors and their families and addresses and mediates barriers to successful family reunification. Methods: NVFS provides comprehensive services to unaccompanied minors and their families. Services include intensive case management, individual inhome counseling, family counseling, family and individual education workshops, and immigration legal support. The case being presented is that of a 15-year-old girl from Guatemala who immigrated on her own to the United States to be reunified with her parents after a 12-year separation. The child has an extensive trauma history and is also pregnant. She benefited from comprehensive services offered through NVFS’s family reunification program. Results: The case presentation will demonstrate how these comprehensive services responded to the client’s immediate basic needs, addressed trauma, and repaired the wounds of separation, with the ultimate goal of strengthening her relationship with her family, developing a plan for her and her baby’s future, and minimizing safety and risk factors. Conclusions: Responding to the psychosocial needs of unaccompanied minors and their families in a timely fashion and through comprehensive social service delivery can help to stave further exposure to risk factors associated with being an unaccompanied minor. This is achieved through addressing and cultivating internal and external strengths and mediating barriers to healthy psychosocial adjustment.

ADOL, CC, FAM http://dx.doi.org/10.1016/j.jaac.2017.07.432

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74.4 TREATING FAMILIES DEALING WITH REUNIFICATION WITH UNACCOMPANIED MINORS John Sargent, MD, Tufts Medical Center, jsargent@ tuftsmedicalcenter.org Objectives: Unaccompanied minors immigrating to America face a number of challenges. Reunification with parents and family members can be emotionally difficult and may require professional assistance. Family therapy approaches offer the potential to enhance the process of reunification and can be developed specifically for that purpose. Methods: This presentation will discuss methods of assisting reconnection and reunification in these families. Reunification support must be culturally acceptable and centered on honest openness about the stresses of the experience for the child. The therapist must be relentlessly compassionate and accepting. Family therapy techniques to diminish defensiveness, explore attachments, and repair wounds of disconnection will be presented. Effective use of translators and other cultural navigators will be discussed. The challenge of responding to children’s unacceptable behaviors while preventing further disconnection and alienation will also be presented. Results: Reunification with family members poses many challenges. The entire family may be overwhelmed by their immigrant experience. They may experience discrimination and racism as immigrants. The children also experience the challenges of learning the language and attending school. Often times, there is a mismatch between the children’s experience of abandonment and fear and parent’s relief at reunification. Altogether, they must deal with the relocation experience, the traumas they experienced prior to relocation, and learn to help each other with their shared pain and stress. The family as a whole must deal with the pressures to acculturate and the parents with children’s socially unacceptable survival strategies and behaviors. Relational treatment, including involved family members, can reduce the challenge of reunifying unaccompanied minors with family members after their immigration into the United States. Specific family therapy techniques can be used to assist with repairing family relations. Conclusions: Attending to the connections between unaccompanied minors and family members, dealing with children’s experience of abandonment and fear and rebuilding attachments among family members, can significantly enhance the reunification process and children’s overall adaptation and well-being.

FT, PAT, SP http://dx.doi.org/10.1016/j.jaac.2017.07.433

CLINICAL PERSPECTIVES 75 CHILD PSYCHOLOGICAL ABUSE: AN OLD CONCEPT, A NEW DIAGNOSIS William Bernet, MD, Vanderbilt University Medical Center, [email protected] Objectives: The goal of this study is to provide a comprehensive understanding of child psychological abuse (CPA), including the history of the topic and a contemporary understanding of CPA. We have entered a time of increased awareness and concern about CPA. When DSM-5 was published in 2013, it finally included the novel diagnosis of “child psychological abuse,” defined as “acts by a child’s parent or caregiver that result . in significant psychological harm to the child.” Methods: The presenters have reviewed the work on CPA as listed as follows: the foundations for understanding CPA in the work of developmental psychology; efforts to understand the concept of “psychological maltreatment”; the various definitions of CPA by professional organizations and governmental bodies; the reported prevalence of CPA; research regarding the relationship between CPA and children’s current and subsequent functioning; research regarding the patterns of attachment of maltreated children to their parents; and the worldwide literature regarding parental alienation and its relationship to CPA. Results: James Garbarino, PhD, who introduced the concept of CPA in a seminal book (The Psychologically Battered Child, 1986) will summarize the history of CPA. Marla Brassard, PhD, will present the current understanding of CPA. She was one of the authors of the recently revised American Professional Society


on the Abuse of Children (APSAC) Guidelines for the Investigation and Determination of Suspected Psychological Maltreatment of Children and Adolescents. Amy J.L. Baker, PhD, will discuss the counter-intuitive observation that maltreated children form and maintain close, intimate bonds with abusive parents. William Bernet, MD, will explain how causing parental alienation in a child— i.e., indoctrinating a child to fear or dislike a parent—has become a contemporary form of CPA associated with the high rate of divorce in many countries. Conclusions: CPA is a damaging form of child maltreatment. Current definitions will aid clinicians, forensic evaluators, and child protection personnel in identifying CPA. Children form strong maladaptive attachments to parents who physically abuse them, i.e., parents who indoctrinate the children to reject their other parent without a good reason.

FAM, FCP, CAN Sponsored by AACAP's Children and the Law Committee http://dx.doi.org/10.1016/j.jaac.2017.07.435

75.1 AN OVERVIEW OF CHILD PSYCHOLOGICAL ABUSE James Garbarino, PhD, Loyola University, [email protected] Objectives: The purpose of this presentation is to explain the concept of child psychological abuse within a broad understanding of child maltreatment. The definition of “child abuse” represents a negotiated settlement between science on one hand and culture on the other, with regard to the minimal standards for child care, parenting, and education. Thus, it is an evolving and changing concept (generally in a more expansive and inclusive direction over time). Methods: The presenter reviewed the foundations for understanding child psychological abuse in the work of developmental psychology. He examined professional efforts to understand the concept of “psychological maltreatment” as a source of trauma in the lives of children and youth and to apply the concept to child protective services. These efforts first came to prominence in the 1980s (e.g., The Psychologically Battered Child, by Garbarino, Guttmann, and Seeley, 1986). Results: Six forms of psychological maltreatment are violations of the child’s basic human rights as listed follows: 1) rejecting—sending the child messages that convey worthlessness and fundamental unacceptability; 2) isolating—cutting the child off from normal social relationships or from forming such relationships in the first place; 3) ignoring—failing to provide the child with essential emotional nurturance and responsiveness; 4) terrorizing—using intense fear as a parenting technique to control the child; 5) corrupting—mis-socializing the child in the direction of values that are antisocial or self-destructive, particularly with respect to sexuality, criminal behavior, and/or substance abuse; and 6) degrading— depriving a child of a personal sense of dignity and self-respect. These behaviors send the message that the child is inadequate, lowly, and inferior compared with other similarly aged children. Conclusions: This conceptualization of psychological maltreatment has proven to be useful in clinical as well as forensic contexts. It has been offered as the framework for prosecuting cases of child psychological abuse. In addition, recent research has confirmed the hypothesis that it is psychological maltreatment that inflicts the core developmental damage in most cases of child abuse and neglect.

CAN, FAM, FCP http://dx.doi.org/10.1016/j.jaac.2017.07.436

75.2 AMERICAN PROFESSIONAL SOCIETY ON THE ABUSE OF CHILDREN (APSAC) REVISED PRACTICE GUIDELINES FOR THE INVESTIGATION AND DETERMINATION OF SUSPECTED PSYCHOLOGICAL MALTREATMENT OF CHILDREN AND ADOLESCENTS Marla Brassard, PhD, Columbia University, brassard@tc. columbia.edu Objectives: The purpose of this presentation is to discuss the newly revised American Professional Society on the Abuse of Children (APSAC) Practice Guidelines for the Investigation and Determination of Suspected Psychological Maltreatment of Children and Adolescents. The presentation

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focuses on the expanded definition of psychological maltreatment and the rigorous process through which the guidelines were updated and then highlights a case illustrating their application in child protection and forensic work. Attendees are referred to the ASPAC Monograph on Psychological Maltreatment for the clinical and forensic application of the Guidelines. Methods: Preliminary to revising the Guidelines, Dr. Brassard, along with Columbia University graduate students, used published reviews and comparisons of all major definitions of psychological maltreatment to ensure that all relevant content was considered. They then reviewed all of the pertinent international research (epidemiological, community, and clinical sample groups) on the relationship between each form of psychological maltreatment and children’s concurrent functioning and later adaptation in adulthood. Subcategories of psychological maltreatment strongly supported by the research literature (e.g., psychological control) were added. Results: The revised APSAC Guidelines retain the same six forms of psychological maltreatment as in earlier publications (spurning; terrorizing; isolating; corrupting/exploiting; emotional unresponsiveness; and mental health, medical, and educational neglect) but with expanded content under each. The revised definition provides clear guidance to child protection workers and forensic evaluators. The literature review in the APSAC Monograph on Psychological Maltreatment provides the research base for testimony; practical worksheets and examples are available for case application. Conclusions: The revised Practice Guidelines are a powerful tool for professionals assessing children for suspected psychological maltreatment.

CAN, DIAG, FAM http://dx.doi.org/10.1016/j.jaac.2017.07.437

allies strongly with one parent (the alienating parent) and rejects a relationship with the other parent (the target parent) without legitimate justification. Methods: The presenter will review the definitions of child psychological abuse and compare them to typical behaviors of alienating parents. In addition, he will review the world literature on parental alienation, which uniformly characterizes child psychological abuse as the indoctrination of a child to reject a relationship with a parent without a good reason. Results: Typical features of psychological maltreatment occur in cases of parental alienation: 1) rejecting—parent A scorns the child when he imitates or resembles parent B; 2) isolating—parent A keeps child from seeing parent B; 3) ignoring—parent A ignores child when he expresses an interest in seeing parent B; 4) terrorizing—parent threatens to kill himself unless children express devotion to him; 5) corrupting—parent A teaches child to lie to parent B and spy on activities in parent B’s household; and 6) degrading—parent A says child is stupid for wanting to spend time with parent B. Furthermore, the presenter will review mental health literature from various countries, such as Argentina, Germany, Italy, South Africa, Spain, Sweden, and the United States, which describes parental alienation as a form of child psychological abuse. He will review the laws of two countries, Brazil and Mexico, which define the parental alienation as a form of child abuse. Conclusions: Indoctrinating a child to hate or fear a parent without a good reason is a form of child psychological abuse. Clinicians should use the DSM-5 diagnosis of child psychological abuse when an alienating parent is determined to cause parental alienation in his or her children. Child protection personnel should investigate cases of parental alienation as instances of child psychological abuse.

CAN, FAM, FCP

75.3 BONDED TO THE ABUSER: HOW AND WHY MALTREATED CHILDREN FORM AND MAINTAIN ATTACHMENTS TO ABUSIVE CAREGIVERS



Amy J.L. Baker, PhD, Vincent J. Fontana Center for Child Protection, [email protected]

SEX TALK: PROMOTING HEALTHY OUTCOMES BY FACING DIFFICULT DISCUSSIONS

Objectives: The purpose of this presentation is to explain how and why children who have been maltreated by a parent will nonetheless form and maintain an attachment to that parent. Methods: The presenter reviewed several bodies of research and clinical writings, including the following: 1) 45 memoirs written by adults who were maltreated; 2) attachment theory as conceptualized by John Bowlby, Mary Ainsworth, Mary Blehar, and other seminal writers; 3) attachment research, including a meta-analytic study of patterns of attachment in maltreated children; 4) a review of research studies in which children in foster care were interviewed; and 5) writings and formalized observations of leaders in the field of treatments for abused and neglected children. Results: The theory and data converge to confirm that regardless of the quality of the parent-child relationship and even in the face of extreme and ongoing maltreatment by a caregiver, maltreated children form and work to maintain close intimate bonds with abusive parents. Conclusions: This conceptualization of the psychology of the maltreated child has relevance for mental health treatment for maltreated children as well as formerly maltreated adults seeking to understand and work through their traumatic childhoods.

Niranjan S. Karnik, MD, PhD, Rush University Medical Center, [email protected]; Larry K. Brown, MD, Brown University Alpert Medical School and Rhode Island Hospital, [email protected]; Scott Leibowitz, MD, Nationwide Children’s Hospital and The Ohio State University, [email protected]

ATTACH, CAN, FAM http://dx.doi.org/10.1016/j.jaac.2017.07.438

75.4 PARENTAL ALIENATION: A SPECIFIC EXAMPLE OF CHILD PSYCHOLOGICAL ABUSE William Bernet, MD, Vanderbilt University Medical Center, [email protected] Objectives: The purpose of this presentation is to explain how causing parental alienation is an important contemporary example of child psychological abuse. Parental alienation is the mental condition of a child (usually one whose parents are engaged in a high-conflict separation or divorce) who

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Objectives: The goal of this session is to provide child psychiatrists with a new set of tools and rubrics by which to talk to children and adolescents about difficult topics relating to sex, sexual behavior, and sexual violence. Methods: Presenters will use a combination of reviewing current research literature and clinical best practices. In addition, several presenters will highlight active research studies that examine the elements of the topics outlined and will include relevant materials and new research when it becomes available. When relevant, AACAP Practice Parameters and Policy Statements will be reviewed and distributed to members who attend the session. The agenda is as follows: 1) Sexual Attraction and Relationships (Cynthia Telingator, SOGII Committee Member); 2) Gender Identity and NonConforming Youth (Rebecca Hopkinson, SOGII Committee Member); 3) Sexting (Andrea Mann, Ethics Committee Member); 4) Human Immunodeficiency Virus Infection (HIV) Prevention and Use of PrEP in Adolescents (Shervin Shadianloo, SOGII Committee Member); 5) Talking about Sexual Violence with Youth (Judy Cohen, Cytomegalovirus Committee Member); and 6) Youth Commercial Sexual Exploitation (Eraka Bath, Children and Law Committee Member). Discussants Larry Brown (HIV Issues Committee Member) and Scott Leibowitz (co-chair of the SOGII committee) will comment on the relevance to clinical practice with all youth and the applicability to the specific unique populations of youth whom they specialize in treating. Results: We anticipate significant interest in this Clinical Perspectives session as the topics addressed in this session touch on issues that child psychiatrists face in everyday practice. The review of sexual development, the impact of sexual and gender variation, impacts of trauma, the involvement of family, the

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role of technology, and youth behaviors are all areas that are parts of what child psychiatrists face and address. Conclusions: The outcomes of this Clinical Perspectives are to give clinicians a set of knowledge and tools to better address the array of issues that arise when discussing sex as a topic defined broadly.

Conclusions: Child and adolescent psychiatrists can provide needed care to transgender children and adolescents by being sensitive to issues of sexuality and educated about ways to engage in discussion with this group of people.

ADOL, GID, SAC http://dx.doi.org/10.1016/j.jaac.2017.07.443

AIDS, CAN, RF Sponsored by AACAP's Child Maltreatment and Violence Committee, Sexual Orientation and Gender Identity Issues Committee, HIV Issues Committee, Ethics Committee, and Children and the Law Committee http://dx.doi.org/10.1016/j.jaac.2017.07.441

76.1 SEXUAL ATTRACTION AND RELATIONSHIPS Cynthia J. Telingator, MD, Cambridge Health Alliance, cindy_ [email protected] Objectives: The goal of this session is to enhance the clinicians’ skill and comfort level in taking a sexual and relationship history. A key developmental task of adolescence is gaining a better understanding of one’s sexuality and identity. An important consideration in working with children and adolescents is learning how to both listen to them and talk about sexual identity, sexuality, sexual orientation, and inherent feelings, experiences, and behaviors. Methods: By use of lecture presentation and clinical examples, the presenter will discuss incorporating the topics of sensuality and sexuality in a developmentally appropriate way as a routine part of history taking and clinical work with children and adolescents. Results: After attending this program, attendees will receive tools to facilitate history taking, discuss sexuality and sexual orientation, and help mitigate negative outcomes due to the omission of these important topics in the field of child and adolescent psychiatry. Conclusions: In 2008, S.M. Harris and K.W. Hays [J Marital Fam Ther 34:239– 250] found that a therapist’s education and supervision experience in talking and thinking about patients’ sexuality are the best predictors of therapists’ initiating sexuality-related discussions with their patients. The ability to learn enhanced skills and achieve increased comfort in discussing these topics, as well as teach others how to more effectively incorporate discussions about sexual health into our clinical practices, will ultimately serve as a benefit to improved health and well-being of patients.

ADOL, GID, HO http://dx.doi.org/10.1016/j.jaac.2017.07.442

76.2 GENDER IDENTITY AND NONCONFORMING YOUTH Rebecca Hopkinson, MD, University of Washington, [email protected] Objectives: The goal of this study is to provide child and adolescent psychiatrists with tools to use in assessing and providing care to individuals with diverse gender identities, specifically with regard to discussing sex and sexuality. Individuals with gender dysphoria have diverse sexual identities that are independent of their gender identity. Development of a sexual identity is a key developmental task of adolescence and can be more complex in an individual who questions and considers a change in gender. Comfort with the assessment of sexuality, sexual behaviors, and the effect on self-concept are vital to the role of the child psychiatrist, and exposure to this growing and changing population is much more common today. Attendees to this presentation will leave with increased facility in considering and discussing the interplay of sexuality and gender identity with their patients. Methods: Lecture format will be used with clinical anecdotes to illustrate key points and ideas. The presenter will discuss the impact of gender transition, including social and medical/anatomical changes, on sex and sexuality. Results: Attendees will gain an understanding of specific aspects of sexuality and sex that should be considered and discussed in the care of individuals with diverse gender identities. Attendees will be comfortable discussion sexuality and sexual health with individuals with gender dysphoria.


76.3 SEXTING Andrea P. Mann, DO, MPhil, University of Chicago, Department of Psychiatry and Behavioral Neuroscience, [email protected] Objectives: The goal of this presentation is to provide child psychiatrists with a definition and overview of sexting behaviors, the psychological and legal ramifications, and approaches for discussing this risky behavior with youth and their parents. Methods: The presentation will consist of a review of the growing literature on sexting as it pertains to prevalence, association with sexual abuse, bullying, and mental health consequences. It will also discuss sexting in the context of normal emerging sexual development. Although there are no current AACAP practice parameters specific to sexting, legal implications and recommendations on how to approach discussions about safe use of technology will be discussed based on guidelines from AAP and Harvard University Berkman Center for Internet and Society. Results: We predict this topic to be of significant interest to practicing child psychiatrists as we discuss the impact of technology on normal sexual development and the potential to cause trauma. Conclusions: This presentation within the Clinical Perspectives session will grow clinicians’ knowledge on an important child public health issue and provide guidelines safeguarding against risky technology use with families.

ADOL, ETH, RF http://dx.doi.org/10.1016/j.jaac.2017.07.444

76.4 HUMAN IMMUNODEFICIENCY VIRUS (HIV) PREVENTION AND USE OF PRE-EXPOSURE PROPHYLAXIS (PREP) IN ADOLESCENTS Shervin Shadianloo, MD, Hofstra Northwell School of Medicine at Hofstra University, shervin.shadianloo@ gmail.com Objectives: Many youths experience their first sexual contact during their adolescence. Adolescents and young adults are at high risk for contracting HIV and are the targeted population for preventative plans. Child and adolescent psychiatrists’ knowledge about these risks and appropriate referrals can potentially prevent or reduce the risk. In this presentation, attendees will learn about the risk of contracting HIV in youth and the use of pre-exposure prophylaxis (PrEP), indications, obstacles, and current CDC guidelines. Methods: The risk of contracting HIV in various sexual and gender minorities will be discussed, as well as the available data on youth and risk of sexually transmitted infections (STI) and HIV infection in youth. This presentation will also highlight the differences between PrEp and postexposure prophylaxis (PEP), current available data, and indications in youth, including CDC guidelines. The screening for risk of HIV in youth, issues of consent and involving parents, and referral to appropriate services will be discussed. The controversy about the use of PrEP, increased risk of other STI, stigma associated with HIV, and compliance will be presented as well. Results: Emtricitabine/Tenofovir oral daily tablet is the only available PrEP and has become widely available and covered by most insurance policies in the United States. Several studies have shown its high efficacy in protecting against HIV contraction in adult males who have sex with males. There is some but limited data on PrEP use in adolescents; however, the current research supports its safety. CDC advises that adolescents at risk should be screened for HIV and that PrEP can be considered. Parental consent remains an issue and needs to be addressed based on jurisdictions. A study of youth ages

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15–17 years on PrEP in the United States shows that the risk of STI decreased and that those who had become positive STI had poor compliance in taking the medication. Conclusions: The stigma associated with HIV has long overshadowed screening, prevention, and treatment of it. Adolescents and youth are key targets for preventative services against HIV, and PrEP has become one of the available methods of prevention. Psychiatrists often see impulsive youth who are at risk for contracting HIV. They should be able to identify these individuals, provide evidence-based information, and refer them to appropriate services.

AIDS, ADOL, SEX http://dx.doi.org/10.1016/j.jaac.2017.07.445

76.5 TALKING ABOUT SEXUAL VIOLENCE WITH YOUTH Judith A. Cohen, MD, Allegheny Health Network, JCohen1@ wpahs.org Objectives: Even though more than 20 percent of youth experience sexual abuse/assault before adulthood, many child and adolescent psychiatrists are uncomfortable talking about sexual violence with youth. This session presents practical ways for child and adolescent psychiatrists, as well as other professionals, to effectively talk about sexual violence with youth. Methods: Judith Cohen, MD, describes the negative mental health and medical impacts of sexual violence on youth and reasons that youth avoid talking about these experiences. Active coping rather than avoidance helps professionals talk to youth about sexual violence. Specifically, this presentation describes how professionals can better talk to youth about sexual violence through 1) providing psychoeducation about healthy vs. unhealthy sexuality; 2) maintaining a nonjudgmental stance; 3) asking directly about sexual violence by using age-appropriate language; and 4) modeling acceptance (open-body posture, not changing speech volume or tone, maintaining eye contact). These strategies also help youth transition to effective traumafocused treatment. Results: Modeling active coping rather than avoidance encourages youth to talk about their sexual violence experiences and helps youth to transition to effective treatment. Conclusions: Child and adolescent psychiatrists can use specific active coping strategies to encourage youth to talk about sexual violence experiences and responses.

EBP, PTSD, STRESS http://dx.doi.org/10.1016/j.jaac.2017.07.446

76.6 YOUTH COMMERCIAL SEXUAL EXPLOITATION Eraka Bath, MD, University of California, Los Angeles Semel Institute for Neuroscience and Human Behavior, ebath@ mednet.ucla.edu Objectives: Commercially sexually exploited youth (CSEY) are exposed to high rates of physical and sexual violence that can have lasting effects on their mental health. CSEY are at risk for PTSD, depression, substance use disorders (SUDs), self-harm, sexually transmitted infections, and reproductive complications. Despite their vulnerability to a myriad of health concerns, programs addressing engagement of CSEY in treatment or the specific mental health need or SUD needs of CSEY are limited. Our study aims to examine CSEY’s perspective on their overall health needs, including barriers to receiving treatment and specific experiences with using available SUD, mental, and reproductive health services. Methods: We performed in-depth thematic content analysis of five focus groups conducted with CSEY (n ¼ 18 girls) at residential group home facilities in Los Angeles, CA. The focus groups were audio-recorded, transcribed, and coded for main themes. The groups explored CSEY’s experiences with health services, including barriers to treatment, preferred services, and recommendations for improving delivery of mental health and SUDs services.

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Results: Findings indicated that CSEY reported a variety of knowledge on community resources providing mental health, SUD, and reproductive health care (free clinics, group homes, drop-in centers). Youth discussed personal, structural, and perceived barriers to receiving mental health services (fear of being arrested by law enforcement, dislike of questions asked by mental health providers, feeling judged, or not wanting to admit to needing treatment). CSEY described innovative recommendations for improving outreach and communication and to enhance delivery of mental health and SUD care. Conclusions: Results indicate that CSEY have insight into their mental health and SUD needs, yet their experiences and perceptions of services create reluctance to access mental health care. It is essential to include the voices of CSEY to inform development and delivery of mental health and SUD programs. Understanding CSEYs’ perceptions of their mental health and SUD needs, patterns, and barriers to using services can assist practitioners in improving the delivery of services to this highly vulnerable and underserved population.

AIDS, AGG, CAN Supported by the AACAP Physician Scientist Program in Substance Abuse, supported by NIDA http://dx.doi.org/10.1016/j.jaac.2017.07.447

CLINICAL PERSPECTIVES 77 INDIVIDUALIZED DEFERRED DISPOSITION DOCKET: ADDRESSING MENTAL ILLNESS IN THE JUVENILE COURT Sarah Mallard Wakefield, MD, Texas Tech University Health Sciences Center, sarah.wakefi[email protected]; Pamela McPherson, MD, Shreveport Mental Health Center, [email protected] Objectives: The first juvenile court was established in Chicago in 1899. Juvenile courts were founded to prevent future recidivism and matriculation into the adult court system. Juvenile courts have become more “criminalized” over the last 30 years as state legislators have enacted new statutes to reduce juvenile crime. Currently, states can vary widely in the definition of the purpose for their juvenile courts with increasing states focused on punishment, deterrence, accountability, and/or public safety. Mental health courts are specialized courts formed to divert appropriate defendants into judicially supervised probation focused on the treatment of mental illness and prevention of future justice involvement. Mental health courts use a community-based multidisciplinary treatment approach to achieve these goals. This presentation will describe the history and purpose of juvenile courts in America to establish a context for understanding mental health courts in the juvenile court system. Methods: The history of the juvenile court system in America, the unique mission it was founded to serve, and the ways in which this has changed over time will be discussed. The environment that prompted the advent of juvenile mental health courts and in what areas of the country these specialized courts have been popular will be discussed. Results: Juvenile courts were established in the best interest of the child to prevent future recidivism but have become more criminalized in focus over the last few decades. Justice-involved youth have a higher rate of mental illness diagnoses than those not involved in the justice system. Conclusions: Juvenile mental health courts can function in the best interest of the child for children and adolescents with mental illness diagnoses involved in the juvenile justice system.

PUP, JJS, SP Sponsored by AACAP's Children and the Law Committee http://dx.doi.org/10.1016/j.jaac.2017.07.449

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77.1 CREATING AN INDIVIDUALIZED DEFERRED DISPOSITION DOCKET, A.K.A. JUVENILE MENTAL HEALTH COURT: WHY DO WE NEED IT? HOW DID WE GET THERE? Laura Alderman, Step Forward: The Community Foundation of North Louisiana, [email protected] Objectives: Juvenile courts vary in their focus around the country on the emphasis that their state statute places on public safety, individual accountability, community protection, punishment, and promotion of child welfare. An exceedingly high number of justice-involved youth also have mental health diagnoses and have a unique set of characteristics, including the need for mental health treatment. These youth can be better served within the juvenile justice system when their mental illnesses are taken into account. The goal of juvenile mental health courts is to increase recognition of mental illnesses that affect a child’s justice involvement and to increase adherence to treatment to reduce recidivism and matriculation into the adult justice system. This presentation will describe how a juvenile mental health court was established through community involvement and the advocacy of interested experts. Methods: Laura Alderman is the founding administrator of the Juvenile Mental Health Court in Caddo Parish, Louisiana and will discuss factors considered in the development of this individualized docket, including organizing community advocacy efforts, seeking input from relevant experts, including child and adolescent psychiatrists in the development of screening and treatment models associated with the court, and establishing training for specialized probation officers. Results: As a community, Caddo Parish determined the need for a Juvenile Mental Health Court. Experts in the community were vital to informing the development of screening and evaluation procedures in addition to recommendation for treatment strategies. Conclusions: Communities can advocate for juvenile mental health courts, and experts in the community, including child and adolescent psychiatrists, can play a vital role in development of these individualized dockets.

JJS, PUP, SP http://dx.doi.org/10.1016/j.jaac.2017.07.450

77.2 A JUDGE’S PERSPECTIVE: WHAT TO KNOW WHEN YOU ARE TREATING A JUSTICE-INVOLVED YOUTH Paul Young, JD, Caddo Parish Juvenile Court, pyoung@ caddo.org Objectives: Juvenile mental health courts have been established across the country to take into consideration the unique characteristics of justiceinvolved youth with mental illness diagnoses and to better prevent recidivism and matriculation into the adult justice system. Juvenile mental health courts attempt to do this by providing judicial oversight of mental health treatment. Mental health treatment is most commonly received in the community setting within existing systems of care. This presentation will describe struggles associated with judicially supervised mental health care for children and families housed in existing community systems and provide recommendations for improved collaborative care of justice-involved youth with mental illness diagnoses. Methods: Judge Young is the presiding judge over the Individualized Deferred Disposition Docket in Caddo Parish, also known as the Juvenile Mental Health Court. Judge Young was previously a mental health advocate attorney for the state of Louisiana. Judge Young will discuss ongoing struggles with judicial oversight of mental health treatment and best practice for child and adolescent psychiatrists to communicate concerns regarding justice-involved youth. Results: Justice-involved youth with mental illness diagnoses often go without treatment. Judicial oversight can improve access to treatment. Feedback from child and adolescent psychiatrists and other treatment providers is helpful for evaluation of the effectiveness of probation programs and determination of changes in probation expectations.


Conclusions: Justice-involved youth with mental illness diagnoses benefit from collaboration between child and adolescent psychiatrists and the judicial system.

CC, JJS, SP http://dx.doi.org/10.1016/j.jaac.2017.07.451

77.3 THE MULTISYSTEM CONTACTS OF YOUTH WITH BEHAVIORAL HEALTH DISORDERS Lisa Callahan, PhD, Policy Research Associates, lcallahan@ prainc.com Objectives: This session will focus on the outcomes of juveniles participating in juvenile court based on research done in collaboration with multiple juvenile mental health courts in the United States through the Policy Research Associates. Methods: Two National Institute of Justice funded studies examine youth in a behavioral health treatment court in one large urban county in Ohio. The first study compares youth who are in the treatment court with similar youth who are processed as usual through probation and court. This study finds that youth in treatment court receive treatment significantly more before and after intake compared with treatment of their peers. A second study focuses on youth in treatment court as one of four “pathways” through the juvenile justice system—regular probation, treatment court, intensive probation, and state detention. This study follows all youth (N ¼ 2,592) who entered the same county’s juvenile court from 2004 to 2008. Data were collected on all subjects through 2013, resulting in a range of five to nine years of follow-up. We examine data from 12 state and local agencies, including criminal justice and social welfare agencies. Results: Youth in treatment court are more likely to have a history of child abuse cases (as a child) and cases of neglect (as a parent). As a child, they are more likely to be temporarily removed from the home and/or placed in a residential center than other court-involved youth. The treatment court youth have better adult criminal justice outcomes than either the intensive probation or state detention youth, yet two-thirds were arrested as an adult. Among the 2,592 youth who entered the juvenile court, approximately 30 percent of the treatment court youth would be considered “desisters,” meaning they had no more contact with either the juvenile or adult criminal court during the followup period, a better outcome than both the intensive probation and state detention youth. Conclusions: There are obvious differences between youth who are selected as appropriate for a juvenile mental health court docket and those who are seen on the typical juvenile court docket. These children have greater social stressors, but they also appear to have improved future outcomes compared with youth in other justice programs.

JJS, LONG, SP Supported by the National Institute of Justice http://dx.doi.org/10.1016/j.jaac.2017.07.452

77.4 CHARACTERISTICS ASSOCIATED WITH SUCCESSFUL COMPLETION OF JUVENILE MENTAL HEALTH COURT PROBATION Stephanie Brennan, MD, Texas Tech University Health Sciences Center, [email protected] Objectives: Although the characteristics of the juvenile mental health courts have been studied, variables related to youth success in these programs have received little attention. This study reports on characteristics of those children assigned to probation under the authority of the juvenile mental health court and factors correlated with success in the program versus removal to state custody. Methods: Demographic, educational, psychiatric, family, legal history, highrisk and protective factors from the Structured Assessment of Violence Risk in Youth (SAVRY), and significant factors from Massachusetts Youth Screening Instrument (MAYSI) and DISC-IV were retrospectively collected from encounters from 2008 to 2015 for children ages 10–18 years who were arrested

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and placed on probation in the Juvenile Court Individualized Disposition Docket (IDD) for youth with serious mental illness. Frequency analysis was performed, and psychosocial risk factors were correlated with one another using chi-square analysis to identify common characteristics of youth in IDD court. Psychosocial risk factors were correlated with frequency of probation violations, new charges while in IDD, sanctions placed while on probation, and removal to state custody. Results: Youth successful in juvenile mental health court probation had greater support from guardians, less previous justice involvement, and fewer new charges during the probationary period. Being at risk for removal to state custody at the beginning of probation did not correlate with eventual removal to state custody. Conclusions: Juvenile mental health courts serve the specific population of justice-involved youth with serious mental illness. Youth complete probation successfully despite being at high risk for removal to state custody.

JJS, PSP, SP http://dx.doi.org/10.1016/j.jaac.2017.07.453

CLINICAL PERSPECTIVES 78 PART 1: COMPLEMENTARY AND INTEGRATIVE MEDICINE IN CHILD AND ADOLESCENT PSYCHIATRIC DISORDERS: FACT, FICTION, AND CHALLENGES IN CLINICAL EDUCATION AND RESIDENCY TRAINING Deborah R. Simkin, MD, Emory University School of Medicine, [email protected] Objectives: The purpose of this Institute is to educate child and adolescent psychiatrists about the research involving complementary and integrative medicine (CIM). Methods: Each presenter will summarize research using the US Preventative Services Task Force criteria. Side effects and drug interactions will also be discussed. Each presenter will review a case example. The following clinicians will review the literature on CIM: Dr. Arnold (ADHD), Dr. Hendren (autism spectrum disorder [ASD]), Dr. Fristad (mood and internalizing disorders), Dr. Simkin (gut-brain axis and food as medicine), Dr. Lubar (neurofeedback), and Dr. Hudziak (meditation). Results: In a 2007 family survey study (N ¼ 112), 74 percent were using complementary and alternative medicine (CAM) for their child with ASD. A 2012 study found that 67 percent of youths with ADHD use CIM. Child and adolescent psychiatry residencies and continuing medical education have historically lacked inclusion of issues related to CIM. Omega-3 (U3) fatty acids were effective in decreasing depressive symptoms in youth with bipolar disorder (BD) and depression, as well as mania in youth with BD. Three agents with a rationale for use with ASD include melatonin, U3 fatty acid, folate, and other micronutrients. Additional agents with promise include N-acetyl cysteine, methyl cobalamin (methyl B12), and digestive enzymes. Quantitative EEG neurofeedback studies targeting ADHD have shown an effect size (ES) ranging from 1.78 to 2.22 for attention (ATT) and 1.2 for hyperactivity without a placebo control compared with stimulant placebocontrolled ES for ATT of 0.84. Dysbiosis and increases in inflammatory agents in the gut signal the vagal nerve, which induces glucocorticoid resistance that impairs negative feedback on the hypothalamic-pituitaryadrenal axis, and overstimulates microglia, which has been associated with symptoms of mental illness. Diet and probiotics have been associated with reduced symptoms of mental illness. Mindfulness has been effective as an adjunct treatment for depression and anxiety disorders. RCTs with micronutrients demonstrated a 50 percent reduction in aggressive conduct disorder in school children and ADHD response rates of 63–76 percent in youth. Conclusions: Psychiatrists and residency training programs need to be prepared to discuss the potential benefits and risks of CIM.

CAM, ADHD, ASD

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Sponsored by AACAP's Complementary and Integrative Medicine Committee, Psychopharmacology Committee, Training and Education Committee, and Health Promotion and Prevention Committee http://dx.doi.org/10.1016/j.jaac.2017.07.455

78.1 COMPLEMENTARY AND INTEGRATIVE MEDICINE IN ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER L. Eugene Arnold, MD, Ohio State University, L.Arnold@ osumc.edu Objectives: The goal of this study is to describe the evidence base of interventions for ADHD other than standard medication and behavioral treatment. Methods: Complementary and alternative treatments are reviewed and classified as to the quality and degree of evidence. Results: Dozens of treatments have been advocated for ADHD. Some verge into standard treatment for specific cases (thyroid for documented low thyroid; iron, zinc, magnesium or specific vitamin for documented insufficiency/deficiency; and chelation for documented heavy metal burden). Most do not have conclusive evidence of effectiveness and safety for ADHD, but some have enough evidence to justify individual patient trials on the basis of being Safe, Easy, Cheap, and Sensible (SECS). These include protein-containing low-sugar breakfast, omega-3 fatty acids, recommended dietary allowance/recommended dietary intake multivitamin/mineral supplementation, attention to seasonal need for vitamin D, minimization of food dye, reasonable refined sugar restriction, moderate exercise, adequate sleep, some brain-training games, and reasonable restriction of TV and electronic device time. For some, the evidence for ADHD symptoms is tenuous, but the intervention has general health benefits and may help ADHD, at least indirectly. For others there is good evidence (e.g., omega-3 fatty acids have a dozen placebo-controlled trials and two meta-analyses showing a small-to-medium benefit). On the other hand some advocate for treatments that carry risk, with little evidence of benefit. At our current state of knowledge we advise against multi-megavitamins, large mineral doses without evidence of insufficiency, large doses of refined amino acids, antifungal treatment without evidence of fungus infection, chelation without evidence of heavy metal poisoning, thyroid hormone without evidence of low thyroid, and most herbs. Herbs are crude drugs that can have side effects and interact with prescription medication. Drug interactions will be discussed. Conclusions: Evidence for complementary/alternative treatments for ADHD varies widely. Most can be combined with standard medication and behavioral treatment, but some can interact adversely.

ADHD, CAM, MDM http://dx.doi.org/10.1016/j.jaac.2017.07.456

78.2 COMPLEMENTARY AND INTEGRATIVE MEDICINE IN THE TREATMENT OF AUTISM SPECTRUM DISORDER Robert L. Hendren, DO, University of California, San Francisco, [email protected] Objectives: The goals of this session are to 1) critically review the wide variety of complementary and integrative medicine (CIM) treatments proposed for the treatment of people with autism spectrum disorder (ASD) using the US Preventive Services Task Force criteria; 2) describe in more detail the studies with stronger evidence of efficacy; 3) describe how to discuss CIM with families of people with ASD; and 4) describe how CIM treatments with the strongest evidence can be incorporated into practice through case examples and what to do if families want to try those treatments without strong evidence. Methods: This update begins with a review of large-scale, web-based surveys conducted on thousands of parents of children with ASD by the Autism Research Institute about their use of and experience with a wide range of

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CIM treatments. This will be followed by critical review of the growing number of metabolic tests used variably for ASD, including gastrointestinal, metabolic, and immunological assessment. CIM treatments for ASD with the strongest evidence and greatest promise will be described in more detail. Results: A rationale for biomedical CIM treatments for ASD is their potentially beneficial effect on epigenetic processes, which are increasingly demonstrated to have a role in the gene x environment interactions that underlie the development of ASD. A review of the evidence reveals that, whereas many CIM treatments are being used with little evidence of efficacy, there is an emerging body of studies that suggest that several of these treatments may be beneficial as targeted treatments for certain individuals. Three agents with a rationale for use with ASD, with at least one RCT showing efficacy and safety data, include melatonin, omega-3, and folate and micronutrients. Additional agents with promise include NAC, methyl cobalamin (methyl B12), and digestive enzymes. Conclusions: Research on CIM treatments for ASD is in its early stages, but emerging data suggest several promising directions for targeted treatments of metabolic processes.

ASD, ND, TREAT http://dx.doi.org/10.1016/j.jaac.2017.07.457

78.3 GUT-BRAIN AXIS AND FOOD AS MEDICINE Deborah R. Simkin, MD, Emory University School of Medicine, [email protected] Objectives: The goal of this session is to discuss the gut-brain axis and food as medicine. Methods: A review of the literature will be discussed. Results: Microbes are necessary for hypothalamic–pituitary–adrenal (HPA) development, but the microbe environment is unstable in the first through third years of life. Early exposure to antibiotics and caesarean sections is associated with a significantly increased rate of food allergy. Intestinal permeability (IP) is related to 50–100 percent of patients with food intolerance to processed foods; pathogen-associated molecular patterns, such as fungi, bacteria-producing endotoxin lipopolysaccharides (LPS), and viruses; and high-fat fast food. In turn, proinflammatory cytokines, such as tumor necrosis factor a, interleukin (IL)-1b, and IL-6, are released, which signal the afferent vagal nerve located in the gut. Chronic signaling induces glucocorticoid resistance that impairs negative feedback on the HPA found in depression, PTSD, and bipolar disorder. Microglia are also activated by cytokines, the afferent vagal nerve, and increased levels of glutamate associated with the acute stress exposure, which all lead to impaired synaptic plasticity. The result is neuronal dysfunction and mental health disorders. This process has been linked to symptoms of depression, autism, and Rett syndrome. Interventions that reduce the inflammatory process have been helpful. In an RCT in 2015, infants who received Lactobacillus rhamnosus or placebo during the first six months of life were studied for 13 years. At the age of 13 years, ADHD or ASD was diagnosed in six of 35 (17.1 percent) children in the placebo group and none in the probiotic group (P ¼ 0.008). The severity of psychiatric symptoms can also be influenced by diet. In one study in 2011, the foods were eliminated until symptoms of ADHD decreased. Of the 78 children who tried the diet, 59 of them improved. However, when re-exposure to the foods occurred, 47 children relapsed after the challenge (60 percent). Open-label studies have shown that treating the gut with probiotics, prebiotics, and dietary changes can attenuate psychiatric symptoms. Conclusions: The gut-brain axis is a complicated process that requires more research.

NI, EBP, CAM http://dx.doi.org/10.1016/j.jaac.2017.07.458


CLINICAL PERSPECTIVES 79 PSYCHOTHERAPY TECHNIQUES FOR TREATING THE MEDICALLY ILL OR INJURED CHILD Carol M. Larroque, MD, University of New Mexico, carol. [email protected]; Annah N. Abrams, MD, Massachusetts General Hospital, [email protected] Objectives: The goals of this presentation are as follows: 1) to describe the emotional burden of physically ill children and their families; 2) to demonstrate a variety of play therapy techniques effective in diagnosis and treatment of medically ill children; and 3) to describe a brief multifamily psychoeducational group for youth suffering from asthma Methods: Carol Larroque, MD, previous director of the Pediatric Consultation Liaison Service at the University of New Mexico, will chair the Clinical Perspective. She will also discuss the manner in which interactive play therapy can be used as a tool to communicate with children and can facilitate healing, especially in cases of medical impasse. Frederick J. Stoddard Jr, MD (Massachusetts General Hospital, Harvard Medical School, and the Shriners Hospital for Children), will share extensive knowledge of children with burn injuries. He will report on a 25-year literature review of play therapy. He will present eight cases of acutely burned children to illustrate therapeutic play techniques for diagnosis and treatment. Marianne Wamboldt, MD (University of Colorado), has much experience treating physically ill children and adolescents. She will describe a multifamily group intervention for youth with asthma and their parents and siblings that was developed at a tertiary care hospital for respiratory illnesses. Annah N. Abrams, MD, former chief of the pediatric consultation liaison service and current director of the Pediatric Psycho-Oncology Division at Massachusetts General Hospital will take the role of discussant. Results: Psychotherapy plays an important role in the treatment of medically ill or injured children and adolescents. Multiple techniques using play therapy and family work are presented. Conclusions: Child and adolescent psychiatrists must be well equipped with a variety of treatment modalities to address the needs of special populations. Play therapy and family therapy are effective tools when working with medically affected children.

PYI, FT, P Sponsored by AACAP's Physically Ill Child Committee http://dx.doi.org/10.1016/j.jaac.2017.07.460

79.1 INTERACTIVE PLAY: A TOOL TO COMMUNICATE WITH THE PHYSICALLY ILL CHILD Carol M. Larroque, MD, University of New Mexico, carol. [email protected] Objectives: The goal of this presentation is to demonstrate ways the use of play can be a creative and successful way to interact with medically ill or injured children and adolescents, especially in difficult situations when there may be an impasse between patient and necessary medical care. Methods: Carol Larroque, MD, previous director of the Pediatric Consultation Liaison Service at the University of New Mexico, will discuss the psychological reasons behind the effectiveness of play when working with physically ill children in the context of a medical setting and how such play can facilitate the child’s role in the healing process. Discussion of case reports will illustrate play techniques effective in positively changing the medical course of a patient and will explore the reasons for success. Three cases of youngsters admitted to the pediatric hospital will be discussed as follows: 1) a healthy toddler who suddenly refused to eat or drink for several days; 2) a latency age boy who experienced significant trauma in a car accident; and 3) a resistant

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teenager newly diagnosed with type 1 diabetes. In discussing these cases, Dr. Larroque will show how they relate to the following four categories of therapeutic playfulness described by Lenore Terr and her colleagues in the article “Playful ’Moments’ in Psychotherapy” (JAACAP, 2006;45:604-613): 1) using the process of play to communicate; 2) commenting pungently and with good timing on play; 3) serving up creative surprise and adventure; and 4) developing mutually understood, imaginative codes. Results: Appropriate play techniques have been shown to be clinically effective in working with children of all developmental ages in a medical setting. Four categorical principles help explain the efficacy. Conclusions: Interactive play is a useful tool to communicate with children in difficult medical situations.

PYI, P, REST http://dx.doi.org/10.1016/j.jaac.2017.07.461

79.2 THERAPEUTIC PLAY IN THE DIAGNOSIS AND TREATMENT OF HOSPITALIZED CHILDREN RECOVERING FROM ACUTE BURNS Frederick J. Stoddard Jr., MD, Harvard Medical School, [email protected] Objectives: The goal of this session is to describe and illustrate methods using therapeutic play in English or Spanish for child psychiatric diagnosis and treatment with acutely burned children. Methods: A PubMed search of the literature over the last 25 years indicated key elements and findings from play therapy. A review of care of hospitalized burned children revealed eight cases that illustrate play modalities essential to diagnosis and/or treatment. Criteria for selection are as follows: 1) ages of children; 2) gender; 3) injury severity; and 4) clinical context of play. Results: The eight children selected were as follows: 1) acute scalding from abuse in a two-year-old boy who played out the abuse in a dollhouse context; 2) puppet play using displacement to enable a five-year-old girl in the intensive care unit to express in play the gasoline explosion that burned her; 3) playing catch with a football with a depressed boy (age 13 years) who suffered facial injury from a bomb; 4) a 10-year-old boy with arm amputations drawing a self-portrait holding a crayon in his toes; 5) a 14-year-old girl with a facial burn drawing an accurate self-portrait; 6) puppet play with four boys undergoing reconstructive surgery, allowing verbal group expression of aggression in a controlled setting; 7) drawings by a 10-year-old girl traumatized by watching images on TV of bodies falling from the World Trade Center; and 8) two seven-year-old boys relieving fears of death by playing out car crashes with matchbox cars. Conclusions: Therapeutic play, adapted to the clinical context of injured children, is useful to clarify diagnosis and initiate age-appropriate expressive treatment, relieving anxiety and/or depression of varying disorders, including pain, delirium, acute stress, PTSD, and depression. The cases are interpreted using the literature review, key findings from therapeutic play, and works by Anna Freud, Lenore Terr, MD, and Steven Ablon, MD.

DEV, DIAG, P http://dx.doi.org/10.1016/j.jaac.2017.07.462

79.3 FAMILIES RATE MULTIFAMILY PSYCHOEDUCATION GROUPS FOR MEDICALLY ILL YOUTH AS HELPFUL Marianne Wamboldt, MD, University of Colorado School of Medicine, [email protected] Objectives: The goal of this session is to present the rationale for and specific techniques of a brief multifamily psychoeducational group as a preventative and therapeutic intervention for youth suffering from asthma, their siblings, and parents. Family-rated attitudinal changes from a series of standardized multifamily groups will be presented. Methods: A multifamily group intervention for youth with asthma and their parents and siblings was developed at a tertiary care hospital for respiratory illnesses. The protocol consisted of a five-hour intervention taking place over two days. Basic asthma education was presented on day one for family members of at least 12 years of age. On day two, there was a

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discussion of ways in which asthma had challenged the ill youth, the siblings of the ill youth, and parents by using a “group in a group” family therapy technique. Negative emotions were normalized, and families were taught to focus their negative emotions on the illness and not the person with the illness. Use of art therapy techniques allowed all ages of the family to participate. Over a six-month period, 17 groups were held. A total of 164 persons older than eight years representing 72 families filled out preand postquestionnaires. A six-item attitudinal measure was developed by the clinical team as part of the program evaluation. Responses were scored on a visual analogue scale. Results: The group as a whole reported statistically significant (P < 0.01) changes in attitudes in a positive direction on two items: “Do you feel others understand and are helpful to your child and family regarding the illness?” and “Is it helpful for family members to share their feelings about the illness with each other?” For each of these questions, there was no significant group change in either direction, but the range of changes across individuals was quite large in both directions. There were no significant group effects. Conclusions: This model was based on a medical setting and used a highly structured protocol, which allowed variously trained clinicians and trainees to lead the group and still maintain effects across groups. It not only was seen to be helpful for families but also for teaching collaborative care to team members from a number of professional backgrounds.

CAM, FAM, PYI http://dx.doi.org/10.1016/j.jaac.2017.07.463

CLINICAL PERSPECTIVES 80 PART 2: COMPLEMENTARY AND INTEGRATIVE MEDICINE IN CHILD AND ADOLESCENT PSYCHIATRIC DISORDERS: FACT, FICTION, AND CHALLENGES IN CLINICAL EDUCATION AND RESIDENCY TRAINING Deborah R. Simkin, MD, Emory University School of Medicine, [email protected] Objectives: The goal of this session is to educate child and adolescent psychiatrists on the research involving complementary and integrative medicine (CIM). Methods: Each presenter will summarize research using the US Preventative Services Task Force criteria. Side effects and drug interactions will also be discussed. The following clinicians will review the literature with regard to CIM: 1) Dr. Fristad (mood and internalizing disorders); 2) Dr. Popper (micronutrients); and 3) Dr. Lubar (neurofeedback [NF]). Results: On the subject of broad-spectrum micronutrients, an RCT found a 50 percent reduction in conduct disorder in school-aged children, and three RCTs showed reduced violence and rule violations (by 25 -40%) in teenage- and young adult-incarcerated offenders. An RCT found that ADHD response rates are 63 -76 percent in youth. Open-label data suggest strong effects in bipolar disorder and non-bipolar depression. However, drug interactions with broad-spectrum micronutrients must be carefully managed. On the subject of neurofeedback, quantitative EEG neurofeedback studies used surface NF for ADHD pre-posteffect sizes of 1.8 -2.2 for attention and 1.2 for hyperactivity/impulsivity. Unlike stimulants, NF effects on ADHD were found to endure for 6 -24 months after discontinuation of treatment. An RCT of NF targeting low-coherence brain regions showed an increase of mean reading scores of 1.2 years over 10 weeks (20 sessions). A double-blind placebo-controlled trial, comparing Low Resolution Electromagnetic Tomography (LORETA) NF to sham EEG-phase NF evaluating changes via MRI and EEG functional connectivity networks, showed improvements in the frontal-parietal network, default mode network, auditory network, and the dorsal attention network. On the subject of internalizing disorders, omega-3 fatty acids combined with psychoeducational/psychotherapy was more effective in youth (compared to placebo or active monitoring) for treatment of the following symptoms: 1) depressive and manic symptoms in youth with bipolar disorder; 2) depressive and behavioral symptoms in endogenous depression (with minimal stressors and positive family history); and 3) executive functioning in both disorders. Few RCTs are available for St John’s Wort,

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S-adenosylmethionine, and 5-hydroxytryptophan in youth, but their adverse effects and drug-drug interactions can be significant Conclusions: Psychiatrists and residency-training programs need to be prepared to discuss the potential benefits and risks of CIM.

DDD, CAM, NM Sponsored by AACAP's Complementary and Integrative Medicine Committee, Psychopharmacology Committee, Training and Education Committee, and Health Promotion and Prevention Committee http://dx.doi.org/10.1016/j.jaac.2017.07.465

80.1 BROAD-SPECTRUM VITAMIN-MINERAL COMBINATIONS FOR TREATING PSYCHIATRIC DISORDERS OF YOUTH Charles W. Popper, MD, Harvard Medical School, Charles_ [email protected] Objectives: Minerals and vitamins are involved in virtually every biological process, so micronutrient deficiencies have broad effects throughout the body and brain. Treatments that remedy deficiencies are examined for effects on psychiatric symptoms and normal mental functions in youth. Methods: Safety and efficacy data on vitamin, mineral, and combination treatments in youths; nutritional epidemiologic findings; proposed mechanisms of action; and clinical implications are reviewed. Results: Micronutrient insufficiencies are present in most youth, even in “well-fed” populations. Certain single nutrients (eicosapentaenoic acid/docosahexaenoic acid, folate, vitamin D, B12) may have clinical value for a few psychiatric indications, but effect sizes (ES) are small, and none are powerful enough to constitute monotherapies. In contrast, micronutrient formulations containing a broad spectrum of minerals, and vitamins appear to be effective in RCTs as potent treatments of aggressive and disordered conduct, ADHD, mood disorders, and anxiety/stress. Three RCTs show reduced violence and rule violations (by 26 -47%) in young incarcerated offenders, and an RCT found reduced aggressive conduct disorder in school-aged children. A RCT found reduced hyperactivity/impulsivity (ES ¼ 0.46 -0.67) and inattention (ES ¼ 0.33 -0.62) scores in adults with ADHD; ADHD response rates were 63 -76 percent in youth and 64 percent in adults. An RCT on depressive symptoms (Montgomery- Asberg Depression Rating Scale 20) and comorbid ADHD in adults showed broad-spectrum micronutrients (ES ¼ 0.64), with an antidepressant effect similar to standard antidepressants. Three RCTs show reduced ratings for anxiety, stress responses, and posttraumatic stress symptoms following natural disasters (ES ¼ 0.7 -1.2). A meta-analysis found improved academic performance in healthy school-aged children (ES ¼ 0.44). Adverse effects, laboratory findings, clinical advisories, and medical cautions are described. Conclusions: Unlike interventions using single minerals or vitamins, broadspectrum micronutrient approaches appear comparable in efficacy to conventional psychopharmacological treatments in youth, with markedly fewer side effects (RCT), fewer relapses (open-label), and a more long-term stable course. This approach deserves additional research and, based on current data, appears to be valid for application now in very limited clinical situations.

CAM, OTH, PPC http://dx.doi.org/10.1016/j.jaac.2017.07.466

80.2 COMPLEMENTARY AND INTEGRATIVE MEDICINE IN MOOD AND INTERNALIZING DISORDERS Mary A. Fristad, PhD, Ohio State University Medical Center, [email protected] Objectives: The goal of this session is to review the literature on complementary and integrative medicine (CIM) in child- and adolescent-internalizing disorders. Methods: Research with regard to exercise, St John’s Wort, S-adenosyl methionine (SAMe), 5-hydroxytryptophan (5-HTP), light therapy, and U3 will be discussed. A double-blinded RCT study of 95 youths (aged 7 -14 years) included 72 youths with DEP (major depression, dysthymic disorder, or depression NOS; Child Depression Rating Scale-Revised scores 40) and 23 youths with BIP (cyclothymic disorder or bipolar disorder NOS). In a 12-week, 2 X 2 design, youths were assigned in equal numbers to U3 þ psychoeducational


psychotherapy (PEP), U3þactive monitoring (AM), or placebo (PBO)þPEP or (PBO)þAM. Results: Little research has been done with regard to exercise, St John’s Wort, SAMe, 5-HTP, and light therapy in youth. Important side effects and drug -drug interactions will be discussed. However, combination treatment (U3þPEP), compared with PBOþAM was more effective in decreasing the following: 1) depressive symptoms in youth with BIP and endogenous DEP (i.e., positive family history, depression with minimal stressors); and 2) behavioral symptoms in youth with DEP. U3 is associated with the following: 1) decreased symptoms of mania in youth with BIP; and 2) improved executive functioning in youth with DEPþBIP. Long-term naturalistic follow-up will provide information on the following: 1) ongoing utilization of U3 and/or PEP; 2) current mood symptom severity and functioning; and 3) whether variants in genes fatty acid desaturase 1 and 2 (FADS1 and FADS2), implicated in polyunsaturated fatty acid (PUFA) metabolism, are associated with mood symptoms and/or moderate treatment effects. Conclusions: Because many parents use over-the-counter CIM products, knowing the side effects and drug interactions is important to child and adolescent psychiatrists. DEP and BIP in youth are significant public health concerns. Current psychopharmacologic treatments for both carry with them certain risks; U3þPEP represent treatments that have lower risk. Consistent with a clinical staging model, utilization of these low-risk interventions at early stages of illness may alter progression to more severe presentations of DEP and BIP. Genetic markers, widely used in other areas of medicine, are still needed to personalize treatment of mood disorders. FADS1/2 was explored to determine their utility in this regard. Further study is warranted.


80.3 SURFACE AND LORETA NEUROFEEDBACK: CLINICAL IMPLICATIONS Joel Lubar, PhD, University of Tennessee, [email protected] Objectives: The goal of this session is to review the literature in the use of quantitative EEG (qEEG) neurofeedback (NF) and differences between surface and Low Resolution Electromagnetic Tomography (LORETA) neurofeedback and its implications as an adjunct in the treatment of child and adolescent psychiatric disorders. Methods: A review of the literature will be discussed, and case examples will be described. Results: qEEG NF studies using surface NF targeting ADHD have shown an effect size (ES) ranging from 1.78 to 2.22 for attention (ATT) and 1.2 for hyperactivity compared with medication ES for ATT of 0.84. Enduring effects continued from six months up to two years, with continued improvement of attention and hyperactivity. However, surface NF often took 40 to 80 sessions. The significant advantage of LORETA is that it unscrambles all of the frequencies under each electrode and finds the deep source location. Therefore, it can train current density on a sample-to-sample basis, even when the sampling rate is 256 samples per second. LORETA can still image activity within a couple of centimeters and can actually measure current density on a voxel-by-voxel basis down to 5 mm3 and at 6,239 locations where there are sufficient pyramidal cells to generate the currents that LORETA is capable of measuring. LORETA NF also allows coherence training. Children who identified with dyslexia (1.5 -2 years delayed) were included in an RCT. Areas showing the most prominent hypocoherence (low coherence) were targeted for training. Mean reading scores increased by 1.243 years in the treatment group, whereas the control group had a decrease in reading scores. fMRI and EEG functional connectivity networks were used to evaluate possible changes for real EEG-phase neurofeedback compared with sham EEG-phase NF in a double-blind placebocontrolled trial. The preliminary results of the functional connectivity MRI measurements indicate that there is an upregulation in the bilateral insulae (BAs 21 and 47) for the frontal-parietal network and the default mode network and a downregulation in BAs 45, 46, 9, 38, 20, 21, 22, and 23 for the auditory network and the dorsal attention network after real NF compared with sham NF. Conclusions: LORETA NF has been replicated with fMRI and can be completed in fewer sessions than surface NF.


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CLINICAL PERSPECTIVES 81 POSITIVE USE OF DIGITAL TECHNOLOGY TO REACH AND TREAT YOUTH IN THE MODERNIZED ERA Mani N. Pavuluri, MD, University of Illinois at Chicago, [email protected] Objectives: Our aim is to enhance the care of youth through informed use of digital tools and minimize the gap between the scientist, clinician, and consumer through the merging of evidence-based interventions and modern technology. Methods: The speakers from AACAP’s Media Committee have evaluated available tools to address the practice gaps through research, review, and the creation of digital technology applications to address vital topics, such as adolescent suicide prevention, positive effects of specific video game play on physical and mental health, dissemination of evidence-based psychoeducation, and the ability of social media to positively connect marginalized youth. Results: Findings on four seminal topics that can be immediately integrated with the clinical practice are presented as follows: 1) evidence that internet resources have the capacity to engage hard-to-reach adolescents, increase social connectedness, offer peer and expert support and psychoeducation, and provide quick access to safety resources; 2) evidence for informative commercial video games that can improve health, often through specific cognitive functions, weighed against risks associated with unhealthy play habits; 3) digital technology platforms to connect the science and service and bridge the existing gap between the two, disrupting the status quo; and 4) information on specific social media groups and online supports that uphold social justice, counteract isolation, and provide a much-needed resource for marginalized youth, including lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth. Conclusions: There are various digital resources that are proven to be useful in promoting mental health through research or available-to-disseminate research discoveries. With the seismic shift and dynamic developments in the digital era, clinicians can now integrate these modern resources to support the health of youth throughout their development. The art and science of service delivery can be enhanced through pragmatic and effective digital tools. The session will conclude with an interactive discussion with the dynamic audience.

MED, COMP, DEV Sponsored by AACAP's Media Committee http://dx.doi.org/10.1016/j.jaac.2017.07.470

81.1 THE DOUBLE EDGE OF DIGITAL MEDIA IN PREVENTING YOUTH SUICIDE Nicholas Carson, MD, FRCPC, Cambridge Health Alliance, [email protected] Objectives: Adolescents with suicidal ideation and behaviors often communicate their distress online to peers, which suggests that digital tools could be an important way to prevent adolescent suicide. Our objectives for this presentation are as follows: 1) to describe how hospitalized adolescents use digital media to communicate suicidality; and 2) to summarize systematic reviews of digital tools for adolescent suicide prevention. Methods: The cross-sectional survey included 241 adolescents hospitalized on an inpatient psychiatric unit at a community hospital in Massachusetts. The survey assessed use of digital media, communication of suicidality online, and history of suicide attempts. We then completed a PubMed search for systematic reviews of digital tools with evidence for adolescent suicide prevention. Results: In the survey sample group, 40 percent of youth reported at least one suicide attempt in the past year. More than one-third (38%) said that they would use a text message to tell someone about their suicidal thoughts, whereas 72 percent said that they would tell someone in person. Almost half (48%) said that they had already had a friend send them a suicidal statement

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by text or online social network. The PubMed search revealed very few controlled trials of digital suicide prevention tools though small trials show promising decreases in suicidal ideation and hopelessness. Conclusions: Adolescents in inpatient psychiatric settings have a high prevalence of self-reported suicide attempts and often communicate their distress in online spaces. The evidence base for suicide prevention using digital tools to help these youth is currently sparse. However, these media have the capacity to engage hard-to-reach adolescents, increase social connectedness, offer peer and expert support, and provide quick access to safety resources.

ADOL, MED, S http://dx.doi.org/10.1016/j.jaac.2017.07.471

81.2 PRESCRIBING PLAYSTATION: WHEN VIDEO GAMES ARE GOOD FOR KIDS Paul E. Weigle, MD, Natchaug Hospital, pweigle@ sbcglobal.net Objectives: The goal of this session is to provide an up-to-date review of data on the positive effects of video games on children and teenagers and the efficacy of video games designed to treat mental illness, teach, and promote healthy habits. Methods: An ongoing, exhaustive literature review was conducted on the positive effects of video game play on physical and mental health. The resulting studies were evaluated for relevancy and level of evidence. The most important and relevant points and themes were consolidated for the presentation, incorporating the author’s clinical experiences. Results: Video game play among youth is ubiquitous, and excessive or unsupervised play carries known health risks. However, research demonstrates that video games can also have a positive impact on physical and mental health. Playing many popular video games improves visual attention, contrast sensitivity, spatial navigation, strategic planning, and fine motor skills in the hands. Incorporating theories of video game design can make healthy and educational tasks more enjoyable, increasing motivation for engagement in a process called “gamification.” Games requiring physical activity can be a good source of exercise. Educational games are commonly used in schools to teach a variety of material and skills, and a myriad of such games are available for home use. Specialized games have been used to teach youth cognitive behavioral skills, social skills, and even traffic safety. Specialized games have been proven effective as treatments for depression, anxiety, and behavioral problems and show promise for schizophrenia. Other specialized video games are effective forms of medical treatments for amblyopia and obesity, aid in physical therapy, and provide valuable distraction from pain during medical procedures. Incorporated into traditional counseling, games can improve alliance and engagement. Conclusions: Certain video games can be used effectively as treatments for a variety of physical and mental health conditions. Many educational video games are effective tools for teaching. Exer-games can be a healthy habit. Many commercial video games can improve specific cognitive functions. In each of these cases, the quality and use of these games vary considerably and must be evaluated on an individual basis and weighed against risks associated with excessive play.

COMP, PRE, TREAT http://dx.doi.org/10.1016/j.jaac.2017.07.472

81.3 TRANSLATION OF SCIENCE TO SERVICE THROUGH DIGITAL TECHNOLOGY Mani N. Pavuluri, MD, University of Illinois at Chicago, [email protected] Objectives: This talk will illustrate multiple digital platforms built to facilitate the translation of science to service. Methods: Research-driven empirical evidence and channels of communication for the audience, such as children, adolescents, parents, teachers, trainees, and clinicians, are carefully reviewed. The digital scientific information is summarized under the following constructs: what (evidence), how (technology), where (platform), and when (frequency and context), with the help of the speaker’s clinical and technical experience of constructing and using the state-of-the-art digital tools.

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Results: The review of the empirical literature paired with digital tools in child psychiatry narrows down to credentialed information sites such as up to date, WebMD, Psychcentral, and MedCircle. Furthermore, there are university websites, blogs, podcasts, empirical therapy modules, and other organizationbased resources. A digital demonstration will follow that highlights a health education network, a scientific translational blog, and clinical utilization of digital tools integrating the diaspora of what is available to translate science to service to our families. This exercise will also illustrate with an example; how to digitally decode brain functions, such as reward system and emotion dysregulation; explain what underlies comorbid disorders; and show with examples the methods to digitally disseminate this information in a way that families can understand. The same methods can be applied in parallel to teaching the child psychiatry trainees to grasp complex concepts in a digestible and attractive manner through digital ports. Conclusions: We are committed to preserving our direct clinical contact with patient families and foster discovery through research. In that process, it is the digital technology that is the key and a positive force to connect the science and service to bridge the existing gap between the two and disrupt the status quo.

ADP, COG, COMP http://dx.doi.org/10.1016/j.jaac.2017.07.473

81.4 SOCIAL MEDIA USE FOR GOOD: SOCIAL JUSTICE AND SUPPORT FOR LGBTQ YOUTH Erin L. Belfort, MD, Maine Medical Center, erin.belfort@ gmail.com Objectives: The goal of this session is to review how marginalized and stigmatized youth, including lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth, use social media for education, support, and social justice aims. Methods: A literature search was performed on the uses of social media for marginalized youth. A review of lay press articles covering various movements, including “Black Lives Matter” and the “It Gets Better” campaign, were reviewed. The author’s experience as a psychiatrist for a Gender Clinic (which serves gender-nonconforming youth and their families) will be incorporated with clinical examples. Results: There are impressive data on the importance of family support and acceptance for gender-nonconforming youth and for youth questioning sexual orientation. This acceptance is protective against mental health comorbidities and negative consequences, such as suicide in a high-risk population. Many children and adolescents must seek such support outside of their own families. In a rural state like Maine, the home of the author’s Gender Clinic, many LGBTQ youth find information and support online and through social media groups. For some, this becomes a protective lifeline when they cannot find the validation and support they need within their families and communities. In a clinical setting, exploring safety with our LGBTQ population must go beyond basic suicide assessment and incorporate safety within one’s family, school, peers, and larger social communities. Exploring sources of safety and support should incorporate a review of offline and online support structures. Conclusions: Certain social media groups and online supports provide a needed resource for marginalized youth such as LGBTQ youth. These groups are beneficial in providing information, education, and social support and promoting advocacy aims and efforts.

ADOL, GID, MED http://dx.doi.org/10.1016/j.jaac.2017.07.474

CLINICAL PERSPECTIVES 82 PROTECTING YOUTH ONLINE: THE LAW, THE RISKS, AND CLINICIANS’ ROLES Caitlin R. Costello, MD, University of California, San Francisco, [email protected]; Bennett L. Leventhal, MD, University of California, San Francisco, bennett.leventhal@ ucsf.edu Objectives: Social media use is integral to the lives of young people, bringing both enrichment and exposure to social, mental health, and legal risks. We


aim to familiarize attendees with the legal status and consequences of juveniles’ social media use; risks of online behavior, including cyberbullying and sexting; the benefits and risks particular to new social media platforms; and the role of clinicians in helping their patients interact safely online Methods: We will review the legal status of juveniles’ online interactions and the exposure of youth to legal consequences through their online risk-taking behaviors. We will highlight areas of online risk, including cross-cultural data on the rates of cyberbullying and characteristics of its participants, as well as the characteristics and consequences of sexting among youth. We will discuss new social media tools and the benefits and risks unique to each platform. Our discussant will address the role of clinicians in guiding patients and families toward safely navigating the online world. Results: Despite recognition in other legal contexts of the immature decisionmaking skills of adolescents, the legal system has not afforded the same consideration to developmental issues related to online behavior. Youth are left vulnerable to serious consequences of online risk-taking behavior, including those associated with cyberbullying and sexting. Data from 15 countries demonstrate that cyberbullying is an international issue. Sexting is associated with exploitation and negative outcomes, including bullying, social isolation, depression, and suicide. Different risks emerge with new social media tools as each platform has different features and opportunities both for enrichment and negative consequences. Conclusions: To participate safely, productively, and positively in the social media era, young people need to have the knowledge of the risks of online interaction, appropriate monitoring of their online activities, and the fostering of mature online decision-making skills. Clinicians must be able to assess their patients’ online behaviors, provide education on risks and collaboration around online decision making, and guide patients and families toward safe and fulfilling online engagement.

ADOL, BLY, FCP http://dx.doi.org/10.1016/j.jaac.2017.07.476

82.1 SOCIAL MEDIA, YOUTH, AND THE LAW: LEGAL RISKS AND PROTECTION FOR YOUNG PEOPLE INTERACTING ONLINE Caitlin R. Costello, MD, University of California, San Francisco, [email protected] Objectives: The increasing investment of young people in social media comes with many mental health and legal risks, including cyberbullying, exposure to online predators, the viewing of ill-considered posts by unintended audiences, and even criminal liability. We will provide participants with education on the legal landscape of young people interacting online, including the limitations of the laws that aim to protect them, the legal risks that youth face when interacting online, and the role that clinicians can play in assessing and mitigating these risks and in providing guidance to patients and their families. Methods: The legal status of juveniles interacting online will be reviewed, including the laws designed to protect them online, inadequacies in this legal protection, and new legislative efforts to protect young people from the risks of their online behavior. We will also examine how the growing body of knowledge of adolescents’ development of mature decision-making skills affects their legal status in other areas in contrast to their legal status online. Results: Federal law requires websites to obtain parental permission to collect the personal information of children under the age of 13 years, leaving juveniles ages 13–17 years legally vulnerable when interacting online. When a user agrees to a website’s terms of service, the user enters a contract with the website. Such contracts between teenagers and websites have been upheld in courts, even though minors are considered legally incapable of entering nononline contacts. In many other areas of the law, adolescents are recognized as being less capable of mature decision making than adults, but this consideration is not applied to the law’s handling of minors interacting online. Recent legislative efforts in some jurisdictions have aimed to increase the protection of youth from the consequences of their online behaviors. Conclusions: Although the law acts in many areas to shield juveniles from the consequences of their developmental immaturity, there is comparatively little legal protection for youth interacting online. Clinicians need to be aware of

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the legal status nationally and in their own jurisdictions, so that they can effectively assess their patients’ exposure to online risks, communicate with them around online decision-making behavior, and guide patients and families toward safely interacting online.

ADOL, FCP, MED http://dx.doi.org/10.1016/j.jaac.2017.07.477

82.2 INTERNATIONAL CROSS-CULTURAL PERSPECTIVES ON CYBERBULLYING Andre Sourander, MD, PhD, University of Turku, andsou@utu. fi; Roshan Chudal, MBBS, MPH, PhD, University of Turku, roshan.chudal@utu.fi Objectives: The majority of research on cyberbullying comes from western countries. These findings have long been extrapolated as being valid in the resource-poor countries without any comparable data. This study was conducted among 30,000 school-aged children (aged 13–16 years) from 15 countries in Europe and Asia to report the following: 1) the rates of cyberbullying and characteristics of being victimized by cyberbullying; and 2) the cross-sectional association between possible associated factors on traditional bullying (age, sex, psychiatric symptoms, general functioning level, psychosomatic symptoms, substance use, traditional bullying and victimization, and school variables) and cyberbully only, cybervictim only, and cyberbully-victim status. Methods: This study was conducted in 15 countries in Europe and Asia. The study questionnaire was distributed to the children through their teachers and completed anonymously. The questionnaire, in addition to demographic variables and general health and psychopathology, included the following two questions on cyberbullying: 1) “during the past 6 months, how often have you been cyberbullied?;” and 2) “during the past 6 months, how often have you cyberbullied others? (1, never; 2, less than once a week; 3, more than once a week; or 4, almost every day).” Results: The percentage of children who reported being cyberbullied less than once a week or never ranged from 1.7 percent (Japan) to 17.8 percent (Israel). Those who reported being cyberbullied more than once a week or almost daily ranged from 0.7 percent (Japan) to 9.1 percent (China). The highest percentages of children cyberbullying others were reported as 12.6 percent (Israel) (less than once a week or never) and 12.5 percent (China) (more than once a week or almost daily). Japanese children reported the lowest rates of cyberbullying others. The analysis on the association with risk factors is currently ongoing. Conclusions: These findings suggest that the burden of cyberbullying among school-aged children is not limited to the developed western countries. An increased risk of psychiatric and psychosomatic problems, among both cyberbullies and victims, points toward its public health importance. Technological advances enhancing the anonymity of the perpetrator, coupled with a larger audience as a result of increasing internet penetration in developing countries, is likely to further increase the burden in the coming days.

ADOL, EPI, PRE http://dx.doi.org/10.1016/j.jaac.2017.07.478

82.3 THE MODERN TEENAGE SEXUAL REVOLUTION? SEXTING AND ONLINE SEXUAL EXPOSURE Swathi Krishna, MD, Emory University School of Medicine, [email protected] Objectives: Sexting is the sending of sexually explicit messages or images by cell phone or online devices. It is a rapidly growing communication method between middle and high school aged youth and has permeated teenage sexual culture. This presentation will discuss the prevalence and risks of sexting in the current teenage population and the culture of modern day sexual expression by teens. Methods: This presentation will highlight the prevalence of sexting within middle and high school aged children and their attitudes regarding these behaviors individually and amongst their peers. We will discuss other behaviors that have been shown to be associated with sexting and underage sexual communication. We will also discuss media case reports of suicide and cyber bullying related to teen sexting and the risks that teens take when exposing themselves and their bodies online and in text messages.

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Results: There is a significant association between teenage sexting and other risky behaviors such as underage sexual activity and substance use. There are also gender disparities within sexting activity: more girls send explicit pictures and more boys receive explicit pictures which shows that the teen sexual culture tends to exploit underage girls in higher proportions. Teens do not understand the consequences or conceive of the risks associated with this form of sexual expression, which often leads to negative outcomes including bullying, social isolation, depression and suicide. Conclusions: Session participants will gain insight into teen sexting culture and be able to recognize real world examples of this rapidly expanding genre. They will ultimately be able to recognize the warning signs of risky teenage online sexual practices and will be able to provide meaningful interventions and knowledgeable discussions regarding the risks, associated consequences and potential outcomes of these behaviors with teens and their families.

ADOL, MED, SAC http://dx.doi.org/10.1016/j.jaac.2017.07.479

82.4 NEW FRONTIERS IN SOCIAL MEDIA Gabrielle L. Shapiro, MD, Icahn School of Medicine at Mount Sinai, [email protected] Objectives: Social media sites and applications (apps) materialize so quickly that it can be difficult for families and clinicians to keep up with where and how young people are interacting online. This presentation will educate the audience on new social media platforms, discuss their benefits, as well as the pitfalls unique to the features specific sites and apps, and provide guidelines and recommendations for clinicians to assess and guide patients and families on safe use of social media. Methods: Informal questioning during clinical interviews of patients (ages 9– 24 years) in a community care child and adolescent clinic and a collaborative care clinic were used to assess the various forms of new social media. Staff from two community clinics met under supervision over a six-month period to discuss clinical issues related to the use of these new social media. In this presentation, new social media platforms will be demonstrated to participants with discussion of the unique risks associated with use of each particular site. Clinical vignettes with examples of positive and negative use of these social media will be presented to the audience. Results: Use of these new social media tools has increased, and some have become increasingly popular among different age cohorts and social groups. Young people can find benefit and enrichment from the of social media; at the same time, parents, school personnel, and the legal community are concerned about inappropriate use and misuse of these social media sites. Guidelines and recommendations for safe use of these media will be presented. Conclusions: New social media tools can provide a positive means of interaction for young people where they can explore their creativity and express themselves. They can also be a place where more anxiety and sometimes dangerous consequences result when not used safely. Concerns regarding the lack of development of communication skills and the ability to relate in “real time” to others are themes of concern.


CLINICAL PERSPECTIVES 83 PSYCHIATRIC CRISIS SERVICES FOR CHILDREN AND FAMILIES: MOBILIZING RESOURCES AND THINKING “OUTSIDE THE BOX” TO MEET COMMUNITY NEEDS Kristina Sowar, MD, University of New Mexico, ksowar@salud. unm.edu; Jennifer Havens, MD, New York University School of Medicine, [email protected] Objectives: The five presenters and discussant in this Clinical Perspectives highlight the challenges associated with pediatric psychiatric crises in standard emergency care settings. Each presenter will focus on a crisis care model that can address urgent patient needs, improve access to mental health care, and decrease unnecessary time or treatments in hospitals

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Methods: A literature review of pediatric mental health emergencies and crisis care systems will be provided. Each presenter will share her experience in creating, implementing, and/or practicing a particular crisis care model, including phone triage systems, mobile crisis clinics, and crisis stabilization and residential units. Presenters will discuss funding and community resources that have made such projects feasible and highlight key components of program development. Results: Communities and agencies are responding to increased emergent pediatric mental health needs by shifting treatment from standard emergency department settings to a continuum of team-based and nonhospital services. Each of the crisis care models included here has improved community access to behavioral health providers and helped triage children to more appropriate locations/programs of care. Data collected from individual sites indicate improved quality of care and interagency relationships, decreased length of stay or need for emergency department visits, increased outpatient follow-up, and decreased need for inpatient hospitalizations. Conclusions: Providing quality care to youth in mental health crises has become a challenge in our current health care system, with the decline of inpatient beds, lack of providers with mental health training, and limited access to community mental health services. A continuum of psychiatric crisis care services can better meet community and patient needs, thereby relieving burden on emergency departments and linking children and families to the services they need. More research on additional outcomes, as well as establishment of national standards of pediatric psychiatric crisis care, is needed.

AGG, S, TREAT Sponsored by AACAP's Community-Based Systems of Care Committee and Emergency Child Psychiatry Committee http://dx.doi.org/10.1016/j.jaac.2017.07.482

83.1 A NON-HOSPITAL CONTINUUM OF CARE MODEL FOR YOUTH IN MENTAL HEALTH CRISIS Deborah Thurber, MD, Ventura County Behavioral Health, [email protected] Objectives: Mental health crises in youth often are triggered by psychosocial stress, such as conflicts with parents/caregivers and peers, school pressures, placement change, or trauma. In reaction, youth can quickly and often impulsively become suicidal/self-injurious or aggressive/destructive and engage in other risky behaviors. This often leads to psychiatric hospitalization or boarding in an emergency department (ED), with little to no form of mental health treatment. Such interventions, often far from home and with little contact with caregivers and other natural means of support, are disruptive, frightening, and stressful to the youth and family. The objective is to describe how a group of county stakeholders developed and implemented a continuum of nonhospital-based youth mental health crisis services. Methods: This presentation includes a review of the clinical rationale; community organization and planning; and development and implementation of a local, nonhospital-based, county-funded continuum of care for youth mental health crises. Results: In 2014, there was a growing concern by Ventura County, California, community stakeholders (behavioral health and primary care providers, ED staff, Juvenile Probation, school districts, child welfare, law enforcement, and elected officials) of the rising number of youth involuntary holds. This often led to children being sent away for inpatient treatment or boarding in EDs. A Children’s Crisis Task Force was established to develop a local alternative to hospitalization. A proposed continuum of care model proposed included a mobile crisis team to respond to crisis calls and attempt to stabilize the youth at home, an up-to-24 hour unlocked Crisis Stabilization Unit (CSU), an unlocked Short-Term Crisis Residential Center (STCRTC), and a mobile aftercare team to assure youth are connected with the appropriate mental health services. Planning occurred for more than two years and included multiple stakeholder meetings to develop policies and procedures and clarify roles and responsibilities. Conclusions: The unique aspects of youth in mental health crisis and declining inpatient beds have led to a need to develop nonhospital crisis intervention programs that focus on family and community involvement,


increasing natural supports and coping skills, and quickly returning the youth to their home and school environments when safely possible.

CC, FUND, TREAT http://dx.doi.org/10.1016/j.jaac.2017.07.483

83.2 USE OF PHONE TRIAGE TO AVOID UNNECESSARY EMERGENCY DEPARTMENT VISITS FOR CHILDREN IN BEHAVIORAL HEALTH CRISIS Kathleen Rae Donise, MD, Brown University Alpert Medical School, [email protected] Objectives: Mental health issues are on the rise for children nationally. Primary care providers, families, and schools bear the burden of managing mental health crises with fewer resources and inconsistent information on how to respond. Sending a child to the emergency department (ED) may appear to resolve a crisis effectively but can cause significant negative impacts for both the medical system and the patient and family and, ultimately, may be unnecessary. Our service seeks to decrease unnecessary ED visits for children in crisis. Methods: Our pediatric behavioral health emergency service (PBHES) is a service under central supervision, operating at multiple sites, provided by employees from Bradley Hospital’s Access Center, Gateway Healthcare, and Rhode Island Hospital/Hasbro Children’s Hospital. We conduct urgent and emergent evaluations at Bradley Access in the Hasbro ED and at Gateway locations. PBHES also has phone crisis lines (“Kids’Link” as well as the main Bradley Access line) to provide information and resources to families, care providers, and youth. The phone is staffed by Master’s level clinicians trained and supervised in determining level of urgency, and the appropriate site for evaluation is based on patient acuity. If it is determined that an urgent evaluation is required but not necessarily within an ED, we have availability to perform these assessments at sites other than the ED. PBHES also has a grant through the Substance Abuse and Mental Health Services Administration, which has allowed our service to work directly with schools to triage children in crisis and avoid unnecessary ED visits. To further improve the triage process, PBHES sought and was awarded a Rhode Island Foundation Grant in 2017 to examine the triage process specifically for parents/ guardians calling for a child in crisis. Results: Through increased public awareness of its crisis lines, PBHES has increased the number of people calling for consultation/triage before assuming that a child requires ED level of care. Call volume has gone up significantly, whereas ED evaluations have remained fairly steady, even in the face of increased emergent mental health needs throughout the state. Conclusions: For many children in crisis, the necessary evaluation and subsequent entry into appropriate type and level of behavioral health care can occur without ever entering an ED.

CON, PRE, SC http://dx.doi.org/10.1016/j.jaac.2017.07.484

83.3 A CRISIS CLINIC PROVIDING RAPID ENGAGEMENT IN SERVICES AND WORKING TO RESOLVE CRISES AND AVOID REPEAT EMERGENCY DEPARTMENT VISITS Phintso Bhutia, MD, Icahn School of Medicine at Mount Sinai, [email protected] Objectives: Child psychiatric evaluations are a significant and growing source of emergency department referrals, often because of insufficient community-based services for children’s mental health. Despite the highly intensive nature of these evaluations, appropriate evaluation and referral for follow-up are often inconsistent or lacking. The objective is to describe a new model of service for providing crisis management for children in the community.

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Methods: Program evaluation was conducted for this model, including qualitative (staffing, administrative structure, child psychiatry resources) and quantitative (patient demographics, volume, clinical characteristics) factors and their effect on the design of this model. Results: This clinic began as a service to help the emergency department (ED) consultation-liaison services find ways to connect patients to appropriate follow-up once they were seen in those services and avoid repeat ED visits. The staffing consists of a half-time coordinator, one child and adolescent psychiatry fellow, and one attending physician with a parttime postdoctoral psychology fellow. The clinic runs from 9:00 am to 1:00 pm, with 60-minute slots for both evaluations and follow-up visits. In its first year, a total of 130 children were evaluated; 103 of them were admitted to the outpatient clinic; 45 percent had been referred from the ED, 15 percent came from inpatient services, 9 percent were self-referrals, and 30 percent were referred by other providers. Of the 103 patients admitted, 26 percent had repeat ED visits or inpatient hospitalizations within 3 months of initial evaluation, and only 7 percent had repeat ED visits within 6 months. Preliminary data show decreases in repeat ED use and also suggest an increase in compliance of patients staying in treatment. Conclusions: The reports of increased use of this service suggest that there is room for such programs. A further direction for improving this service is to have a significant and meaningful impact on ED use and decrease rates of inpatient hospitalizations. Further studies could help improve quality of crisis interventions and identify assessment measures to standardize the care in the community.

CON, FAM, PRE http://dx.doi.org/10.1016/j.jaac.2017.07.485

83.4 HOW TO SURVIVE IN THE WILD WEST: HOW TO MAXIMIZE WHAT YOU HAVE WHEN WHAT YOU HAVE ISN’T MUCH Jennifer Purses, DO, MultiCare Mary Bridge Children’s Hospital & Health Center, [email protected] Objectives: This presentation offers an overview of our experience embedding community crisis partners in a pediatric emergency department (PED) in an effort to decrease average length of stay (ALOS) for patients presenting with psychiatric crisis and to improve service delivery. Methods: When youth present to our PED reporting psychiatric crisis, they are evaluated for medical stability and then seen by a hospital crisis social worker (SW). If the SW determines that the patient/family could benefit from outpatient community crisis services, the family is then referred to Catholic Community Services (CCS). They must wait for CCS staff to come to the hospital and discuss a safety plan with them. Delays in care and family dissatisfaction with recommendations are not uncommon. Additionally, referral to CCS is a necessary step for inpatient admission referral for Medicaid patients in our county, and families are frequently dissatisfied when CCS clinicians determine that they can work with patient/family in the community setting and do not recommend admission. Our piloted intervention was to co-locate CCS services to maximize efficiency, decrease time to service encounter, and involve them as early as possible in the evaluation/ treatment planning process. CCS workers were embedded two nights per week during highest volume times. CCS workers and hospital SW did not change scope of services provided, nor did they change their roles with patients and families. Data were reviewed for all pediatric patients presenting with primary psychiatric diagnosis or acute psychiatric challenge during a sixmonth period pre- and postintervention. Results: Data showed decreased ALOS for target youth. In addition, clinical implications of the qualitative benefits of embedding CCS workers should not be overlooked. Increased trust, enhanced interagency relationships, and disposition outcome feedback between CCS and ED staff were reported as factors promoting family and team confidence in disposition planning, which enhanced provider confidence and decreased unnecessary delay in discharge. Conclusions: Inadequate mental health resources pose a complex challenge not only to patients but also to the healthcare centers that exist for them.

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Linking to outpatient resources at the time of crisis has demonstrated decreased ALOS for these patients and has also resulted in qualitative improvements.

CON, FAM, OTH http://dx.doi.org/10.1016/j.jaac.2017.07.486

83.5 ESTABLISHING THE FOUNDATION AND PAVING THE WAY FOR EXPANSION OF PEDIATRIC CRISIS SERVICES IN AN ACADEMIC AND COMMUNITY SETTING Kristina Sowar, MD, University of New Mexico, ksowar@salud. unm.edu Objectives: There are many limitations to providing effective care for children with psychiatric needs in standard emergency department settings. Thus, further models of mental health crisis care are being designed and implemented. In this talk, we will examine the process of assessing needs and instituting new emergency services in our community and also discuss relative barriers to this venture. Methods: A literature review of psychiatric crisis care services was completed; information gathering and networking were completed at meetings and through colleagues engaged in such work. Funding sources were explored at the local, state, and national level through grant foundations, school and state resources, and via conversations with managed care organizations and commercial insurance agencies. Results: Several important factors and barriers were identified in this process, with regard to establishing and implementing a new crisis care service. These factors include: 1) availability of clinician time/energy; 2) value of a needs assessment (to determine current services in place and those that can expand; areas of concern, and those in most need for intervention); 3) identification of areas that can be more quickly improved through outreach, education, advocacy, and recruiting of interested individuals; 4) exploration of funding sources through grants, programs, fundraising, and conversations with managed care and commercial insurance companies; 5) implementation of research efforts; and 6) possible expansion to traditional-age or adult services. Conclusions: Various psychiatric crisis care services are being implemented in communities to more effectively meet urgent behavioral health needs of children and families. However, this process requires significant time, effort, funding, networking, and community support. This presentation highlights some important considerations and also barriers to care in the process and provides resources for participants to take back to their communities.

FUND, OTH, PRE http://dx.doi.org/10.1016/j.jaac.2017.07.487

CLINICAL PERSPECTIVES 84 PSYCHOTROPIC POLYPHARMACY: A SERIOUS CONCERN AMONG CHILDREN AND ADOLESCENTS IN THE UNITED STATES OF AMERICA FOSTER CARE SYSTEM Florence V. Kimbo, MD, MetroHealth Medical Center, fl[email protected]; Caroly Pataki, MD, University of California, Los Angeles David Geffen School of Medicine, [email protected] Objectives: The goals of this study are as follows: 1) to present methods of identifying polypharmacy among youth in foster care; 2) to review the current guidelines for screening and assessment of polypharmacy; 3) to identify roles played by involved parties; and 4) to further recommend methods to help implement said guidelines to overall reduce polypharmacy. Methods: In the first hour, we plan on educating the participants on the frequency of polypharmacy among youths in the foster care system. We will also talk about factors responsible for polypharmacy in this population of

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patients and its implications. In the second hour, we plan to break out into three groups; each group will talk about one or two classes of medications responsible for polypharmacy in this population of patients. This small group will be dedicated to discussing individual cases brought by participants. During the third and final hour, we plan to regroup and talk about available state policies and practice parameters. We will provide and review available assessment tools pertinent to our population of interest. We will also organize recommendations for formulation of guidelines and parameters to share professionally and with advocacy groups. Results: The consensus from all published articles was that there is significantly a higher rate of psychotropic polypharmacy among youths in the foster care system compared with youths in the general population. We aim for participants to complete the workshop with an overall understanding and specific tools with which they are better prepared to care for this population of patients. We intend on doing this by presenting the data on polypharmacy and its implication and discussing available policies already implemented to reduce polypharmacy and recommendations to use available policies and/or create new ones. Conclusions: The increased prevalence of psychotropic use among youths in the foster care system cannot be overemphasized. Although there are varying state policies and federal laws to help safeguard psychotropic polypharmacy, many states still lack strong psychotropic monitoring policies, as proven by varying reports and increasing trends in the prevalence of psychotropic polypharmacy among youths in the foster care system. It is important to discuss the challenges and further recommend guidelines to reduce psychotropic polypharmacy among youths in the foster care system.

FOC, PRE, PPC Sponsored by AACAP's Adoption and Foster Care Committee http://dx.doi.org/10.1016/j.jaac.2017.07.489

84.1 LITERATURE REVIEW Adefolake Akinsanya, MD, MetroHealth Medical Center, [email protected] Objectives: The goal of this presentation is to discuss background and epidemiology of psychotropic polypharmacy among youths in the foster care system in the United States. Methods: A literature search was conducted of PubMed, Medline, Embase, Cochrane collaboration, and PsycInfo databases for published articles in any language that evaluated psychotropic use in the US foster care system. I plan to discuss the frequency of polypharmacy, factors responsible for polypharmacy in this population, and commonly prescribed psychotropic drugs in this population while encouraging discussion. Results: The general consensus from all published articles was that there is significantly higher rate of prescribed psychotropic among youths in the foster care system compared with youths in the general population. Some of the challenges faced include multiple foster homes placements, marked behavioral problems, multiple mental health diagnosis, lack of advocacy, and lack of continuity of care and follow-up evaluations. Conclusions: The increase prevalence of psychotropic use among youths in the foster care system cannot be overemphasized. There is a need to evaluate the challenges and discuss further guideline recommendations to reduce psychotropic polypharmacy among this population of patients.

ADOL, FOC, PTA http://dx.doi.org/10.1016/j.jaac.2017.07.804

84.2 REVIEW OF CASES Suneela Cherlopalle, MD, Case Western Reserve University School of Medicine and MetroHealth Medical Center, [email protected] Objectives: The goal of this presentation is to discuss three case series demonstrating psychotropic polypharmacy among youths between the ages of 8 and 17 years in the foster care system. Methods: We reviewed three cases, and information was collected via thorough chart review in the electronic medical records. We also obtained collateral information from multidisciplinary team members involved in the care of the youths.


Results: After reviewing three patient case series, it was evident that youth in foster care often have been prescribed three or more psychotropic medications, with no evidence-based indication for prescribed medication. It was also evident psychotropic drugs were being prescribed to manage behavioral problems rather than diagnostic entities. In these case scenarios, patient faced serious or life-threatening side effects such as renal failure, metabolic syndrome, and lithium toxicity. They have been prescribed medications at high dosages and also from different psychotropic classes, often making it difficult to understand the target symptoms. Conclusions: Youth in foster care appear to be at a larger risk for being prescribed multiple psychotropic medications, which often have serious side effects. By the case series above, behavioral problems are also treated with medications and demonstrate the need for awareness, systematic approach, and also an algorithm to help guide the physicians in making medication recommendations.


84.3 STRATEGIES TO ENHANCE PHARMACOLOGICAL MANAGEMENT Florence V. Kimbo, MD, MetroHealth Medical Center, fl[email protected] Objectives: The goal of this presentation is to present strategies to enhance psychiatric pharmacological management of youth in foster care. Methods: I will review charts of case subjects identified as taking three or more psychotropic medications. I will look at the diagnostic processes leading to the diagnoses and the pharmacological agents used and their rationale. I will then review the AACAP guidelines parameters for the diagnoses, discuss with the treating psychiatrists, and together come up with a plan to minimize polypharmacy and incorporate strategies for a better outcome of treatment. Results: Diagnostic procedures do not often follow AACAP practice parameters. The art of combining medications is often challenging. Documentation, especially on the rationale for each pharmacological intervention, is often insufficient. Strategies to monitor potential effects are not often clearly identified. Conclusions: Given some significant adverse effects that can result from the use of psychotropic drugs, and especially the challenges involved in treating youth in the foster care system, a methodological approach to diagnoses and decision making is of the utmost importance. History taking is crucial, and use of recommended available diagnostic tools is important. The art of pharmacological management needs to be thorough with consultation of experts when needed. Clear concise documentation of rationale and parameters for monitoring is necessary with reference to AACAP guidelines and evidence-based practice. Always remember the Hippocratic Oath, especially “Do no harm.”


CLINICAL PERSPECTIVES 85 COMMUNICATION AND LANGUAGE DISORDERS IN CLINICAL POPULATIONS FROM A BROAD PERSPECTIVE Theodore A. Petti, MD, MPH, Rutgers University Robert Wood Johnson School of Medicine and Rutgers University Behavioral HealthCare, [email protected]; Theodore Shapiro, MD, NewYork-Presbyterian/Weill Cornell Medical Center, [email protected] Objectives: The goals of this session are as follows: 1) to review the importance for awareness, assessment, and treatment of communication disorders in the pediatric populations; 2) to describe the neurobiology of language and pragmatic language acquisition deficits across multiple neurodevelopmental disorders; 3) to describe the role of language in emotional regulation by children ascertained for autism spectrum disorder (ASD); 4) to provide an overview of the principles of language intervention for children from ages 3 to 18 years, with special attention to

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interventions aimed at addressing pragmatic/social language; and 5) to review evidence base for treatment selection for language and communication disorders. Methods: The literature of communication disorders, including language deficits and social and pragmatic communication disorder, is summarized for pediatric clinical populations. Relevance and efforts for early identification and intervention for these disorders is discussed. The neurobiology of language and pragmatic language acquisition deficits across multiple neurodevelopmental disorders is detailed. Essential features of these deficits in different disorders are compared to identify common and specific features of language functioning. Differential benefits of specific interventions for specific language difficulties are considered. Data are reported of an ascertained group of children and adolescents with ASD regarding the role of structural language deficits and gender in aggressive behavior. Systematic literature review is used to identify the level of evidence that exists for a range of treatments addressed to children with communication and language disorders. Implications from systematic evaluations for efficacy level of current interventions are reported. Results: Rapid advances in assessment and diagnosis, depicting the underlying biology, as well as the impact and treatment of communication disorders, are considered, which ultimately may inform prevention and improved treatment of language and communication disorders in youth. Conclusions: Understanding communication disorders is critical to clinical practice. The outcome can be improved through early identification and treatment by clinicians.

PRE, COMD, NEURODEV Sponsored by AACAP's Health Promotion and Prevention Committee http://dx.doi.org/10.1016/j.jaac.2017.07.491

85.1 IDENTIFYING LANGUAGE AND COMMUNICATION DEFICITS IN CLINICAL SETTINGS Theodore A. Petti, MD, MPH, Rutgers University Robert Wood Johnson School of Medicine and Rutgers University Behavioral HealthCare, [email protected]; Tatyana Elleseff, MA, CCC-SLP, Rutgers-University Behavioral Health Care, [email protected]; Rajeswary Muthuswamy, MD, Rutgers-University Behavioral Health Care, [email protected]; Suzanne Lind, MD, Rutgers-University Behavioral Health Care, lindsm@ubhc. rutgers.edu Objectives: The goals of this session are as follows: 1) to review prevalence of communication deficits in a clinical population; 2) to present validation of selfreported communication deficits in a clinical population; 3) to provide an update in performance improvement for earlier detection of communication disorders across clinical settings; and 4) to consider implications for diagnosis, formulation, and treatment planning of such efforts. Methods: A summary defines the evidence base for social (pragmatic) communication disorder and reviews prevalence data for receptive, expressive, and social (pragmatic) language disorders in pediatric clinical populations. Relevance for early identification and intervention for these disorders is discussed. Efforts and results are presented to validate an easy-to-administer scale for self-reported communication deficits completed by youth in a therapeutic day school, their parents, and teachers. Preliminary results from the related quality improvement initiative are considered. Results: Youth (N ¼ 50; ages 11–18 years), their parents, and teachers completed a forced-choice scale on the extent to which they have trouble, such as understanding what teachers, parents, or peers say; what they read; and with saying or writing what they think. The scale also assessed the extent of anger experienced when unable to communicate effectively and whether help was provided or wanted in specified communication areas. Analyses of data for 50 youth, including the completed scales and full or screening evaluations by language pathologists confirming scale validity, are presented. Results of record reviews for documentation of communication disorder presence or absence are reported. Conclusions: Considerable literature documents the high prevalence of communication disorders in youth presenting for mental health services.

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Comorbidity with other disorders frequently masks their presence. Many youth in restrictive clinical settings report substantial communication deficits. Few had been identified previously. The validity of a scale with high internal consistency is discussed, and its relevance for clinical care discussed. Greater awareness of these disorders for earlier identification and treatment, as demonstrated by record review before and after study components’ implementation, has major importance for education and training.

COMD, NEURODEV, PRE http://dx.doi.org/10.1016/j.jaac.2017.07.492

85.2 LANGUAGE DIFFICULTIES ACROSS VARIOUS NEURODEVELOPMENTAL DISORDERS: SAME OR DIFFERENT? Elena L. Grigorenko, DPhil, Baylor College of Medicine and the University of Houston, [email protected] Objectives: In this session, the presenters will describe the neurobiology of language and pragmatic language acquisition difficulties across multiple neurodevelopmental disorders, compare the essential features of these difficulties in different disorders to identify common and specific features of language functioning, and consider differential benefits of specific interventions for specific language difficulties. Methods: The neuroscience of developmental disorders has been evolving at a rapid pace as have the tools to facilitate this process. The findings from one laboratory are integrated with the literature to produce the understanding of the underlying neurobiology of language and pragmatic language acquisition difficulties across multiple neurodevelopmental disorders, including genomic disorders. The categorical relevant diagnoses include language and communication disorders, autism spectrum disorders, learning disorders, and conduct disorders. Essential features of language and communication deficits in the different DSM-5 categorical disorders are used to identify common and specific features of language functioning. Attempts to connect differential profiles of language and language-related deficits to their differential etiologies are described. Likewise, developmental outcomes are considered in light of the deficits; critically combined with observations, when possible, these outcomes are used to depict the differential benefits of specific interventions, as applied to specific language difficulties rather than specific diagnoses. Results: The neurobiology of deficits in language and other forms of communication is considered as a means to understand an aspect of shared and divergent underpinnings of neurodevelopmental and disruptive disorders classified in DSM-5. The evidence base for these considerations is presented in a manner to allow clinicians the ability to better conceptualize the role of language and communication in case formulation and treatment planning. Conclusions: Greater attention must be paid to the role that language and deficits in communication play in neurodevelopmental and other disorders of children and emerging adults. In the future, therapeutic interventions may be informed by the specific language deficits determined in the patient.

COMD, NEURODEV, PRE Supported by NIH Grants R01 DC007665-05 and P20 HD091005-01. http://dx.doi.org/10.1016/j.jaac.2017.07.493

85.3 EMOTIONAL REGULATION IN CHILDREN WITH AUTISM SPECTRUM DISORDER WITH AND WITHOUT STRUCTURAL LANGUAGE IMPAIRMENT Yuli Fradkin, MD, Rutgers-University Behavioral Health Care and Rutgers University Robert Wood Johnson Medical School, [email protected]; Judy Flax, D Phil, Rutgers University, fl[email protected]; Christine Gwinn, BA, Rutgers University, [email protected]; Sherri Wilson, MSW, Rutgers University, [email protected]; Karen Law, BA, Rutgers University, [email protected]; Linda Brzustowicz, MD, Rutgers University, brzustowicz@dls. rutgers.edu

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Objectives: The goals of this session are to describe language ability’s role in emotional regulation by children ascertained for autism spectrum disorder (ASD) and discuss study results related to gender and higher-order language functioning in the context of earlier studies. Methods: A family genetics study of ASD identified 130 children and adolescents ascertained for ASD and determined structural and higher-order language ability based on standardized assessment scales and on diagnostic tools for ASD. Structural language ability (syntax, grammar, phonology, vocabulary) was determined by the Clinical Evaluation of Language Fundamentals-4. Higher-order language abilities, such as inferences, ambiguities, and pragmatic language, were assessed using the suprasegmental block of the Comprehensive Assessment of Spoken Language (CASL). Overall language status (nonverbal, minimally verbal, or phrase speech) for those unable to take standardized assessments, either because of low language ability or noncompliance, was determined by responses by caregivers on the Autism Diagnostic Interview-Revised (ADI-R). Of 210 children ascertained for an ASD diagnosis, 130 had sufficient language data for analysis. Aggression was determined by ADI-R questions on aggression toward self and others. Results: There was no significant difference for IQ in males (P ¼ 0.07) and females (P ¼ 0.018) in both the language-impaired and normal language development groups. Children with structural language impairment and those with minimal language as determined by ADI-R had significantly higher rate of aggressive behaviors to themselves (P ¼ 0.037) but not to others. When controlled for gender, males were significantly more aggressive to themselves (P ¼ 0.007) and nonfamily members (P ¼ 0.024). Aggression toward nonfamily members was significantly correlated with higher-order language variables in males (r ¼ 0.27; P ¼ 0.05). ASD probands with structural language impairments showed more aggressive behavior toward others. In addition, aggression was significantly correlated with some higher-order language skills in males. Conclusions: This study indicates that greater deficits in structural language predict greater associated aggression in ASD. Future research into therapeutic interventions for youth with ASD must take language ability into account.

COMD, NEURODEV, PRE Supported by New Jersey Governor’s Council for Medical Research and Treatment of Autism, NIMH Grant U24 MH068457, and National Institute on Deafness and Other Communication Disorders Grant R01 DC009453 http://dx.doi.org/10.1016/j.jaac.2017.07.494


85.4 WHAT WORKS FOR TREATING LANGUAGE DISORDERS IN CHILDREN Rhea Paul, DPhil, CCC-SLP, Sacred Heart University, PaulR4@ SacredHeart.edu Objectives: The goal of this session is to provide an overview of the principles of language intervention for children from ages 3–18 years of age and review the evidence base for selection of treatments for language disorders in preschool-aged and school-aged children, with special attention to interventions aimed at addressing pragmatic and social communication disorders. Methods: Systematic literature review is used to identify the level of evidence that exists for a range of treatments addressed to children with communication and language disorders. Several approaches to remediating language problems in children with established and emerging evidence base were found. Active ingredients of these approaches are detailed. Other treatments commonly used, with little or no evidence in the research literature, are also presented. Results: Several approaches to remediating language problems in children with an established and emerging evidence base are considered. These include the clinician-directed approach; child-centered intervention, and hybrid or combinations of the two approaches. Other forms of treatment in common use, with little or no evidence in the research literature, are critiqued. Conclusions: Speech-language pathologists provide services to children with disorders of communication with a diagnostic range, including autism spectrum disorder (ASD), learning disabilities, intellectual disability, and developmental speech and language disorders. The disorders affect the ability to pronounce speech sounds; learn words for understanding and expressing concepts; comprehend and produce novel sentences that express feelings, thoughts, and attitudes; and comply with the social rules that govern conversation in their cultures. The evidence-based approaches for addressing language problems in children are comprehensively described. Health professionals will become more familiar with the range of interventions and their demonstrated base for efficacy in treating communication deficits. They will be encouraged to use the gained knowledge through earlier detection of deficits in language and communication; referral for assessment and treatment; and communication and advocacy with patients, their families, and school personnel for greater awareness and treatment to address communication and language deficits throughout childhood.

COMD, NEURODEV, PRE http://dx.doi.org/10.1016/j.jaac.2017.07.495

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EXTENDED WORKSHOPS 1 Trauma-Focused Cognitive-Behavioral Therapy for Interpersonal Violence: Practical Strategies for Child Psychiatrists 2 Meditation/Mindfulness: Use in Clinical Practice 3 Introduction to Motivational Interviewing: Skill-Building Fundamentals 4 Dialectical Behavior Therapy Toolkit for Child Psychiatrists: Targeting SelfInjury and Suicidal Behavior 5 Fundamentals in Mentalization-Based Treatment for Suicidal and SelfInjurious Youth

EXTENDED WORKSHOP 1 TRAUMA-FOCUSED COGNITIVE-BEHAVIORAL THERAPY FOR INTERPERSONAL VIOLENCE: PRACTICAL STRATEGIES FOR CHILD PSYCHIATRISTS Judith A. Cohen, MD, Allegheny Health Network, JCohen1@ wpahs.org; Anthony Mannarino, PhD, Allegheny Health Network, [email protected]; Nathaniel G. Sharon, MD, University of New Mexico School of Medicine, [email protected] Objectives: Interpersonal violence is associated with increased risk for developing PTSD and associated problems (e.g., depression, substance abuse). Lesbian, gay, bisexual, and transgender (LGBT) youth, youth in child welfare, and those in the juvenile justice system experience high rates of interpersonal violence, but PTSD is under recognized in these populations. This extended workshop provides additional time and opportunity for child and adolescent psychiatrists to learn core trauma-focused (TF)-CBT techniques that can improve their ability to care for youth who experience interpersonal violence Methods: The workshop provides training, practice, and expert feedback in TF-CBT techniques of the following: 1) applying gradual exposure to overcome trauma avoidance; 2) psychoeducation about interpersonal violence for caregivers (including those who are nonsupportive of the youth); 3) managing traumatic behavior problems; 4) encouraging adaptive affective expression related to interpersonal violence experiences; and 5) cognitively processing interpersonal violence for youth and caregivers. TF-CBT developers Judith Cohen, MD, and Anthony Mannarino, PhD, provide training, demonstration role plays, videos, and expert feedback in these techniques. Nathan Sharon, MD, a TF-CBT-trained child psychiatrist with recognized expertise in treating gender diverse youth, provides demonstration role plays and expert feedback in applying TF-CBT techniques for traumatized LGBT youth. Participants engage in hands-on practice of each technique during the workshop and receive expert feedback. A DSM-5 PTSD rating scale and technique handouts are provided. Results: Through proven CBT implementation techniques, child psychiatrists gain mastery in implementing core TF-CBT techniques for youth who are traumatized by interpersonal violence. These techniques can be used in a variety of practice settings. Conclusions: Implementing core TF-CBT techniques with increased skill and fidelity can improve child psychiatrists’ quality of care for youth who experience interpersonal violence.

EBP, PTSD, CAN Sponsored by AACAP's Child Maltreatment and Violence Committee and Sexual Orientation and Gender Identity Issues Committee http://dx.doi.org/10.1016/j.jaac.2017.07.497

EXTENDED WORKSHOP 2 MEDITATION/MINDFULNESS: USE IN CLINICAL PRACTICE Deborah R. Simkin, MD, Emory University School of Medicine, [email protected]; James J. Hudziak, MD, University of Vermont and Fletcher Allen Health Care, james.hudziak@ uvm.edu; Basant Pradhan, MD, Cooper Medical School of Rowan Unviersity and Cooper University Hospital, [email protected]

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1.0 — 3.0 Objectives: The goal of this session is to provide a hands-on workshop on mindfulness-based stress therapy (MBST) and a combination of mindfulnessbased cognitive behavioral therapy (MBCT) and yoga called Trauma Interventions using Mindfulness-Based Extinction and Reconsolidation (TIMBERª) Methods: The workshop will be scheduled as follows: 8:00 am to 8:30 am— group-guided, focused-attention meditation with guided imagery (Dr. Simkin); 8:30 am to 9:30 am—discussion of research and methods using MBST in youth (Dr. Hudziak); 9:30 am to 10:30 am—demonstration of MBST (Dr. Hudziak); 10:30 am to 10:45 am—break; 10:45 am to 11:45 am—MBST rehearsal by audience; 11:45 am to 12:00 pm—questions; 12:00 pm to 1:00 pm—lunch; 1:00 pm to 2:00 pm—Dr. Pradhan will present data of efficacy, components of TIMBER, and methods in TIMBER, including standardized scales used in TIMBER (Assessment Scale for Mindfulness Interventions, Arousal Response to Trauma Memory Activation, and PTSD-specific scales); 2:00 pm to 3:15 pm—TIMBER is shown step by step through case examples and TIMBER video; 3:15 pm to 3:30 pm— break; 3:30 pm to 4:30 pm—rehearsal of TIMBER with audience participation; and 4:30 pm to 5:00 pm—questions. Results: Current data on these meditation/mindfulness techniques show promise for treating symptomatic anxiety, depression, and executive function in youth. TIMBER integrates the principles of yoga and MBCT. In TIMBER, the psycho-physical manifestations of the hyperarousal episodes and the reappraisal/modifications of the trauma experiences are being done by cognitiveemotive restructuring using cognitive-behavioral and yoga interventions to induce new learning using combined extinction and reconsolidation approaches. Unlike the extinction-only approaches, which have no effect on the original memories of trauma, the reconsolidation-based approaches have been found to update the trauma memories and thus result in new learning. This technique has been useful in patients with refractory PTSD. Conclusions: At the end of this workshop, clinicians will be able to learn techniques that they can use in their office for patients and their families.

EBP, AD, CAM Sponsored by AACAP's Complementary and Integrative Medicine Committee and Health Promotion and Prevention Committee http://dx.doi.org/10.1016/j.jaac.2017.07.498

EXTENDED WORKSHOP 3 INTRODUCTION TO MOTIVATIONAL INTERVIEWING: SKILL-BUILDING FUNDAMENTALS Joseph S. Lee, MD, Hazelden Betty Ford Foundation, [email protected]; Christian Thurstone, MD, Denver Health and the University of Colorado, Christian.Thurstone@ dhha.org Objectives: There is a critical need to provide evidenced-based psychotherapy training to child and adolescent psychiatrists. Motivational interviewing is a humanistic, client-centered, and evidenced-based psychotherapy that can be adopted for use in almost any clinical setting. This day-long workshop will provide sufficient time for hands-on training in motivational interviewing theory and fundamental skills for residents, faculty, and students Methods: This day-long workshop is designed for participants with beginning and intermediate knowledge of motivational interviewing. The workshop will highlight four essential processes of motivational interviewing as follows: 1) engaging; 2) focusing; 3) evoking; and 4) planning. Emphasis will be placed on core skills such as 1) open-ended questions; 2) affirmations; 3) reflections; and 4) summaries. Instruction will be provided by rotational lecture presentations, interactive exercises, small group experiential exercises, and auditing of video samples. Results: By the end of the workshop day, participants will gain confidence in basic motivational interviewing skills to elicit change in talk within clients and to handle client ambivalence. Moreover, even beginner-level trainees will become inspired by their development to pursue further psychotherapy training. Conclusions: Child and adolescent psychiatrists can become very effective at psychotherapy. Motivational interviewing will be a ubiquitous tool that will foster the adoption of evidenced-based therapy approaches regardless of the clinical setting, thus benefitting physicians, clients, and families alike.

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EXTENDED WORKSHOPS 4.0 — 5.0

EBP, P, SUD Sponsored by AACAP's Substance Use Committee and Committee on Medical Students and Residents

EXTENDED WORKSHOP 5


FUNDAMENTALS IN MENTALIZATION-BASED TREATMENT FOR SUICIDAL AND SELF-INJURIOUS YOUTH

EXTENDED WORKSHOP 4 DIALECTICAL BEHAVIOR THERAPY TOOLKIT FOR CHILD PSYCHIATRISTS: TARGETING SELF-INJURY AND SUICIDAL BEHAVIOR Mary S. Ahn, MD, UMass Medical School, maryahnmd@gmail. com; Blaise Aguirre, MD, McLean Hospital, baguirre@ partners.org Objectives: This presentation will provide assessment and treatment tools in DBT to address nonsuicidal self-injury (NSSI) and suicidal behavior in adolescents. Adolescent suicide is the third leading cause of death in the United States, and NSSI has been reported to occur in up to 23 percent of adolescents. DBT significantly reduces NSSI and suicidal ideation in adolescents Methods: The speakers will present the current literature regarding the context of NSSI and suicidal behaviors that transects across many DSM-5 diagnoses. Special attention will also be spent discussing assessment, including screening for co-occurring borderline personality disorder. In addition, risk assessment regarding NSSI that leads to suicidal behaviors will be discussed. Results: Blaise Aguirre, MD, is a key speaker and the only certified DBT trainer to date who is a child psychiatrist. Together with Mary Ahn, MD, a certified coach and educator, they will highlight common therapeutic strategies. Skill development will be practiced through clinical vignettes that demonstrate each DBT competency. Furthermore, clinician wellness will be addressed to mitigate burnout often found in working with this complex, high-acuity patient population. Conclusions: NSSI and suicidal behaviors are a growing problem among adolescents across several diagnostic criteria. Child psychiatrists can provide the necessary assessment to formulate the right treatment plan for both the adolescents and families.

TREAT, S, SIB Sponsored by AACAP's Psychotherapy Committee http://dx.doi.org/10.1016/j.jaac.2017.07.500


Laurel L. Williams, DO, Baylor College of Medicine, laurelw@ bcm.edu; Owen S. Muir, MD, New York University, [email protected]; Carl Fleisher, MD, University of California, Los Angeles, cfl[email protected]; Efrain Bleiberg, MD, Baylor College of Medicine, ebleiberg@ menninger.edu; Chris Grimes, LCSW, Baylor College of Medicine, [email protected]; Carlene MacMillan, MD, Ellenhorn New York City PACT, [email protected]; Liz Cracknell, RMN, Anna Freud Centre, [email protected] Objectives: Mentalizing-based treatment (MBT) has developed over the last two decades as a coherent conceptual framework and has an increasingly and empirically supported approach to treating borderline personality disorder, family treatment of children and adolescents, eating disorders, and self-harming adolescents. In this workshop, participants will learn about 1) how mentalizing capacities develop in the context of attachment relationships and 2) the impact of neurodevelopmental changes in adolescent’s mentalizing capacities Methods: This extended workshop will offer a blend of focused didactics, with several small group experiences on the MBT approach to treatment with adolescents, families, groups, and systems of care. Results: Participants will understand the basic premise of using mentalizing theory and practice key mentalizing techniques under the guidance of experienced mentalizing therapists. Conclusions: The aim of MBT is to provide clinicians working with adolescents and their families with a conceptually sound and empirically supported approach to address adolescent disturbances of self, affect, and impulse regulation.

P, SIB, S Sponsored by AACAP's Psychotherapy Committee and Complementary and Integrative Medicine Committee http://dx.doi.org/10.1016/j.jaac.2017.07.501

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HONORS PRESENTATIONS 1 Child Psychiatry-Inspired Health Promotion and Illness Prevention Goes to College 2 Honors Presentations TED Talks 3 Improving Primary Care Access and Quality of Care for Children With Mental Health Needs: The Child and Adolescent Psychiatrist Primary Care (CAP-PC) Experience 4 Now Is the Time! Expanded Roles for Child and Adolescent Psychiatrists in School-Based Mental Health 5 And Then There Was Intersubjectivity: Treating Child Self and Mutual Dysregulation During Traumatic Play 6 Why Would Anyone Want to Be a Medical Educator?

HONORS PRESENTATION 1 AACAP IRVING PHILIPS AWARD FOR PREVENTION

CHILD PSYCHIATRY-INSPIRED HEALTH PROMOTION AND ILLNESS PREVENTION GOES TO COLLEGE James J. Hudziak, MD, Vermont Center for Children, Youth, and Families, [email protected] Objectives: Rates of negative health outcomes (alcohol, drug, assault, and academic failures) are at a near epidemic level in colleges around the country. Interventions to reduce these negative outcomes have led to mixed results. This lecture will focus on the University of Vermont (UVM) Wellness Environment (WE), created by Dr. James Hudziak in 2015, which proposed to use health promotion and illness prevention strategies to improve outcomes in college-aged students. Methods: UVM WE is an incentivized-based behavioral change healthcare program that is the upward extension of the Vermont family-based approach, which argues that health promotion is more powerful than prevention, which in turn is more powerful than intervention. In WE, all students are provided with a personal trainer, yogi/yogini, mindfulness instructor, nutritionist, and relationship advisor all at no additional charge. The only requirement is that the environment must be free of alcohol or drugs. Dr. Hudziak developed a personalized medicine application (App) to track health and wellness. Results: UVM WE has had the lowest alcohol and other drug violations and the highest student retention at UVM for the past two years. The program has grown from 120 to 1200 students in that same period of time. Using an Appbased assessment, WE students exercised and slept more but drank and used drugs less at college than usual. The program has generated international interest. Conclusions: Incentive-based health promotion illness prevention strategies developed by child and adolescent psychiatry practitioners can lead to better outcomes in college-aged (transitional-aged) brains.

COLST, NEURODEV, DEV http://dx.doi.org/10.1016/j.jaac.2017.09.004

HONORS PRESENTATION 2.1 AACAP ELAINE SCHLOSSER LEWIS AWARD FOR RESEARCH ON ATTENTION-DEFICIT DISORDER

CAN WE IMPROVE TREATMENTS FOR ATTENTION-DEFICIT/HYPERACTIVITY DISORDER? James T. McCracken, MD, University of California, Los Angeles, [email protected] Objectives: ADHD represents a prevalent and largely persistent childhood onset disorder. Despite treatments, impairment is common, and disorder course is unchanged. Cognitive deficits represent sources of impairment and persistence. This presentation summarizes research on combination pharmacotherapy aimed at improving clinical and cognitive outcomes in ADHD and whether EEG-based signatures of treatment may yield insight into the

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1.0 — 2.2 mechanisms of combination therapy, possibly representing a biomarker of response. Methods: A randomized, double-blind, placebo-controlled comparative trial of dexmethylphenidate (DMPH), guanfacine (GUAN), and combination (COMB) enrolling subjects ages 7–14 years with ADHD is described. We examined three primary outcomes: 1) symptomatic benefit; 2) cognitive enhancement; and 3) EEG spectral power changes. Results: A total of 207 subjects received drug therapy, 182 completed clinical and cognitive assessments, and 179 provided EEGs at baseline and at weeks four and eight. Clinically, a modest, consistent superiority in ADHD-Rating Scale-IV (ADHD-RS-IV)–inattentive symptom scores for COMB versus DMPH (P ¼ 0.05) and GUAN (P ¼ 0.02) groups was seen, as well as for Clinical Global Impression-Improvement (P ¼ 0.01). Cognitive improvement was restricted to working memory, with COMB and DMPH significance versus control subjects (D ¼ 0.25 and –0.30), respectively. EEG showed distinct profile by condition, with DMPH and COMB showing increased centroparietal beta and decreased theta; COMB was associated with greater decreases in theta versus DMPH and GUAN. Conclusions: A combination of DMPH and a-agonist treatment represents a strategy for improved ADHD clinical outcomes, but findings illustrate the challenge of normalizing cognition in ADHD. More research is needed on approaches to address ADHD cognitive deficits, which may yield disordermodifying therapies.

PPC, ADHD, COG http://dx.doi.org/10.1016/j.jaac.2017.09.005

HONORS PRESENTATION 2.2 AACAP NORBERT AND CHARLOTTE RIEGER AWARD FOR SCIENTIFIC ACHIEVEMENT

FAMILY IMPACTS OF PEDIATRIC OBSESSIVECOMPULSIVE DISORDER S. Evelyn Stewart, MD, British Columbia Children’s Hospital Research Institute and University of British Columbia, [email protected] Objectives: Familial aspects of pediatric OCD, including accommodation and treatment, have received notable and warranted attention. However, individual perspectives of its repercussions on family functioning, including emotional parental burden, have not been closely examined. The present study details this topic using a large, multicenter sample group. Methods: Participants included 354 OCD-affected youth and mothers and fathers ascertained through pediatric OCD programs in Boston, MA, USA (n ¼ 180) and Vancouver, Canada (n ¼ 174). The validated OCD Family Functioning (OFF) Scale and standard OCD measures were completed. Descriptive, between-site and cross-perspective comparative analyses were followed by regression model testing to predict family impairment. Results: Family functioning was negatively impacted from youth, mother, and father perspectives. Impairment was reportedly more extensive at the time of the worst OCD severity and was greater from maternal versus paternal viewpoints. Most frequently impacted family tasks and implicated OCD symptoms included morning and bedtime routines and intrusive thoughts. Emotional repercussions included stress and anxiety, followed by frustration/anger in youth and sadness in parents. Nearly half of mothers and a third of fathers reported daily occupational impairment. Compared with youth self-report, parents perceived fewer social and academic impacts on their child. Family accommodation most consistently predicted family impairment, especially from parent perspectives. OCD and compulsion severity, contamination and religious obsessions, and comorbidities also predicted various perspectives of family subdomain impairment. Conclusions: This study quantitatively details the pervasive burden that pediatric OCD places on families, as reported from complementary relative perspectives. Further attention to this topic is warranted in clinical and research realms.

FAM, OCD, PAT http://dx.doi.org/10.1016/j.jaac.2017.09.006

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HONORS PRESENTATIONS 2.3 — 2.5

HONORS PRESENTATION 2.3 AACAP GEORGE TARJAN, MD, AWARD FOR CONTRIBUTIONS IN DEVELOPMENTAL DISABILITIES

CARE NOT CURE: THE BASQUE CRADLE-TOGRAVE APPROACH TO AUTISM SPECTRUM DISORDER SENDATU EZ, BAINA BAI ZAINDU: AUTISMOAREKIKO EUSKAL IKUSPEGIA BIZIALDI OSOAN NO CURAR, PERO CUIDAR: EL ENFOQUE VASCO PARA TEA A LO LARGO DE LA VIDA Joaquin Fuentes, MD, Policlinica Gipuzkoa, fuentes.j@ telefonica.net Objectives: The goal of this presentation is to familiarize attendees with the system of care for citizens with autism spectrum disorders (ASD) developed for more than 35 years in the County of Gipuzkoa, Basque Country, Spain. Methods: The presentation will briefly cover the following topics: 1) describe community resources available; and 2) identify the basic principles followed in the program (local identification of needs; embedment into the community and multi-agency support; compliance with best practice guidelines; searching for outcomes; and finally—but not last—empowerment of stakeholders). The current actions of the European Parliament and the European Commission in ASD (Autism Spectrum Disorders in Europe, ASDEU Project) will be reviewed, along with the plans for European practice guidelines in ASD, to be established for next year by the European Society for Child and Adolescent Psychiatry (ESCAP). Results: Many coordinated efforts are in process now in Europe to determine the ASD European Strategy, using referents of care and free access to community programs characterized by excellence. Conclusions: There are coherent ways to improve the quality of life of citizens with ASD. The challenge is to disseminate these practices and adapt them to the conditions of each country, including the United States.

PUP, ASD, TREAT http://dx.doi.org/10.1016/j.jaac.2017.09.007

HONORS PRESENTATION 2.4 KLINGENSTEIN THIRD GENERATION FOUNDATION AWARD FOR RESEARCH IN DEPRESSION OR SUICIDE, SUPPORTED BY THE KLINGENSTEIN THIRD GENERATION FOUNDATION

NEONATAL AMYGDALA FUNCTIONAL CONNECTIVITY AT REST IN HEALTHY AND PRETERM INFANTS AND EARLY INTERNALIZING SYMPTOMS Cynthia Rogers, MD, Washington University in St. Louis School of Medicine, [email protected] Objectives: Alterations in the normal developmental trajectory of amygdala resting-state–functional connectivity (rs-FC) have been associated with atypical emotional processes and psychopathology. Little is known, however, regarding amygdala rs-FC at birth or its relevance to later socialemotional development. This study examined amygdala rs-FC in healthy, full-term (FT) infants and in very preterm (VPT) infants and tested whether


variability of neonatal amygdala rs-FC predicted internalizing symptoms at age 2 years. Methods: Resting-state–fMRI data were obtained shortly after birth from 65 FT infants [gestational age (GA) 36 weeks] and 57 VPT infants (GA < 30 weeks) at term equivalent. Voxelwise correlation analyses were performed using individual-specific bilateral amygdala regions of interest. Total internalizing symptoms and the behavioral inhibition, depression/withdrawal, general anxiety, and separation distress subdomains were assessed in a subset (n ¼ 44) at age 2 years using the Infant Toddler Social Emotional Assessment. Results: In healthy FT infants, amygdala rs-FC patterns were similar to those of older children and adults, positive correlations with subcortical and limbic regions and negative correlations with many cortical regions. VPT infants demonstrated similar results but with decreased magnitude. Neonatal amygdala rs-FC predicted internalizing symptoms at age two years with regional specificity consistent with known pathophysiology in older populations: connectivity with the anterior insula related to depressive symptoms, with the dorsal anterior cingulate related to generalized anxiety and with the medial prefrontal cortex related to behavioral inhibition. Conclusions: Amygdala rs-FC is well established in neonates. Variability in regional neonatal amygdala rs-FC predicted internalizing symptoms at age two years, suggesting that risk for internalizing symptoms may be established in neonatal amygdala functional connectivity patterns.

IMAGS, INF, EC http://dx.doi.org/10.1016/j.jaac.2017.09.008

HONORS PRESENTATION 2.5 AACAP JEANNE SPURLOCK LECTURE AND AWARD ON DIVERSITY AND CULTURE

OLA: AN INDIGENOUS HEALTH SYSTEM THAT COULD CHANGE OUR HOMELAND Naleen N. Andrade, MD, University of Hawaii, John A. Burns School of Medicine, [email protected] Objectives: This presentation is designed to help the participant accomplish the following: 1) describe how Native Hawaiians define Ola, “health and wellness” as a function of spiritual and emotional relationships within the family, with a focus on children and adolescents; 2) describe some of the pertinent health/mental health disparities—and some of the causal relationships—that impact Native Hawaiians in their homeland; and 3) explain how health leaders are combining indigenous Hawaiian practices, population health, and healthcare payment transformation to develop a health and wellness system of care for Native Hawaiians in their homeland. Methods: A “TED Talk” model of presentation will review salient findings, research advances, and insights of what has been learned from the 30-year history of the Native Hawaiian Healthcare federal law and the Native Hawaiian Health Care System that it proposed. Results: Inadequate federal funding spawned a leveraging model from public and private resources, which should be further developed. Interventions often did not occur within families, and adolescents were not consistently provided with life skills and experiences that developed their Native Hawaiian ethnocultural identification. New models of healthcare reform and population health require that the existing health care system be updated. Conclusions: The knowledge gained from analyzing results is being applied to extend and amend the existing legislation to create a new indigenous model of health and wellness. Participants will gain an understanding of how this year’s Spurlock Award recipient is working with key health leaders and institutions to develop a system of health and wellness that is driven by systematically partnering indigenous and western healthcare models to engage and advance Ola within Native Hawaiians in their homeland.

ADMIN, PUP, TREAT http://dx.doi.org/10.1016/j.jaac.2017.09.009

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HONORS PRESENTATION 3 AACAP NORBERT AND CHARLOTTE RIEGER SERVICE PROGRAM AWARD FOR EXCELLENCE

IMPROVING PRIMARY CARE ACCESS AND QUALITY OF CARE FOR CHILDREN WITH MENTAL HEALTH NEEDS: THE CHILD AND ADOLESCENT PSYCHIATRY FOR PRIMARY CARE CAP PC EXPERIENCE David L. Kaye, MD, University at Buffalo, [email protected] Objectives: Although child mental health problems are widespread, few get adequate treatment and there is a severe shortage of child psychiatrists. To address this public health need, many states have adopted collaborative care programs to assist primary care providers to better assess and manage pediatric mental health concerns. This report adds to the small literature on collaborative care programs and describes one large program that covers most of the state of New York. Child and Adolescent Psychiatry for Primary Care, a component program of New York State’s Office of Mental Health (OMH) Project Treatment Education Activists Combating HIV (TEACH), has provided education and consultation support to primary care providers in 90 percent of New York State since 2010. The program is a uniquely designed collaboration of five medical schools with hubs at each site that shares one tollfree number and works together to provide education and consultation support services to primary care physicians (PCPs). Methods: The program developed a clinical communications record to track information on all consultations, which forms the basis of much of this report. Two-week surveys following consultations, annual surveys, and pre- and posteducational program evaluations have also been used to measure the success of the program. Results: Child and Adolescent Psychiatry for Primary Care has grown in the six years of the program and has provided 8,013 phone consultations to more than 1,500 PCPs. The program synergistically provided 17,523 continuing medical education credits of educational programming to 1,200 PCPs. PCP users of the program report very high levels of satisfaction and self-reported growth in confidence. Conclusions: Child and Adolescent Psychiatry for Primary Care demonstrates that large-scale collaborative consultation models for primary care are feasible to implement and popular with PCPs and can be sustained. The program supports increased access to child mental health services in primary care and provides child psychiatric expertise for patients who would otherwise have none.

CON http://dx.doi.org/10.1016/j.jaac.2017.09.010

HONORS PRESENTATION 4 AACAP SIDNEY BERMAN AWARD FOR THE SCHOOL-BASED STUDY AND TREATMENT OF LEARNING DISORDERS AND MENTAL ILLNESS

NOW IS THE TIME! EXPANDED ROLES FOR CHILD AND ADOLESCENT PSYCHIATRISTS IN SCHOOL-BASED MENTAL HEALTH Erika Ryst, MD, University of Nevada, Reno, eryst@med. unr.edu Objectives: The field of school-based mental health offers unique and timely opportunities for child psychiatrists to partner with schools in meeting the mental health needs of youth. Increasingly, federal agencies, such as the Substance Abuse and Mental Health Services Administration (SAMHSA), are launching new national initiatives to promote mental health prevention and

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services in schools. For example, after the Newtown, Connecticut school shooting in 2012, President Obama released his “Now is the Time” presidential plan. Through this initiative, SAMHSA allocated $40 million for the development of school district demonstration projects in 20 states. This grant program, “Project AWARE (Advancing Wellness and Resilience Education)” aims to develop innovative strategies within schools to increase mental health awareness, to identify youth mental health problems early, and to connect youth to school-based and community-based mental health services. Methods: Using two specific examples, this Honors Presentation will illustrate opportunities for child psychiatrists in school-based mental health programs. First, Nevada Project AWARE (Advancing Wellness And Resilience in Education) will be described, with a particular focus on the role of one child psychiatrist’s involvement in the project. Second, a new project jointly sponsored by AACAP’s School Psychiatry Committee and the AAP Council on School Health will be introduced. This Project ECHO (Extension for Community Healthcare Outcomes) School-Based Mental Health Clinic will be a telementoring project and offer professional development opportunities to school-based mental health providers. Through the ECHO videoconferencing modality, child psychiatrists can engage in a nontraditional professional activity that disseminates the child psychiatrist’s expertise and increases the capacity of the mental health workforce. Results: Just as integrated healthcare models expand the role of child psychiatrists within pediatric care, school-based mental health programs allow child psychiatrists to forge new roles in areas such as prevention, public policy, system change, and workforce development. Special competencies are required for these new opportunities and will be discussed. Conclusions: The field of school-based mental health represents an area of opportunity for child psychiatrists as schools across the country begin to implement programs aimed at improving mental health.

CAD, SC, EDUC http://dx.doi.org/10.1016/j.jaac.2017.09.011

HONORS PRESENTATION 5 AACAP NORBERT AND CHARLOTTE RIEGER PSYCHODYNAMIC PSYCHOTHERAPY AWARD

AND THEN THERE WAS INTERSUBJECTIVITY: TREATING CHILD SELF AND MUTUAL DYSREGULATION DURING TRAUMATIC PLAY Daniel S. Schechter, MD, University of Geneva Hospitals and Faculty of Medicine, [email protected] Objectives: The goal of this session is to test the following hypotheses: 1) if the child’s striving toward intersubjective states with the traumatized parent must be avoided by her to maintain her own psychobiological homeostasis in the wake of violent trauma (i.e., domestic violence), the child’s emotional communication will not be received by that parent and that the risk for further psychological and/or somatic symptoms, impairment, and retraumatization will increase; and 2) if the psychotherapist is able to help the traumatized parent jointly attend to the child’s communication of a traumatic memory trace and support her curiosity and desire to make-meaning, intersubjectivity can begin to be restored and the traumatized parent can feel more competent. Depending on the child’s age, the child can also be helped to understand better parental emotional cues. This intervention can lead to a deeper and more mutative process. Methods: Empirical neurobiological research with violence-exposed mothers suffering from PTSD and their young children will be reviewed. Then case vignettes will be presented to illustrate psychodynamically-based, researchinformed psychotherapeutic techniques to help restore mother–child “moments of meeting,” with the psychotherapist’s reflective support. Results: The clinical examples in this presentation have shown that despite maternal avoidance, numbing, and dissociation during the parent–child play sessions, with psychotherapeutic intervention, traumatized mothers and children can begin to demonstrate shared meaning, relief, and even joy at mutual

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approach. The traumatized parent and child’s tendency to flee in one way or another leads ultimately to greater mutual distress. Conclusions: The clinical observations presented in this paper are consistent with empirical research that shows that interpersonal violence-related PTSD among parents can impair their capacity to self-regulate emotionally, behaviorally, physiologically, and at the level of brain activity, despite their best efforts and intentions. This tendency toward self-dysregulation can be impairing to parent–child interactive behavior, particularly when the traumatized child has the need to express a dysregulated or dysregulating aspect of his or her own adverse experience(s).

P, PAT http://dx.doi.org/10.1016/j.jaac.2017.09.012

HONORS PRESENTATION 6 AACAP CANCRO ACADEMIC LEADERSHIP AWARD

WHY WOULD ANYONE WANT TO BE A MEDICAL EDUCATOR? Thomas F. Anders, MD, Brown University and the University of California, San Francisco, [email protected]


Objectives: The goal of this presentation is to provoke a thoughtful dialogue among child and adolescent psychiatry educators about the challenges and opportunities that portend the future of training and education in child and adolescent psychiatry. Methods: AACAP’s Training and Education Committee members were polled regarding their views related to the challenges facing teaching and training in child and adolescent psychiatry. Results: The responses were far reaching and described a broad array of issues that forecast a potentially exciting future for education science and faculty development, in general, and for child and adolescent psychiatry educators, in particular. The responses focused on the differing needs of a variety of student learners, such as: 1) clarifying and objectifying educational outcomes for these diverse student groups; 2) insuring that national regulations produce significant educational gains; 3) promoting educators as academic leaders who will make both the business and moral case for education; and 4) resources,. Conclusions: In sharp contrast to the title of this presentation, emerging collaborative teaching, multidisciplinary educational support groups (e.g., the recently established AACAP Alliance for Learning and Innovation, with over 200 members), and continuous local and national faculty development programs should offer child and adolescent psychiatry teachers an exciting slice of the educational pie.

AC, REST http://dx.doi.org/10.1016/j.jaac.2017.09.013

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INSTITUTES 1 Advanced Psychopharmacology Update: Balancing Benefits and Risks 2 Research Institute: This Is Your Brain on Child Psychiatry. Any Questions? A Practical Update on the Impact of Neuroimaging Findings in Child Psychiatry 3 Autism Spectrum Disorder: From Clinical Practice to Cutting Edge Research 4 Family-Based Psychiatric Interventions for Physically Ill Children 5 Lifelong Learning Institute: Module 14: Relevant Clinical Updates for Child and Adolescent Psychiatrists 6 Insomnia: The Sleeping Giant of Pediatric Public Health 7 Intellectual Disability and Co-Occurring Psychiatric Disorders: Diagnosis, Treatment, and Forensic Issues 8 Practical Pediatric Psychopharmacology for Pediatricians and Non-Child Psychiatrists

INSTITUTE 1 ADVANCED PSYCHOPHARMACOLOGY UPDATE: BALANCING BENEFITS AND RISKS Jeffrey R. Strawn, MD, University of Cincinnati, strawnjr@uc. edu; Barbara J. Coffey, MD, MS, Icahn School of Medicine at Mount Sinai, [email protected] Objectives: Accumulating data support the efficacy of psychopharmacologic interventions for a number of psychiatric disorders in youth; however, in parallel, studies increasingly reveal a clearer picture of the adverse effects or side-effect profiles of these treatments. This Institute seeks to review and apply current data related to efficacy of psychotropic medications in youth, as well as the prevalence and management of medication-related adverse effects Methods: This advanced Institute will present recent clinical trial data and data related to efficacy and side-effect management of selected medications in pediatric patients with anxiety, depressive, bipolar, autism spectrum, tic, and obsessive compulsive disorders and ADHD. Case presentations will be used to illustrate pragmatic aspects of adverse effects and tolerability concerns with second-generation antipsychotic (SGA) drugs, stimulants, and antidepressants, as well as attendant evidence-based management strategies for these adverse effects. Results: A comprehensive evaluation of both positive and negative clinical trials of psychopharmacologic treatments for anxiety, depressive, bipolar, autism spectrum, tic, and obsessive compulsive disorders and ADHD are reviewed and discussed. Adverse effects of treatment are manageable and recent data related to maximizing the tolerability of antidepressants, SGA drugs and stimulants are reviewed and applied to representative clinical vignettes. Guidelines for decision making in medication choice, weighing efficacy and risk, will be presented. Conclusions: These case-focused presentations highlight significant advances in the evidence base for psychopharmacologic interventions in youth. Additionally, the tolerability of antidepressants, stimulants, and SGA drugs in youth are comprehensively reviewed to provide a framework for monitoring and management of these side effects.

PPC, MDM, MAE http://dx.doi.org/10.1016/j.jaac.2017.07.503

1.1 PSYCHOPHARMACOLOGIC TREATMENT OF DEPRESSIVE DISORDERS IN CHILDREN AND ADOLESCENTS Karen Dineen Wagner, MD, PhD, University of Texas Medical Branch, [email protected] Objectives: The goal of this session is to provide an update on the evidence base for the psychopharmacologic treatment of depressive disorders in children and adolescents. Methods: Data available from controlled antidepressant treatment studies for children and adolescents with major depression will be reviewed. A clinical treatment algorithm for major depression based on study findings will be discussed, as well side effects and associated management strategies.

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1.0 — 1.3 Results: Response rates to initial antidepressants are approximately 50–60 percent, and approximately 50 percent of youths who fail to respond to an initial antidepressant will respond to an alternative antidepressant. Cognitive behavioral therapy in combination with medication treatment increases response rates and decreases relapse rates. Conclusions: The evidence base regarding monotherapy treatment for youth with major depression has increased, but the evidence base for combination pharmacotherapy remains extremely limited, despite its common use in clinical practice.

ADP, DDD, PPC http://dx.doi.org/10.1016/j.jaac.2017.07.504

1.2 PSYCHOPHARMACOLOGY OF OBSESSIVECOMPULSIVE DISORDER: WEIGHING THE EVIDENCE VERSUS THE RISK John T. Walkup, MD, Ann and Robert H. Lurie Children’s Hospital of Chicago, [email protected]; Justin W. Mohatt, MD, Weill Cornell Medical College, jum9071@med. cornell.edu Objectives: Beginning in the late 1980s, serotonin reuptake inhibitors (SRIs) entered the market, and for the first time, effective treatments were available for OCD, a condition that up until then had been unresponsive to existing norepinephrine reuptake inhibitors and dopamine blockers. With the advent of pharmacological responsiveness of OCD to SRIs, the search was on to extend the efficacy of SRIs to other disorders that were characterized by repetitive thoughts and behaviors—the OCD spectrum. This review will discuss successful treatment trials for some subtypes of OCD and also highlight the efficacy for disorders of repetitive thoughts and behaviors considered to be part of the OCD spectrum. Methods: The session will review child (and adult) SRI treatment trials for conditions that are considered part of the OCD spectrum, including OCD, anxiety disorders, anorexia, trichotillomania, skin picking, body dysmorphic disorder, kleptomania, pyromania, pedophilia, tic disorders, hoarding, excessive shopping, and repetitive behaviors in autism spectrum disorder. Results: The data suggest that the promise of SRI benefit for a variety of repetitive thoughts and behavior disorders has not been realized. SRIs are effective for a narrow range of repetitive thoughts and behavior disorder. For those conditions unresponsive to SRI, the risk benefit ratio is negative. Conclusions: Based on multiple treatment trials of SRI medications for disorders characterized by repetitive thoughts and behaviors, it appears that the hypothesized OCD spectrum is much narrower than originally conceptualized. The risk benefit ratio is variable depending upon what repetitive behavior and thoughts are targeted by SRI medications.

MAE, OCD, PPC http://dx.doi.org/10.1016/j.jaac.2017.07.505

1.3 ANXIETY DISORDERS IN YOUTH: EFFICACY AND ADVERSE EFFECTS OF PSYCHOPHARMACOLOGIC INTERVENTIONS Jeffrey R. Strawn, MD, University of Cincinnati, strawnjr@ uc.edu Objectives: The goals of this session are to review and apply current data efficacy and tolerability data for psychopharmacologic interventions in youth with non–OCD anxiety disorders and to review recent data related to antidepressantrelated adverse effects in children and adolescents with anxiety disorders. Methods: Data from 12 studies of psychopharmacologic interventions in youth with non–OCD anxiety disorders are reviewed and summarized, including nine trials that include SSRIs and SSNRIs. Side-effect profiles of SSRIs and SSNRIs are reviewed, and a meta-analysis (random-effects model) of response trajectory, suicidality, and adverse effects for SSRIs and SSNRIs in pediatric patients with anxiety disorders (N ¼ 1,673) will be described. SSRIrelated side effects from the Child and Adolescent Anxiety Multimodal Study will be reviewed, in addition to a network meta-analysis of antidepressant tolerability in youth. Results: SSRI/SSNRIs are efficacious for the treatment of non–OCD anxiety disorders with SSRIs associated with greater effect sizes, although this

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difference fails to reach statistical significance. Antidepressant response occurs early in the course of treatment (within the first two weeks), and the odds of additional increases in response plateaus by the eighth week of treatment. Antidepressants are associated with increased activation in children and adolescents with anxiety disorders (OR: 1.86), whereas, in general, tolerability of antidepressants is lower in the SSNRIs relative to SSRIs. Conclusions: SSRI/SSNRIs are well tolerated and efficacious for the treatment of non-OCD anxiety disorders, although sparse data exist for other psychopharmacologic treatments in this population.

ADP, AD, AXX http://dx.doi.org/10.1016/j.jaac.2017.07.506

1.4 ADVANCED PSYCHOPHARMACOLOGIC TREATMENT FOR THE CHILD AND ADOLESCENT WITH AUTISM SPECTRUM DISORDER Jeremy Veenstra-VanderWeele, MD, Columbia University, [email protected] Objectives: The goals of this session are to update the participants about current evidence on medications in autism spectrum disorder (ASD) and to provide an approach to assessment, treatment, and referral for co-occurring behavioral and psychiatric problems, with an emphasis on making decisions by balancing potential benefits and risks. Methods: A clinical case example will be used to provide a relevant framework for decision making using an evidence-based approach. Recent systematic reviews, meta-analyses, and practice pathways, as well as randomized controlled trials from 2016 and 2017, will be reviewed and presented. Results: This presentation will describe current evidence for treatment of irritability/aggression symptoms, repetitive behavior, co-occurring ADHD, and cooccurring anxiety symptoms in ASD. Integrated medical, psychiatric, and behavioral assessment for these symptoms will be discussed, with an emphasis on practical approaches for evaluation and management. Treatment pathways for different symptom domains will be presented, including irritability/aggression, repetitive behavior, ADHD, anxiety, and mood symptoms. A common clinical case presentation will be used as an example of the potential benefits and risks in management of psychiatric and behavioral comorbidity in ASD. Conclusions: Children and adolescents with ASD often present with multiple medical and behavioral problems that can best be managed using an integrated approach coordinated by a frontline provider who steps up to lead a coordinated care team.

ASD, CM, PPC http://dx.doi.org/10.1016/j.jaac.2017.07.507

1.5 PSYCHOPHARMACOLOGIC TREATMENT OF MOODS, EPISODES, AND OUTBURSTS Gabrielle A. Carlson, MD, SUNY at Stony Brook, Gabrielle. [email protected] Objectives: Bipolar disorder (BD) guidelines need to address the prevailing mood being treated (mania or depression), the fact that it is relapsing and recurring, and for some who feel that there is a prepubertal subtype, the fact that there are explosive outbursts that characterize it. Disruptive mood dysregulation disorder (DMDD) is also defined by irritable mood and often crippling outbursts. This presentation will discuss current thinking about treatment of these components. There are some similarities and differences. Methods: Two cases will be presented that illustrate the issues that often need to be treated in patients with BD and DMDD. The current status of the treatment literature for BD mania and depression will be reviewed, pulling in adult psychiatry literature where relevant. For DMDD, the question of how to treat the outbursts will be discussed. Results: There are no new approved treatments for mania in young people, although there are several new neuroleptic drugs available for adults. There have been some advances in the treatment of bipolar depression. Finally, the current status of managing severely irritable children will be discussed, although there is not enough literature to provide data on treatment trials, and clearly there are no FDA-approved medications for DMDD. Treatments include many of the medications for which there is an abundant literature on


adverse events. Treatment guidelines do take the question of medication safety into consideration. Conclusions: Although advances are gradually being made in treating children with severe mood problems, there is a considerable distance yet to go.

APS, BD, DMDD http://dx.doi.org/10.1016/j.jaac.2017.07.508

1.6 RECOGNITION AND MANAGEMENT OF SECOND-GENERATION ANTIPSYCHOTICASSOCIATED ADVERSE EFFECTS Melissa P. DelBello, MD, MS, University of Cincinnati, [email protected]; Jeffrey R. Strawn, MD, University of Cincinnati, [email protected]; Luis Patino Duran, MD, University of Cincinnati, [email protected] Objectives: The goal of this session is to review tolerability data of antipsychotic drugs and mood stabilizers in youth and to present evidence-based monitoring and management strategies for selected adverse effects, including dyslipidemia, weight gain, and hyperprolactinemia. Methods: This presentation will briefly review tolerability and adverse effects data from randomized trials of second-generation antipsychotic (SGA) drugs and mood stabilizers in youth. Evidence for specific interventions to manage metabolic adverse effects, including metformin and omega-3 fatty acids, will be reviewed. We will also review data supporting the use of aripiprazole for hyperprolactinemia. Results: SGAs and mood stabilizers vary in their risk for specific adverse effects. Moreover, weight gain, dyslipidemia, and hyperprolactinemia may present specific challenges in youth. Results from randomized controlled trials of youth treated with SGA suggest that metformin is safe, well tolerated, and effective in attenuating treatment-related weight gain and improves insulin sensitivity. Aripiprazole may be an effective treatment for lowering prolactin levels of individuals treated with SGA drugs. Conclusions: Metabolic risk profiles vary between specific antipsychotic drugs and should inform treatment selection. Education on adverse effects, as well as dietary and lifestyle counseling should be part of any antipsychotic treatment regimen. Routine monitoring of side effects is essential, and benefits must be balanced against the varying adverse effect risks; however, specific evidence-based pharmacologic interventions may mitigate treatment-related adverse effects of SGA drugs.

APS, BD, PTA http://dx.doi.org/10.1016/j.jaac.2017.07.509

1.7 PHARMACOLOGIC STRATEGIES IN TREATMENT-REFRACTORY ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER Timothy E. Wilens, MD, Massachusetts General Hospital and Harvard University, [email protected] Objectives: Increasingly difficult cases of children with ADHD are presenting to child psychiatrists requiring practitioners to learn new strategies for the management of medication-related side effects, refractory core-ADHD symptoms, and treatment of comorbidities. Methods: A systematic review of the literature from historic, recently completed, and ongoing trials was reviewed to elucidate data on stimulant and nonstimulant treatments for ADHD. The limited data on the management of side effects were punctuated by anecdotal and open reports. Results: The literature, combined with clinical experience, indicates that alterations in the use of traditional stimulants in existing and novel release forms, atomoxetine, a agonists, the use of alternative agents, and combinations of medications can enhance a patient’s response to ADHD treatment. Strategies exist for management of common comorbid conditions. Many side effects are predictable and can be managed. Conclusions: Pharmacologic strategies will be reported for those who 1) have not responded to traditional agents; 2) present with comorbidities; and 3) are experiencing treatment-emergent adverse effects. Both empirically derived data and illustrative cases will be used in the presentation.

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ATA, ADHD, PPC http://dx.doi.org/10.1016/j.jaac.2017.07.510

1.8 PSYCHOPHARMACOLOGIC TREATMENT OF TICS AND TOURETTE’S DISORDER Barbara J. Coffey, MD, MS, Icahn School of Medicine at Mount Sinai, [email protected] Objectives: The goals of this session are to describe a systematic approach to disentangling tic and nontic psychiatric symptoms in the evaluation and treatment of children and adolescents with tics and Tourette’s disorder (TD) and to discuss evidence-based guidelines for use of formally approved and off-label medications for the treatment of tics. Methods: Review of recent studies on the use of neuroleptic drugs, a agonists, stimulants, and other medications in patients with TD and comorbid psychiatric disorders will provide updated evidence for efficacy. Data on adverse effects of the major classes of medication used to treat patients with tic disorders will be reviewed. Guidelines for balancing effectiveness against risk will be presented. Results: Aripiprazole is now formally approved for labeling for the treatment of tics in TD. However, as experience has accumulated, so have metabolic problems with use of this medication. Stimulants, among the most effective psychopharmacological treatments for ADHD in youth and adults, are being used increasingly in children and adolescent with tic disorders. Although there is no evidence to suggest that stimulants cause or increase tics, some children may be vulnerable to new onset or exacerbations of tics in the context of stimulant treatment. a Agonists, which are used off label, are frequently recommended as first-line agents for treatment of tics for youth and adults with TD because of their relatively benign adverse effect profile; however, these medications often cause sedation or irritability. Comprehensive behavioral intervention for tics (CBIT) is often recommended as first-line treatment for tics, but trained therapists are difficult to find. Finally, novel agents, which may provide a more favorable benefit to risk ratio for treatment of tics, have been investigated in the past several years, but these agents are not commercially available. Guidelines for choice of target symptoms, medication class, and suggested algorithms will be recommended for youth and adults with tics and TD. Conclusions: Clinical decision making can be complicated in treatment of Tourette’s disorder, as comorbidity with other psychiatric disorders is frequent. Tic and nontic symptoms need to be disentangled and prioritized, and effectiveness and risk need to be weighed for individual patients to determine the best approach to management.

PPC, TICS, TD http://dx.doi.org/10.1016/j.jaac.2017.07.511

INSTITUTE 2 RESEARCH INSTITUTE: THIS IS YOUR BRAIN ON CHILD PSYCHIATRY. ANY QUESTIONS? A PRACTICAL UPDATE ON THE IMPACT OF NEUROIMAGING FINDINGS IN CHILD PSYCHIATRY Daniel P. Dickstein, MD, Brown University and Bradley Hospital, [email protected]; David Cochran, MD, PhD, UMass Medical School, david.cochran@umassmemorial. org; Bradley Peterson, MD, Children’s Hospital Los Angeles, [email protected] Objectives: This Institute will provide updates on the current state of neuroimaging research from a practical, clinician-focused standpoint and discuss future challenges and opportunities for clinically relevant imaging research. It will provide a clear description of how neuroimaging shapes our understanding of psychiatric diagnoses and treatments today and show an appreciation of how this will change over the next 10 years Methods: The Institute will consist of seven presentations in three sections. After each set of presentations, there will be a panel discussion

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involving the preceding presenters. In part one (Drs. Milham and Gogtay), the focus will be on how neuroimaging informs our current understanding of mental health disorders, in comparison to typical development. In part two (Drs. Delbello, Croarkin, and Leibenluft), we will focus on how neuroimaging has informed treatment of neuropsychiatric disorders in three modalities: psychopharmacology, somatic therapy (specifically repetitive transcranial magnetic stimulation), and cognitive therapies. In part three (Drs. Frazier and Poldrack), the focus will shift to large-scale questions of how the challenges associated with neuroimaging datasets will be addressed in the future. Results: The Institute will provide attendees with an up-to-date assessment of how neuroimaging studies inform our current understanding of mental health disorders, how they have led to developments in treatment across disorders and modalities, and how the challenges associated with broader use of neuroimaging data are being addressed. Conclusions: These presentations will provide a comprehensive look into how neuroimaging is being used to directly answer important clinical questions and demonstrate the relevance of these findings to clinical practice. Continued innovation and refinement are needed to realize the full potential of pediatric neuroimaging. Open science and interdisciplinary collaboration can accelerate the pace of progress toward these goals.

IMAGS, R, NEURODEV Sponsored by the Research Committee and Supported by the Research Initiative http://dx.doi.org/10.1016/j.jaac.2017.07.513

2.1 MAKING NEUROIMAGING MORE REPRODUCIBLE AND TRANSPARENT Russell A. Poldrack, PhD, Stanford University, russpold@ stanford.edu; Krzysztof J. Gorgolewski, Stanford University, [email protected] Objectives: There is increasing concern that common research practices may reduce the reproducibility and generalizability of research findings. These concerns are particularly acute for domains such as functional neuroimaging in which the data are high-dimensional and there is a great deal of flexibility in data analysis. Methods: I will discuss a number of approaches that are being developed to improve reproducibility, including study preregistration, the tracking of analysis workflows across the lifespan of a project, and the quantification of how results vary across workflows. I will also discuss several strategies to increase transparency, including data/code sharing and detailed standards for data and metadata description and study reporting. Results: I will present the brain imaging data structure (BIDS) and BIDS applications (Apps) projects, both of which provide the basis for greater transparency and reproducibility of data analyses. Conclusions: Current practices must be improved if we hope to achieve a robust understanding of psychiatric disorders using neuroimaging.

DAM, IMAGS, NEURODEV Supported by the Laura and John Arnold Foundation, NIDA Grants R21DA034316, and National Science Foundation Grant ACI-1131441 http://dx.doi.org/10.1016/j.jaac.2017.07.514

2.2 CLINICALLY USEFUL BRAIN IMAGING FOR NEUROPSYCHIATRY: CAN WE GET THERE? Michael P. Milham, MD, PhD, Child Mind Institute, eszter. [email protected] Objectives: In the past decade, resting-state fMRI (R-fMRI) has emerged as a mainstream imaging approach. Despite initial concerns regarding the nature of fMRI signals at rest, insufficient understanding of the physiology underlying R-fMRI fluctuations, and lack of agreement about appropriate preprocessing and data reduction steps, the field has since documented high reproducibility of findings and moderate-to-high test-retest reliability. Large-scale, multicenter studies have demonstrated the value of R-fMRI for characterizing

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pathophysiological processes and feasibility of using R-fMRI for biomarker identification. We will review the promises and pitfalls of R-fMRI, as well as the major innovations required to achieve meaningful translational outcomes. Methods: Dr. Milham will describe an agenda for the application of R-fMRI techniques in child psychiatry. He will emphasize goals to 1) redefine psychiatric nosology in terms of neuroscience; 2) revolutionize clinical practice through the development of biomarkers; and 3) bring personalized medicine to psychiatry. The readiness of R-fMRI approaches will be discussed through the lens of the criteria used to evaluate clinical tests (i.e., validity, reliability, sensitivity, specificity, and applicability) and alternative fMRI methodologies considered. Gaps and needs will be identified, and the potential of emerging conceptual, analytical, and cultural innovations to address them will be highlighted. Results: The audience will learn of the promises of R-fMRI for child and adolescent mental health and develop a practical understanding of the obstacles ahead that must be overcome to significantly impact public health. They will learn about large-scale initiatives helping to deliver the data necessary to “change the game” for child and adolescent mental health and the design needs for future studies to continue this process. Practical expectations for the short- and long-term will be proposed. Conclusions: Resting-state fMRI is rapidly advancing the agenda of biological psychiatry and may be the key to pediatric neuroimaging attaining deliverable clinically useful tools. Continued innovation and refinement are needed to realize the full potential of R-fMRI. Open science and interdisciplinary collaboration can accelerate the pace of progress toward these goals.

IMAGS, NEURODEV, R http://dx.doi.org/10.1016/j.jaac.2017.07.515

2.3 CHILDHOOD-ONSET PSYCHOSIS AND TYPICAL DEVELOPMENT: INSIGHTS FROM NEUROIMAGING STUDIES Nitin Gogtay, MD, National Institute of Mental Health, [email protected] Objectives: Psychotic illnesses in children are rare but can be severe. Childhood-onset schizophrenia (COS), with onset of psychosis before age 13 years, is a rare form of schizophrenia that represents a more severe and chronic form of the adult-onset illness. Prospective imaging studies of pediatric psychoses and COS, along with their siblings with no psychosis, provide unique insights into brain development in psychotic illnesses as a whole. Methods: Prospective MRI scans that included structural, resting-state, functional, and diffusion tensor imaging were obtained every two years on children with psychosis; their full siblings; and healthy, matched control subjects. Longitudinal structural, functional, and diffusion tensor imaging analyses were conducted to examine brain development in pediatric psychoses. Results: COS brain development shows progressive loss of gray matter volume and cortical thinning, ventricular enlargement, progressive decline in cerebellar volume, and a significant but fixed deficit in hippocampal volume; findings that seem dimensionally regulated and diagnostically specific. COS also show a slower rate of white matter growth and disrupted local connectivity strength. Sibling studies indicate that siblings with no psychosis share many of these brain abnormalities, including decreased cortical thickness and disrupted white matter growth, yet these abnormalities normalize with age, further suggesting that these abnormalities are age-dependent trait markers. Conclusions: Longitudinal neuroimaging studies remain a valuable tool for assessing the neurobiology of schizophrenia and other psychotic illnesses, and parallel studies in unaffected siblings provide insights into both risk and resilience in these illnesses.

IMAGS, LONG, SZ http://dx.doi.org/10.1016/j.jaac.2017.07.516

2.4 NEURAL MARKERS OF TREATMENT EFFECTS AND RESPONSE IN YOUTH WITH FIRST-EPISODE MANIA Melissa P. DelBello, MD, MS, University of Cincinnati, [email protected]; Luis Patino Duran, MD, University of Cincinnati, [email protected]; Jeffrey R. Strawn, MD,


University of Cincinnati, [email protected]; Christina Klein, MPH, University of Cincinnati, christina.klein@ uc.edu; Jeffrey Welge, PhD, University of Cincinnati, [email protected]; Thomas Blom, MS, University of Cincinnati, [email protected]; Caleb Adler, MD, University of Cincinnati, [email protected] Objectives: Although adolescence is the most common period of onset of bipolar disoder (BD), youth with mania often undergo several unsuccessful medication trials prior to achieving mood stabilization. Understanding the neurophysiologic effects of pharmacological interventions in these youth will clarify the impact of antimania treatments on the neurodevelopment of BD and may lead to the identification of neurobiological markers associated with treatment response. We examined the differential effects of quetiapine (QUET) and lithium (Li) on neural function in youth afflicted with first-episode (FE) mania. Methods: Youth with FE mania (N ¼ 110; ages 10–17 years) were randomized to six weeks of double-blind treatment with Li versus QUET. Group-matched healthy comparison (HC) youth (n ¼ 62) were also recruited. fMRI scans were obtained at baseline and at week six while performing a task of sustained attention. Event-related, voxel-wise group comparisons were performed. Results: There were significantly more responders to QUET (42/59, 71 percent) than to Li (25/54, 46 percent, P < 0.007). Compared with HC, FE exhibited decreased activation in the left fusiform and parahippocampal gyri, bilateral thalamus, and right caudate and greater activation in the left middle and superior frontal gyri at baseline. Compared with baseline, administration of Li at week six exhibited increased activation in the left amygdala and parahippocampal gyrus, bilateral putamen, posterior cingulate, and precuneus, as well as right caudate, thalamus, and superior frontal gyrus; QUET exhibited decreased activation in the left supramarginal gyrus, and bilaterial middle frontal gyri and increased activation in left brain activation (BA) as follows: 10, 24, and 32. Decreased activation in the left BA (40), inferior parietal lobule, supramarginal gyrus, and precuneus was associated with Li response, whereas increased activation in left anterior cingulate and right BA (10) was associated with QUET response. Conclusions: Our findings suggest the differential neural effects of Li and QUET in youth with mania. Baseline dysfunction in distinct brain regions may serve as markers of specific treatment response. We will discuss these findings in the context of other studies that examine the neurofunctional effects of pharmacological treatments and predictors of response and adverse effects in youth who have BD or are at-risk for bipolar disorder.

BD, IMAGS, PPC Supported by NIMH Grants MH077138, MH083924, and MH080973 http://dx.doi.org/10.1016/j.jaac.2017.07.517

2.5 TRANSCRANIAL MAGNETIC STIMULATION IN THE TREATMENT OF CHILD AND ADOLESCENT PSYCHIATRIC DISORDERS Paul E. Croarkin, DO, Mayo Clinic, [email protected]; Jennifer L. Vande Voort, MD, Mayo Clinic, vandevoort. [email protected]; Magdalena Romanowicz, MD, Mayo Clinic, [email protected]; Deniz D. Camsari, MD, Mayo Clinic, [email protected]; Charles Lewis, MD, Mayo Clinic, [email protected] Objectives: Participants will gain an appreciation of the current and future roles of neuroimaging in optimizing repetitive transcranial magnetic stimulation (rTMS) research protocols with children and adolescents. Methods: Presentation from a member with an active research program will focus on noninvasive brain stimulation in children and adolescents. Results: Initial therapeutic pilot studies have demonstrated that rTMS may have promise for adolescents with MDD, ADHD, and autism spectrum disorder (ASD). Larger, double-blind, randomized, sham-controlled studies of MDD and ASD are in progress. A recent study of adolescent MDD examined the use of MRI-guided treatment localization for rTMS delivery. These data suggest that standard coil placement techniques, such as the 5-cm rule and Beam F3 method, provide divergent treatment locations. However, the clinical impact of MRI-guided approaches is undetermined. Recent adult studies

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using rTMS have examined resting-state connectivity biomarker approaches for MDD. Emerging data suggest that high-frequency rTMS treatments may modulate frontostriatal connectivity. Other recent efforts have identified a resting-state biotype, which may predict responsiveness to rTMS therapy for MDD. Although data from future adolescent studies may diverge from adults, these initial efforts will inform future study design. Existing studies with magnetic resonance spectroscopy suggest that successful rTMS in adolescent depression may potentiate cortical glutamate neurotransmission. Conclusions: Prior studies suggest that rTMS will play an important role as a neurophysiological probe and therapeutic intervention in future research. Synergistic research with neuroimaging modalities holds the promise of enhancing the efficacy of therapeutic rTMS and informing developmental neuroscience. Ideal future study designs with rTMS and neuroimaging will concurrently address both of these broad goals.

DDD, IMAGS, NM Supported by Pfizer ASPIRE Grant WS1976243, Assurex, Neuronetics, the Brain and Behavior Research Foundation, the Mayo Clinic Foundation, and NIMH Grant K23 MH100266 http://dx.doi.org/10.1016/j.jaac.2017.07.518

2.6 USING BRAIN-BASED MECHANISMS TO INFORM NOVEL TREATMENTS FOR SEVERE IRRITABILITY Ellen Leibenluft, MD, National Institute of Mental Health, [email protected]; Katharina Kircanski, PhD, National Institute of Mental Health, [email protected]; Joel Stoddard, MD, MAS, University of Colorado Denver, [email protected]; Argyris Stringaris, MD, PhD, National Institute of Health, [email protected]; Daniel S. Pine, MD, National Institute of Mental Health, daniel.pine@ nih.gov; Melissa A. Brotman, PhD, National Institute of Mental Health, [email protected] Objectives: Brain-based research can guide the development of novel treatments for severe irritability, as operationalized in DSM-5 classification of disruptive mood dysregulation disorder (DMDD). This presentation will describe two such treatments: interpretation bias training (IBT) and an exposure-based CBT for frustration, accompanied by parent training. Methods: Studies using standardized behavioral paradigms and fMRI were used to test the hypothesis that irritability in youth is associated with aberrant responses to frustration (including decreased threshold, increased amplitude, and increased duration of the emotional response) and aberrant approach responses to threat. This translational model for irritability further posits specific deficits relevant to aberrant reward processing, including deficits in the content and process of instrumental learning, and increased sensitivity to reward omission. Results: With regard to aberrant responses to threat, research indicates that, relative to healthy youth, those with DMDD are more likely to view ambiguous faces as angry rather than happy. Furthermore, one clinical trial demonstrated that computer-based training designed to rectify this interpretation bias was effective in decreasing aggression in youth at risk for criminal behavior. We have demonstrated that such training can shift perceptions in youth with DMDD and are now conducting a randomized clinical trial to test whether such shifts are associated with decreased irritability. The new CBT treatment posits that parent training can be used to alter the child’s deficits in instrumental learning secondary to suboptimal reinforcers in the home environment and that exposing children to frustrating situations in a graded fashion will, through extinction learning, allow them to develop increased tolerance for frustration and more adaptive coping strategies. For both studies, fMRI studies pre- and posttreatment will test whether the hypothesized brain mechanisms mediate clinical response. Conclusions: Translational neuroscience research can suggest new avenues to address the dearth of evidence-based treatment for the common and impairing clinical presentation of severe irritability in children.

CBT, IMAGS, IMD http://dx.doi.org/10.1016/j.jaac.2017.07.519

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2.7 EVERYONE LIKES CANDI: DATA SHARING AND NEUROINFORMATICS TO ADDRESS BIG DATA QUESTIONS Jean A. Frazier, MD, UMass Medical School, Jean.Frazier@ umassmed.edu; Steve Hodge, MA, UMass Medical School, [email protected]; Jean-Baptiste Poline, PhD, Helen Wills Neuroscience Institute, [email protected]; Christian Haselgrove, BA, UMass Medical School, Christian. [email protected]; David Cochran, MD, PhD, UMass Medical School, [email protected]; David Kennedy, PhD, UMass Medical School, David. [email protected] Objectives: A substantial amount of neuroimaging data are now being shared that will allow us to answer important questions, thanks to efforts by the NIH Pediatric Database (PEDS); Autism Brain Data Exchange (ABIDE); and Pediatric Imaging, Neurocognition and Genetics (PING). We will discuss the use of these shared resources and ways to use them to answer important questions. For example, in typical development, do multiple sources of developmental data tell us the same things about the developmental trajectory and sex effects? Methods: By use of these shared data resources and a specific structural analysis workflow (Freesurfer), we can ask for a given statistical model if there is consistency of effect. As an example structure that lets us examine some specific questions in this data, we explore the total hippocampus volume in these datasets. Results: Our first analysis looks at the sex effect of the total hippocampus volume across three datasets: PING, PEDS, and ABIDE, including 95% confidence limits for the model [total hippocampus volume w sex + age + sex age + total cerebral volume (TCV) + site]. Neither PEDS (N w 300) nor ABIDE (N w 400) indicates a significant gender effect, whereas the sex effect is significant and seen to be w3% in the PING (N w 1,200) dataset. Using the PING data, where we have access to the most complete set of behavioral and demographic factors, we generate 32 model permutations that include the following factors: age, sex, site, socioeconomic status (SES), genetic ancestry factors, and intracranial volume (ICV). Accounting for ICV greatly reduces the magnitude of the sex effect that is over and above the allometric scaling of total brain. All of these sex effects are significant, and despite being lower in magnitude, the models that include ICV show an increase in R2 from w0.25 to w0.40, indicating a better overall fit to the data. Conclusions: These results demonstrate that, even before considering the subtle modulations caused by diagnostic effects of child mental health disorders, careful attention to data model and data sources is needed to definitely document developmental factors in brain-imaging data.

DAM, IMAGS, NEURODEV Supported by NIH-National Institute of Biomedical Imaging and Bioengineering Grant P41 EB019936 and NIH-NIMH Grant R01 MH083320 http://dx.doi.org/10.1016/j.jaac.2017.07.520

INSTITUTE 3 AUTISM SPECTRUM DISORDER: FROM CLINICAL PRACTICE TO CUTTING EDGE RESEARCH Alexander Kolevzon, MD, Icahn School of Medicine at Mount Sinai, [email protected] Objectives: The goal of this Institute is to provide an update on assessment and management of autism spectrum disorder (ASD) while placing emphasis on the advances in neuroscience and translational research. Attendees will gain knowledge on the impact that molecular genetics has in our understanding of the neurobiology of ASD and in the development of novel therapeutics Methods: Presentations are crafted to build on each other. Morning sessions will provide a comprehensive review of current practice parameters in the management of ASD; afternoon sessions will integrate cutting-edge research progress to inform management. Presenters will use a multimedia approach with videos and vignettes and illustrate clinical relevance throughout the Institute.

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Results: ASD is a heterogeneous disorder with diverse, yet overlapping, neurobiological underpinnings. As a consequence, the clinical presentation and course are often complex. The foundation for a sound assessment lies in a comprehensive clinical evaluation, paired with gold-standard autismdiagnostic assessments and measures of cognitive and adaptive function. Behavioral interventions are considered the cornerstone of treatment. Traditionally, pharmacological interventions have targeted specific symptom domains and comorbid psychiatric conditions. Recently, advances in neuroscience have opened a window into the neurobiological basis for the disorder, and novel treatments are being developed to target diseasespecific mechanisms. Next-generation genetic analyses have allowed us to identify hundreds of genetic variants, yielding an understanding of the functional pathways involved in the neurobiology of ASD. Model systems also allow us to identify neural processes and test hypotheses with genetic, electrophysiological, and pharmacological tools. In parallel, biomarker discovery will be critical to stratify variants, guide diagnosis, and predict treatment outcomes. The future of clinical management in ASD will integrate these findings to classify cases of ASD and optimize treatment outcomes. Conclusions: The proposed Institute will present an interdisciplinary and collaborative approach to ASD management that spans current clinical practice to translational research and delineates a conceptual model that shifts the paradigm of how we approach therapeutics in ASD.

EBP, GS, ASD http://dx.doi.org/10.1016/j.jaac.2017.07.522

3.1 CLINICAL DIAGNOSIS AND GOLD STANDARD ASSESSMENT David Grodberg, MD, Yale Child Study Center, david. [email protected] Objectives: The objective of this presentation is to familiarize participants with the components of an autism-focused psychiatric evaluation and to provide information on gold-standard diagnostic assessments in autism spectrum disorder (ASD). Special emphasis will be given to differential diagnoses, comorbidity, and complex symptom presentations. Methods: Diagnostic criteria and key aspects of the psychiatric evaluation will be presented, including the use of the Autism Mental Status Exam (AMSE), followed by a description of gold-standard assessment tools including: the Autism Diagnostic Observation Schedule, Second Edition (ADOS-2); Autism Diagnostic Interview-Revised (ADI-R); Social Communication Questionnaire (SCQ); and Social Responsiveness Scale (SRS). Results: The foundation for a sound assessment in ASD is a comprehensive psychiatric evaluation to 1) identify core deficits; 2) characterize associated features; and 3) recognize comorbid psychiatric and medical conditions. Clinicians with specialized training in ASD use standardized assessments to clarify diagnosis and evaluate associated symptoms. Individuals with ASD often present with comorbid diagnoses, which can significantly impair social, academic, and adaptive functioning, and are often the target of pharmacological and behavioral interventions. Making treatment recommendations requires an understanding of the complexities of an ASD presentation. We will review the use of the Autism Mental Status Examination (AMSE), a brief diagnostic classification tool that structures the observation and recording of social, communicative, and behavioral functioning in ASD. In addition, gold-standard diagnostic assessments will be presented, including the ADOS-2 and ADI-R. The interpretation of standard scores obtained through measures of cognitive and adaptive skills will also be discussed. Case vignettes and questions will be used to establish proof of concept and solidify knowledge. Conclusions: At the conclusion of this presentation, attendees will: 1) recognize the core features and associated symptoms of ASD; 2) appreciate the usefulness of the AMSE; 3) understand the purpose of gold-standard assessment tools in ASD; 4) know what referral questions and tests to request in the assessment of ASD; and 5) learn a framework for the psychiatric formulation in ASD with a focus on treatment recommendations.

DIAG, MDM, PSP http://dx.doi.org/10.1016/j.jaac.2017.07.523


3.2 EVIDENCED-BASED BEHAVIORAL AND PHARMACOLOGICAL INTERVENTIONS Pilar Trelles, MD, Icahn School of Medicine at Mount Sinai, [email protected] Objectives: This presentation will provide attendees with a framework in the treatment of autism spectrum disorder (ASD) by reviewing evidence-based behavioral and pharmacological therapies in the management of core symptoms and associated features. Methods: A review of the literature was conducted to 1) identify therapies; and 2) define core and associated symptoms that have been targeted as outcomes in clinical trials. Behavioral interventions will focus on educational programs for children with ASD, modular treatments to target social skills in children and adolescents with ASD, and treatments to manage behavioral problems. Pharmacological treatments will use a symptomdomain approach. Results: The foundation of treatment for ASD relies on psychosocial treatments, whereas pharmacological interventions target associated features. Early intervention programs aim to alter developmental trajectories in young children with ASD. In later development, psychosocial interventions are used to manage problem behaviors and associated psychiatric disorders. We will review several evidence-based educational programs, social skills programs, and behavioral strategies. Pharmacological approaches will be reviewed using a dimensional approach. We will focus on providing information on the following families of medications: neuroleptic drugs, mood stabilizers, serotonergic medications, and medications used in the treatment of irritability and aggression, ADHD, restrictive and repetitive behaviors, and anxiety. For each intervention, we will review the theoretical neurobiological framework, as well as the latest research regarding effectiveness. Videos and case vignettes will be used to highlight central topics. Conclusions: At the conclusion of this presentation, attendees will gain knowledge of the following: 1) behavioral models used in early childhood; 2) key aspects of social skills programs for school-aged children and adolescents; 3) positive behavioral support and functional behavioral assessment strategies for problem behaviors; and 4) pharmacological interventions, with an emphasis on clinical trials and expert recommendations.

EBP, PPC, P http://dx.doi.org/10.1016/j.jaac.2017.07.524

3.3 NOVEL PHARMACOLOGICAL INTERVENTIONS Roberto Canitano, MD, University Hospital of Siena, [email protected] Objectives: The goal of this presentation is to provide an overview of novel pharmacological treatments in autism spectrum disorder (ASD). This presentation will focus on evidence from clinical trials using novel treatments targeting disease-specific mechanisms. Methods: A review of the literature was conducted to identify the following: 1) ASD disease-specific mechanism and 2) novel pharmacological therapies in ASD. Treatments will be presented by pharmacological action. Results: Excitation/inhibition (E/I) imbalance in neural circuits has been implicated in the etiology of ASD and, as such, is a target of novel treatments. Clinical trials have focused on reducing excessive glutamatergic and increasing GABAergic transmission to normalize E/I imbalance. A large RCT of memantine, a noncompetitive N-methyl-D-aspartate receptor antagonist, did not yield positive results. N-Acetylcysteine (NAC), a glutamate modulator, has been found to be effective in the management of irritability in ASD in two RCTs. Arbaclofen, a GABAergic agonist, was found to improve socialization in ASD in an open-label study and one RCT. Loop diuretics have gained interest as they are thought to modulate GABAergic signaling. Bumetanide was found to improve prosocial behaviors in one RCT, but results have yet to be reproduced. Oxytocin and vasopressin, involved in social behavior, offer a venue for intervention. Acute oxytocin administration improves emphatic accuracy in healthy adults and social deficits in ASD. RCTs of oxytocin show promise in enhancing socialization; however, evidence is limited. Therefore, larger, more rigorous clinical trials are needed. Interestingly, oxytocin has been found to improve GABAergic transmission. Finally, melatonin’s role in the establishment and synchronization of circadian rhythms has been linked to synchrony in motor,

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emotional, and social rhythms, all implicated in social development. Combined approaches using melatonin and behavioral interventions seem to improve core deficits and to normalize the sleep-wake cycle. Conclusions: Despite advances in our understanding of ASD and promising pharmacological treatments targeting disease-specific mechanisms, studies are urgently needed to 1) identify subgroups of ASD in which a given treatment would be most effective; and 2) identify biomarkers to stratify ASD and measure outcomes. Future studies should also involve larger populations.

PPC, R, TREAT http://dx.doi.org/10.1016/j.jaac.2017.07.525

3.4 GENE DISCOVERY: UNDERSTANDING THE ARCHITECTURE OF AUTISM SPECTRUM DISORDER Catalina Betancur, MD, PhD, INSERM, Universit e Pierre et Marie Curie, [email protected] Objectives: This presentation will provide attendees with up-to-date information on the genetic architecture of autism spectrum disorder (ASD) by reviewing recent large-scale studies of structural and sequence variants and their contribution to gene discovery. Methods: A literature review will be discussed. Results: The genetic architecture of ASD is highly heterogeneous and involves hundreds of loci, each contributing to a very small fraction of cases. The pace of gene discovery has greatly accelerated in recent years, fueled by advances in genetic analysis technologies using microarrays and next-generation sequencing. To date, a genetic etiology is identified in w20 percent of the patients, including chromosomal rearrangements, copy number variants (CNV), and sequence variants. All of these abnormalities are rare and often occur de novo but can sometimes be inherited. Many of the genetic variants identified in ASD confer risk for a broad range of neurodevelopmental and neuropsychiatric disorders, including intellectual disability and epilepsy. Despite the extreme genetic heterogeneity, many genes converge in functional pathways, giving insights into the underlying pathophysiology and providing therapeutic targets. In particular, a large number of genes implicated in ASD and other neurodevelopmental disorders are involved in synaptic function and chromatin modification. Conclusions: At the conclusion of this presentation, attendees will gain knowledge about the following: 1) the genetic defects underlying ASD and their overlap with other neurodevelopmental conditions; 2) recent advances in genetic analysis technologies and their applications in clinical practice; and 3) how genetic findings in ASD offer a window into functional pathways involved in the neurobiology of the disorder and can lead to novel therapeutic approaches.

GS, NEURODEV, R http://dx.doi.org/10.1016/j.jaac.2017.07.526

3.5 MODELS SYSTEMS: UNDERSTANDING NEUROBIOLOGY Jeremy Veenstra-VanderWeele, MD, Columbia University, [email protected] Objectives: This presentation will highlight the path from identification of genetic or environmental risk factors to an understanding of the resulting neurobiological origins of autism spectrum disorder (ASD) using model systems. Methods: Examples will be used to examine the strengths and weaknesses of different model systems. In silico and cellular models, including induced pluripotent stem cells, will be featured as a way to examine the consequences of human gene variants, including early neurodevelopment. Nematode, Drosophila, and zebrafish will be discussed as tools to probe the impact of mutations on protein function and neurodevelopment, as well as screening for potential drugs. Rodents offer many tools for manipulation of genes and circuits that can recapitulate social and repetitive behavior. Primate models have become an option with new gene editing technology. Finally, the strengths and limitations of studying syndromal populations will be discussed. Results: Emerging findings across model systems identify different neurobiological pathways downstream of ASD risk factors. As one example, aberrant postsynaptic protein synthesis is observed across multiple models of

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syndromal ASD. Other model systems demonstrate an imbalance in excitatory and inhibitory neurotransmission, although the direction of this imbalance is inconsistent. Multiple model systems have yielded neurobiological hypotheses that can be tested with genetic or pharmacological tools. A few of the drugs that rescue brain or behavior in model systems have been tested in humans with ASD, but none have yet transformed care. Conclusions: Disparate results across model systems suggest that there are multiple routes from ASD risk factors to downstream symptoms. Emerging areas of convergence suggest that some neurobiologically-based treatments are likely to span subgroups of children with common pathways or systems involved in their ASD.

ANI, GS, ND http://dx.doi.org/10.1016/j.jaac.2017.07.527

3.6 BIOMARKER DISCOVERY: THE KEY TO DEVELOPING NEW TREATMENTS Jennifer Foss-Feig, PhD, Icahn School of Medicine at Mount Sinai, [email protected] Objectives: This presentation will provide background on biomarker discovery for autism spectrum disorder (ASD). It will highlight promising electrophysiological and neuroimaging research development and validating new tools to stratify patients and objectively measure treatment response. Methods: A review of the literature and research funding priorities was conducted to summarize the following: 1) current challenges for biomarker discovery in ASD; 2) consensus thinking regarding moving the field forward; and 3) published research on promising neuroimaging and electrophysiological biomarkers. EEG was conducted in children with the following: 1) idiopathic ASD (iASD); and 2) Phelan–McDermid syndrome (PMS), where there is known genetic etiology and constrained heterogeneity. Markers of both low-level sensory and higher-order social functioning were probed, and comprehensive clinical characterization was conducted. Results: Task-based EEG revealed that children with iASD differed from typically developing (TD) control subjects on several paradigms as follows: visual-evoked potentials (VEP), auditory gap detection, auditory habituation, language learning, and social orienting. It is noteworthy that the degree of reduction in EEG response correlated with core symptoms, suggesting that neural markers track with behavior in a meaningful way. Children with PMS showed neural alterations that also differed from TD. During some tasks (VEP, auditory habituation), degree of neural response attenuation was more severe in PMS than in iASD. In others, neural response was spared in PMS (language learning, social orienting). Critically, neural response patterns in PMS overlapped with those in a substantial subset of children with iASD. As both animal and human subject research in PMS has made significant advances toward identifying novel treatments, biomarkers that are useful for stratifying iASD along lines relevant for PMS may be key to targeted treatment approaches. Conclusions: Attendees will gain knowledge of the following: 1) why developing strong biomarkers is key to advancing treatment development for ASD; 2) what electrophysiological biomarkers show promise in terms of tracking with symptoms and subtyping more homogeneous groups of ASD; and 3) how biomarkers developed in monogenic forms of ASD can inform more rapid treatment development for ASD broadly.

DIAG, R, TREAT http://dx.doi.org/10.1016/j.jaac.2017.07.528

3.7 EXPERIMENTAL THERAPEUTICS Alexander Kolevzon, MD, Icahn School of Medicine at Mount Sinai, [email protected] Objectives: To date, the development of pharmacological treatments in autism spectrum disorder (ASD) has mainly relied on strategies loosely related to what is known about the neurobiology of the disorder, using etiologically heterogeneous sample groups and delivering intervention broadly, with mixed success. More recently, genetic discovery and model systems have led to important opportunities for developing novel, disease-modifying therapeutics. The presentation will focus on the impact of translational research on developing therapeutics.

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Methods: This presentation will review the emerging development strategy of new treatments in ASD by emphasizing earlier presentations on the genetic architecture of ASD (Betancur) and findings from model systems (Veenstra-VanderWeele). Specific emphasis will be placed on the strategies used in fragile X syndrome, Rett syndrome, tuberous sclerosis, and Phelan-McDermid syndrome. By use of concepts presented in the talk on biomarkers (Foss-Feig), this presentation will also highlight the relevance of treatments developed in rare genetic forms of ASD to ASD more broadly. Results: Cellular and molecular analyses have identified common pathways involved in synaptic plasticity and signaling of ASD. Rare causal variants provide a disease model that has the potential to change the paradigm of how we understand the etiology of ASD and how it is approached therapeutically. Animal models have led to a deeper understanding of ASD pathophysiology and to clinical trials of novel therapeutics. In addition, brain imaging and electrophysiological techniques may provide important opportunities to identify biological markers of disease that can be used to stratify subgroups in ASD and to predict and monitor treatment response. Conclusions: Several recent exciting developments in clinical trials, with single gene causes of ASD, serve to provide optimism that the strategy outlined herein will lead to new, targeted, and potentially disease-modifying therapeutics for neurodevelopmental disorders in the near future.

Objectives: The goals of this session are as follows: 1) to describe the familybased integrated care (FBIC) paradigm; and 2) to describe the implementation of this model in the Hasbro Children’s Partial Hospital Program (PHP), a day hospital program treating youth aged 6–18 years, with a range of complex pediatric illnesses that include eating disorders, chronic pediatric illnesses complicated by nonadherence and/or psychiatric comorbidity, refractory pain disorders, and somatoform illnesses. Methods: The experience in the use of the FBIC model at the Hasbro Children’s PHP since 1998 will be described, including conceptual model, population served, program structure, and interdisciplinary team structure, illustrated by case examples. Results: Participants will acquire a clear understanding of the FBIC model and application of the model in the context of a PHP, which has treated more than 2,000 patients and families. Participants will become familiar with a model of integrated care that has applicability across illnesses and levels of care. Conclusions: The experience gleaned from the implementation of FBIC in a PHP setting for treatment of complex pediatric illnesses provides an important example of the utility of this model for treating medical and mental illnesses. The expansion of this model across other levels of care in child psychiatry and pediatric settings is an important area for training and program development.

ANI, GS, TREAT


Supported by National Institute of Neurological Disorders and Stroke Grant U54 NS092090-01 and Eunice Kennedy Shriver National Institute of Child Health and Human Development Grant U01HD073984 http://dx.doi.org/10.1016/j.jaac.2017.07.529

INSTITUTE 4 FAMILY-BASED PSYCHIATRIC INTERVENTIONS FOR PHYSICALLY ILL CHILDREN Thomas A. Roesler, MD, University of Washington School of Medicine, [email protected]; Gary Maslow, MD, MPH, Duke University, [email protected] Objectives: This institute exposes general child psychiatrists and those specifically interested in the treatment of medically ill children to new models of care that specifically involve family and social systems Methods: The institute showcases a selection of model programs from around the country that demonstrate treatment of a variety of children with different medical conditions using a family system theoretical base. Specific populations treated in these programs include chronically ill children with diabetes, conversion disorders, chronic pain syndromes, eating disorders, and others. Treatment options for children receiving the medical care they do not need at the instigation of a caretaker are discussed. In addition, we cover helping families deal with major life changes, such as transition to adulthood and loss of a child to an illness. Results: Participants will be exposed to well-functioning alternative treatments for medical conditions that often do not respond to usual medical or psychiatric interventions and learn ways to deal with major life events revolving around an ill child. Conclusions: As we respond to the need for true integrated care in our medical delivery system, child psychiatrists need models and specific tools that prepare them to address new populations.

PYI, FT, BRV Sponsored by AACAP's Family Committee and Physically Ill Child Committee http://dx.doi.org/10.1016/j.jaac.2017.07.531

4.1 FAMILY-BASED INTEGRATED CARE FOR COMPLEX MEDICAL ILLNESS: THE HASBRO CHILDRENS’ PARTIAL HOSPITAL MODEL Michelle L. Rickerby, MD, Brown University Alpert Medical School, [email protected]


FAM, PAH, PYI

4.2 FAMILY-BASED PREVENTION AND INTERVENTIONS FOR OBESITY AND EATING DISORDERS Kristina Schwerin, MD, University of California, Davis, krissy@ schwerno.com Objectives: The audience will develop skills to guide families in the prevention of obesity and eating disorders. They will also become familiar with evidence-based treatments, primarily family-based, for anorexia nervosa, bulimia nervosa, and binge-eating disorder in children and adolescents. Methods: The presentation will begin with highlighting the importance of the child and adolescent psychiatrist’s role in prevention, recognition, and treatment of eating disorders. The presenter will challenge the notion that obesity and eating disorders are “opposites” in etiology and intervention, and will introduce the concept of an integrated approach to understanding and preventing obesity and eating disorders that focuses on healthy family-based lifestyle modification. Research shows that motivational interviewing can help families incorporate such modifications. Participants will move away from a weightcentered approach to obesity management and learn to recognize risky eating disorders where youth do not present as underweight (i.e., atypical anorexia). Clinical vignettes will help demonstrate these concepts. The presentation will then shift to a discussion of evidencebased treatment for obesity and eating disorders, focusing on the centrality of the family in such treatments. Research shows that familybased treatment is effective and superior in comparison to individual therapies for adolescents with eating disorders. Results: Participants will learn to take a no-blame approach with families because research shows no evidence that families are the cause of eating disorders but good evidence that families are an important resource in facilitating a full recovery. This approach to family involvement in the treatment of adolescent obesity and eating disorders has been determined to be more effective than an adolescent-only focus. Conclusions: Eating disorders are often underrecognized, yet high risk problems with the highest mortality rate of any mental illness. Obesity is a well-recognized problem in youth but research shows that dieting interventions predispose to both overweight and underweight eating problems. Family-based interventions focused on lifestyle are critical for the prevention and management of obesity, and family therapies are the strongest evidencebased treatments for eating disorders in youth.

EA, FT, OBE http://dx.doi.org/10.1016/j.jaac.2017.07.533

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4.3 FAMILY-BASED TREATMENT FOR YOUTH WITH CHRONIC PAIN Cynthia Harbeck-Weber, PhD, Mayo Clinic, HarbeckWeber. [email protected] Objectives: The goals of this session are as follows: 1) discuss the biopsychosocial model of chronic pain in youth; 2) discuss the bidirectional impact of chronic pain on family relationships and dynamics; 3) discuss familybased treatment strategies to assist youth who are disabled by their chronic pain return to active, age-appropriate functioning; and 4) discuss research demonstrating the efficacy of family-based approaches to treating chronic pain. Methods: The presenter will discuss family-based approaches to treating youth with chronic pain at outpatient settings and an intensive treatment program. Results: Chronic pain is a frequent condition among youth, occurring in 15–20 percent of children and adolescents. Chronic pain has a significant impact on the youth themselves, as well as family members and society. Research suggests that CBT is effective and includes strategies such as relaxation, changing the youth’s cognitions about their pain, and behavioral activation. However, many providers find CBT strategies difficult to implement with this complex patient population. Clinicians have found it helpful to include family members (especially parents) to help them shift their parenting skills related to the pain, and some research supports this approach. Examples of this approach at outpatient locations and an intensive pain rehabilitation center with a strong parent component will be given. Research regarding family-based treatment will also be described. Conclusions: Chronic pain has a significant impact on family life. Understanding this relationship and providing family members tools to assist their youth with chronic pain can help providers deliver empirically based treatment strategies to youth with chronic pain.

ADOL, PAT, SOM http://dx.doi.org/10.1016/j.jaac.2017.07.534

4.4 BECOMING AN ADULT WITH AN ILLNESS: SYSTEMATIC APPROACH TO FAMILIES Gary Maslow, MD, MPH, Duke University, gmaslow@ gmail.com Objectives: Youth with chronic physical illness often struggle to thrive and develop independence, both as it relates to disease self-management and general independence. Family members, including parents who struggle with their own distress related to their child’s illness, play a critical role in promoting or impairing the development of independence. The objective of this presentation is to describe the Positive Youth Development perspective and its application to promoting positive outcomes for youth with chronic illness and their parents. Methods: First, we will review a study of the quality of life for 350 youth– parent dyads, comparing the quality of life of youth with chronic illness with their peers and the quality of life of parents of youth with and without chronic illness. Specific youth and parent factors that promote quality of life will be reviewed. Second, a group mentoring program for youth with chronic illness and their parents will be described. Data on youth and parent outcomes will be presented, including changes in quality of life and parent distress. Specific family approaches to promoting dialogue between youth and parents will be presented. Third, a novel coaching intervention will be presented that provides both youth and their parents with coaches to help promote important discussions. Youth receive coaching from older young adults who have successfully become independent, whereas parents receive coaching from other parents who have already navigated this transition. Data from a pilot study of 24 youth and 24 parents will be presented. Results: Participants will develop a familiarity with a theoretical approach to the development of youth with chronic physical illness that can be broadly applied. The distress experienced by parents of youth with chronic illness is important to recognize and address. Participants will gain familiarity with two family-based interventions that provide an opportunity for youth and parents to learn how to communicate more effectively.

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Conclusions: Family intervention is critical to promote positive adult outcomes for youth with physical illness. Child and adolescent psychiatrists working with families can promote the growth of youth and also help parents cope with their own distress to the benefit of the whole family.

ADOL, FAM, PYI Supported by the Templeton Foundation http://dx.doi.org/10.1016/j.jaac.2017.07.535

4.5 FAMILY-BASED PSYCHOSOCIAL ASSESSMENT AND INTERVENTION IN PEDIATRIC ONCOLOGY Anne Kazak, PhD, Nemours/Alfred I. duPont Hospital for Children, [email protected] Objectives: The care of pediatric patients with complex medical needs must necessarily be conceptualized within the context of the family. Further, collaboration with families in identifying psychosocial needs and formulating treatment needs is essential. Although the psychosocial needs of children with cancer and their families have been long recognized, the systematic assessment of these needs and delivery of care matched to them have not yet been achieved across treatment centers. Methods: This presentation will focus on two of the 2015 Childhood Cancer Psychosocial Standards of Care (see the December 2015 special issue of Pediatric Blood and Cancer). The Psychosocial Assessment Tool (PAT) is a parent report, evidence-based screener of psychosocial risk that can be used to identify psychosocial concerns early in treatment and maps onto the Pediatric Psychosocial Preventative Health Model (PPPHM), which can be used to match risk and treatment. This is consistent with standard 1 (assessment). The Surviving Cancer Competently Intervention Program (SCCIP) will be presented as an example of a family-based intervention to reduce symptoms of posttraumatic stress and support adaptive coping in family members. Results: Participants will be able to use the PAT and SCCIP to deliver familyoriented psychosocial care in pediatric cancer. Throughout the presentation, issues related to implementation (facilitators, challenges) of care, consistent with the standards, will be addressed. Conclusions: Family-oriented psychosocial care is necessary to augment overall care outcomes and offers psychosocial team members doable options to facilitate such care.

EBP, FAM, OTH http://dx.doi.org/10.1016/j.jaac.2017.07.536

4.6 FAMILY APPROACHES TO PALLIATIVE PSYCHIATRY FOR CHILDREN AND YOUNG ADULTS WITH LIFE-LIMITING MEDICAL CONDITIONS Pamela J. Mosher, MD, MDiv, Princess Margaret Cancer Centre and the Hospital for Sick Children, pjmosher@ yahoo.com Objectives: The goals of this session are as follows: 1) to describe two clinical collaborations to integrate child/adolescent psychiatry with pediatric and young adult palliative care; 2) to review family therapy approaches that support children and adolescent/young adult (AYA) patients with life-threatening or terminal diseases and their family members; and 3) to discuss aspects of child, adolescent, and adult grief through interventions by psychiatrists that support the family-grieving process. Methods: The importance of identifying and supporting the psychological needs of pediatric and AYA patients with terminal diagnoses as they face end of life cannot be overstated. Children, adolescents, and young adults who are dying are often reticent to discuss their fears/agonies to clinicians or family members for many reasons. This creates unique strain for patients and family ecosystems. This presentation explores two models of integrating child and adolescent psychiatry with pediatric and AYA palliative care services. These models were created to identify patient and family psychological needs early and provide support, including grief support, well in advance of death. The first model is that of an embedded

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psychiatrist on the Pediatric Advanced Care Team at Sick Kids Hospital in Toronto. The second model is an integrated care clinic between psychiatry and palliative care for AYA patients at Princess Margaret Cancer Centre. Clinical vignettes will highlight the essential voice child and adolescent psychiatrists can bring to children and AYAs receiving palliative care and to the family’s anticipatory grief and postdeath grief experiences. Results: Attendees will leave with an understanding of two possible approaches to building bridges between child psychiatry and pediatric/AYA palliative care services in their local settings and to improving mental health care for the most medically ill patients they may serve. Conclusions: The psychological distress of the patient and family are priorities when pediatric or AYA patients are receiving palliative care in the setting of terminal disease. Attempts to alleviate this distress must be made by psychosocial professionals. Incorporating family therapy principles can lead to increased support during this crucial time and potentially aid the bereavement process for those who remain.

BRV, FAM, P http://dx.doi.org/10.1016/j.jaac.2017.07.537

4.7 FAMILY-BASED EVALUATION AND TREATMENT OF MEDICAL CHILD ABUSE Thomas A. Roesler, MD, University of Washington School of Medicine, [email protected] Objectives: The objectives of this session are indicated as follows: 1) to acquaint child and adolescent psychiatrists with the concept of medical child abuse (MCA), which is defined as a child receiving unnecessary and harmful, or potentially harmful, medical care at the instigation of a caretaker; 2) to review the process for evaluating whether a child has experienced MCA and to determine whether child protection efforts are indicated; 3) to help the child and adolescent psychiatrist learn how to support medical colleagues as they resolve the abusive situation; and 4) to discuss family and individual treatment plans for the perpetrators of abuse. The concept of MCA supplants Munchausen’s syndrome by proxy (MSBP). MSBP was felt to be rare and a result of parental character defects. More recently, harmful uses of the medical care system have been recognized as fairly common and not restricted to severe, reportable cases. Parents can have many motivations. Presentations fall on a continuum from mild to severe. On the severe end, the treatment received could be life threatening, such as a child receiving a bowel transplant that was never indicated. On the mild side, a parent could insist on diagnostic tests for illnesses discovered on the internet that have no basis in the real life of the child. In most mild cases, the physician comes to understand that the care received has been inappropriate and works with the parent to re-establish healthy parameters for asking for and giving medical care. In moderate situations, physicians will want to work with the child protection community to ensure that the child remains safe while the family undergoes necessary changes that allow the child to remain in the home. In life-threatening situations, removing the child from the home and possible termination of parental rights must be considered. Treatment options for perpetrators may consist of treating an anxiety disorder, OCD, a delusional system, or a severely distorted cognitive belief system. Methods: The presenter will use a PowerPoint presentation to cover the main concepts and incorporate case vignettes to illustrate the steps in evaluation and treatment. Results: Participants will appreciate their role in children’s hospital settings in evaluating and intervening to protect children from this form of maltreatment. Conclusions: A family-based approach is critical to providing support in the children’s hospital setting to assess the difficult situation that arises from medical child abuse and to help protect children.

CAN, FAM, FT http://dx.doi.org/10.1016/j.jaac.2017.07.538


INSTITUTE 5 LIFELONG LEARNING INSTITUTE: MODULE 14: RELEVANT CLINICAL UPDATES FOR CHILD AND ADOLESCENT PSYCHIATRISTS Andrew T. Russell, MD, University of California, Los Angeles Semel Institute for Neuroscience and Human Behavior, [email protected]; Sandra B. Sexson, MD, Medical College of Georgia at Augusta University, ssexson@ augusta.edu Objectives: AACAP’s Lifelong Learning Committee has developed a series of modules to assist members in staying up to date on current issues within the field of child and adolescent psychiatry and in fulfilling lifelong learning and self-assessment requirements of Maintenance of Certification (MOC). This Institute reviews Lifelong Learning Module 14. The articles selected for this year’s module address ADHD, conduct disorder, gender-nonconforming youth, mood disorders, substance use disorders, and ethical dilemmas, among other timely topics. The articles are relevant to every practicing child and adolescent psychiatrist Methods: Leading experts will review and present the articles. The presenters are encouraged to provide context to the articles and include their clinical experience. Results: Child and adolescent psychiatrists will enhance their clinical practice through presentations that combine the latest research with the expertise of leading physicians within the field. Conclusions: This Institute is designed to assist members with the lifelong learning component of the maintenance of certification requirement. It also serves as an excellent update for all practicing child and adolescent psychiatrists by selecting and reviewing the most current and important articles impacting clinical practice.

PSP, PPC, TREAT Sponsored by AACAP's Lifelong Learning Committee http://dx.doi.org/10.1016/j.jaac.2017.07.540

5.1 IRRITABILITY AND DISRUPTIVE MOOD DYSREGULATION DISORDER Ellen Leibenluft, MD, National Institute of Mental Health, [email protected] Objectives: The goal of this session is to review articles chosen by the Work Group on Lifelong Learning addressing current concepts and understanding on irritability and disruptive mood dysregulation disorder (DMDD). These articles focus on the following: 1) the brain circuitry mediating irritability in youths; and 2) controversies and challenges regarding DMDD, including its overlap with ODD. Methods: This presentation reviews articles from the following perspectives: importance/context, participants, hypotheses and findings, implications for clinical practice, and recommendations for future practice and research. Results: 1) Irritability is a very common clinical problem that can be conceptualized as aberrant responses to frustration and to threat. This model outlines testable hypotheses with treatment implications. 2) DMDD arose from the controversy regarding the diagnosis of pediatric bipolar disorder. To understand the differential diagnosis of DMDD versus bipolar disorder, it is crucial to be able to differentiate chronic from episodic irritability. 3) DMDD is designed to capture severely irritable children. It differs from ODD in that DMDD sets a higher threshold for irritability and that ODD also includes criteria for oppositionality. The irritability threshold for DMDD is arbitrary, which is problematic. Secondary analyses of clinical data sets do not find differences in impairment or symptoms between youth with ODD and youth with DMDD. Data do indicate differential longitudinal associations for the irritable versus oppositional dimensions of ODD and indicate genetic associations between irritability and anxiety/depression.

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Conclusions: Irritability is an important symptom in pediatric clinics, which along with the diagnosis of DMDD, requires more study.

DMDD, DBD, IMD http://dx.doi.org/10.1016/j.jaac.2017.07.541

5.2 ETHICAL DILEMMAS: WHAT CONNECTS WHOLE GENOME SEQUENCING, MANAGEMENT OF PSYCHOGENIC NONEPILEPTIC SEIZURES, AND PSYCHIATRISTS’ USE OF SOCIAL MEDIA? Gail Ann Edelsohn, MD, MSPH, Community Care Behavioral Health Organization, [email protected] Objectives: The goal of this session is to review articles selected by AACAP’s Lifelong Learning Committee that share a common focus on current ethical issues, principles, and policy implications while addressing different topics, including clinical practice, research, social media, and the 2014 AACAP Code of Ethics. Articles include ethical issues relevant to 1) the reporting of results of whole-genome sequencing (WGS) as a genetic test for autism spectrum disorder (ASD) to patients and families and the use of clinically obtained WGS for future research; 2) the diagnosis and management of psychogenic nonepileptic seizures; 3) psychiatrists interacting with the media; and 4) key changes in the 2014 AACAP Code of Ethics. Methods: The articles are reviewed highlighting the key findings, clinical and research implications, ethical issues, professionalism, and ethical frameworks and principles. Beyond the content review of the articles, additional ethical issues will be identified, and competing ethical frameworks and principles from AACAP’s Code of Ethics will be offered. Results: 1) WGS is anticipated to be the standard of care for molecular diagnosis of ASD. There is a lack of consensus of return for all findings, incidental findings, and only actionable findings for children. The principles of integrity, beneficence, nonmaleficence, and justice along with the child’s best interests should be used to guide ethical decision making. The use of clinical WGS findings for research will require addressing consent, including risk/benefits, privacy, and database governance structure. 2) Effective diagnosis of psychogenic nonepileptic seizures requires video EEG. The communication of the diagnosis to parents may raise ethical concerns. Use of virtue ethics and the social contract between professionals and patients is recommended. 3) Psychiatrists engaged in public commentary on social media may benefit from a series of reflective questions to guide ethical decisions. 4) AACAP’s 2014 Code of Ethics revisions focused on youth perspective in participation in treatment, assent, and consent in research and challenges posed by changes in psychiatry and society. Conclusions: Child and adolescent psychiatrists inevitably encounter ethical dilemmas in clinical care, research, or engaging with the public via social media and can obtain guidance from the application of ethical principles.

ASD, ETH, OTH http://dx.doi.org/10.1016/j.jaac.2017.07.542

5.3 CONDUCT DISORDER, VIOLENCE, AND THE TREATMENT OF AGGRESSION Christopher R. Thomas, MD, University of Texas Medical Branch, [email protected] Objectives: The goal of this session is to review articles chosen by the Work Group on Lifelong Learning addressing current concepts and understanding in conduct disorder, violence, and the treatment of aggression. Methods: This presentation reviews articles from the following perspectives: importance/context; theoretical concepts and findings; and implications for clinical practice and future research. Results: 1) There are now a number of evidence-based medications for the treatment of aggression. 2) Positive reinforcement by parents can buffer heritable risks for callous and unemotional behaviors. 3) Access to urban greenspace reduces aggressive behaviors in neighborhood

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adolescents. 4) Firearms pose a serious risk for children, and steps must be taken to protect them. 5) Children’s exposure to intimate partner violence is a serious risk factor, comparable with other forms of abuse and neglect in its impact. 6) The International Children’s Continence Society recommends a behavioral approach coupled with psychoeducation as the best practice in managing functional nonretentive fecal incontinence. Conclusions: It is important for child mental health professionals to be aware of the factors influencing development, especially those relating to violence.

CD, DMDD, OTH http://dx.doi.org/10.1016/j.jaac.2017.07.543

5.4 SOCIAL DETERMINANTS OF CHILD MENTAL HEALTH Bonnie T. Zima, MD, MPH, University of California, Los Angeles Health Services Research Center, bzima@mednet. ucla.edu Objectives: This module will provide an overview of five selected papers related to social determinants of mental health, including immigration, child maltreatment, household food insecurity, and maternal depression. In addition, findings from a recent consensus statement on recommended amount of sleep for children and youth by age range will be reviewed. Methods: This session provides a critical review of five selected papers with commentary to facilitate discussion on the applicability of the study’s findings to the assessment and treatment of child psychiatric disorders. Results: Together, the selected papers span a number of different formats, including a review paper that supports adaptation of a conceptual model to guide the assessment and treatment of children with family history of immigration, a 30-year longitudinal cohort study examining the association between maternal depression and adult outcomes, association between low and very low food insecurity and risk for child mental disorder, use of the modified Delphi panel to develop a consensus statement, and a review of the literature on the relationship between various types of child maltreatment exposure and changes in brain morphology and physiology. The strengths and limitations of these papers will be reviewed to stimulate discussion for future research. Conclusions: Together, these studies exemplify the complexity of eliciting the influence of social determinants on the risk for childhood psychiatric disorders and adverse outcomes. Given that approaches for precision medicine are adapted for child psychiatric disorders, additional research is needed to improve methods to adjust for the influence of social determinants.

OTH, RF, SLP http://dx.doi.org/10.1016/j.jaac.2017.07.544

5.5 WHAT’S NEW IN SUBSTANCE USE DISORDERS, CIGARETTE USE, AND ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER IN ADOLESCENTS? Timothy E. Wilens, MD, Massachusetts General Hospital and Harvard University, [email protected] Objectives: The goal of this session is to review articles chosen by the Work Group on Lifelong Learning addressing current concepts and understanding in the following areas: 1) longer-term course of ADHD; 2) a trial of combination pharmacotherapy in ADHD; 3) tobacco use in adolescents; 4) opioid use in young people; and 5) effects of cannabis in adolescents. Methods: This presentation reviews articles from the following perspectives: importance/context; participants; hypotheses, study design, and findings; implications for clinical practice; limitations; and recommendations for future practice and research. Results: The studies report the following: 1) approximately 50 percent of children with ADHD will persist with the disorder into adulthood with noted predictors of remission—those with remitted ADHD fared better than those with persistent ADHD; 2) the combination of guanfacine plus methylphenidate is more efficacious than either treatment alone; 3) tobacco use is common in adolescents—particularly those with comorbid psychopathology; 4) opioid use often initiates in childhood and is associated with high rates of

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morbidity and mortality in young people; and 5) cannabis use in adolescents is associated with neurocognitive difficulties that may persist into later adulthood. The risk of psychotic symptoms seems to be directly related to cannabis use in young people. Conclusions: Many children with ADHD continue to have persistent ADHD into adulthood with persistence associated with generally more problematic outcomes. When combined with stimulants, guanfacine is more effective than monotherapy with either treatment alone. Tobacco disorders are common in youth, particularly those with dual diagnosis. Opioid use disorders in youth are increasing, with severe morbidity and mortality associated with them. Recreational cannabis use in adolescents is linked to a number of problematic outcomes, including higher rates of psychotic symptoms. Effective treatments exist for cannabis use disorders.

ADHD, OTH, SUD http://dx.doi.org/10.1016/j.jaac.2017.07.545

5.6 CHILDHOOD AND ADOLESCENCE UPDATE: GENDER-NONCONFORMING YOUTH AND SEX EXCHANGE AMONG YOUTH Richard R. Pleak, MD, Hofstra Northwell School of Medicine at Hofstra University, [email protected] Objectives: The goals of this study are to review articles chosen by the Work Group on Lifelong Learning addressing current concepts and understanding in the following areas: 1) knowns and unknowns about gender-nonconforming children; 2) vulnerability and resilience among gender-nonconforming children and adolescents; and 3) sex exchange among youth. Methods: This presentation reviews articles from the following perspectives: importance/context, participants, hypotheses and findings, implications for clinical practice, and recommendations for future practice and research. Results: 1) Prospective follow-up studies of gender-nonconforming children show that few of these children have persistence of their crossgender identification into adolescence and adulthood; however, there are questions and criticisms of these studies. 2) Gender-nonconforming children and adolescents have higher rates of mental disorders and suicide largely attributed to ostracism and discrimination, but many are resilient, and mental health professionals can be of help to assist these youth and their families. 3) In the National Longitudinal Study of Adolescent Health, almost five percent of 11,620 youth reported sex exchange (sex work), higher in males and in those with histories of childhood sexual abuse; these youth were at greater risk for sexually transmitted diseases (STDs). Conclusions: Gender-nonconforming children and adolescents are still too little understood and are vulnerable for mental disorders and suicidality; therefore, they and their families can benefit from therapy. More definitive studies need to be done regarding persistence of cross-gender identification from childhood into adulthood. Sex exchange occurs in adolescents and young adults in the general population, not just in runaway and homeless youth, and is linked with childhood sexual abuse and higher risk for STDs.

GID, OTH, SEX http://dx.doi.org/10.1016/j.jaac.2017.07.546

5.7 UPDATE ON DEPRESSION TREATMENT, ANTIPSYCHOTIC EFFICACY, AND SIDE EFFECT MANAGEMENT; EATING DISORDERS; AND EMERGING MODELS OF THE PSYCHIATRIC INTERVIEW AND TREATMENT OF PERSONALITY DISORDERS John T. Walkup, MD, Ann and Robert H. Lurie Children’s Hospital of Chicago, [email protected] Objectives: The goal of this session is to review 10 articles chosen by the Work Group on Lifelong Learning that address the following areas: 1) ECT and antidepressant efficacy in children and adolescents; 2) eating disorders in


males; 3) clozapine in early onset schizophrenia; 4) metabolic effects and management of antipsychotic drugs; 5) approaches to the psychiatric interview; 6) psychotherapy for borderline personality; and 7) suicide in children and adolescents. Methods: This presentation will review and place each article into its research and clinical context. Results: There are a number of effective treatments for depression in youth, including antidepressants and ECT for a subgroup of youth with severe mood disorders. Antipsychotic drugs similarly are very effective for a range of problems in children and adolescents but often have substantial metabolic side effects that require effective management. There has been an evolution in the presentation of eating disorders with younger patients, more males, and co-occurring complex personality disorders. Lastly, training in the psychiatric interview and psychotherapy can vary considerably from nondirective, alliance-building approaches to those that focus on data collection and technical approaches to problem solving. Newer approaches to the interview and psychotherapy are proposed that are positive and engaging but also grounded in the here and now. Conclusions: Although child and adolescent psychiatry remains extremely eclectic in practice, we have made great strides in our capacity to understand the range of problems we see in treatment development and in facilitating positive outcomes for children and families.

DDD, OTH, TREAT http://dx.doi.org/10.1016/j.jaac.2017.07.547

INSTITUTE 6 INSOMNIA: THE SLEEPING GIANT OF PEDIATRIC PUBLIC HEALTH Anna Ivanenko, MD, PhD, Northwestern Feinberg School of Medicine, [email protected]; Jess P. Shatkin, MD, MPH, New York University School of Medicine, jess.shatkin@ nyumc.org Objectives: The goal of this session is to provide practicing clinicians with valuable advanced knowledge on the epidemiology, pathophysiology, and pharmacological and behavioral treatment of insomnia as commonly seen among children, adolescents, and young adults with psychiatric conditions Methods: This session will include a comprehensive literature review and case-based presentations. Results: Dr. Lewin will present on epidemiology of insomnia and neurobehavioral consequences of insufficient sleep. Dr. Johnson will focus on sleep requirements throughout development and evaluation of insomnia. Physiology of sleep states and circadian rhythm will be covered by Dr. Baroni. In his two presentations, Dr. Shatkin will provide practical guidelines on the use of sleep education and hygiene, in addition to an overview of cognitive behavioral therapy for insomnia with children, adolescents, and young adults. Dr. Owens will review a systematic approach to using medications for the treatment of pediatric insomnia. Finally, Dr. Ivanenko will address common challenges in the treatment of sleep problems in mental health settings. Conclusions: Learning how to address sleep disorders using behavioral and pharmacological treatments will provide clinicians with essential tools for their psychiatric practice.

CBT, SLP, TREAT http://dx.doi.org/10.1016/j.jaac.2017.07.549

6.1 EPIDEMIOLOGY OF INSOMNIA AND NEUROBEHAVIORAL CONSEQUENCES OF INSUFFICIENT SLEEP Daniel S. Lewin, PhD, George Washington University School of Medicine, [email protected] Objectives: Part one of this talk will focus on the epidemiology of common behaviorally based sleep problems and how recent changes in diagnostic

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criteria are likely to affect these estimates. Part two of the talk will focus on the impact of deficient sleep (both sleep duration and sleep period timing) and neurocognitive function and neurobehavioral regulation. Methods: This session will provide a comprehensive literature review. Results: There is now ample evidence that adolescents do not obtain adequate sleep. Several recent national epidemiologic studies provide up-todate data on the prevalence of deficient sleep and sleep disorders, with important differences across different demographic groups. Some of these studies identify causes of sleep disturbances, which in many cases overlap with comorbid psychiatric disorders and increased risk-taking behavior. The specific mechanisms that link deficient sleep and decrements in neurobehavioral function have been identified in adults, and some recent data point to comparable results in pediatric populations. Conclusions: This presentation will provide attendees with evidence of the magnitude of sleep problems in pediatric populations and consequences that lead to decrement in academic function, increased risk of depression, inattention, impulsivity, and substance abuse.

Objectives: Insomnia is a common and often impairing condition across all age-groups. The main goal of this presentation is to examine how circadian rhythms and basic circuitries of sleep and arousal contribute to this condition. Methods: Comprehensive literature review and discussion will take place. Results: Regular sleep-wake alternating pattern is highly regulated by complex, interrelating systems that include multiple brain regions, neurotransmitters, and hormones. Disruption of one of these areas and/or circuits might lead to insomnia. Major current theories of insomnia pathophysiology include cortical hyperarousal (an imbalance between arousal and sleep-driving mechanisms), circadian dysrhythmia, and abnormal sleep homeostasis. A possible contribution of major neurotransmitters systems such as histamine, orexin, and g-aminobutyric acid will be discussed. Imaging or electroencephalographic or endocrine markers linked to insomnia pathophysiology will also be illustrated. Conclusions: This presentation will propose and discuss current theories linked to the pathophysiology of insomnia.

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6.2 SLEEP REQUIREMENTS THROUGHOUT DEVELOPMENT AND ETIOLOGY OF INSOMNIA: SCREENING AND EVALUATION OF INSOMNIA IN CHILDREN AND ADOLESCENTS Kyle P. Johnson, MD, Oregon Health and Science University, [email protected] Objectives: Children and adolescents commonly experience insomnia, either transiently or persistently. This problem not only causes youth distress and often impairment, it also concerns parents who seek out consultation from medical professionals, including child and adolescent psychiatrists. To accurately assess the problem, it is imperative that these medical professionals understand sleep requirements of youth and how those requirements change across development. Given the relative frequency of this complaint, child psychiatrists should understand the proposed etiology of both acute and chronic insomnia and be proficient in screening and evaluating pediatric insomnia. Methods: Comprehensive literature review and lecture and discussion will be presented. In addition, case material will be presented to reinforce teaching. Results: The sleep requirements of children at different developmental stages will be discussed. A well-accepted model for the development and persistence of insomnia will be reviewed. Screening methods for insomnia will be discussed, with further evaluation strategies outlined. Conclusions: Children and adolescents frequently suffer with insomnia. It is estimated that approximately 50 percent of one-year-old children experience sleep-onset or bedtime-settling difficulties and 30 percent of one-year-old children have problematic night wakings. These sleep difficulties occur in toddlers at similar rates. If sleep difficulties persist into the preschool-age years, they are at risk to become chronic. Approximately one-third of schoolage children have significant parent-reported sleep problems, primarily sleeponset struggles often exacerbated by anxiety. One in five teenagers experience significant sleep difficulties with several potential causes, including delayed sleep phase syndrome, an anxiety disorder, a depressive disorder, or primary insomnia. Teenagers with insomnia often experience daytime sleepiness, which can negatively impact academic and driving performance. More and more, child and adolescent psychiatrists are asked to assess insomnia in their patients. In providing the best assessment, it is critical that child psychiatrists understand how sleep needs and patterns change over development.

DIAG, NSS, SLP http://dx.doi.org/10.1016/j.jaac.2017.07.551

6.3 PHYSIOLOGY OF SLEEP AND CIRCADIAN RHYTHMS Argelinda Baroni, MD, New York University, argelinda. [email protected]

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6.4 SLEEP EDUCATION AND HYGIENE Jess P. Shatkin, MD, MPH, New York University School of Medicine, [email protected] Objectives: This presentation will provide participants with an understanding of standard sleep hygiene recommendations and their utility, along with other less commonly addressed interventions, to promote a good night’s sleep. At the end of this presentation, participants will be able to 1) describe the evidence base for typical sleep hygiene recommendations; 2) identify the effects of exercise, napping, caffeine, alcohol, tobacco, and marijuana on sleep; and 3) determine which sleep hygiene practices are likely to be most effective for children and adolescents. Methods: This presentation will draw upon a comprehensive literature review, the physiology of sleep, and case-based material. Results: Sleep hygiene is ubiquitously recommended by psychiatrists, psychologists, and healthcare providers for the treatment of insomnia. However, many commonly suggested techniques are not founded upon convincing research and have not been proven effective in trials. In addition, there are other methods based on findings from sleep physiology studies that may be effective and worth using with children and adolescents who struggle with sleep. This presentation will describe the current knowledge base and deficit in sleep hygiene and then make sensible, evidence-based recommendations for improving sleep in children and adolescents. Common behavioral and exogenous factors, such as exercise, napping, caffeine, alcohol, and tobacco, and their effects on sleep will also be addressed. Conclusions: Understanding the physiology and circadian rhythmicity of sleep is key to understanding and applying sleep hygiene effectively. This presentation will summarize the core components of sleep hygiene that are likely to be of use for children and adolescents.

EDUC, SLP, TREAT http://dx.doi.org/10.1016/j.jaac.2017.07.553

6.5 COGNITIVE-BEHAVIORAL THERAPY FOR INSOMNIA Jess P. Shatkin, MD, MPH, New York University School of Medicine, [email protected] Objectives: CBT for insomnia (CBT-I) in adolescents and young adults is a brief intervention that includes both behavioral and psychological procedures. At the end of this presentation, participants will be able to 1) describe when and for whom CBT-I is an appropriate form of treatment intervention; 2) provide practical guidelines for conducting CBT-I, including stimulus control, sleep restriction, cognitive restructuring, and sleep hygiene; and 3) practice arousal reduction and biofeedback for the treatment of insomnia. Methods: This session will provide a comprehensive literature review, lecture, and discussion. Results: Medications for the treatment of insomnia are sometimes necessary but most often are insufficient to fully address the problem. CBT-I, by

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contrast, represents an easily taught series of skills that are portable and time and cost effective. The utility of CBT-I has been repeatedly demonstrated for adults and adolescents. The goal of CBT-I is to alter the factors that perpetuate insomnia and include the following: 1) behavioral factors, such as poor sleep habits, and irregular sleep schedules; 2) psychological factors, such as unrealistic expectations, and rumination over the consequences of insomnia; and 3) physiological factors, such as hyperarousal and somatic and mental tension. CBT-I is indicated for primary and secondary insomnia in adolescents and adults and can be delivered on a one on one basis; in groups; and via telephone, telemedicine, and video. This presentation will describe the use of CBT-I and necessary adjustments when applying these techniques with children. Participants will practice arousal reduction and biofeedback techniques. Conclusions: The use of cognitive-behavior therapy for insomnia will be described, and participants will engage in a series of applied exercises to enhance their therapeutic skills.

CBT, SLP, TREAT http://dx.doi.org/10.1016/j.jaac.2017.07.554

6.6 MEDICATIONS FOR INSOMNIA Judith Owens, MD, MPH, Boston Children’s Hospital, judith. [email protected] Objectives: The goals of this session are as follows: 1) to provide an update on current pharmacologic prescription options available for the treatment of pediatric insomnia; 2) to review the data supporting safety and efficacy of over-the-counter (OTC) medications, including melatonin; and 3) to present an outline to assist the child mental health professional in developing a practical and rational approach to using sedative hypnotic drugs in clinical practice, including patient and medication selection and potential pitfalls in management. Methods: This session will include comprehensive literature review, lecture and discussion, and case presentations. Results: Although there is widespread use of a large variety of prescription and OTC drugs for insomnia in child mental health settings, little data exist from randomized controlled trials regarding their safety and efficacy for the treatment of insomnia in children and adolescents, and no hypnotic drugs have yet been approved by the US Food and Drug Administration for use in children. Despite this, there are several new developments in the pharmacologic treatment of insomnia of which the child psychiatrist should be aware, including several new insomnia drugs that have recently been approved in adults. Given the relative lack of empirical data, mental health providers are faced with considerable challenges in the use of pharmacotherapy in treating insomnia in the pediatric population; thus, development of a systematic and rational approach is imperative. In addition, case presentations of common scenarios in child psychiatry clinical practice may help inform appropriate decision making in the face of limited evidence. Conclusions: The current status of knowledge regarding sedative/hypnotic drugs and pharmacological treatment of pediatric insomnia will be discussed in detail during the presentation.

PPC, SLP, TREAT http://dx.doi.org/10.1016/j.jaac.2017.07.555

6.7 TREATING SLEEP DISORDERS IN CHILDREN WITH PSYCHIATRIC DIAGNOSES: A CASE-BASED APPROACH Anna Ivanenko, MD, PhD, Northwestern Feinberg School of Medicine, [email protected] Objectives: Sleep problems often occur in the context of mental illness. Symptoms of insomnia identified early in childhood have been later correlated with anxiety, depression, attentional difficulties, family or parental distress, chronic persistent sleep problems, aggression, and social problems. This presentation will review the clinical approaches to children presenting with comorbid sleep disorders to psychiatric practice. Methods: Case-based examples and literature review will be presented.


Results: Complex bidirectional relationships exist between psychiatric disorders and sleep problems that present common challenges to clinicians. The speaker will provide case presentations discussing common challenges in the treatment of sleep disorders comorbid with psychiatric conditions such as ADHD, autism spectrum disorder, and mood and anxiety disorders among children and adolescents. Conclusions: A large number of children and adolescents with sleep problems remain unidentified and untreated. Differential diagnosis and effective management of insomnia will be discussed as an essential part of comprehensive psychiatric evaluation and treatment.

ADOL, SLP, TREAT http://dx.doi.org/10.1016/j.jaac.2017.07.556

INSTITUTE 7 INTELLECTUAL DISABILITY AND CO-OCCURRING PSYCHIATRIC DISORDERS: DIAGNOSIS, TREATMENT, AND FORENSIC ISSUES James C. Harris, MD, Johns Hopkins University School of Medicine, [email protected] Objectives: The goals of this study are to understand the assessment, diagnosis, and treatment of children and adolescents with a diagnosis of intellectual disability/intellectual developmental disorder (ID/IDD) and a cooccurring psychiatric disorder who are often underserved and historically stigmatized and to discuss the gaps in psychiatric interventions and how they may be met Methods: This session will provide a review of the DSM-5 process and the evidence base that led to the new DSM-5 definition of ID (IDD); a review of pertinent issues in the diagnosis of co-occurring psychiatric disorders in ID (IDD); and a review of neurobiological, clinical, and epidemiological literature pertinent to targeted treatment for behavioral phenotypes in neurodevelopmental syndromes. Additionally, the session will evaluate the evidence base of published pharmacotherapy trials for co-occurring conditions in ID (IDD), such as autism spectrum disorder (ASD); review the empirical basis for behavioral interventions for challenging behaviors (aggression, self-injury, and disruptive behavior); review research on family care for persons with ID (IDD) and the literature on effective family interventions; and review the literature on legal and ethical issues pertaining to ID (IDD) and co-occurring psychiatric disorder. Results: These reviews will provide a new understanding of the following gaps in knowledge: 1) DSM-5 diagnostic criteria for ID (IDD) and the new DSM emphasis on adaptive behavior in three domains (conceptual, social, and practical adaptation); 2) assessment and treatment of co-occurring psychiatric disorders in people with ID (IDD); 3) targeted neurobiological treatment of neurogenetic syndromes; 4) rational and evidence-based psychopharmacology for co-occurring psychiatric disorders; 5) behavioral interventions and combined drug and medication interventions; 6) family interventions, including mindfulness-based strategies; and 7) legal and ethical issues necessary for effective care of affected children and their families. Conclusions: This Institute will provide new knowledge for participants that will allow them to provide better care for people with ID (IDD) and their families based on in-depth presentations and panel discussions that will focus on case examples to illustrate effective treatment.

PPC, ID, CM Sponsored by AACAP's Autism and Intellectual Disability Committee http://dx.doi.org/10.1016/j.jaac.2017.07.558

7.1 UNDERSTANDING THE INTELLECTUAL DEVELOPMENTAL DISORDER ADAPTIVE REASONING PARADIGM SHIFT IN DSM-5 James C. Harris, MD, Johns Hopkins University School of Medicine, [email protected]

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Objectives: The review of the DSM-5 revision resulted in a new category, neurodevelopmental disorders, a name change from mental retardation to intellectual disability (ID) (intellectual developmental disorder, IDD) and revised diagnostic criteria that emphasize adaptive functioning. Methods: A review of the DSM-5 neurodevelopmental group procedures and review of the evidence base led to the new definition. Results: The inclusion of the new category neurodevelopmental disorders in DSM-5 parallels that of major neurocognitive disorder (e.g., dementia). Both are viewed in DSM-5 as health conditions. The elimination of axis 2 meant that a definition of ID (IDD) by IQ number as in DSM-IV would no longer suffice for a defined mental disorder in DSM-5. Thus, a consensus definition of intelligence is incorporated in the criteria for the first time to define deficits in general mental functioning. Intellectual functions include reasoning, problem solving, planning, abstract thinking, judgment, academic learning, and learning from experience confirmed by both clinical assessment and individualized, standardized intelligence testing. Although IQ testing is required, adaptive functioning is emphasized, with emphasis placed on how well a person copes with the common tasks of everyday life in three general domains: conceptual, social, and practical. Intelligence and adaptive functioning are linked through adaptive reasoning. IQ scores no longer designate mild, moderate, severe, and profound levels of severity. These specifiers are based on adaptive functioning in the three domains. The new definition identifies gullibility and lack of risk awareness as characteristic features. Assessment requires a face-to-face clinical psychiatric evaluation. Conclusions: The new classification and text descriptions of ID (IDD) have important implications for assessment, epidemiologic studies, intervention, service provision, forensics, and outcome.

ID, ND, PSP http://dx.doi.org/10.1016/j.jaac.2017.07.559

7.2 DIAGNOSING CO-OCCURRING MENTAL DISORDERS IN CHILDREN AND ADOLESCENTS WITH INTELLECTUAL DISABILITY/INTELLECTUAL DEVELOPMENTAL DISORDER Kerim M. Munir, MD, DSc, Boston Children’s Hospital and Harvard Medical School, [email protected] Objectives: This presentation describes the co-occurrence and assessment of mental disorders (MD) in children and adolescents with intellectual disability (ID) and intellectual developmental disorders (IDD). The presentation offers modifications in assessment techniques for differential diagnosis of MD, with a particular emphasis on DSM-5 conceptualization of ID and IDD that include both intellectual and adaptive functioning deficits. Methods: The clinical and epidemiological literature on MD in children and adolescents with ID/IDD is reviewed. The modifications for assessment of MD in ID/IDD include the following: the use of broad- and narrow-band behavior rating scales of symptoms and symptom domains, any corresponding DSM scales, and use of multiple informant sources; direct and indirect interview techniques, with special attention to modifications for use with nonverbal children and adolescents; and consideration of neurological, medical, and genetic syndromes that may transform expression of co-occurring MD. Results: Children and adolescents with ID/IDD are at greater risk for MD compared with the general population. Both the prevalence and clinical presentation of MD are modified by child and adolescent age, gender, and ID/IDD severity. Most common MD in children and adolescent with ID/IDD include the following: other neurodevelopmental disorders (e.g., ASD, ADHD, specific learning, and stereotyped movement with and without self-injurious behaviors, and other specified and unspecified neurodevelopmental disorders); anxiety, depression, mood disorder, psychosis, and trauma- and stressrelated disorders; OCD-related disorders; and disruptive, impulse-control, and conduct disorders. Pitfalls in diagnosis include an over-reliance on the use of partial criteria, incomplete review of the overarching clinical syndrome, short-circuiting of differential diagnosis, and premature use of psychopharmacological interventions that may alter manifestation of MD and delay their targeted treatment.

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Conclusions: The diagnosis of MD in children and adolescents with ID/IDD entail a systematic review of multiple factors within a requisite biopsychosocial framework and integrated consideration of home, education, and social environments.

CM, ID, ND http://dx.doi.org/10.1016/j.jaac.2017.07.560

7.3 RECOGNIZING THE BEHAVIORAL PHENOTYPE IN NEUROGENETIC SYNDROMES AND POTENTIAL INTERVENTIONS Robert L. Hendren, DO, University of California, San Francisco, [email protected] Objectives: In this session, we will do the following: 1) discuss the value of recognizing the behavioral phenotype in genetic disorders, such as 22q11.2, tuberous sclerosis, fragile X syndrome, Angelman syndrome, and phenylketonuria (PKU); 2) apply these behavioral phenotypes to psychiatric disorders, such as schizophrenia, depression, autism, and ADHD; and 3) explore targeting treatments at shared metabolic mechanisms of gene expression. Methods: This presentation will review significant advances occurring in genetics, gene expression, and metabolomics research to identify the behavioral phenotype and associated neurobiological mechanisms of several single and complex genetic neurodevelopmental disorders and treatments successfully targeting these mechanisms. Results: The behavioral phenotype connects to underlying neurodevelopmental processes and is beginning to explain the ongoing developmental metabolic processes shown to be treatment targets for biomedical and penetrating psychosocial interventions. These interventions can improve gene x environment interactions, enhance developmental progression, reverse neurobiological dysfunction, protect through high-risk periods, and promote or create healthy neurodevelopment. Evidence for several processes, including oxidative stress, immune and inflammatory; mitochondrial dysfunction; g-aminobutyric acid (inhibitory) and glutamate (stimulatory); free fatty acid metabolism; and the microbiome and epigenetic processes that show commonalities across several neurodevelopmental disorders, will be discussed. Treatments targeted at one or more of these common pathways that demonstrate usefulness will also be discussed. Several clinical examples with vignettes will be presented Conclusions: Effective treatments for single and complex genetic disorders are increasingly focused on common behavioral phenotypes and the underlying gene expression through metabolic processes that become targets for process enhancing or correcting interventions. Many challenges exist for designing and carrying out clinical trials to demonstrate the efficacy of targeted biomedical treatments, but treatment paradigms are increasingly shifting from those that target diagnoses to those that target gene expression processes.

GS, ID, ND http://dx.doi.org/10.1016/j.jaac.2017.07.561

7.4 BEHAVIOR ANALYTIC APPROACHES TO PROBLEM BEHAVIOR IN INTELLECTUAL AND DEVELOPMENTAL DISABILITIES Louis Hagopian, PhD, Kennedy Krieger Institute, hagopian@ kennedykrieger.org Objectives: The goals of this session are to review behavioral interventions for problem behavior (aggression, self-injury, disruptive behavior, etc.) in persons with intellectual disability (ID) and to summarize currently used assessment and treatment procedures and their empirical support. Methods: This presentation describes applied behavior analysis, its empirical support, and its use for addressing problem behavior in persons with ID and intellectual developmental disabilities (IDD). A neurobehavioral model that integrates behavioral analytic and psychiatric

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approaches is also described. Case examples illustrating behavioral and pharmacological interventions and their coordinated application will be presented. Results: In the context of deficits in communication, adaptive behavior, and intellectual functioning associated with IDD, problem behavior can emerge and come to be strengthened by reinforcement in the environment. Decades of research show that in at least two-thirds of cases, problem behavior is maintained by socially mediated variables (e.g., problem behavior functions to escape tasks, access attention, gain access to preferred items). Behavioral treatments based on an understanding of the behavioral function are highly effective in reducing problem behavior and teaching adaptive skills, but in many cases, problems with emotion regulation also necessitate the use of medications. Conclusions: Problem behavior in persons with IDD can have a range of determinants, including environmental, biological, and psychiatric variables. Functional behavioral assessment procedures can precisely identify environmental variables maintaining problem behavior and thus help delineate what remaining dimensions of the clinical presentation seem biological and would require psychopharmacologic intervention. Singlecase design methodologies used to evaluate behavioral intervention effects are also ideally suited to objectively evaluate psychopharmacological interventions.

CBT, DBD, ID http://dx.doi.org/10.1016/j.jaac.2017.07.562

7.5 PHARMACOTHERAPY FOR CO-OCCURRING PSYCHIATRIC CONDITIONS IN INTELLECTUAL DISABILITY AND AUTISM SPECTRUM DISORDER Robert L. Findling, MD, MBA, Kennedy Krieger Institute and Johns Hopkins University, [email protected] Objectives: The goal of this session is to provide a review of what is known (and what is not known) about the pharmacological treatment of co-occurring psychiatric conditions in patients suffering from intellectual disability (ID) and autism spectrum disorder (ASD). Furthermore, medication treatment data on neurogenetic syndromes that are associated with ID/ASD will also be considered. The clinical relevance of the extant research data and evidence-based treatment approaches will be discussed. Methods: For this presentation, data from published clinical trials for ID and ASD will be reviewed. In addition, information from relevant scientific meetings will be considered. Results: In patients with ID, the most methodologically stringent data suggest that symptoms of ADHD may improve with methylphenidate. Similarly, the cautious use of antipsychotic drugs may be beneficial for children with ID and substantive and impairing disruptive behavior disorders (DBDs). Data for patients with ID and other psychiatric conditions are limited. For patients with ASD, there is evidence to support the assertion that patients with ADHD and DBDs may benefit from certain pharmacotherapies. Selective serotonin re-uptake inhibitors do not have the data to support their efficacy in reducing repetitive behaviors in ASD. Conclusions: More rigorous study is needed to examine what role, if any, medication management may have in youths with ID who are suffering from mood and anxiety disorders. In addition, for patients with ID, there are limited data on the long-term safety and effectiveness of treatment with psychotropic agents. Compared with patients with ID, more is known about the medication treatment of patients with ASD. For this reason, evidence-based decisions about prescribing psychiatric agents to these vulnerable patients with ASD can be made more frequently. However, most studies that have reported efficacy for medications in those with ASD are generally of short duration. As a result, the ability to draw definitive conclusions about long-term tolerability or effectiveness is limited.

CM, ID, PPC http://dx.doi.org/10.1016/j.jaac.2017.07.563


7.6 FAMILY INTERVENTIONS FOR CHILDREN WITH NEURODEVELOPMENTAL DISABILITIES AND CO-OCCURRING BEHAVIORAL AND MENTAL DISORDERS Elisabeth Dykens, PhD, Vanderbilt Kennedy Center and Vanderbilt University Medical Center, elisabeth.dykens@ Vanderbilt.Edu Objectives: The goals of this sessions are to do as follows: 1) discuss key findings on the health and mental health vulnerabilities of parents of offspring with neurodevelopmental disorders, including autism spectrum disorders, Down syndrome, rare genetic syndromes, and mental illness; and 2) demonstrate the need for novel interventions that directly address the stress and distress of these parents. Methods: This presentation will summarize research on family care providers and the nascent literature on effective interventions for them, including cognitive behavioral therapies, thematic and informational groups, and mindfulness practices. Results: Neurodevelopmental disorders are the most prevalent chronic health conditions among our nation’s children, and the health and mental health problems in parents of these children now have become an urgent public health concern. Beyond elevated stress, depression, anxiety, sleep, and health problems, these parents also show reduced immune function, shorter telomere length, and blunted diurnal cortisol trajectories—all indicative of stress chronicity. Results will be shared from our large, randomized clinical trial in parents of children with autism and other disabilities comparing mindfulness-based stress reduction to an intervention based on principles of positive psychology. Our trial demonstrated significant effects of both mindfulness and positive psychology practices in reducing these problems in the short- and long-term. Mindfulness practices led to more immediate reductions in depression and anxiety, with large effect sizes. Findings also demonstrated the utility of using trained, supervised peer mentors to deliver treatments. Conclusions: Interventions are sorely needed that reduce parental distress and enhance their health and well-being. As most adults with intellectual and other disabilities co-reside with their aging parents, such interventions can position parents to more effectively care for their children in the long-term. New disability policies are needed to support such efforts.

FAM, ID, PAT http://dx.doi.org/10.1016/j.jaac.2017.07.564

7.7 LEGAL, ETHICAL, AND FORENSIC ISSUES IN INTELLECTUAL AND DEVELOPMENTAL DISABILITIES Ludwik S. Szymanski, MD, Boston Children’s Hospital and Harvard Medical School, [email protected] Objectives: This presentation will review legislation, legal entitlements, techniques of forensic psychiatric assessment in criminal and civil proceedings, and ethical issues pertinent to persons who have an intellectual and developmental disability (ID/DD). Methods: Both federal and state legislations and laws, as well as case law, are pertinent here; thus, their principles will be reviewed. Although state laws may differ from one another, the important underlying principles are usually similar and will be discussed and illustrated with case examples Results: Persons with ID may be involved in civil proceedings, which may include determining general legal competence; need for guardianship; assessment of competence to enter into a contract, including marriage, to provide informed consent (such as for medical treatment or participation in a research study); and parental competence in child protection and custody cases. The diagnosis of ID does not automatically imply legal incompetence, which has to be determined through court decision, usually based on assessment by a clinical team, focused on a person’s ability to make rational and informed decisions. Assessment in criminal proceedings may include determination of competence to stand trial, criminal responsibility, and competence to testify as a witness. Psychiatric testimony on whether the

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accused meets the diagnostic criteria for ID may make a difference between life and death since execution of persons with ID is unconstitutional. A separate category comprises cases concerning constitutional rights of persons in state-run institutions to adequate care, including mental health care. People with ID/DD have the right to the same protection as everyone else if they are subjects in medical research, as well as a right to be such subjects if ethical and legal principles of informed consent are followed. The techniques of psychiatric assessment pertaining to various competencies will be reviewed and illustrated with case examples. Conclusions: Psychiatric assessment of various forms of legal competence of persons who have ID/DD is most important. Yet, there exists a professional practice gap in this area, as few training programs include teaching the necessary skills. The techniques of psychiatric assessment have to be adapted to a person’s cognitive and communication skills

ETH, FCP, ID http://dx.doi.org/10.1016/j.jaac.2017.07.565

INSTITUTE 8 PRACTICAL PEDIATRIC PSYCHOPHARMACOLOGY FOR PEDIATRICIANS AND NON-CHILD PSYCHIATRISTS Adelaide S. Robb, MD, Children’s National Medical Center, [email protected] Objectives: The primary objective of this Institute is to provide practical information to early career psychiatrists and pediatricians on the use of psychotropic medications in their practices Methods: The presentations will include discussions of clinically relevant aspects of pediatric psychopharmacology for the treatment of ADHD, depression, and anxiety disorders. Additionally, management of medications for bipolar disorder, pervasive developmental disorders, and aggression will be addressed. Recent literature will be reviewed, and discussions will focus on medication selection, initiation, titration, and management. After the more formal didactics, brief vignettes will allow for the application of information from earlier presentations and audience involvement in practical clinical discussions. Results: Recent clinical trials provide a growing evidence base for the use of psychotropic medications in the treatment of children and adolescents with mental illness. In all categories of psychotropic medications, we have large clinical trials funded by both industry and federally that demonstrate safety and/or efficacy in pediatric mental illness, including ADHD, anxiety, depression, bipolar, and aggression in autism spectrum disorder. Conclusions: Awareness of recent research and the application of practical clinical information pertaining to pediatric psychopharmacology can inform and positively impact patient care.

ADP, APS, STIM Sponsored by AACAP's Psychopharmacology Committee http://dx.doi.org/10.1016/j.jaac.2017.07.567

8.1 TREATMENT OF ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER Timothy E. Wilens, MD, Massachusetts General Hospital and Harvard University, [email protected] Objectives: With the increasing presentation of children and adults with ADHD, practitioners are requiring strategies for those individuals with the disorder and those who do not respond to or cannot tolerate traditional treatment. Methods: A systematic review of the literature was undertaken to elucidate data on stimulant and nonstimulant pharmacological treatments for ADHD simplex and for treatment refractory or comorbid ADHD. Studies using controlled, open, retrospective, and case series will be highlighted and “weighted” according to the study design. Longer-term outcomes of existing agents and recently published data are favored.

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Results: The literature, combined with practice parameters and the clinical experience, indicate that both stimulants and nonstimulants remain among first-line pharmacotherapy for ADHD in preschoolers, latency/school-aged youth, and adolescents. Alterations in the use of traditional stimulants, the use of nonstimulants, and combinations of medications can enhance a patient’s response to ADHD. Data on the FDA-approved combination of a agonists and stimulants will be reviewed. A discussion of predictable (e.g., weight loss) and idiosyncratic adverse effects will be undertaken. Conclusions: In this session, recent pharmacological strategies for treating children and adolescents with ADHD will be presented, incorporating new research findings and FDA approvals with systematic clinical observation.

ATA, ADHD, STIM http://dx.doi.org/10.1016/j.jaac.2017.07.568

8.2 MAJOR DEPRESSIVE DISORDER IN CHILDREN AND ADOLESCENTS Boris Birmaher, MD, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, birmaherb@ upmc.edu Objectives: This session focuses on the diagnosis and management of depression in children and adolescents. Methods: Data on the prevalence of depression, comorbid disorders, and clinical course of depression in children and adolescents will be reviewed. Factors that affect the course of depression will be discussed. The evidence base for antidepressant treatment in children and adolescents will be reviewed. The role of psychotherapy alone and in conjunction with medication will be discussed. Results: Response rates to initial antidepressants are approximately 50–60 percent, and approximately 50 percent of youths who fail to respond to the initial antidepressant will respond to an alternative antidepressant. Cognitive behavioral therapy in combination with medication treatment increases response rates and decreases relapse rates. Comorbid disorders, parental depression, and psychosocial factors affect treatment response. Conclusions: It is important to select evidence-based treatments in the management of depression in children and adolescents.

ADP, DDD, S http://dx.doi.org/10.1016/j.jaac.2017.07.569

8.3 ASSESSMENT AND TREATMENT OF ANXIETY DISORDERS IN CHILDREN AND ADOLESCENTS John T. Walkup, MD, Ann and Robert H. Lurie Children’s Hospital of Chicago, [email protected] Objectives: The goal of this session is to provide attendees with the skill set necessary to complete a basic assessment of childhood anxiety in a primary care setting, to implement initial pharmacological treatment, and to provide guidance consistent with principles of cognitive behavioral therapy. Methods: A review of the treatment literature for child and adolescent anxiety disorders was conducted. Results: The session will begin with an overview of the basic elements of an assessment for childhood anxiety disorders that can be carried out by a primary care clinician. Treatment options will then be reviewed. Relevant recent studies and literature will be presented, providing a rationale for the use of these treatments, as well as a foundation for treatment selection. The strengths and weaknesses of the treatment interventions will be discussed, along with suggestions for how to decide on the most appropriate treatment modality for an individual patient. In addition, the key principle of cognitive behavioral therapy that can be used to guide families and children with anxiety disorders will be discussed. Conclusions: Anxiety disorders are common in children and adolescents but are also commonly overlooked. Data clearly demonstrate that treatment can significantly lower distress and improve functioning.

ADP, AD, AXX http://dx.doi.org/10.1016/j.jaac.2017.07.570

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8.4 TREATMENT OF BIPOLAR DISORDER AND IRRITABILITY IN AUTISM

8.5 CASE STUDIES IN PEDIATRIC PSYCHOPHARMACOLOGY

Adelaide S. Robb, MD, Children’s National Medical Center, [email protected]

Martine M. Solages, MD, Children’s National Health System, [email protected]

Objectives: The objective of this presentation is to teach early career clinicians the key elements about the diagnosis, treatment, and short- and longterm management of children with bipolar disorder (BD) and aggression in autism. As more children with these disorders are being treated in the community, it is important for pediatricians and psychiatrists to recognize these disorders and manage them with psychotropic medications. Methods: For each disorder, we describe the DSM-5 diagnostic criteria, common presenting symptoms, and pharmacological treatments, including mood stabilizers and second-generation antipsychotic drugs, strategies for initiating treatment, monitoring regimens, and recommendations for length of treatment and discontinuation strategies. The talk covers important side effects, studies in children supporting the use of these medications for BD and aggression in autism, and FDA concerns. Results: This talk teaches pediatricians and early career psychiatrists the basics about diagnosis, treatment, and management of BD and aggression in autism in their pediatric outpatients. Conclusions: Knowing how to manage these serious childhood mental illnesses allows pediatricians to work closely in collaboration with psychiatric colleagues in the care and management of these children.

Objectives: This session allows the attendee to apply information from the didactic presentations, as well as clinical experience, to a series of patient vignettes and provide an opportunity for practical application of the data presented earlier in the Institute. Methods: Vignettes are presented by the faculty, followed by an interactive format with discussion of patient management by faculty and attendees. The cases focus on typical patient presentations that are simple as well as complex. The use of concomitant medications, comorbidities, side-effect management, and issues pertaining to the extended use of psychotropic medications are addressed. Time is allotted for attendees to discuss challenges to using pediatric psychopharmacology in their own practices. Results: The practical application of the data demonstrates how the information presented on pediatric psychopharmacology can impact attendees’ clinical practice. Conclusions: The participants will know how to approach the disorders in their practice and have additional practice at identifying the presentation of common psychiatric disorders in the primary care and emergency department settings.

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NEW RESEARCH POSTERS Poster Session 1: Adolescence, Early Childhood, Inpatient, Neuroimaging, Pharmacotherapy Poster Session 2: Cognitive-Behavioral Therapy, Depressive Disorders, Diversity and Culture, External Consultation/Schools/Forensic/Community, Family Therapy, Forensic Issues, Group Therapy, Health Care Economics/Managed Care/ Population Health, Neuromodulation, Obsessive-Compulsive Disorder, Outpatient, Pediatric Consultation Liaison, Prevention, Systems of Care, Training Issues Poster Session 3: Complementary and Integrative Medicine, Diagnostic Methods, Epidemiology, Feeding and Eating Disorders, Intellectual Disabilities, Oppositional Defiant Disorder, Protective Factors, Risk Factors, SleepWake Disorders, Social Media/Use of Electronics, Specific Learning Disorders, Suicidal/Self-Injury Behavior, Treatment Planning Poster Session 4: AIDS/HIV, Anxiety Disorders, Developmental Psychopathology, Disruptive Behavior Disorders, Disruptive Mood Dysregulation Disorder, Divorce/Adoption/Foster Care, Health Care Economics/Managed Care/ Population Health, Irritability/Dysregulation, Medical Factors Affecting Psychological Disorders, Neuroanatomy/Neurophysiology, Parenting/Child Care/ Abuse/Neglect, Personality Disorders, Schizophrenia and Other Psychotic Disorders, Sexuality and Gender Issues, Somatic Symptom and Related Disorders, Tic Disorders/Stereotypic Disorders, Trauma- and Stressor-Related Disorders Poster Session 5: Aggression/Violence, Autism Spectrum Disorder, Behavioral Therapy, Bipolar Spectrum Disorders, Disorders Due to Another Medical Condition, Infancy, Neuroanatomy/Neurophysiology, Normal Child Development, Partial Hospitalization, Residential Treatment, Transitional-Age Youth Poster Session 6: Attention-Deficit/Hyperactivity Disorder, Other or Mixed, Substance Related and Addictive Disorder

NEW RESEARCH POSTER SESSION 1 1.1 DISRUPTIVE MOOD DYSREGULATION DISORDER: ENHANCING OBJECTIVE ASSESSMENTS IN VERY YOUNG CHILDREN Ashley P. Martinez, BS, Brown University, ashley_martinez@ brown.edu; John R. Boekamp, PhD, Bradley Hospital, [email protected]; Sarah E. Martin, PhD, Simmons College, [email protected]; Mia DeMarco, BS, Bradley Hospital, [email protected]; Lauren R. Mernick, MA, Bradley Hospital, [email protected]; Jeffrey I. Hunt, MD, Brown University Alpert Medical School, [email protected] Objectives: Chronic irritability and temper outbursts are characteristic of several forms of mental illnesses, including disruptive mood dysregulation disorder (DMDD). This relatively new disorder is characterized by a minimum of three weekly temper outbursts, irritable/angry mood for most of the day nearly every day for at least 12 months, and an onset criterion of at least six years. Several studies, however, have found that DMDD can be identified in children under the age of 6 years. Research on DMDD in very young children has been hampered by the limited availability of measures of irritability in this age group. The current study examines the feasibility and preliminary validity of a brief measure of irritability for use with very young children that was originally developed for older children and adolescents. Methods: Participants are ages 3 to 7 years, who presented to a partial hospital treatment program for young children with severe emotional and behavioral disturbances. The Affective Reactivity Index (ARI) is a seven-item measure of irritable mood and associated functional impairment that has demonstrated adequate validity in older children. The ARI was administered to parents and program milieu therapists on admission, weekly, and at discharge. The Multidimensional Assessment of Preschool Disruptive Behavior (MAP-DB) is a parent rating scale that measures aspects of disruptive behavior. Both the preschool (ages 3–5 years) and Early School-Age Versions (ages 6–8 years) have been validated in young children. In this study, the Temper Loss subscales (22 and 39 items, respectively) were used. The MAPDB was administered at admission and discharge. Results: Ongoing data collection supports assessment feasibility. Both parents and staff have been able to successfully complete the weekly ARI.

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1.1 — 1.3 Preliminary data suggest that ARI may be sensitive to change over the course of treatment in several participants. When data collection is completed (expected sample size of 35 to 40 participants), change in irritability will be examined, as well as differences in ratings between parents and staff. Conclusions: It is expected that parent and staff ARI ratings will change over time, with significantly higher scores at admission compared with discharge. We expect that parent and staff ARI ratings will correlate significantly, but mean parent and staff ratings will differ significantly.

RI, DMDD, EC Supported by the AACAP Summer Medical Student Fellowship, which is supported by AACAP's Endowment Fund and partially supported by the Ruth and Peter Metz Family Foundation http://dx.doi.org/10.1016/j.jaac.2017.09.015

1.2 REPORTED SLEEP DISTURBANCES IN INCARCERATED ADOLESCENTS WITH SUBSTANCE USE DISORDERS: ASSESSING THE NEED FOR A SLEEP HYGIENE PROTOCOL Thea A. Belay, BA, Brown University, [email protected] Objectives: There is little knowledge about rates of sleep disruption in incarcerated samples of justice-involved youth with a history of substance use. This study explores the rates of reported sleep disturbance and prescription medication use related to sleep in a sample of incarcerated adolescents with a history of substance use. Findings may be relevant to the development of a targeted sleep hygiene protocol that addresses co-occurring disorders. Methods: This retrospective chart review evaluated adolescents incarcerated at a juvenile detention facility in Rhode Island. Charts of youth that were referred for individual therapy in the clinical treatment program were reviewed as part of this study (n ¼ 83). Those who were still under the age of 19 years at the time of evaluation were included in the analysis. Chart review included nursing intake forms (with presence or absence noted for sleep disturbance and substance use), urine toxicology screen, psychiatric evaluation (including further details regarding sleep patterns), and results of the Adolescent Substance Abuse Subtle Screening Inventory (SASSI-A2). Results: In this sample of incarcerated adolescents, 58.2 percent (n ¼ 39) reported substance use via self-report and denied substance use problems on the SASSI, and 32.8 percent (n ¼ 22) of participants reported both substance use via self-report and substance use problems on the SASSI, but the differences were not significant (Chi square ¼ 0.62, p ¼ 0.74). Additionally, 68.3 percent (n ¼ 56) of participants reported sleep problems and were prescribed sleep medications; 8.5 percent (n ¼ 7) of participants reported having a sleep problem but were not prescribed sleep medications; 12.2 percent (n ¼ 10) of participants denied sleep problems at intake but were later prescribed sleep medications. These overall group differences were statistically significant (Chi square ¼ 12.22, p < 0.001). Conclusions: This review highlights the prevalence of sleep disturbance, prescription of sleep medication, and substance use in this population of incarcerated adolescents in the context of concern for misdiagnosis and potential for medication diversion. The results support the development of a protocol for objectively assessing and managing reported sleep disturbance in the context of treatment of co-occurring disorders in a correctional setting.

JJS, SLP, SUD Supported by the AACAP Jeanne Spurlock Research Fellowship in Substance Abuse and Addiction for Minority Medical Students, which is supported by NIDA and AACAP's Campaign for America's Kids http://dx.doi.org/10.1016/j.jaac.2017.09.016

1.3 ABNORMAL NEURAL CONNECTIVITY IN GIRLS BUT NOT BOYS WITH AUTISM: A GROUP-MATCHED, QUALITY-CONTROLLED, DIFFUSION TENSOR IMAGING STUDY Roger J. Jou, MD, MPH, PhD, Yale Child Study Center, roger. [email protected]; Jiedi Lei, MSC, Yale University, jiedi.lei@yale. edu; Emma K. Lecarie, BA, BS, Yale University, emma.lecarie@ yale.edu; Daniel Y.J. Yang, PhD, George Washington

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NEW RESEARCH POSTERS 1.4 — 1.5

University, [email protected]; Pamela E. Ventola, PhD, Yale University, [email protected]; Denis G. Sukhodolsky, PhD, Yale University, denis.sukhodolsky@yale. edu; Kevin A. Pelphrey, PhD, George Washington University, [email protected] Objectives: This diffusion tensor imaging (DTI) study compared a large sample of individuals with autism spectrum disorder (ASD) with neurotypical (NT) peers, while matching for common confounding variables that may give rise to artefactual findings driving conflicting results across a large body of research literature. Methods: A total of 130 children were divided into four groups: 25 girls with ASD, 65 boys with ASD, 16 NT girls and 24 NT boys. Participants underwent clinical assessment and DTI on a 3 T MRI scanner. All scans were pre-processed using FMRIB Software Library (FSL), including eddy current correction and estimation of the diffusion tensor, which enables calculation of fractional anisotropy (FA), a common measure of white matter integrity. A multi-step procedure was used to complete scan quality assurance which consisted of visual inspection by two independent raters while removing compromised data (intraclass correlation coefficient >0.90). Voxel-wise group comparisons were performed using tract-based spatial statistics. Areas of significant difference were identified (p < 0.05 corrected) using threshold-free cluster enhancement. A tractography atlas was used to identify affected fiber tracts and quantify affected voxels per tract. Results: No main effect of group nor gender were observed for age nor fullscale IQ. For the Social Responsiveness Scale, there was no main effect of gender, though a main effect of group was noted. No main effect of group was observed for any motion parameters (displacement, rotation, and translation). There were widespread regions of both hemispheres where FA was significantly reduced in girls with ASD. All fiber types were represented, including association, commissure, and projection fibers. Abnormalities in association fibers were more prominent in the left hemisphere. In stark contrast, there were no significant differences in FA in boys with ASD. Conclusions: While these findings are consistent with previous studies examining girls with ASD, it does not support the existence of widespread abnormalities reported in majority of studies including males with ASD. However, these findings are congruent with more recent studies implementing stringent data quality protocols which do not report widespread abnormalities. These findings also support the assertion that ASD manifests differently in girls who may be more severely affected.

IMAGS, ASD, ND Supported by the AACAP Junior Investigator Award, NIMH Grant R01MH084080, Autism Speaks Grant 1344, the Simons Foundation Grant SFARI95489, the Daniel Jordan Fiddle Foundation http://dx.doi.org/10.1016/j.jaac.2017.09.017

1.4 IMPACT OF INPATIENT CHILD AND ADOLESCENT PSYCHIATRY DEVELOPMENTALLYINFORMED PSYCHOSOCIAL PROGRAMMING ON THE SUCCESS OF PATIENTS AND MEDICAL STUDENTS AT MOUNT SINAI Mitchell D. Arnovitz, BS, SUNY Upstate Medical University, [email protected]; Maya Hubert, MD, Icahn School of Medicine at Mount Sinai, [email protected]; Timothy R. Rice, MD, Icahn School of Medicine at Mount Sinai, [email protected] Objectives: Despite efforts, recruitment of physicians in training into the field of child and adolescent psychiatry remains a critical issue, considering that our country is experiencing a shortage of child and adolescent psychiatrists to care for our nation’s youth. Psychosocial initiatives are common in inpatient units and provide a unique opportunity for preclinical medical students to gain exposure to patient care and to the field of child and adolescent psychiatry. At this point, there is no literature evaluating the effect of medical student participation in these programs on medical education. In this study, we aim to assess the impact of voluntary participation in weekly psychosocial programming on all participants. Specifically, we are evaluating medical


students’ perceived benefit in obtaining clinical skills and in developing an interest in pursuing a career in child and adolescent psychiatry. Methods: An anonymous 15-item questionnaire was distributed electronically to medical students who participated in guided reading and group discussions in our unit from January 2017 to June 2017. In addition, a semi-structured interview was developed and is being administered to consenting participants. Results: Survey results are currently being collected and processed for volunteers. To date, we have recruited seven participants, the majority being first-year medical students. Participation rates varied from one to four times (mean ¼ 2.0), and 71 percent were female. Remarkably, 100 percent of participants recommend this experience to medical students with an interest in pediatrics or psychiatry, and 86 percent recommend it to all medical students, regardless of specialty interest. In our cohort, 71 percent indicated that their time in the unit increased their understanding of mental illness and subsequently made them feel more comfortable working with patients. All respondents indicated that their time in our unit has made them more aware of the challenges faced by mental healthcare providers; likewise, all reported that their participation enhanced their medical education and would benefit them regardless of their choice of specialty. Finally, most medical students who volunteered preclinically in our unit (71%) disclosed that the experience has made them more likely to choose a career in child and adolescent psychiatry. Conclusions: Preliminary results suggest that medical students benefit from early preclinical exposure to child and adolescent psychiatry. They reported feeling more comfortable in their clinical interactions, understanding of mental health concerns, and interest in pursuing a career in child and adolescent psychiatry. As such, the intervention seems to be a valuable tool for educating medical students and generating interest in child and adolescent psychiatry.

AC, ICP, CAD Supported by the AACAP Summer Medical Student Fellowship, which is supported by AACAP's Endowment Fund http://dx.doi.org/10.1016/j.jaac.2017.09.018

1.5 FACTORS IMPACTING THE RESILIENCE OF TRAUMA-AFFECTED YOUNG CHILDREN IN A THERAPEUTIC DAYCARE SETTING Ram Chettiar, DO, Kansas University Medical Center, [email protected]; Shilpa Sachdeva, MD, University of Kansas Medical Center, [email protected]; Manish K. Jha, MD, University of Texas Southwestern Medical Center, [email protected]; Brian Cuthbertson, MD, Rediscover, [email protected]; Ahmed Maher, MD, University of Colorado-Denver, [email protected]; Matthew Brown, DO, Rogers Behavioral Health, matthew. [email protected]; Jesus-Martin Maldonado-Duran, MD, Baylor College of Medicine, [email protected] Objectives: The goal of this presentation is to identify factors and prognostic indicators of resilience in trauma-affected young children in a therapeutic daycare setting. Methods: This cross-sectional study assessed 102 children (ages 1–6 years) who have survived maltreatment and were referred for psychiatric care in a therapeutic daycare setting. The children were provided full psychiatric evaluation and treatment. Collateral information was provided by their primary caregivers. Variables studied include the following: presenting problem, diagnoses, substance exposure in utero, type of trauma, quality of caregiving, caregiver psychopathology, pharmacological treatment, level of intelligence, level of attractiveness, presence of dissociation, type of attachment, and level of resilience. Results: The demographics of the 102 children studied included 68 percent male and 32 percent female with 54 percent African American, 34 percent Caucasian, and 12 percent other ethnicities. We found that of children rated to be highly intelligent, 67 percent were also estimated to have high resilience. Conversely, 83.3 percent of children with low intelligence were

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estimated to have low resilience. This association of intelligence and resilience was highly significant (P < 0.0001). We found a similar association between perceived attractiveness and resilience. Children with high attractiveness (57.6%) were estimated to have high resilience, whereas 72.7 percent with low attractiveness were estimated to have low resilience (P ¼ 0.027). We did not find any significant association between estimates of resilience and the presence of dissociative symptoms, quality of caregiving, or the attachment style. Conclusions: Estimates of resilience are significantly associated with intelligence and attractiveness, but not with presence of dissociative symptoms, quality of caregiving, or the attachment style. The traumatized child’s experience with primary caregivers, ability to form secure attachments, and potential for resiliency may help guide clinicians in their psychiatric management of the child.

FOC, EC http://dx.doi.org/10.1016/j.jaac.2017.09.019

1.6 EARLY-ONSET BIPOLAR DISORDER CHARACTERISTICS, OUTCOMES, AND PREDICTORS OF TREATMENT RESPONSE Asha Dusad, MD, University of Connecticut, dusad@uchc. edu; Daniel F. Connor, MD, University of Connecticut Medical School, [email protected]; Julian Ford, DrPH, University of Connecticut, [email protected]; Gerald Pearson, APRN, University of Connecticut, [email protected]; Victoria Scranton, University of Connecticut, vscranton@ uchc.edu Objectives: The goals of this presentation are to assess patient characteristics and clinician-rated outcomes for children diagnosed with early-onset bipolar disorder (BD) from a single clinic site and to assess predictors of treatment response. Methods: Data accrual was by retrospective chart review. Two senior faculty reviewed medical records from 714 unique pediatric patients who were evaluated and treated at an academic tertiary child and adolescent psychiatry clinic between 2006 and 2012. Charts of children with BD, meeting study inclusion/exclusion criteria, were reviewed in more detail (N ¼ 50). For this sample group of children with BD, patient characteristics, comorbid psychopathology, high-risk behaviors, symptom severity, systems of care involvement, and types of treatment provided were assessed by chart review. Outcomes were assessed using pre- and post-Clinical Global Impression (CGI)-Severity and Children’s Global Assessment Scale (CGAS) scores; a CGI-Improvement score at final visit determined responder status (N ¼ 41 with complete outcome data). Outcome predictors were assessed using multiple linear regression. Results: Clinic prevalence rates for early-onset BD were seven and 1.5 percent for very early-onset BD. High rates of comorbid psychiatric diagnoses, comorbid symptoms, previous and current systems of care service utilization, and high-risk behaviors were found. Paired sample t-tests found significant improvement in CGI-Severity and CGAS scores, but only 40.5 percent of the sample group met a priori responder criteria. Controlling for age and the number of clinic visits completed, the parent-reported Child Behavior Checklist (CBCL) total T-score at clinic admission and the number of lifetime systems of care for the child both were significantly inversely associated with improvement. Conclusions: Early-onset BD is a complex and heterogeneous psychiatric disorder. Evidence-based treatment should emphasize psychopharmacology with adjunctive family and individual psychotherapy. Strategies to improve engagement in treatment may be especially important. Given high rates of high-risk behaviors in these youths, regular mental health follow-up to assess safety is important. Additional evidence-based treatments for pediatric BD are needed.

BD, SAC, TREAT http://dx.doi.org/10.1016/j.jaac.2017.09.020

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1.7 PARENTAL DEPRESSIVE SYMPTOMS AND EARLY CHILDHOOD BEHAVIORAL AND EMOTIONAL PROBLEMS AS MEASURED IN PEDIATRIC PRIMARY CARE SETTINGS Elise M. Fallucco, MD, University of Florida College of Medicine - Jacksonville, [email protected]; Peggy Greco, PhD, Nemours Children’s Specialty Care, [email protected]; Petra Aldridge, MS, University of Florida College of Medicine - Jacksonville, paldrid@gmail. com; Valentina Bolanos, MPH, University of Florida College of Medicine - Jacksonville, [email protected]; Kitty Leung, MD, University of Florida College of Medicine Jacksonville, [email protected]; Emma Robertson Blackmore, PhD, Halifax Health, Emma. [email protected] Objectives: Longitudinal studies show that parental depression is associated with an increased risk for behavioral and emotional problems (BEPs) in children. Yet, little is known about this association during the preschool years, a critical time for emotional development. This study examined the prevalence of depressive symptoms among parents attending pediatric well visits with their preschool-aged child and explored which types of BEP symptoms were associated with parental depression. Methods: Parents of children aged 3–5 years completed Early Childhood Screening Assessments (ECSA) during wellness visits (n ¼ 2,645). The ECSA is a 36–item screening tool that assesses parental report of child BEP, rated on a three-point Likert scale. The ECSA also includes the Patient Health Questionnaire-2 to assess parental depression symptoms. A principal component analysis of the ECSA identified five measurement factors that were used as predictors of caregiver depression in a logistic regression model. Results: Parents (n ¼ 82; 3.1%) reported depressive symptoms. There was a significant association between caregiver-depressive symptoms and a positive screen for BEPs based on the total child score (P < 0.0001). Three factors of childhood BEPs predicted increased risk for caregiver depression as follows: 1) irritability/oppositionality/aggression [X2 ¼ 21.9, P < 0.0001; OR 7.5 (95% CI 3.2–17.4)]; 2) hyperactivity/inattention/impulsivity [X2 ¼ 14.8, P < 0.0001; OR 3.2 (95% CI 1.8–5.7)]; and 3) anxiety/trauma [X2 ¼ 4.4, P < 0.03; OR 2.2 (95% CI 1.1–4.6)]. Conclusions: Parents of preschool-aged children who exhibit irritability, oppositionality, aggression, and ADHD-type symptoms were significantly more likely to report depressive symptoms than parents whose children did not exhibit those BEPs. Pediatric wellness visits may be an opportune time to assess both child BEPs and parental depressive symptoms, given their strong association and the relevance of parental mood for child behavioral and emotional development. Identification of parental depressive symptoms may facilitate referral for treatment, which, in turn, may mitigate the effects of parental depression on child behavioral and emotional development.

PSC, DDD, EC Supported by Substance Abuse and Mental Health Services Administration and the Hall-Halliburton Foundation http://dx.doi.org/10.1016/j.jaac.2017.09.021

1.8 TRAINING IN MINDFUL PARENTING SKILLS: A FEASIBILITY PILOT WITH EFFECTS ON MINDFULNESS, MOOD, AND PARENTING IN A LOW-INCOME SAMPLE Erin T. Mathis, PhD, Georgetown University, erin.mathis@ georgetown.edu; Hillary A. Robertson, MPH, Georgetown University, [email protected]; Celene E. Domitrovich, PhD, Georgetown University, cd1029@ georgetown.edu; Janaire T. Hawkins, BS, MedStar Georgetown University Hospital, Janaire.T.Hawkins@gunet.

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georgetown.edu; Matthew G. Biel, MD, MSc, Medstar Georgetown University Hospital, Mgb101@gunet. georgetown.edu Objectives: Mindfulness is learning to observe and accept one’s thoughts, emotions, and physical sensations, as well as external events, as opposed to identifying with or reflexively reacting to them. Mindfulness-based clinical interventions demonstrate significant positive impact for a range of conditions, including depression, anxiety, and addiction. An increasingly promising approach is to apply the principles of mindfulness to the challenges of parenting. Families experiencing poverty, toxic stress, and other risk factors are at greater risk for mental and physical health problems. These experiences undermine optimal parenting support, increasing risk for mental health problems in offspring. Mindful practice cultivates patience, compassion, and the capacity to maintain an emotional “even keel.” These skills are relevant for enhancing parental responsiveness and attunement. The present study tests a model for training in mindful parenting skills for low-income parents whose children attend an early education center in Washington, DC. Methods: Participants (N ¼ 11) attended one-hour, weekly mindful parenting sessions for six weeks. Participants ranged in age from 21 to 45 years (M ¼ 30.6; 82% African American, 18% multiracial; 92% female) and had children between 0-5 years of age. Data was collected at two time points (pre-intervention and post-intervention) on mindfulness, mood, and parenting. Results: On average, participants experienced a trend level decrease in parental distress, t(10) ¼ 1.82, p ¼ 0.10, d ¼ 0.36, depression symptoms t(10) ¼ 1.62, p ¼ 0.10, d ¼ 0.44, and a trend level increase in limit setting with their children t(10) ¼ -2.06, p < 0.10, d ¼ 0.59. In addition, correlations of postintervention data indicate that increases in mindful parenting was associated with significant decreases in parental distress (r ¼ -0.64), and increases in positive affect (r ¼ 0.60), supportive communication (r ¼ 0.61), and child autonomy (r ¼ 0.70). Conclusions: The results indicate promising potential effects of a mindful parenting intervention given the small sample size of the study. Findings support the application and feasibility of conducting mindful parenting groups with at-risk families. Additional findings from a second mindful parenting group will be available to further replicate these findings.

R, EC, PAT Supported by the Marriott Foundation http://dx.doi.org/10.1016/j.jaac.2017.09.022

1.9 PSYCHOTROPIC MEDICATION INITIATION AND CUMULATIVE EXPOSURE FROM BIRTH THROUGH AGE 7 IN A MEDICAID-INSURED POPULATION Dinci Pennap, MPH, University of Maryland, Baltimore, [email protected]; Mehmet Burcu, MS, PhD, University of Maryland, Baltimore, [email protected]; Daniel J. Safer, MD, Johns Hopkins University, dsafer@jhmi. edu; Julie Zito, PhD, University of Maryland, Baltimore, jzito@ rx.umaryland.edu Objectives: The goals of this study were the following: 1) to assess the cumulative incidence of any psychotropic medication use from birth through age seven years in a large, statewide Medicaid-insured population; 2) to assess cumulative psychotropic exposure, measured in days, by age seven years; and 3) to compare clinical characteristics of preschool initiators (aged 14 years) with early school medication initiators (aged 5-7 years). Methods: In a longitudinal design, we used Medicaid administrative data to establish a cohort of children born in 2007 (N ¼ 35,244). The study outcomes were: 1) a Kaplan Meier adjusted cumulative incidence of any psychotropic medication use from birth through age seven years; 2) cumulative psychotropic medication exposure days in preschool initiators and early school initiators; and 3) psychiatric diagnostic groups among preschool initiators vs early school initiators. Results: The cumulative incidence of any psychotropic medication use ranged from 0.3 percent (age 1) to 2.5 percent (age 4) to 26.6 percent by age seven years. Stimulants (22.9%) and alpha-agonists (5.9%) were the


most commonly used medications by age seven years. The cumulative stimulant exposure was 230 median days (range ¼ 88 - 464 days) while alpha-agonist exposure was 195 median days (range ¼ 74 - 436 days). Among preschool psychotropic initiators, the leading psychiatric diagnostic groups were behavioral disorders (22.0%), learning disorders (9.3%), adjustment disorders (2.6%) and autism (2.5%). Behavioral disorders (62.9%), adjustment disorders (8.9%), depression (4.9%) and anxiety disorders (3.1%) led among early school initiators. Conclusions: A longitudinal perspective on very young children offers a closer look at the trajectories of psychotropic medication use and has implications for long-term safety.

EPI, PTA, EC http://dx.doi.org/10.1016/j.jaac.2017.09.023

1.10 SOCIAL-EMOTIONAL AND BEHAVIORAL PROBLEMS IN TODDLERS WITH LANGUAGE DELAY Audrey Thurm, PhD, National Institute of Mental Health, [email protected]; Cristan A. Farmer, PhD, National Institute of Mental Health, [email protected]; Stacy Manwaring, PhD, University of Utah, Stacy.Manwaring@ hsc.utah.edu; Lauren Swineford, PhD, Washington State University, [email protected] Objectives: Toddlers with language delay are at risk for persistent difficulties in language and cognitive development and may be at increased risk for social-emotional and behavioral problems. However, the relationship of these social-emotional and behavior problems to language itself is not well understood. Methods: Participants included toddlers with receptive and expressive language delay (n ¼ 30) or typical development (n ¼ 61), evaluated at both 18 and 24 months. Social-emotional functioning was assessed using the InfantToddler Social and Emotional Assessment (ITSEA), and nonverbal cognitive ability and receptive and expressive language were measured using the Mullen Scales of Early Learning. Results: Compared with typically developing toddlers, toddlers with language delay had significantly higher mean scores on all ITSEA domains at 18 and 24 months, with dysregulation and competence showing the most separation. The rate of “clinical concern” on these domains was not high in either group, with the exception of competence, in which 63 percent of toddlers (age 18 months) with language delay were in the clinical concern range. Socialemotional and behavioral problems were dimensionally related to receptive and expressive language, with greater language delay associated with higher ITSEA scores. When controlling for nonverbal cognitive ability, 18-month ITSEA scores were not related to change in language between 18 and 24 months. Conclusions: Social-emotional and behavioral problems, as measured by the ITSEA, are related to receptive and expressive language abilities in toddlers (ages 18 and 24 months), although social-emotional and behavioral problems in this study did not predict short-term language gains in a sample group that included children with significant language delays.

CM, ND, EC Supported by the NIMH Intramural Research Program Grant ZIAMH002868 http://dx.doi.org/10.1016/j.jaac.2017.09.024

1.11 AUTISM SYMPTOMS COMPARISON BETWEEN CURRENT AND PAST BEHAVIOR THROUGH AUTISM DIAGNOSTIC INTERVIEWREVISED (ADI-R) Gema Torres-Suarez, MD, Hospital Psiquiatrico Infantil Dr. Juan N. Navarro, [email protected]; Erika Ordaz-Rios, Hospital Psiquiatrico Infantil Dr. Juan N. Navarro, neor21@ gmail.com; Enrique Navarro-Luna, MD, Hospital Psiquiatrico Infantil Dr. Juan N. Navarro, enriquenavarroluna@outlook. com; Yassel Flores-Rodriguez, MD, Hospital Psiquiatrico

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Infantil Dr. Juan N. Navarro, [email protected]; Jose Juan Escoto Lopez, MD, Hospital Psiquiatrico Infantil Dr. Juan N. Navarro, [email protected]; Belen CarmonaRuiz, MD, Hospital Psiquiatrico Infantil Dr. Juan N. Navarro, [email protected]; Jorge Chavez-Dozal, MD, Hospital Psiquiatrico Infantil Dr. Juan N. Navarro, [email protected]; Lilia Albores-Gallo, MD, DrPH, Hospital Psiquiatrico Infantil Dr. Juan N. Navarro, lilialbores@ gmail.com Objectives: Autism spectrum disorder (ASD) symptoms show variation across development. It is known that Hispanic children with autism show less restrictive interest, stereotypic movements, and higher social reciprocity problems; however, there has been no research on the variations of symptoms in Mexican children with ASD. The aim of this study was to compare the change in symptoms of ASD across the Autism Diagnostic Interview–Revised (ADI-R) algorithms (“current,” “ever,” or “most abnormal behavior”) in a transversal study in a clinical sample group of Mexican children with ASD. Methods: A comparative, cross-sectional study consisting of a clinical sample group of Mexican children and adolescents with ASD was assessed through the ADI-R. This instrument is a semi-structured parent interview considered to be the gold standard for ASD diagnosis. Items on the ADI-R are coded for current, ever, or most abnormal behavior (4–5 years). Most of the symptoms are rated as 0, 1, 2, or 3. Two total scores, a total raw score, and a recoded total score (3 is recoded to 2; the scores of 7, 8, and 9 are recoded to 0) can be calculated for each of the following three subdomains: 1) social interaction; 2) communication; and 3) restrictive interests and stereotypical behavior. Results: The ADI-R was administered to parents of 136 children and adolescents, with an age range of 2 to 17 years (mean age 7–13 years; SD ¼ 3.5; 78.8% males). The punctuation of the social interaction impairments domain shows a median change from current behavior [median (Mdn) ¼ 5.32] to ever or most abnormal behavior (Mdn ¼ 22.52) of 17.19 (Mdn; 95% CI 18.71, 15.68; P ¼ 0.001). The communication domain shows a median change from current behavior (Mdn ¼ 4.36) to ever or most abnormal behavior (Mdn ¼ 16.47) of 12.11 (Mdn; 95% CI 13.21, 11; P ¼ 0.001). The communication nonverbal domain shows significant reductions from current behavior (Mdn ¼ 8.17) to ever or most abnormal behavior (Mdn ¼ 10.37), with a statistically significant median change of 2.19 (Mdn; CI 95% 3.23, 1.15; P ¼ 0.001). In contrast, the restricted interests and stereotypical behavior domain show no significant change from current behavior (Mdn ¼ 5.84) to ever or most abnormal behavior (Mdn ¼ 6.36), with a change of 0.52 (Mdn; 95% CI 1.30, 0.26); P ¼ 0.19). Conclusions: Symptoms of autism measured through ADI-R comparing the current, ever, or most abnormal behavior in Mexican children with autism showed significant reductions, similar to longitudinal international studies. Longitudinal studies are expensive and time consuming. Our results suggest that transversal studies can provide similar information. Therefore, researchers in low- and middle-income countries should consider transversal studies as a viable, cost-effective alternative to longitudinal experimental designs. These results suggest the importance of assessing current, ever, or most abnormal behavior.

EPI, ASD, EC http://dx.doi.org/10.1016/j.jaac.2017.09.025

1.13 EVALUATION OF EMOTION REGULATION AND MINDFULNESS IN ADOLESCENTS WITH AND WITHOUT IDENTITY CONFUSION F.C. Cuhadaroglu, Hacettepe University Faculty of Medicine, [email protected]; Somaye Aghazade, Hacettepe University Faculty of Medicine, somaye_aghazade@ yahoo.com Objectives: There is no study investigating the effect of emotion regulation and mindfulness of the adolescent on identity formation. This study aimed to evaluate emotion regulation and mindfulness levels in adolescents with and without identity confusion.

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Methods: This is a cross sectional study with a sample consisting of 104 adolescents (aged 12-18 years) admitted to an outpatient child and adolescent psychiatry clinic. Those with intellectual disability and chronic physical or neurological illnesses were excluded. All participants were assessed with the Kiddie Schedule for Affective Disorders and Schizophrenia for School Aged Children-Present and Lifetime Version (K-SADS-PL), the Difficulties in Emotion Regulation Scale (DERS), the Sense of Identity Assessment Form (SIAF), and Five Facet Mindfulness Questionnaire (FFMQ). The results were analyzed by SPSS 16; ANOVA, t-test, correlation analyses and Chi-square were used. The study was confirmed by the institutional review board of Hacettepe University. Results: DERS (r ¼ 0.676, p < 0.01) and FFMQ (r ¼ -0.524, p < 0.01) scores were highly correlated with identity confusion. Adolescents with identity confusion had more difficulty in regulating their emotions than adolescents without identity confusion [t(102) ¼ -8,2, p < 0.001] and mindfulness levels were lower in the first group [t(102) ¼ 5.95, p < 0.001]. Moreover, depression (c2 ¼ 6,16, p < 0.05), generalized anxiety disorder (c2 ¼ 4,37, p < 0.05), and PTSD (c2¼6,36, p < 0.05) were diagnosed more among those with identity confusion. ODD had the highest negative association with emotion regulation (t ¼ 3.68, p < 0.01) and mindfulness (t ¼ -2.94, p < 0.04). Conclusions: This study provides data to understand some developmental factors which can be associated with identity confusion in adolescence. It may be motivating to plan further interventional and longitudinal research to understand the factors in the development of identity confusion.

ADOL, IDD, DEV Supported by the Scientific Research Unit of Hacettepe University, Ankara, Turkey http://dx.doi.org/10.1016/j.jaac.2017.09.027

1.14 CORRELATIVE STUDY OF ANTERIOR PITUITARY-THYROID AXIS AND PROLACTIN OF PATIENTS WITH FIRST-EPISODE BIPOLAR MANIA Yuncheng Zhu, MD, Shanghai Changning Mental Health Center (Green Land Hospital of Bio-X Center, Shanghai Jiaotong University), hellfi[email protected]; Weidong JI, MD, Shanghai Changning Mental Health Center (Green Land Hospital of Bio-X Center, Shanghai Jiaotong University), [email protected] Objectives: The goal of this study is to learn about the interaction between thyroid-stimulating hormone (TSH) and prolactin (PRL) hormones secreted by anterior pituitary function with first-episode bipolar disorder (BD) in manic state. Methods: The present cross-sectional study was conducted to test the hemoconcentrations of TSH/TT3/TT4/FT3/FT4 and PRL between a total of 65 patients diagnosed with first-episode BD in manic state according to the ICD-10, and 62 healthy control subjects matched with age and gender. The correlation of pathophysiological conversions of neuroendocrine and clinical characteristics of BD-mania were attempted to be associated. Results: There was no statistical significance between BD in the manic state group and healthy control subjects in the TSH group [1.84 (0.99, 2.65) vs. 1.49 (1.06, 2.12), Z ¼ 0.692, P > 0.05]. After groups were formed according to gender, results showed that TSH/PRL in female bipolar disorder in manic state group was higher than in female healthy control subjects [1.94 (1.23, 2.89) vs. 1.49 (1.07,2.04), Z ¼ 1.984]/[672.5 (333.0, 1,058.0) vs. 320.0 (263.5, 432.5), Z ¼ 3.496] with statistical significance (P < 0.05). There was an inverse relationship between PRL and TSH of female BD-mania established in correlation analysis (r2 ¼ 0.25, F ¼ 9.53, P < 0.01, y ¼ b0 + b1/x, b0 ¼ 291.50, b1 ¼ 793.92). Conclusions: The difference of TSH between genders indicates that the gender factor may have an impact on the compensation of hormones secreted by anterior pituitary function with bipolar disorder in manic state. The increased hemoconcentrations of TSH and PRL in female patients may be responsible for the onset of the disease and may have an inverse relationship between the two hormones. The above phenomena were not found in male patients.

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BD, R, NEURO Supported by Key Specialty Project of Shanghai Municipal Health and Family Planning Commission Grant ZK2015B01 and Key Specialty Project of Shanghai Changning District Municipal Health and Family Planning Commission Grant CN2015001 http://dx.doi.org/10.1016/j.jaac.2017.09.028

1.15 TREATMENT UTILIZATION PATTERNS IN ADOLESCENTS WHO DIED BY SUICIDE Gagandeep Singh, MD, Henry Ford Health System, [email protected]; Shehryar Khan, MD, Henry Ford Health System, [email protected]; Brian Ahmedani, PhD, Henry Ford Health System, [email protected]; Deepak Prabhakar, MD, MPH, Henry Ford Behavioral Health Services, [email protected] Objectives: Even though we have made tremendous progress in identifying risk factors for suicide in adolescents, there is limited information on health care utilization prior to death by suicide. Our study objective was to determine whether treatment utilization patterns are different in adolescents who died by suicide compared with adolescents who did not die by suicide. Methods: We conducted a case control study comparing treatment utilization in individuals who died by suicide (n ¼ 104) with control subjects who did not (n ¼ 416). Participants were 3.00). Results: DBD and ADHD groups did not differ from controls for the NAcc, but DBD showed weaker connectivity with posterior insula, compared to ADHD. Controls and DBD were not significantly different in the Amyg connectivity. Subjects with ADHD showed atypical Amyg connectivity with: 1) visual cortex; 2) precentral gyrus; and 3) inferior parietal lobule. Subjects with ADHD, compared to DBD, showed weaker Amyg functional connectivity with visual cortex. Inattention and aggression scores were associated with NAcc connectivity to fusiform gyrus and dorsomedial prefrontal cortex. Inattention was correlated with Amyg connectivity to inferior parietal lobule, middle temporal gyrus, and superior precentral sulcus. Aggression was related with Amyg connectivity to precuneus and superior frontal gyrus. Rule-breaking scores were correlated with NAcc-superior frontal gyrus connectivity, and with Amyg connectivity to posterior cingulate cortex, precuneus, medial prefrontal cortex, and lingual gyrus. Conclusions: Our results suggest that the traditional categorical approach is not sufficient to characterize the NAcc and Amyg functional connectivity in DBD and ADHD, and propose that a dimensional approach may contribute to better examine DBD and ADHD neurobiology.

IMAGS, ADHD, DBD Supported by the National Institute of Developmental Psychiatry for Children and Adolescent Grants CNPq 465550/2014-2 and FAPESP 2014/50917-0, and the S~ao Paulo Research Foundation Grant 2013/08531-5 http://dx.doi.org/10.1016/j.jaac.2017.09.036

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1.23 A PILOT RESTING STATE FUNCTIONAL CONNECTIVITY STUDY OF THE KYNURENINE PATHWAY IN ADOLESCENTS WITH DEPRESSION AND HEALTHY CONTROLS Samuel J. DeWitt, PhD, Icahn School of Medicine at Mount Sinai, [email protected]; Kailyn A. Bradley, PhD, Icahn School of Medicine at Mount Sinai, samuel.dewitt@ mssm.edu; Na Lin, PhD, Icahn School of Medicine at Mount Sinai, [email protected]; Chunli Yu, MD, Icahn School of Medicine at Mount Sinai, [email protected]; Vilma Gabbay, MD, MS, Icahn School of Medicine at Mount Sinai, [email protected] Objectives: The neuroimmunological kynurenine pathway (KP) has been hypothesized to play a role in depressive/anhedonic symptoms and related central nervous system disturbances. Indoleamine 2,3-dioxygenase (IDO) is the rate limiting enzyme which leads to neurotrophic [kynurenic acid (KA)] and neurotoxic [quinolinic acid (QUIN)] branches. In this pilot, we sought to examine associations between blood KP neuro-toxic/trophic measures and an anhedonia/depression associated network in youth with MDD and healthy controls (HC). Methods: Subjects were 14 psychotropic medication-free adolescents with MDD and seven HC, aged 12-19 years. All underwent resting-state fMRI scans. Voxel-wise maps were generated indicating correlation strengths among four bilateral seeds [(dorsal anterior cingulate cortex (dACC), perigenual ACC (pgACC), subgenual ACC (sgACC) and nucleus accumbens (NAc)] and remaining brain regions. fMRI analyses were family-wise error corrected. KP metabolites were measured by a liquid chromatography–tandem mass spectrometry. Results: Connectivity between the right dACC and the right precuneus was positively correlated with KA levels. This same cluster demonstrated an inverse correlation with IDO activity. Exploratory analysis at a more liberal clustering threshold showed KA/QUIN ratio was positively correlated with connectivity between the pgACC and the right medial prefrontal cortex. Lastly, connectivity between pgACC and left inferior temporal gyrus was positively correlated with QUIN levels. Conclusions: This pilot study is the first report in depressed adolescents demonstrating associations between the KP and anhedonia/depressionassociated brain network. This pilot adds evidence to the putative role of the KP in MDD.

IMAGS, NI, DDD Supported by NIMH Grants MH095807 and MH101479 http://dx.doi.org/10.1016/j.jaac.2017.09.037

1.24 A RESTING STATE FUNCTIONAL MAGNETIC RESONANCE IMAGING (FMRI) STUDY OF ATTENTION NETWORK DYSFUNCTION IN ADOLESCENTS WITH BULIMIA NERVOSA Mirjana Domakonda, MD, Columbia University Medical Center and The New York State Psychiatric Institute, [email protected]; Xiaofu He, PhD, Columbia University Medical Center and New York State Psychiatric Institute, [email protected]; Rachel Marsh, PhD, Columbia University Medical Center and New York State Psychiatric Institute, [email protected] Objectives: The onset of bulimia nervosa (BN) in adolescence typically involves loss-of-control (LOC) eating followed by compensatory behaviors to avoid weight gain. Patients often exhibit a preoccupation with food- and weight-related stimuli, and these maladaptive cognitions are thought to impair information processing by influencing or disrupting attentional processes. In addition to these attentional problems, recent evidence suggests that childhood diagnosis of ADHD is associated with more severe BN symptoms in adolescents. Despite these clinical findings, little is known

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about the underlying neural mechanisms that govern attentional processes in BN. Methods: We collected resting-state fMRI images from 42 adolescents with symptoms of BN (aged 17.2 1.9 years) and 37 age-matched healthy control (HC) subjects (aged 16.9 2.3 years). Group differences in functional connectivity within and between the dorsal attentional network (DAN)/ventral attentional network (VAN) and the default mode network (DMN) were examined. Resting-state functional connectivity was correlated with BN symptoms and performance on the Continuous Performance Task-II (CPT-II). Results: A whole-brain voxelwise analysis revealed increased connectivity between the VAN right ventral supramarginal gyrus (vSMG) and the DMN posterior cingulate cortex (PCC) in BN compared with HC adolescents. Exploratory analyses also revealed increased connectivity in BN compared with HC subjects between the vSMG and the DAN right intraparietal sulcus and from the vSMG to two additional DMN regions, the left and right lateral parietal cortices. We are currently conducting path analyses to determine whether such increased connectivity between networks in BN mediates associations of BN symptoms with performance on the CPT-II. Conclusions: Our preliminary findings suggest disruptions in attentional network connectivity in adolescents with BN. Increased connectivity with the DMN may contribute to the difficulty shifting attention away from food- and weight-related stimuli. Such attentional disruptions may contribute to the development and maintenance of BN symptoms. Future studies will focus on the developmental trajectory of connectivity within these attentional circuits and whether these circuits may serve as potential biomarkers for identifying adolescents at risk of developing BN symptoms.

ADOL, IMAGS, BNN http://dx.doi.org/10.1016/j.jaac.2017.09.038

1.26 NEUROCHEMICAL PREDICTORS OF COGNITIVE-BEHAVIORAL THERAPY RESPONSE IN PEDIATRIC OBSESSIVE-COMPULSIVE DISORDER (OCD) Tord Ivarsson, MD, PhD, The Center for Child and Adolescent Mental Health, Eastern and Southern Norway, tord.ivarsson@ r-bup.no; Gudmundur A. Skarphedinsson, PhD, University of Iceland, [email protected]; Karin A. Melin, RN, MSc, Sahlgrenska University Hospital, [email protected]; Goran Starck, PhD, Sahlgrenska University Hospital, goran. [email protected]; Maria Ljungberg, PhD, Sahlgrenska University Hospital, [email protected] Objectives: The goal of this presentation is to identify neurochemical factors predicting the outcome of CBT. Methods: We included 24 patients with DSM-IV-classified moderate-severe OCD (aged 11–17 years). Primary outcome was the Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) before and after manualized CBT. Magnet resonance spectroscopy was used to identify neurochemicals in four volumes of interest: 1) the right caudate (superior part of the head and anterior part of the body); 2) medial-cranial thalamus; 3) bilateral posterior cingulum; and 4) bilateral occipital cortex (neocortical control area). The metabolites were used as factors in linear mixed-effects models, controlling for confounders, such as age and gender. Results: Several neurochemical variables were associated with worse CBT outcome as follows: lower caudate g-aminobutyric acid (GABA) (t ¼ 2.64, P ¼ 0.02); higher glutamate/glutamate complex signals in posterior cingulum (t ¼ 2.5; P ¼ 0.02 and t ¼ 2.89; P ¼ 0.01, respectively); tendencies to higher glutamate/glutamate complex signals in thalamus (t ¼ 1.81; P ¼ 0.09 and t ¼ 2.07; P ¼ 0.06, respectively); and lower thalamic aspartate (t ¼ 2.02; P ¼ 0.06). Furthermore, higher caudate N-acetyl aspartate-glutamate (NAAG) (t ¼ 4.59; P ¼ 0.04), cingulate N-acetyl aspartate (t ¼ 2.15; P ¼ 0.04) (NAA), and NAA-NAAG (t ¼ 2.36; P ¼ 0.03) were associated with worse CBT outcome.

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Conclusions: These findings may reflect an imbalance between inhibitory and excitatory processes in the brain circuits that mediate goal-directed behaviors in pediatric OCD and may compromise CBT work in those with more marked neurochemical deviations. Limited numbers render our data uncertain, indicating a need for replication. The role of the NAA/NAAG/NAA-NAAG, as part of the neurons’ energy and waste handling in cooperation with astrocytes and oligodendrocytes, could indicate an excitatory overload that is associated with worse outcome. Furthermore, neurochemicals related to OCD severity and CBT in previous studies were not only replicated, indicating a need to be aware of the risk of chance findings, but also that neurochemical factors leading to OCD may differ from factors contributing to treatment nonresponse.

IMAGS, OCD http://dx.doi.org/10.1016/j.jaac.2017.09.040

1.27 THE COMPARISON OF FUNCTIONAL MAGNETIC RESONANCE IMAGING (MRI) FINDINGS BETWEEN ADOLESCENTS WITH OBSESSIVE-COMPULSIVE DISORDER (OCD) AND HEALTHY CONTROLS Duygu Kinay, MD, Istanbul University, duygukinayy@hotmail. com; Ç i gdem Ulas¸o glu Yıldız, MSC, Istanbul University, [email protected]; Elif Kurt, MSC, Istanbul University, [email protected]; Kardelen Ery€ urek, MSC, Istanbul University, [email protected]; Tamer Demiralp, MD, Istanbul University, demiralp@istanbul. edu.tr; Murat Cos¸kun, MD, Istanbul University, drmc78@ gmail.com Objectives: Few studies examined the executive function deficits of OCD in youth, and data on the relationship of these deficits with the activity of the cortical regions are scarce. In this study, we compared fMRI findings between treatment-naive adolescents with OCD and healthy control subjects during resting state and multisource interference task (MSIT), which according to the literature activates the cingulo-fronto-parietal circuits associated with attention. Methods: fMRI data during resting state and MSIT were acquired from 15 unmedicated adolescents with OCD and 15 healthy control subjects that matched on age, gender, education, and handedness. Experiments were performed on a 3 T MRI scanner. Data were preprocessed using SPM-8 (Statistical Parametric Mapping) software. Intrinsic connectivity networks (ICNs) during both resting state and MSIT were obtained by applying separate independent component analyses using the GIFT (Group ICA Of fMRI) toolbox. Voxelwise comparisons of the ICNs between the two groups were conducted by using the two-sample t-test with cluster-level family-wise error (FWE) correction as implemented in the second-level analysis module of the SPM-8 software. Results: Adolescents with OCD showed stronger intrinsic functional connectivity in the precuneus component of the default mode network (DMN) (Brodmann’s area 7: medial and lateral parietal cortex) during resting state [height threshold: P < 0.001 uncorrected; cluster-level FWE corrected, P ¼ 0.03; Montreal Neurological Institute (MNI) peak coordinates: 4, 68, 38; cluster size ¼ 115 voxels]. On the other hand, adolescents with OCD showed decreased intrinsic functional connectivity in the anterior DMN during MSIT (height threshold: P < 0.01 uncorrected; cluster-level FWE corrected, P ¼ 0.015; MNI peak coordinates: 14, 40, 28; cluster size ¼ 770 voxels). Conclusions: These findings provide evidence supporting the hypothesis that, besides the orbito-fronto-striatal circuits, alterations in DMN, which is an important large-scale network related to the allocation of resources for higher mental processes such as attention, executive functions and cognitive flexibility might play a significant role in the pathophysiology of OCD.

ADOL, NEUROA, OCD Supported by Istanbul University Scientific Research Projects Unit Project 21107 http://dx.doi.org/10.1016/j.jaac.2017.09.041


1.28 EARLY CANNABIS USE INITIATION AT 12–14 YEARS OLD ASSOCIATED WITH THINNER FRONTAL AND TEMPORAL CORTICAL THICKNESS

Flavie Laroque, MSC, University of Montreal, flavie.laroque@ umontreal.ca; Josiane Bourque, MSC, University of Montreal, [email protected]; Sean Spinney, Universit e de Montr eal, [email protected]; Rachel Sharkey, MSC, Montreal Neurological Institute, [email protected]; Travis Baker, PhD, Center for Molecular and Behavioural Neuroscience, [email protected]; Alain Dagher, PhD, Montreal Neurological Institute, alain. [email protected]; Hugh Garavan, PhD, University of Vermont, [email protected]; Marco Leyton, PhD, Montreal Neurological Institute, [email protected]; Jean Seguin, PhD, University of Montreal, jean.seguin@ umontreal.ca; Robert Pihl, PhD, McGill University, robert. [email protected]; Patricia Conrod, PhD, CHU Sainte-Justine, [email protected] Objectives: The increase of cannabis use from 12 percent in 2008 to 15 percent in 2015 among Quebec youth and the future legalization of cannabis have intensified public health actions to fully understand its effects on the brain. Thinner cortical thickness has been identified in adolescents using cannabis but most studies focused on those aged 15 and older. This investigation compares cortical thickness measures in early cannabis users aged 12 to 14 years compared to non-using control subjects. Methods: Eleven cannabis users and 11 non-user adolescents (mean age ¼ 13.8 0.6, 7 females in each group) were matched on age, gender, handedness, socioeconomic status, IQ, alcohol use, and personality. The Detection of Alcohol and Drug Problems in Adolescents (DEP-ADO) screening tool was used to evaluate cannabis use frequency among adolescents. Youth in the non-users group had never used cannabis in their lifetime, while youth in the cannabis user group were categorized as occasional users. All participants underwent MRI anatomical scans and cortical thickness reconstruction was performed with two automated pipelines, CIVET 2.0 and Freesurfer. Region by region ANCOVA were conducted using SPSS with Freesurfer data. To confirm our results by a more restrictive approach, whole brain cortical thickness group differences were assessed using generalized linear mixed effects model in SurfStat. Both analyses were covaried for age, gender, handedness, and intracranial volume. Results: Compared to non-users, cannabis users had significantly thinner cortices in temporal and frontal regions when assessed region by region. Supporting those results, the statistically stringent whole brain analysis also showed significantly thinner cortices in the left middle temporal gyrus of cannabis users Conclusions: To our knowledge this is the first study to evaluate cortical thickness in a group of early cannabis user adolescents. Our findings are consistent with previous results in older adolescents and indicate that even at an early age of cannabis use, brain abnormalities are observed.

IMAGS, EC, SUD Supported by Canadian Institutes of Health Research Grant 126053 http://dx.doi.org/10.1016/j.jaac.2017.09.042

1.29 GLUTAMATERGIC NETWORK GENE MUTATION, SUBCORTICAL BRAIN VOLUME, AND PSYCHIATRIC FUNCTIONING IN SUBJECTS WITH ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) Claudia Lugo-Candelas, PhD, Columbia University Medical Center and The New York State Psychiatric Institute, [email protected]; Hakon Hakonarson, MD, The Children’s Hospital of Philadelphia and The Perelman School of Medicine at the University of Pennsylvania, hakonarson@

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email.chop.edu; Liza Squires, MD, Aevi Genomic Medicine, Inc, [email protected]; Vanessa Bastidas, BS, New York State Psychiatric Institute, Vanessbastida@nyspi. columbia.edu; Susie Hong, BS, New York State Psychiatric Institute, [email protected]; David Semanek, BA, New York State Psychiatric Institute, SemanekD@nyspi. columbia.edu; Jonathan Posner, MD, Columbia University, [email protected] Objectives: An enrichment in copy number variants (CNVs) in a network of genes impacting glutamatergic signaling and neuronal connectivity (GRM) has been identified in subjects with ADHD. Beyond a diagnosis of ADHD, little is known about the neural and psychiatric phenotype of subjects with GRM CNVs. We examined subcortical brain volume and functioning in subjects with ADHD with and without GRM CNVs and in healthy controls (HC). Methods: Subcortical brain volume, psychiatric functioning, and genetic data were analyzed in 72 subjects with (n ¼ 39) and without (n ¼ 33) ADHD (mean age ¼ 10.38 3.09 years; 52 males; 20 females). Structural MRI brain scans were analyzed using Freesurfer. This pilot of eight subjects with ADHD were genotyped: seven had GRM CNVs. Psychiatric functioning was assessed via the Child Behavior Checklist. Results: In line with prior research, subjects with ADHD demonstrated volumetric reductions in the left putamen (p ¼ 0.05), right accumbens (p ¼ 0.05), and left amygdala (p ¼ 0.04), with similar trends in the left hippocampus (p ¼ 0.06), and right caudate (p ¼ 0.09). Subjects with ADHD had increased volume in the left thalamus (p ¼ 0.03) with a trend in the left pallidum (p ¼ 0.09). Post-hoc analyses indicated this increase was driven by subjects with GRM CNVs, who had greater left thalamus and pallidum volumes than the HCs (ps < 0.003), and ADHD subjects without GRM mutations (ps ¼ 0.001). ADHD subjects with GRM CNVs were reported to have more depression, social problems, aggression, and rule-breaking behavior than ADHD subjects without GRM CNVs (ps < 0.02) and HCs (ps < 0.002). Conclusions: ADHD subjects with GRM CNVs present a distinct profile from those without GRM CNVs, including differences in brain structure and psychiatric symptoms. Metabotropic glutamate receptors are present in the thalamus and have been implicated in psychiatric disorders, yet their role in psychiatric disease is unknown. Preliminary data suggests that within this heterogeneous disorder, subjects with ADHD with GRM mutations may represent a more impaired subsample with a distinct neurobiological profile. Research will need to explore the role of GRM CNVs in the pathophysiology of ADHD.

GS, ADHD, NEUROA Supported by NIMH Grant R01 MH101172 http://dx.doi.org/10.1016/j.jaac.2017.09.043

1.30 SEX DIFFERENCES IN CEREBRAL BLOOD FLOW AMONG ADOLESCENTS WITH BIPOLAR DISORDER Rachel H.B. Mitchell, MD, MSC, Sunnybrook Health Sciences Centre and the University of Toronto, rachel.mitchell@ sunnybrook.ca; Arron W. Metcalfe, PhD, Sunnybrook Research Institute, [email protected]; Henri J.M. Mutsaerts, PhD, Hurvitz Brain Institute, Sunnybrook Research Institute, [email protected]; Bradley J. MacIntosh, PhD, Sunnybrook Research Institute, [email protected]; Benjamin I. Goldstein, MD, PhD, Sunnybrook Health Sciences Centre, [email protected] Objectives: Developmental sex differences in cerebral blood flow (CBF) may be implicated in the female predominance [2:1; female (F) to male (M) ratio] of bipolar disorder (BD) in adolescence. In childhood, CBF declines in both sexes and then increases mid-adolescence in females; it continues to decline and then plateau in males. For the first time, we examined sex differences in CBF across adolescents with BD vs. healthy control (HC) subjects.

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Methods: CBF MRI was acquired using arterial spin labeling (ASL) in 91 adolescents [BD: n ¼ 45 (19 M, 26 F); HC: n ¼ 46 (19 M, 27 F)] matched for age (14–20 years). Whole-brain, voxel-based analysis was performed with FSL software in a general linear model with diagnosis and sex as fixed factors, and age as a covariate. Main effects of diagnosis and sex and the diagnosis-by-sex interaction were evaluated controlling for age; the diagnosis-by-sex-by-age interaction was also tested. All results were thresholded at cluster forming (P < 0.005) and cluster corrected for familywise error (P < 0.05). Results: Diagnosis effects (BD > HC) were found in the striatal attention system (inferior frontal gyrus, caudate, and mid-anterior cingulate). There was a main CBF effect of sex (F >M), observed in the default mode regions (ventral medial prefrontal cortex, precuneus, and posterior cingulate). A significant diagnosis-by-sex-by-age interaction was also evident in the striatal attention system (inferior frontal gyrus, caudate/thalamus, and somatosensory cortex). Preliminary analysis demonstrated similar sex-specific CBF patterns of development in each region with a diagnosis-by-sex-by-age interaction. In HCs, sex differences in CBF development were similar to established norms (decline and plateau in males, “u-shape” in females). Regional CBF declined later with age for BD males compared with HC male counterparts, suggesting delayed CBF development. CBF levels declined more rapidly for BD females compared with HC female counterparts, suggesting advanced or premature CBF development. Conclusions: Aberrant CBF development in both male and female adolescents with BD may inform the neurobiology underlying the sex disparity in prevalence of adolescent BD.

ADOL, IMAGS, BD http://dx.doi.org/10.1016/j.jaac.2017.09.044

1.31 A COMPARATIVE STUDY OF FUNCTIONAL CONNECTIVITY IN FIRST-EPISODE DRUG-NAIVE ADOLESCENTS WITH MAJOR DEPRESSIVE DISORDER Sangwon Park, MD, Korea University College of Medicine, [email protected]; Jeonho Lee, MD, Korea University Medical Center, [email protected]; Moon Soo Lee, MD, Korea University Guro Hospital, [email protected]; Eunsoo Suh, MD, Korea University College of Medicine, [email protected]; Jihyun Kim, MD, Korea University College of Medicine, [email protected]; Jongha Lee, MD, Korea University College of Medicine, [email protected]; Sangil Suh, MD, Korea University College of Medicine, [email protected] Objectives: MDD is a quite common psychiatric disorder in adolescents. The disorder can affect brain structure and its functional connectivity (FC). As adolescence is a critical period for brain maturation and development, MDD also seems to affect the FC in young adolescents. We aim to compare the FC of patients’ brains with that of the control group. Methods: We recruited 24 drug-naïve adolescents aged 13-18 years with first-onset MDD at the adolescent psychiatry clinic of Korea University. We have only chosen a drug-naïve patient, so that we exclude the effect of unexpected pharmacotherapeutic medications on the brain. For the control group, we gathered 24 volunteers who had never been treated for psychiatric disorders. Once they were eligible to participate in our study, we conducted resting state fMRI scans. We also performed evaluations using the Hamilton Depression (HAM-D) Rating Scale and other psychological tests in both groups. Seed-to-voxel and region of interest (ROI)-toROI FC analyses were performed using the CONN-fMRI functional connectivity toolbox v17. All effects noted below are significant at p < 0.05 with cluster-wise false discovery rate (FDR) correction for multiple comparisons. Results: Healthy controls had greater FC than patients in medial frontal cortex and right caudate nucleus than regions including both hippocampus and both insular cortex. In contrast, patients with MDD demonstrated greater FC

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relative to healthy controls in anterior cingulate cortex than regions including left cerebellum and cerebellar vermis. Conclusions: Our results show altered FC of several regions associated with cognitive, affective, memory, and higher cognitive function in first-episode drug-naïve adolescents with MDD. Further studies using prospective designs are also needed to detect the long-term effect of treatment on the brains of adolescents with mood disorders.

IMAGS, NEUROA, DDD Supported by Basic Science Research Program of the National Research Foundation of Korea's Ministry of Education Grant NRF-2014R1A1A2054904 http://dx.doi.org/10.1016/j.jaac.2017.09.045

1.32 ELECTROENCEPHALOGRAM (EEG) FRONTAL ASYMMETRY AND ERROR-RELATED SIGNALS ARE POTENTIAL MARKERS OF INTERNALIZING AND EXTERNALIZING BEHAVIORS IN CHILDREN: A META-ANALYSIS Virginie C. Perizzolo, MSC, University of Geneva Hospitals and Faculty of Medicine, [email protected]; Oph elie Favrod, MS, Ecole Polytechnique F ed erale de Lausanne (EPFL), ophelie.favrod@epfl.ch; Dominik A. Moser, PhD, Icahn School of Medecine at Mount Sinai, [email protected]; Sandra Rusconi Serpa, University of Geneva, [email protected]; Michael H. Herzog, Ecole Polytechnique F ed erale de Lausanne (EPFL), Michael.herzog@epfl.ch; Daniel S. Schechter, MD, University of Geneva Hospitals and Faculty of Medicine, daniel. [email protected] Objectives: The frontal hemispheric asymmetry and error-related components, as measured by EEG, are often considered to be biological correlates or “indicators of risk” for psychopathology. Here, we performed a metaanalysis to define specific patterns of frontal hemispheric asymmetry at rest. We tested whether the association of the EEG patterns with child psychopathology, such as internalizing symptoms and externalizing behaviors, are potential risk indicators. In addition, we conducted an analysis to test whether amplitude modulation of the error-related negativity (ERN) is also related to child-internalizing symptoms and externalizing behaviors. Methods: We conducted two distinct meta-analyses (resting states vs. eventrelated potential) that included a total of 31 studies (N ¼ 2,186). For each study included, we calculated Cohen’s d between internalizing symptoms/ externalizing behaviors (reported with questionnaires) and the amplitude of the ERN in the go/no-go and Flanker tasks or the alpha asymmetry at rest as measured in frontal electrodes. Standardized effect sizes (Hedges’ g) were calculated using Cohen’s d multiplied by the coefficient J, which is a correction for small sample sizes. Hedges’ g was introduced as a generic effect size in the OpenMeta Analyst software (http://www.cebm.brown.edu/openmeta/) with the corresponding variance (SE). We used the continuous random-effect analysis with the DerSimonian-Laird (DL) method. The meta-analysis software computed the effect sizes, with 95 percent confidence intervals and the pooled effect size g*. Results: We found a significant relationship between greater right frontal asymmetry and internalizing symptoms (P ¼ 0.012). In addition, we found a significant relationship between higher ERN amplitudes and the severity of internalizing symptoms (P ¼ 0.006). The association between externalizing behaviors and alpha frontal asymmetry at rest was not significant, probably because of the lack of statistical power (k ¼ 2). Conclusions: Our results show that frontal asymmetry in resting states is a probable biological indicator of risk for childhood psychopathology, specifically of the development of internalizing symptoms. Resultsalso supported that ERN amplitude was significantly related to internalizing symptoms.

PSP, IMAGS, INF Supported by the National Center of Competence in Research SYNAPSY and Swiss National Science Foundation Grant 51NF40-158776 http://dx.doi.org/10.1016/j.jaac.2017.09.046


1.34 SAFETY OF LONG-TERM TREATMENT WITH LURASIDONE IN CHILDREN AND ADOLESCENTS WITH BIPOLAR DEPRESSION: WEEK 28 RESULTS OF A TWO-YEAR OPENLABEL EXTENSION STUDY Kiki Chang, MD, Stanford University Medical Center, [email protected]; Melissa P. DelBello, MD, MS, University of Cincinnati, [email protected]; Robert Goldman, PhD, Sunovion Pharmaceuticals Inc., [email protected]; Michael Tocco, PhD, Sunovion Pharmaceuticals Inc., Michael.Tocco@sunovion. com; Andrei A. Pikalov, MD, Sunovion Pharmaceuticals Inc., [email protected]; Josephine Cucchiaro, PhD, Sunovion Pharmaceuticals Inc., Josephine.Cucchiaro@ sunovion.com; Antony Loebel, MD, Sunovion Pharmaceuticals Inc., [email protected] Objectives: The goal of this presentation is to evaluate the long-term safety and tolerability of lurasidone in children and adolescents with bipolar depression. Methods: Patients ages 10–17 years with a DSM-5 diagnosis of bipolar I depression were randomized to six weeks of double-blind (DB) treatment with lurasidone (20–80 mg per day) or placebo. The primary efficacy measure was the Children’s Depression Rating Scale, Revised (CDRS-R). Patients who completed six weeks of DB treatment were eligible to enroll in a two-year, open-label (OL) extension study in which patients were continued on lurasidone (Lur-Lur) or switched from placebo to lurasidone (Pbo-Lur). Here, we present the results of an interim analysis at week 28. Results: A total of 223 patients entered the extension study, and 155 (69.5%) completed 28 weeks of treatment (mean daily dose, 52.6 mg). A total of 8.1 percent of patients discontinued because of an adverse event, consisting of mental health disorders (n ¼ 18), akathisia (n ¼ 3), abdominal pain (n ¼ 1), and pruritus (n ¼ 1). Eight patients (3.6%) met criteria for treatment-emergent mania. A total of 4.5 percent of patients reported suicidal ideation, and five patients (2.2%) made a suicide attempt. The three most common adverse events in the Lur-Lur and Pbo-Lur groups, respectively, were headache (22.6 and 16.7%), nausea (12.2 and 16.7%), and anxiety (12.2 and 7.4%); extrapyramidal symptoms (nonakathisia) were reported by 3.5 and 11.1 percent, respectively. In the Lur-Lur/Pbo-Lur groups, small median changes from DB baseline to week 28 were noted for total cholesterol (5.0/3.0 mg/dL), LDL cholesterol (3.0/2.5 mg/dL), triglycerides (5.0/1.0 mg/dL), and glucose (+1.0/+1.0 mg/dL); mean change in weight at week 28 was +2.6/+3.4 kg (vs. an expected weight gain of +2.4/+2.2 kg, based on normative CDC data). In the Lur-Lur/Pbo-Lur groups, median change in prolactin from DB baseline to week 28 was +1.55/+2.60 ng/mL for females and +1.25/+1.80 ng/mL for males. No patients had a corrected QT interval Fridericia’s formula (QTcF) 460 or an increase from DB baseline in QTcF of 60 milliseconds. Conclusions: In children and adolescents with bipolar depression, up to 28 weeks of treatment with lurasidone was generally well tolerated, with headache, nausea, and anxiety being the most common adverse events. Minimal effects were observed on weight, metabolic parameters, and prolactin levels.

APS, BD, DDD Supported by Sunovion Pharmaceuticals Inc. http://dx.doi.org/10.1016/j.jaac.2017.09.048

1.35 PREVENTING METABOLIC SYNDROME IN CHILDREN AND ADOLESCENTS PRESCRIBED ANTIPSYCHOTICS: A LITERATURE REVIEW Raminder Pal Cheema, MD, Baylor College of Medicine, [email protected]; Muhammad Zeshan, MD, Boston Children’s Hospital, [email protected]; Nusrat Jahan, MD, MPH, Rush University Medical Center,

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[email protected]; Pankaj Manocha, MD, BronxLebanon Hospital Center at Icahn School of Medicine at Mount Sinai, [email protected] Objectives: The goal of this presentation is to summarize the recent literature on preventing, diagnosing, and treating metabolic syndrome in children and adolescents taking antipsychotic drugs. Methods: We searched PubMed database for articles describing metabolic syndrome in children and adolescents caused by antipsychotic drugs, using the key words as follows: metabolic syndrome (MetS), children, adolescents, and antipsychotics. Out of the initially screened 67 articles, the articles were further short-listed to nine articles, which met all the inclusion and exclusion criteria. These articles focused on directly measuring the effect of antipsychotic drugs on one or more of the five MetS parameters (BMI, waist circumference, fasting blood lipid and blood sugar, and blood pressure) defined by the new International Diabetes Federation. Moreover, we also found and screened five potentially relevant and systemic literature reviews and one meta-analysis article, which were all published within the last 5 years. Results: Upon reviewing the literature, it is evident that the recommendations for monitoring at baseline and at ongoing follow-up evaluations every quarter during the first year vary among the antipsychotic drugs. There is consensus in literature about the need for monitoring multiple variables, including but not limited to height; weight; BMI; waist circumference; blood pressure; fasting blood glucose; lipid panel (total cholesterol, low-density lipoprotein, highdensity lipoprotein, and triglycerides); transaminases (aspartate transaminase and alanine transaminase); prolactin (PRL); and extrapyramidal syndrome (EPS). The evidence for metabolic monitoring is strongest at baseline and at three months. Our research team further stratified into SR (strongly recommended), WR (weakly recommended), and NR (not recommended), based upon the consensus developed upon review of literature. Conclusions: Second-generation antipsychotic (SGA) drugs are widely used among children and adolescent psychiatrists for treatment of various disorders, and there is growing evidence that suggests that children who take antipsychotic medications are at a higher risk for weight gain and metabolic syndrome than adolescents and adults. Early identification of children at risk and preventive action are very important to reduce morbidity and mortality in adulthood. Unless action is taken, this could be the first generation where children may die before their parents.

EBP, APS, MAE http://dx.doi.org/10.1016/j.jaac.2017.09.049

1.36 PHYSICIAN PEER-INFLUENCE ON PRESCRIBING PSYCHOTROPIC POLYPHARMACY IN THE TREATMENT OF CHILDREN AND ADOLESCENTS WITH MENTAL DISORDERS Navneet Upadhyay, MS, University of Houston, nvntupa@ gmail.com; Rohan A. Medhekar, PhD, University of Houston, College of Pharmacy, [email protected]; Kayo Fujimoto, PhD, University of Texas Health Science Center at Houston, [email protected]; Rajender R. Aparasu, PhD, University of Houston, College of Pharmacy, [email protected]; Vinod Bhatara, MD, University of South Dakota Sanford School of Medicine, [email protected]; Michael L. Johnson, PhD, University of Houston, College of Pharmacy, [email protected]; Joy P. Alonzo, PharmD, University of Houston, College of Pharmacy, jpalonzo@ central.uh.edu; Heidi Schwarzwald, MD, MPH, Texas Children’s Health Plan, [email protected]; Hua Chen, MD, PhD, University of Houston, College of Pharmacy, [email protected] Objectives: The goal of this session is to examine the effect of physician’s peer influence on the prescription of psychotropic polypharmacy (PP) among children and adolescents treated for mental disorders (MD). Methods: A retrospective study was conducted using the 2013–2015 administrative claims data from Texas Children’s Health Plan. The study included the

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following individuals: 1) aged 18 years; 2) diagnosed with MD; and 3) received psychotropic prescriptions from a single prescriber during the study period. The outcome of interest was PP, defined as the receipt of two or more psychotropic medications from different drug classes concurrently for 60 days. Multilevel generalized linear-mixed model was used to study the association between physician-level, peer-influence measures, and patient-level risks of receiving PP by adjusting for the practice-, physician-, and patient-level covariates. This study measured physician peer influence using social network measures. Two network measures were used: affiliation exposure (AE) and structural equivalence (SE). AE represents the extent to which a physician is exposed to the PP-prescribing behavior of other physicians via sharing of patients. SE measures the degree to which a physician is exposed to the PPprescribing behaviors of their structurally equivalent peers. Results: Children and adolescents (N ¼ 24,147) had a diagnosis of MD and received at least one psychotropic medication. Of this population, 13,045 (54.02%) met the study inclusion criteria. The multilevel models found that as a physician is exposed more to their peers prescribing PP through the sharing of same patients (AE), there is 77 percent higher likelihood for their patients to receive PP (OR ¼ 1.766; 95% CI 1.027–3.037); in addition, as physicians occupy more comparable position in patient-sharing network to other physicians prescribing PP (SE), the higher the likelihood of their patients receiving PP (OR ¼ 4.236; 95% CI 2.071–8.666). Physician specialty and patient-level factors, including gender, race, and diagnosis of ADHD, bipolar disorder, and depression, were associated with prescription of PP. Conclusions: Physician peer influence was strongly associated with PP, implying that targeting and changing the prescribing behaviors of guidelinenonconcordant physicians could be useful in enhancing the diffusion of guideline-concordant practices among other physicians.

P, ADOL, RF http://dx.doi.org/10.1016/j.jaac.2017.09.050

1.37 IS USE OF PSYCHOTHERAPY ASSOCIATED WITH LOWER NEED FOR PSYCHOTROPIC POLYPHARMACY AMONG MEDICAID CHILDREN? Xiaouxue Chen, MPH, HealthCore, Inc., xchen@healthcore. com; Whitney York, MS, HealthCore, Inc., wyork@healthcore. com; Yiqiong Xie, DrPH, HealthCore Inc., yxie@healthcore. com; John Barron, PharmD, HealthCore Inc., JBarron@ healthcore.com; Gosia Sylwestrzak, MA, HealthCore Inc., [email protected]; Keith Isenberg, MD, Anthem Insurance Companies, Inc., [email protected] Objectives: The increasing trend of psychotropic polypharmacy among children is concerning as evidence for safety and efficacy around medication combination is limited. Psychotherapy is an alternative approach, either alone or in combination with psychotropic medications, and is often considered effective and with less risk. The study examines the impact of adding psychotherapy to pharmacological therapy on polypharmacy among children covered under Medicaid. Methods: Patients (aged 0–17 years) with psychotropic polypharmacy (2 medication classes with 30 overlapping days) and one year of continuous Medicaid enrollment were identified from Anthem Medicaid claims data from January 2013 to June 2016. Patients receiving various types of counseling (psychotherapy group) were identified and assigned an index date as the earliest therapy date. Patients without therapy were assigned a random index date. Baseline and treatment characteristics were compared between groups. Generalized estimating equations model controlling for baseline characteristics was used to assess the impact of psychotherapy on the likelihood of co-prescription of two to three or more medication classes and the duration of overlap between two and more medications after initial therapy. Results: We identified 31,754 Medicaid children with psychiatric polypharmacy. Of them, 12,064 (38.0%) received counseling. The average number of counseling visits was 6.4 over three months after initial therapy (interquartile range: 2–8). Female sex, prior psychiatric diagnoses, and a history of crisis management were more prevalent in the counseling

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PPC, P, TREAT Supported by Anthem, Inc. http://dx.doi.org/10.1016/j.jaac.2017.09.051

1.38 EFFICACY AND SAFETY OF SHP465 MIXED AMPHETAMINE SALTS IN CHILDREN AND ADOLESCENTS WITH ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER (ADHD): A RANDOMIZED, PLACEBO-CONTROLLED STUDY Matthew Brams, MD, Baylor College of Medicine, [email protected]; Ann Childress, MD, Center for Psychiatry and Behavioral Medicine, Inc., [email protected]; Michael S. Greenbaum, MD, Capstone Clinical Research Center, [email protected]; Ming Yu, MD, PhD, Shire, [email protected]; Brian Yan, PhD, Shire, byan@ shire.com; Margo Jaffee, BS, Shire, [email protected]; Brigitte Robertson, MD, Shire, [email protected] Objectives: The goal of this study is to evaluate the efficacy, tolerability, and safety of SHP465 mixed amphetamine salts (MAS) in children and adolescents with ADHD. Methods: This randomized, double-blind, placebo (PBO)-controlled, doseoptimization study enrolled children and adolescents (ages 6–17 years) with DSM-IV-Text Revision-defined ADHD and baseline ADHD Rating Scale IV (ADHD-RS-IV) total scores 28. Participants from 36 US clinical research sites were randomized 1:1 to SHP465 MAS [week 1: 12.5 mg; week 2: titrated to 25 mg based on efficacy, safety, and tolerability; weeks 3–4: the final titrated dose (12.5 or 25 mg) was maintained] or PBO. The primary (ADHD-RS-IV total score change from baseline to week 4) and key secondary [Clinical Global Impressions–Improvement (CGI-I) score at week 4] efficacy endpoints were assessed using linear mixed-effects models for repeated measures. Safety and tolerability, including treatment-emergent adverse events (TEAEs) and vital sign changes, were examined descriptively. Results: Of 264 randomized participants (PBO, n ¼ 132; SHP465 MAS, n ¼ 132), 29 were discontinued from the study (PBO, n ¼ 13; SHP465 MAS, n ¼ 16). The least squares (LS) mean (95% CI) ADHD-RS-IV total score change from baseline to week four was significantly greater with SHP465 MAS than PBO [–20.7 (–22.9, –18.5) vs. –10.8 (–13.0, –8.5); P < 0.001; effect size ¼ 0.80]. The LS mean (95% CI) CGI-I score at week four was significantly lower (indicating greater improvement) with SHP465 MAS than PBO [2.2 (2.0, 2.4) vs. 3.0 (2.8, 3.2); P < 0.001; effect size ¼ 0.65]. The frequency of TEAEs was 46.6 percent (61/131) with PBO and 67.4 percent (89/132) with SHP465 MAS. TEAEs reported at a frequency of 10 percent (SHP465 MAS; PBO) were decreased appetite (30.3%; 6.9%), headache (12.1%; 10.7%), and insomnia (11.4%; 1.5%). Mean SD changes from baseline at the final on-treatment assessment for SHP465 MAS and PBO, respectively, were 5.7 11.78 and 0.7 10.79 beats per minute for pulse, 3.8 9.15 and 2.1 8.72 mm Hg for systolic blood pressure, and 4.0 8.23 and 0.5 7.45 mm Hg for diastolic blood pressure. Conclusions: SHP465 MAS was superior to PBO in reducing ADHD symptoms and improving global functioning in children and adolescents with ADHD. The safety and tolerability profile of SHP465 MAS was consistent with the known profiles of other stimulants.


PPC, RCT, STIM Supported by Shire http://dx.doi.org/10.1016/j.jaac.2017.09.052

1.40 LURASIDONE EXPOSURE RESPONSE IN PEDIATRIC BIPOLAR DEPRESSION: SIMULATION AND COMPARISON TO ADULTS Sunny Chapel, PhD, Ann Arbor Pharmacometrics Group Inc., [email protected]; Yu-Yuan Chiu, PhD, Sunovion Pharmaceuticals Inc., [email protected]; Jongtae Lee, PhD, Ann Arbor Pharmacometrics Group Inc., [email protected]; Felix Agbo, PhD, Sunovion Pharmaceuticals Inc., [email protected]; Antony Loebel, MD, Sunovion Pharmaceuticals Inc., Antony. [email protected] Objectives: In adults with bipolar depression, a population dose-response analysis has shown that higher doses of lurasidone are likely to produce greater antidepressant effects. The aim of the current analysis was to evaluate the consistency of the exposure-response relationship of lurasidone between children/adolescent and adult patients with bipolar depression. Methods: An external posterior predictive check (PPC) was conducted to evaluate the utility of an adult exposure-response model in predicting efficacy for children and adolescent patients with bipolar depression (N ¼ 343) who were randomized in a double-blind, placebo-controlled, six-week study of flexibly dosed lurasidone (20–80 mg per day). In the event that the external PPC demonstrated differences in the efficacy between pediatric and adult patients, further model development was planned with appropriate covariates to help explain the discrepancy. The updated model was then to be used to determine pediatric doses in children and adolescents that produce similar efficacy to adults. In the pediatric study, the Children’s Depression Rating Scale, Revised (CDRS-R) was administered weekly over the course of the treatment period and converted to the adult efficacy measure, the Montgomery-Asberg Depression Rating Scale (MADRS) total score to compare with the adult model. Results: The adult population exposure-response model was not able to adequately predict the mean MADRS change from baseline or the placebocorrected mean MADRS change from baseline for the pediatric patients. However, a revised model based on combined adult and pediatric data that included a separate baseline MADRS for pediatric and adult patients, but did not include the effect of age on maximum placebo effect, adequately described the dose-response relationship for a fixed dose study design in pediatric populations. Using the revised model, the simulated dose-response relationship in pediatric patients was shown to be similar to that in adult patients. Conclusions: This modeling and simulation indicated that, as in adults, higher doses of lurasidone are likely to result in greater drug-related improvements in depressive symptoms for children and adolescent patients with bipolar depression. ˇ

group (OR: female, 1.26; ADHD, 1.64; depression, 3.64; anxiety, 2.70; disruptive disorders, 2.57; and crisis, 7.43; all P < 0.001). In the six months after the start of therapy, the counseling group was more likely to be coprescribed medication classes [n 2; adjusted OR (aOR) ¼ 1.49, P < 0.001; n 3; aOR ¼ 1.33, P < 0.001]. They also had longer duration of overlap between two or more medications (adjusted mean difference ¼ 11.2 days, P < 0.001). Conclusions: Psychotherapy did not appear to reduce psychotropic polypharmacy in children under Medicaid. The result may be confounded by unmeasured severity and other risk factors. Further work considering the impact of specific therapy services on polypharmacy, especially medication dosing, is warranted.

PKS, APS, BD Supported by Sunovion Pharmaceuticals Inc. http://dx.doi.org/10.1016/j.jaac.2017.09.054

1.41 PEDIATRIC PSEUDOPHEOCHROMOCYTOMA ASSOCIATED WITH CLOZAPINE TREATMENT: TWO CASES IN CHILDHOOD-ONSET SCHIZOPHRENIA PATIENTS Lorie Shora, MS, National Institute of Mental Health, [email protected]; David Driver, MD, National Institute of Mental Health, [email protected]; Judith L. Rapoport, MD, National Institute of Mental Health, [email protected] Objectives: Pseudopheochromocytoma (PPC), a syndrome mimicking pheochromocytoma (PC) without a tumor, is a rare and potentially dangerous side effect of clozapine characterized by paroxysmal

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hypertension. There are nine reported cases of clozapine-induced PPCs in adults. Here we report two cases of patients with childhood-onset schizophrenia (COS) diagnosed with the first pediatric clozapine-induced PPC and describe an effective management strategy (concurrent a and b blockers) for use in patients with PPC who highly benefit from ongoing clozapine treatment. Methods: For 26 years, the NIMH has screened and admitted patients to a longitudinal COS study. In the study cohort (n ¼ 136), clozapine is the most prescribed medication and is both effective and highly maintained after discharge. Patients return to the NIMH every 1-2 years to allow for continued assessment of symptoms, medications, and side effects. Results: Patient A experienced dose-dependent tachycardia and paroxysmal hypertension after clozapine initiation (175 mg) at the NIMH. Because of the syndrome’s rarity, the possibility of PPC was only recognized at a follow-up visit. Outpatient laboratory testing and abdominal imaging ruled out PC and revealed elevated plasma fractionated normatanephrine (259 pg/ml), urine norepinephrine [72 mg iodine/g creatinine (gCR)], and urine normetanephrine (615 mg/gCR). Patient B similarly experienced dose-dependent tachycardia, paroxysmal hypertension, and nausea and vomiting after clozapine initiation (400 mg) at the NIMH. Imaging, including bilateral kidney ultrasound and abdominal ultrasound, and laboratory testing ruled out PC and found elevated levels of plasma norepinephrine (1,675 pg/ml) and fractionated normatanephrine (257 pg/ ml). After PPC diagnosis confirmation, both patients were effectively managed on a and b blockers to allow for ongoing clozapine treatment, which had significant clinical benefit. Conclusions: Although extremely rare, PPC is a side effect of clozapine that can occur in children and adults. PPC does not require clozapine cessation; instead, use of concurrent antihypertensive medication can safely manage symptoms. Clinicians should be aware of this syndrome and consider PPC in diagnostic evaluations of patients taking antipsychotic drugs who present with blood pressure abnormalities or other PPC symptoms.

APS, CVF, NEURO Supported by NIMH Intramural Research Program Grant NCT00049738, ZIA MH002581-25 http://dx.doi.org/10.1016/j.jaac.2017.09.055

1.42 BENEFITS OF VERY LOW DOSE FLUOXETINE IN CHILDREN WITH AUTISM SPECTRUM DISORDERS Judith Ann Crowell, MD, Stony Brook University, Judith. [email protected]; Lauren Spring, MD, Stony Brook University, [email protected]; Zoya Popivker, DO, Stony Brook University, zoya.popivker@ stonybrookmedicine.edu; Paul Mitrani, MD, Stony Brook University, [email protected] Objectives: Literature reviews suggest that SSRIs are not effective in children with autism spectrum disorders (ASDs), with evidence of possible harm. For this reason, and because many of our patients are very young and/or have had multiple side effects with medication trials, we are very cautious in SSRI dosing and often use liquid fluoxetine at initial visit. We present a case series in which low-dose fluoxetine was beneficial for children with ASD. Methods: Fourteen children with ASD had a trial of liquid fluoxetine over the past three years. The SSRI was used to target anxiety, irritability, tantrums, and/or aggression regarding change and transitions, and other rigid/repetitive symptoms. For 11 children, the starting dose was 2 mg daily, and three had started doses of 4 to 5 mg. Diagnosis was made or confirmed by one of the authors. In each case, the child had the diagnosis corroborated by an independent clinician. All children received special education services with an autism classification. Children ranged in weight from 14.97 to 87.09 (BMI 0.6–99.5, IQ ¼ 50–120, X ¼ 97.5) and started with a dose of fluoxetine (2–5 mg, X ¼ 3 mg); final dose (2–15 mg, X ¼ 5.9 mg); and treatment duration to date (4–34 months; X ¼ 12.1 months). Presenting problems, outcomes, and side effects were recorded. Results: Twelve children showed significant decrease in irritability and rigid, repetitive behaviors with doses as low as 2 mg. Ten patients showed signs of improvement within 2-4 days of starting the SSRI. Seven improved socially

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and/or improved interest in others and conversational ability. Two did not tolerate the SSRI (activation), and three showed signs of activation with dose increase. There was no correlation between response and age, gender, weight, or IQ. Conclusions: On the whole, these children responded very well to low dose fluoxetine. There are many reports and trials indicating that fluoxetine can be beneficial in treating ASD symptoms. However, the response to very low dose and rapid onset observed here suggest a mechanism of action differing from the slower onset, higher dose treatment of depression, and anxiety in typically developing individuals. Research is needed to identify people who are very sensitive to medications, including those with ASD and, thus, those who may only benefit with a very low dose.

ADP, ASD, MAE http://dx.doi.org/10.1016/j.jaac.2017.09.056

1.43 PSYCHOTROPIC MEDICATION UTILIZATION IN MEDICAID-ELIGIBLE CHILDREN AGES 0-2 YEARS: LONGITUDINAL VIEW Gail Ann Edelsohn, MD, MSPH, Community Care Behavioral Health Organization, [email protected]; Jaswinder Ghuman, MD, Community Care Behavioral Health and University of Pittsburgh Medical Center, ghumanjk@ upmc.edu; Vicki Martin, MD, MBA, Community Care Behavioral Health Organization, [email protected]; Shari L. Hutchison, MS, Community Care Behavioral Health Organization, [email protected]; Irina Karpov, MS, Community Care Behavioral Health Organization, karpovio@ ccbh.com; Meghna Parthasarathy, MS, Community Care Behavioral Health Organization, [email protected]; Kim Castelnovo, RPH, Community Care Behavioral Health Organization, [email protected] Objectives: There is limited data on the prescribing of psychotropic drugs in preschool-aged children. We investigated psychotropic utilization in a cohort of children aged 0 to 2 years and examined predictors of continued utilization through ages 3 to 5 years. Methods: Medicaid-enrolled children (ages 0–2 years) who were prescribed psychotropic medication in 2010–2013 were examined to determine who continued treatment on the same psychotropic medication versus those who did not continue at ages 3 to 5 years in 2014–2016. Univariate analyses were used to determine the groups, and multivariate regression was used to determine factors that could predict continued psychotropic utilization for youth ages 0 to 2 years. Results: We identified 994 children (ages 0–2 years) who were prescribed a psychotropic drug. Utilization per 1,000 Medicaid-eligible youth (ages 0–2 years) was low (8.7). Common medications used were benzodiazepines (60%), mood stabilizers (24%), and alpha-agonists (20%). At ages 3 to 5 years, 29 percent (n ¼ 292) remained on the same psychotropic medication, and 21 percent of children ages 0 to 2 years were on two or more psychotropic drugs concurrently; 17 percent continued treatment at ages 3 to 5 years. There were no differences in gender, race, or ethnicity for the cohort of children ages 0–2 years and those who remained on psychotropic drugs at ages 3–5 years. The likelihood of remaining on a psychotropic at ages 3 to 5 years is 39 percent lower (P ¼ 0.01) for those without behavioral health services compared with those with inpatient/crisis/partial services and 55 percent lower (P ¼ 0.003) compared with those who receive community-based services. Children with a mental health diagnosis were >1.5 times more likely to remain on psychotropic drugs at ages 3 to 5 years (P ¼ 0.002). Children (ages 3–5 years) newly identified with psychotropic utilization (n ¼ 5,317) had higher rates of ADHD medications than children who continued treatment, and they had similar rates of concurrent utilization (18%). Conclusions: The likelihood of very young children remaining on psychotropic drugs is associated with the presence of behavioral health services and the intensity of such services.

PTA, EC http://dx.doi.org/10.1016/j.jaac.2017.09.057

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1.44 QUANTIFYING MEDICATION ADHERENCE AMONGST CHILDREN AND ADOLESCENTS WITH SEVERE MENTAL ILLNESS: A METAANALYTIC APPROACH Juliet B. Edgcomb, MD, PhD, University of California, Los Angeles, [email protected] Objectives: Nonadherence is a prevalent and costly problem. Knowledge of predictors of child and adolescent adherence to pharmacologic mental health treatment remains fragmented. Multiple recent reviews have attempted to address this topic; however, no meta-analytic or quantitative synthesis of the literature has yet been performed. The goal of this meta-analysis was to evaluate predictors of nonadherence amongst youth with severe mental illness (SMI). Methods: A systematic review and meta-analysis of empirical studies published between 1980 and 2017 was conducted. SMI was operationalized as a diagnosis of primary psychotic disorder, affective disorder (major depressive disorder or bipolar disorder), recent suicide attempt, or psychiatric hospitalization. Studies were retrieved from three electronic databases using Boolean operations and reference list searches. Pooled significance analysis of individual predictors was conducted via Z-transform testing. Where available, effect size estimates were pooled using DerSimonian-Laird random-effects meta-analysis. Results: Of 4,530 studies, 30 were eligible for inclusion, yielding an N of 180,907 patients (49.2% female, mean age ¼ 14.3 years, SD ¼ 1.6). The estimated pooled prevalence of nonadherence in SMI was 40.9 percent. Children and adolescents with greater illness severity [OR 2.48 (95% CI 1.45–4.22)] and comorbid substance abuse [OR 1.77 (95% CI 1.53–2.06)] had a higher prevalence of nonadherence. Insight (P ¼ 0.012), antidepressant use (P ¼ 0.02), positive attitude toward medication (P ¼ 0.009), concurrent psychotherapy (P ¼ 0.048), and positive physician–patient relationship (P ¼ 0.02) were associated with higher levels of adherence. Number of medications (P < 0.0001) and occurrence of side effects (P ¼ 0.046) were associated with nonadherence. Conclusions: This is the first quantitative meta-analytic investigation of predictors of pharmacologic treatment adherence among children and adolescents with SMI. Resultssuggest that the severity of the patients’ disease condition, health beliefs, and comorbid disease can predict their adherence. Findings contribute to greater clinician awareness of the potential for nonadherence and to better treatment advice and mitigation of early medication discontinuation.

EPI, PPC, TREAT http://dx.doi.org/10.1016/j.jaac.2017.09.058

1.45 SHORT- AND LONG-TERM PROLONGED RELEASE MELATONIN TREATMENT FOR SLEEP DISORDERS IN CHILDREN WITH AUTISM SPECTRUM DISORDERS – RESULTS OF A PHASE III RANDOMIZED CLINICAL TRIAL Robert L. Findling, MD, MBA, Kennedy Krieger Institute and Johns Hopkins University, [email protected]; Paul Gringras, MD, Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, Paul.Gringras@gstt. nhs.uk; Tali Nir, MA, Neurim Pharmaceuticals, talin@neurim. com; Nava Zisapel, PhD, Neurim Pharmaceuticals, NavaZ@ neurim.com Objectives: There is a lack of evidence-based pharmacological treatments with regulatory approval for children with sleep difficulties in association with neurodevelopmental disorders. Controlled studies to date have not provided the necessary evidence on long-term efficacy and safety of any such medication. An innovative pediatric-appropriate prolonged-release melatonin formulation (pedPRM), designed to reproduce the endogenous release profile of the hormone at night, was recently developed. The aim of this study was to assess the short- and long-term efficacy and safety of pedPRM vs placebo for sleep disorders in children with autism spectrum disorder (ASD) and other neurodevelopmental disorders.


Methods: This was a phase III multicenter, placebo-controlled study in children aged 2-17.5 years with: 1) a confirmed history of ASD according to either DSM-IV/5 or ICD-10 criteria, or 2) a disabling neurogenetic disorder. Patients also had to have parent reported sleep impairment (more than 3 months of 6 hours of continuous sleep and/or 0.5 hour sleep latency in 3 out of 5 nights). Children (N ¼ 125) who failed to improve on basic sleep hygiene and behavioral intervention and were eligible following a 2-week single-blind placebo run-in were randomized in a 1:1 ratio to receive either pedPRM or placebo (2 mg escalated to 5 mg after 3-week double-blind period, if needed) in a 13-week double-blind treatment period, followed by a 13-week openlabel period on the final dose, with continued efficacy and safety monitoring. The a priori primary outcome measure was total sleep time assessed by caregivers’ Sleep and Nap Diary (SND). Results: Statistically significant and clinically relevant effects of pedPRM vs placebo were observed in total sleep time (p ¼ 0.034) and sleep initiation (p ¼ 0.01). Effects were maintained in the long-term period. PedPRM was well tolerated and no unexpected safety issues were reported. Conclusions: PedPRM was effective and safe for the short- and long-term treatment of sleep disorders in children with ASD and other neurodevelopmental disorders. The formulation was well tolerated in a population who may have significant difficulties in swallowing. PedPRM may provide a safe evidence-based pharmacological intervention for children with ASD who suffer from sleep disorders refractory to sleep behavioral interventions.

SLP, ASD, TREAT Supported by Neurim Pharmaceuticals, Inc. http://dx.doi.org/10.1016/j.jaac.2017.09.059

1.46 THE ROLE OF SECOND GENERATION ANTIPSYCHOTICS ON REHOSPITALIZATION IN CHILDREN AND ADOLESCENTS IN AN INPATIENT UNIT Raunak Khisty, MD, MPH, Wake Forest University School of Medicine, [email protected]; Kateland Branch, MD, Wake Forest University School of Medicine, katie.branch@ gmail.com; Naomi Leslie, MD, Wake Forest University Baptist Medical Center, [email protected] Objectives: The goals of this study are to 1) examine the rate of rehospitalization for children and adolescents (aged 5 at study baseline. Efficacy analyses included change from baseline to week six in Children Depression Rating Scale, Revised (CDRS-R) score (the primary outcome) and Clinical Global Impressions, Bipolar Severity of Depression Score (CGI-BP-S), using mixed model for repeated measures analysis. Results: At baseline, mixed features were present in 54.2 percent of patients (lurasidone, n ¼ 97 of 173; placebo, n ¼ 89 of 170). Treatment with lurasidone (vs. placebo) was associated with significantly greater reductions in CDRS-R scores at week six in the mixed-features group (21.5 vs. 15.9; P < 0.01; effect size ¼ 0.45) and in the group without mixed features (20.4 vs -14.8; P < 0.01; effect size ¼ 0.45). Likewise, lurasidone was associated with greater effect size (vs. placebo) for reductions in CGI-BP-S scores at week six in the mixed features group (1.6 vs. 1.1; P < 0.001; effect size ¼ 0.57) and in the group without mixed features (1.3 vs. 1.0; P ¼ 0.05; effect size ¼ 0.30). Rates of protocol-defined treatment-emergent hypomania or mania were similar for lurasidone and placebo in patients with mixed features (lurasidone 8.2% vs. placebo 9.0%) and without mixed features (lurasidone 1.3% vs. placebo 3.7%). Conclusions: Lurasidone was found in this post hoc analysis to be efficacious in the treatment of child and adolescent patients with bipolar disorder who presented with mixed features (assessed cross-sectionally at study baseline).


There was no increased risk of treatment-emergent mania observed in patients with or without mixed features.

ADOL, BD, DDD Supported by Sunovion Pharmaceuticals Inc. http://dx.doi.org/10.1016/j.jaac.2017.09.064

1.51 PREVALENCE, ASSESSMENT, AND MANAGEMENT OF PSYCHOTROPIC DRUGINDUCED MOVEMENT DISORDER IN A PEDIATRIC POPULATION Muhammad Puri, MD, Institute of Living at Hartford Hospital, [email protected]; Shabber Abbas, Bergen Regiona Medical Center, [email protected]; Charles Caley, Institute of Living at Hartford Hospital, [email protected]; Salma Malik, MD, DFAACAP, MS, Institute of Living at Hartford Hospital, [email protected] Objectives: The study of drug-induced extrapyramidal symptoms (EPS) in the pediatric population is an area of growing interest and concern given the frequency of use in psychiatry. This study was conducted to describe published cases and to identify risk factors for the purposes of making management recommendations. Methods: A PubMed search from the past 10 years was conducted to identify pediatric case studies reporting involuntary EPS following use of psychotropic medication. Identified cases were further evaluated on the basis of standard demographic characteristics, acute versus chronic onset movement disorder type, psychiatric diagnosis, and type of psychotropic drug used. All cases were also rated with an adverse drug reaction probability scale. Results: A total of 49 cases were identified. Patients had a mean age of (13.12 4.36 years) and were predominantly male (72%). Various offending psychotropic drugs were identified including second-generation anti-psychotics, antidepressants, and psychostimulants. Second-generation anti-psychotics were most commonly implicated (35 patients; 71.4%) and among them risperidone was most frequently implicated and quetiapine the least. Dystonia was reported in 44 patients and tardive dyskinesia in one patient. Mean of Naranjo scale scores was 5.58 2.00 (range ¼ 1-11). Dystonia occurred early and late in roughly equal number of patients. In one case, tardive dyskinesia was reported after discontinuation of risperidone. In most cases, the discontinuation of the offending agent and use of an anticholinergic were sufficient to treat symptoms effectively. In few cases, dystonia reoccurred after restarting the medication. Conclusions: Psychotropic medications do increase the vulnerability of the pediatric population to involuntary movement disorders. In particular, secondgeneration anti-psychotics, SSRIs, and stimulants should be prescribed with caution and should be closely monitored for symptom development. Development of treatment guidelines may help clinicians devise safer management strategies. Further research is needed to elaborate on the risks versus benefits of prescribing these drugs for psychiatric disorders in children.

ADP, APS, PPC http://dx.doi.org/10.1016/j.jaac.2017.09.065

1.52 A PHASE II STUDY TO DETERMINE THE EFFICACY, SAFETY, TOLERABILITY, AND PHARMACOKINETICS OF A CONTROLLED RELEASE (CR) FORMULATION OF MAZINDOL IN ADULTS WITH ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) Tim Wigal, PhD, AVIDA Inc., [email protected]; Jeffrey Newcorn, MD, Icahn School of Medicine at Mount Sinai, [email protected]; Nelson Handel, MD, Dothan Behavioral Medicine Clinic, Harmonex Neuroscience Research, [email protected]; Sharon B. Wigal, PhD, AVIDA Inc., [email protected]; Ioulietta Mulligan, PhD, Worldwide Clinical Trials, [email protected];

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Virginia Schmith, PhD, Nuventra Pharma Sciences, gschmith@ nuventra.com; Eric Konofal, MD, PhD, Hopital Robert Debr e, [email protected]

Pharmaceuticals & Development, Inc., bev@ ironshorepharma.com; Jeffrey Newcorn, MD, Icahn School of Medicine at Mount Sinai, [email protected]

Objectives: Mazindol, an investigational agent, was originally developed as an appetite suppressant in 1973, but was withdrawn from United States and European markets by 2002 for reasons unrelated to efficacy or safety. Mazindol controlled release (CR) is a new formulation with a lower Cmax than the immediate release (IR) tablet and an equivalent area under the curve (AUC). The primary objective of this study was to evaluate the efficacy of mazindol CR in adult patients with ADHD. Additionally, the safety, tolerability and pharmacokinetics were assessed. Methods: This was a randomized, double-blind, placebo-controlled, flexible dose trial of mazindol CR versus placebo (1:1) for six weeks in 85 participants with ADHD. The mazindol CR dose was titrated (1 mg daily x 7 days, then 2 mg daily x 7 days, then 3 mg daily x 7 days) based on clinical response and tolerability. Most participants reached a dose of 3 mg by end of study although dose reductions were allowed due to lack of tolerability. Participants remained on a fixed dose for the final four weeks of the study, with dose reductions allowed due to lack of tolerability. The primary endpoint was the reduction in ADHD-Rating Scale-DSM-5 (ADHD-RS-5) total score at the end of treatment (day 42). Secondary endpoints were responders as measured by ADHD-RS-5 (30% and 50% reduction) and by the Clinical Global Impression – Global Improvement (CGI-I) score (1 or 2). Safety and tolerability were assessed through adverse event reporting (AEs), vital signs, physical examination, laboratory parameters, and assessment of suicide risk on the Columbia-Suicide Severity Rating Scale (C-SSRS). Results: Participants (N ¼ 85) were randomized (n ¼ 43 mazindol CR, 42 Placebo); 75 participants completed. Using a repeated-measures mixed-effect model, mazindol CRwas different from placebo for each of the six weekly measurement beginning at day seven (p < 0.005), with a least squares mean (LS) difference (mazindol CR-placebo) of -13.2 (p < 0.001) at day 42 (intent-totreat population). There were substantially more responders defined by ADHD-RS-5 (30% and 50% reduction) and by CGI-I (1 or 2) for mazindol CR than for placebo (p < 0.001). AEs were reported in 31 and 21 participants from the mazindol CR and placebo group, respectively. The primary AEs were dry mouth (23% vs 4.8%), decreased appetite (9.3% vs 7.1%), and increased heart rate or tachycardia (16% vs 0%). No serious AEs were reported. The one discontinuation due to AEs was a placebo participant. Mazindol CR had a moderate effect on heart rate and a small effect on blood pressure. Conclusions: This study demonstrated that mazindol CR was efficacious in the treatment of adults with ADHD, with an effect size of 1.09, was well-tolerated, with no discontinuations in the mazindol CR group related to treatment, and that progression to phase three studies is warranted.

Objectives: The efficacy and safety of DR/ER-MPH, a delayed-release and extended-release methylphenidate, were evaluated in a phase 3 trial of children with ADHD. In addition to improving ADHD symptoms, DR/ER-MPH demonstrated statistically significant reductions in at-home functional impairment versus placebo (PBO); however, it is unknown if these improvements are clinically relevant. This post hoc analysis evaluated the clinical meaningfulness of DR/ER-MPH versus PBO in improving at-home functional impairment. Methods: Data were analyzed from a randomized, double-blind, multicenter, PBO-controlled, phase three trial of HLD200 in children (aged 6-12 years) with ADHD (NCT02520388). At-home early morning functional impairment was assessed by the Before School Functioning Questionnaire (BSFQ) and Parent Rating of Evening and Morning Behaviors-Revised (PREMB-R) morning (AM) subscale. At-home late afternoon/evening functional impairment was assessed by the PREMB-R evening (PM) subscale. Clinically meaningful improvements were defined using anchor-based estimates with Clinical Global Impression-Improvement (CGI-I) scores of 1 (very much improved) and 2 (much improved) as anchors. Cumulative percentages of children with changes from baseline in BSFQ, PREMB-R AM, and PREMB-R PM anchored to CGI-I were assessed. Results: Using CGI-I scores of 1 and 2 as anchors, reductions in BSFQ of 27 and 20, PREMB-R AM of five and three, and PREMB-R PM of nine and five were defined as clinically meaningful. After three weeks of treatment, a higher proportion of children treated with DR/ER-MPH versus PBO demonstrated a “much or very much improved” (CGI-I 2) change from baseline in BSFQ (65.4% vs 43.3%; P ¼ 0.012), PREMB-R AM (73.4% vs 41.3%; P < 0.001), and PREMB-R PM (64.6% vs 42.7%; P ¼ 0.01). Similarly, a higher proportion of children treated with DR/ER-MPH versus PBO demonstrated “very much improved” (CGI-I ¼ 1) change from baseline in BSFQ (51.3% vs 23.9%; P ¼ 0.001), PREMB-R AM (45.6% vs 24.0%; P ¼ 0.008), and PREMB-R PM (46.8% vs 24.0%; P ¼ 0.005). Conclusions: Clinically meaningful and statistically significant improvements in at-home functional impairment from the early morning until evening were achieved as shown by multiple validated rating scales in children with ADHD treated with DR/ER-MPH for three weeks.

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PPC, ADHD, TREAT Supported by NLS Pharma http://dx.doi.org/10.1016/j.jaac.2017.09.066

1.53 CLINICALLY MEANINGFUL IMPROVEMENTS WITH DR/ER-MPH IN AT-HOME FUNCTIONAL IMPAIRMENT DURING THE EARLY MORNING, LATE AFTERNOON, AND EVENING IN CHILDREN WITH ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) Timothy E. Wilens, MD, Massachusetts General Hospital, [email protected]; Stephen V. Faraone, PhD, SUNY Upstate Medical University, sfaraone@childpsychresearch. org; Paul Hammerness, MD, Boston Children’s Hospital, paul. [email protected]; Steven R. Pliszka, MD, University of Texas Health Science Center at San Antonio, [email protected]; Norberto J. DeSousa, MA, Ironshore Pharmaceuticals & Development, Inc., bert@ ironshorepharma.com; F. Randy Sallee, MD, PhD, Ironshore Pharmaceuticals & Development, Inc., randy@ ironshorepharma.com; Bev Incledon, PhD, Ironshore

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ADHD, SAC, STIM Study was funded by Ironshore Pharmaceuticals & Development, Inc. http://dx.doi.org/10.1016/j.jaac.2017.09.067

1.54 IMPACT OF MILIEU ON RESTRAINT FREQUENCY ON A CHILDREN’S INPATIENT UNIT Jaclyn D. Chua, DO, Stony Brook University, jaclyn.chua@ stonybrookmedicine.edu; Katherine Pan, MD, Stony Brook University University Hospital, [email protected]; Tahsin N. Hasan, MD, Stony Brook University University Hospital, tahs. [email protected]; Chetan Chauhan, MD, Stony Brook University University Hospital, chetan.chauhan@ stonybrookmedicine.edu; Jisoo Kim, DO, Stony Brook University University Hospital, jisoo.kim@ stonybrookmedicine.edu; Peng Pang, MD, Staten Island Medical Center, [email protected]; David M. Margulies, MD, SUNY at Stony Brook, David.Margulies@ stonybrook.edu; Gabrielle A. Carlson, MD, SUNY at Stony Brook, [email protected] Objectives: Approximately half of psychiatrically hospitalized youth display aggressive behaviors. Restraints may be required to ensure the safety of the youth and staff. However, the association of restraints with negative psychological and physical outcomes warrants the least restrictive methods in the treatment of agitation. Although there are a few studies of predictors of restraint use, there are almost no data on the impact of unit milieu on restraints. The goal of this poster is to use a

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natural experiment of milieu change to study restraint frequency on a children’s inpatient unit. Methods: With institutional review board approval, 503 psychiatrically hospitalized children (ages 5–12 years) from four cohorts were studied. The first two cohorts were when the unit had a full-time attending; the third and fourth cohorts represented major milieu changes. The third cohort had no fixed leader, 50 percent of attending time, and weakening of the behavior modification program. The final cohort saw complete discontinuation of the behavior program in the service of following policy changes toward using verbal de-escalation instead of behavior modification. Numbers of children needing restraint (seclusion and physical restraint) and number of restraints needed, controlling for length of stay (LOS), and five of the following predictors were examined: age, gender, admission for outbursts, percent of attending time, and loss of behavior modification program. Chi-square, MannWhitney U, and t-tests were used for data analysis. Results: Children had a mean age of 9.7 years (SD ¼ 2.1; 75% male); 61 percent were admitted for severe outbursts, median LOS was 16 days, 18.5 percent had any restraint, and 80 percent had ADHD and ODD. Age, gender, and admission for outbursts were associated with more children needing restraints. The latter doubled [15.6–28%, P ¼ 0.005; OR 2.098 (95% CI 1.240, 3.548)], with the loss of the behavior program. The biggest predictor of actual number of restraints needed was the decrease in attending time when restraint number doubled from 100 to 199 restraints per 1,000 patient days. Conclusions: Good leadership, positive reinforcement, and predictable consequences are important components for appropriate treatment of explosive children. Although verbal de-escalation is effective in some populations, in young children with predominantly ADHD and ODD, increased attention to agitated behavior only served to increase it.

Methods: The study sample group consisted of 95 youth (ages 8–17 years; mean SD, 13.9 2.5 years) hospitalized consecutively during a 12-month period. During a standardized interview with a caregiver, aggressive behaviors were assessed using the modified overt aggression scale (MOAS). The 16-item MOAS measures verbal or physical aggression, with violence defined as a score 3 in any of the subscales. EE was measured using the Five-Minute Speech Sample (FMSS), subsequently coded utilizing the EE- and FMSScoding systems. MOAS scores were compared with EE ratings and sociodemographic and clinical variables using independent sample t-tests, regression analyses, and Chi-square tests. Results: Youth (90.5%) hospitalized for an acute exacerbation of a primary disruptive mood dysregulation disorder, psychotic disorder, or posttraumatic stress disorder displayed aggressive behaviors preceding their admission. Of these youth, 37.8 percent displayed verbal violence, 24.2 percent physical violence, and 30.5 percent had property destruction scores of 3. Aggressive behaviors (MOAS 1) were associated with older age (P ¼ 0.03). Caregivers classified with increased overall (P ¼ 0.02) or critical (P ¼ 0.02) EE were more likely to report that their child or adolescent was aggressive. Inpatients displaying higher scores on the verbal, physical, and property aggression MOAS subscales were also more likely to have caretakers with high rather than low EE (P < 0.05). Conclusions: These results suggest that aggression is displayed by more than 90 percent of children hospitalized for mental illness. Moreover, the aggressive behavior conveys a substantial emotional burden on the primary caregiver, as measured by elevated EE. Further research should evaluate the role of EE reduction in clinical outcomes.

AGG, FAM, ICP Supported by a 2015 APA Resident Research Psychiatric Scholars Fellowship http://dx.doi.org/10.1016/j.jaac.2017.09.069

AGG, ICP http://dx.doi.org/10.1016/j.jaac.2017.09.068

1.55 STRESSORS AND AGGRESSORS: VIOLENT AGGRESSION OFTEN PRECEDES INPATIENT ADMISSION AND EXACERBATES CAREGIVER STRESS Isha R. Jalnapurkar, MD, University of Texas Health Science Center at Houston, [email protected]; Pratikkumar Desai, MD, MPH, University of Texas Health Science Center at Houston, [email protected]. edu; Anastasia M. Pemberton, MD, University of Texas Health Science Center at Houston, [email protected]. edu; Serena Mammen, University of Texas Health Science Center at Houston, [email protected]; Mary Clare Bruce, BA, The Harris Center for Mental Health and IDD, [email protected]; Zachary J. Sullivan, DO, University of Texas Health Science Center at Houson, zachary. [email protected]; Dana W. Hipp, MD, University of Texas Health Science Center at Houston, Dana.W.Hipp@uth. tmc.edu; Alexandra N. Duran, University of Texas Health Science Center at Houston, [email protected]; Iram Kazimi, MD, University of Texas Health Science Center at Houston, [email protected]; Cristian Zeni, MD, PhD, University of Texas Health Science Center at Houston, [email protected]; Teresa Pigott, MD, University of Texas Health Science Center at Houston, teresa.a.pigott@ uth.tmc.edu Objectives: Youth with severe mental illness have higher rates of aggression. Aggressive and violent outbursts in the home can lead to physical and/or emotional injury to self/others, often leading to hospitalization. Elevated family stress as measured by expressed emotion (EE) in primary caregivers has been linked to increased relapse in patients with mental illness, but the relationship with aggression is poorly studied. Thus, the current study examined the prevalence of recent aggressive behavior in pediatric inpatients and its potential association with EE and other demographic and clinical variables.


1.56 SEE SPOT HELP: EFFECTS OF A DOG VISITATION PROGRAM ON MEDICATION USAGE AND BEHAVIOR AMONG PEDIATRIC PSYCHIATRIC INPATIENTS Trixie Lipke, MD, University of Chicago Medical Center, [email protected]; Kristen C. Jacobson, PhD, University of Chicago, [email protected]; Peter Nierman, MD, Lakeshore Hospitalu, pnierman@yoda. bsd.uchicago.ed; Karam Radwan, MD, University of Chicago Medical Center, [email protected] Objectives: Despite the popularity of animal visitation, few studies have examined its effects in psychiatric hospitals. This study evaluated the effects of a new pet therapy visitation program on outcomes. We anticipated that children would require less medication, engage in more programming, and be calmer on days of dog visits. Methods: A community hospital had recently established a dog visitation program, and we offered to provide a quality improvement project to monitor the potential effects of this intervention. We obtained institutional board review approval and consent to conduct a retrospective chart review of all children (ages 4–12 years) who were hospitalized between October 1, 2015 and September 30, 2016. We analyzed 55 charts, with 53 unique children represented in three months looking at frequency of emergency medication and restraint usage, as well as morning (AM)- and evening (PM)-coded behaviors, blood pressure, and heart rate. Coded behaviors were categorized as good, disruptive, or aggressive; the count in each category was the score. Good behavior (up to 2) was quantified as child being observed as calm and/or redirectable. Disruptive behavior (up to 9) and aggressive behavior (up to 5) were also charted by nursing and included behaviors such as follows: verbal threats, hitting staff, and hitting other children. Results: We found a day of the week effect, with Monday morning being the worst day for good behavior, with a large and statistically significant result [F(1,149) ¼ 15.62, P < 0.001]. Monday mornings had a large effect size for aggression [F(306,6.35), P < 0.0001] and was statistically the most aggressive day of the week. Tuesdays (day of dog visit) were not associated with the best behavior and, in fact, were statistically worse than Wednesday (P ¼ 0.056), the best day of the week. There was a large interaction between time of day and day of week [F(6,1496) ¼ 2.41, P ¼ 0.03], with behavior improving on Tuesday afternoons (after dog visit) and also on Monday afternoons.

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Conclusions: We found no evidence for a positive effect of the dog visitation program on Tuesday. This was not attributed to a lack of statistical power (>200 data points/child/day of week). Study design was limited by the frequency of dog visits. Monday mornings were statistically the most aggressive, disruptive, and least positive day of the week for children who were hospitalized psychiatrically.

EBP, RCR, CAM http://dx.doi.org/10.1016/j.jaac.2017.09.070

1.57 PREDICTING THE RISK OF REHOSPITALIZATION TO A CHILD AND ADOLESCENT PSYCHIATRY UNIT: EFFECTS OF AN INITIAL LENGTH OF STAY Matej Markota, MD, Mayo Clinic, [email protected]; Alastair McKean, MD, Mayo Clinic, mckean.alastair@mayo. edu; Magdalena Romanowicz, MD, Mayo Clinic, romanowicz. [email protected]; Jennifer L. Vande Voort, MD, Mayo Clinic, [email protected] Objectives: Length of hospitalization on child and adolescent psychiatry units has markedly shortened over the past decades. Hospitalizations that are too short may inadequately address the complex needs of patients of child and adolescent psychiatry, whereas prolonged stays may cause increased stress at the time of reintegrating with community and school. Little is known about the optimal length of stay in this population. The main goal of this study was to investigate the association between the length of an initial psychiatric hospitalization and risk of rehospitalizations in the first year postdischarge (PD). Methods: We conducted a retrospective analysis of subjects between the ages of 11 and 18 years (71% female) who were admitted to the child and adolescent psychiatry unit at Mayo Clinic in Rochester, MN, during the study period between January 1, 2015 and December 31, 2015. We excluded all patients who were previously admitted to our unit between January 1, 2014 and December 31, 2014, as well as patients with diagnoses of eating disorders, schizophrenia and other forms of psychoses, bipolar disorder, and reactive attachment disorder. Our cohort consisted of 523 individual patients, of which 109 were readmitted within 365 days. Logistic regression was used to quantify the relationship between length of the initial hospitalization and the number of all rehospitalization days in a period of one year PD. Rehospitalization was analyzed separately for the following periods: 0–30 days PD, 30–90 days PD, 90–365 days PD, and 0–365 days PD. Resultswere adjusted for the effects of Patient Health Questionnaire (PHQ)-9 scores at the time of the initial admission, age, and gender. Results: The average length of first hospitalization was 6.5 days (SD 3.1). There was no significant association between the length of stay and rehospitalization at 0–30 days PD. Risk of rehospitalization was positively associated with longer durations of the initial hospitalization at 30–90 days PD (P ¼ 0.002). There was no significant association between initial length of stay and rehospitalization at 90–365 days PD. Conclusions: Our findings suggest that longer hospitalizations are associated with increased risk of rehospitalization at 30–90 days PD, but not between 0– 30 and 90–365 days PD. Further work will aim to better explain the positive association between length of first hospitalization and rehospitalizations during the PD period of 30–90 days.

RCR, TREAT http://dx.doi.org/10.1016/j.jaac.2017.09.071

1.58 PREDICTORS OF SECLUSION AND RESTRAINTS IN AN INPATIENT PEDIATRIC PSYCHIATRIC HOSPITAL: A RETROSPECTIVE CHART REVIEW Marwa Badawy, MD, University of Missouri, badawym@health. missouri.edu; Neetu Nair, University of Missouri, nnq35@mail. missouri.edu; Christopher Sinkler, BS, University of Missouri, [email protected]; Garima Singh, MD, University

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of Missouri, [email protected]; Ravi Shankar, MD, University of Missouri, [email protected] Objectives: Seclusion and restraints (S&R) in child psychiatric hospitals is used for imminent risk of harm. The aim of this study is to determine risk factors in S&R. Early identification and treatment planning may improve outcomes. Methods: A questionnaire created to assess risk factors for S&R was used to review inpatient charts from 2012 to 2013. Time, type, reason, and S&R duration were gathered. A total of 18 factors were identified as risk factors for predicting number and S&R duration. Significant risk factors from Chi-square tests were included in multivariate regression models. SPSS statistical program, version 24.0 (IBM Corporation), was used for analysis. Results: Chi-square test between risk factors and number of S&R revealed strong association for physical abuse lX 2 (9) ¼ 17.229, P < 0.05] and conduct disorder [X2 (9) ¼ 18.358, P < 0.05]. Intellectual disability (ID) [X2 (9) ¼ 14.747, P < 0.1] and autism spectrum disorder (ASD) [X2 (9) ¼ 14.747, P < 0.1] showed association trending toward significance with number of S&R. There was strong correlation between ASD and ID (r ¼ 0.524, P ¼ 0.000). Multiple regression model with these factors did not reach significance [R2 (adj) ¼ 0.013, P > 1]. Risk factors were tested for influence on S&R duration. Chi-square test revealed strong association between S&R duration and ID [X2 (2) ¼ 9.314, P ¼ 0.009]; nonsuicidal self-harm [X2 (2) ¼ 7.690, P ¼ 0.021]; ADHD [X2 (2) ¼ 12.530, P ¼ 0.002]; ASD [X 2 (2) ¼ 9.314, P ¼ 0.009]; and trends for age on admission and ODD. Resulting multiple regression model was significant for predicting S&R duration [R2 (adj) ¼ 0.257, F(6,48) ¼ 4.109, P ¼ 0.002]. Nonsuicidal self-harm and ADHD were significantly predictive of S&R duration, whereas other factors were insignificant in the model [R2 (adj) ¼ 0.3, F(2,52) ¼ 12.574, P ¼ 0.000]. Chisquare analysis showed strong statistical significance between S&R duration and manual holds [X2 (2) ¼ 6.624, P < 0.05], locked seclusions [X2 (2) ¼ 24.058, P < 0.001], and mechanical restraints [X2 (2) ¼ 34.869, P < 0.001]. Conclusions: Study indicated strong statistically significant association between number of S&R and physical abuse and conduct disorder. Nonsuicidal self-harm and ADHD were strongly predictive of S&R duration. Duration of S&R also showed a strong association with the types of S&R. More research is necessary in this area.

ICP, RCR, RF http://dx.doi.org/10.1016/j.jaac.2017.09.072

1.59 EXPLORING RISK FACTORS OF RECIDIVISM AMONG CHILDREN AND ADOLESCENTS IN AN INPATIENT PSYCHIATRIC HOSPITAL Sadiq Naveed, MD, KVC Health Systems, [email protected]; Ahmed Waqas, MD, KVC Hospitals, ahmedwaqas1990@ hotmail.com; Kapil Aedma, MD, KVC Hospitals, kaedma@kvc. org; Muhammad H. Sheikh, MBBS, KVC Hospitals, [email protected]; Dhrumil Patel, MD, KVC Health Systems, [email protected]; Vishal Adma, MD, KVC Hospitals, [email protected] Objectives: In recent decades, some research has been published elucidating the factors associated with risk of readmissions and length of stay among adult patients with mental health disorders. Rapid readmissions put a preventable strain on limited resources that are allocated to mental health institutions. There is a paucity of data studying these factors in inpatient child psychiatric settings in Kansas, hence, warranting this study. Methods: We retrospectively reviewed the data of a cohort of patients admitted in July to December 2016 at a community hospital in Kansas City, Kansas. Before initiating the study, all data were deidentified by removing all identifying parameters of patients to ensure anonymity. Data related to age, gender, household income, the number of readmissions, the length of stay, psychiatric diagnoses, number of medical diagnoses, suicidal attempts, suicidal ideations, addictive behaviors, delinquent behavior, stability index, family history, and social history were obtained. All data were analyzed in SPSS, version 21. Pearson correlations and linear regression analysis were run

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to identify the predictors of early readmission among patients after adjusting for their age and gender. P value < 0.05 was considered significant. Results: There were a total of 1,585 patients, including 876 (55.3%) males and 709 (44.7%) females. Mean age at admission was 14.20 years (6.71), mean length of stay was 7.46 (12.29) days, and mean number of days taken to readmission was 138.05 (209.20). Length of stay was significantly associated with more days taken for readmission (r ¼ 0.10), higher number of episodes (r ¼ 0.18), fire setting (r ¼ 0.10), self-harm (r ¼ 0.10), manic episode (r ¼ 0.10), property destruction (r ¼ 0.10), suicidal ideation (r ¼ 0.10), addictive behaviors (r ¼ –0.10), mentally ill mother (r ¼ 0.10), higher number of medical diagnoses (r ¼ 0.50), psychiatric diagnoses (r ¼ 0.10), and higher number of safety holds (r ¼ 0.60). The number of days to readmit was significantly associated with animal cruelty (r ¼ 0.22), suicidal ideation (r ¼ 0.11), and highrisk behavior (r ¼ 0.10). Conclusions: Length of stay and increasing risk of readmission are significantly associated with several modifiable factors. These factors can be modified by designing effective policies and, hence, reduce health costs.

RCR, RF http://dx.doi.org/10.1016/j.jaac.2017.09.073

1.60 IMPACT OF MILIEU ON PRO RE NATA (PRN) MEDICATION USE IN A CHILDREN’S INPATIENT UNIT Katherine Pan, MD, Stony Brook University Hospital, kpan87@ gmail.com; Tahsin N. Hasan, MD, Stony Brook University Hospital, [email protected]; Jaclyn D. Chua, DO, Stony brook University University Hospital, jaclyn.chua@ stonybrookmedicine.edu; Jisoo Kim, DO, Stony Brook University Hospital, [email protected]; Chetan Chauhan, MD, Stony brook University University Hospital, [email protected]; David M. Margulies, MD, SUNY at Stony Brook, David.Margulies@ stonybrook.edu; Peng Pang, MD, Staten Island Medical Center, [email protected]; Gabrielle A. Carlson, MD, SUNY at Stony Brook, [email protected] Objectives: Minimizing PRN medication use is a goal of treating children in confined settings. Although there are a few studies of predictors on PRN use, there are no data on the impact of unit milieu on frequency of PRN use. The goal of this poster, and its companion on restraints, is to use a natural experiment of milieu change to study rates of PRN use on a children’s inpatient unit. Methods: With approval from the institutional review board, 503 psychiatrically hospitalized children (ages 5–12) from four cohorts were studied. The first two cohorts were when the unit had a full-time attending physician; the third and fourth represented major milieu changes. The third cohort had no fixed leader, 50 percent attending time, and weakening of the behavior modification program. The final cohort saw complete discontinuation of the behavior program in the service of following policy changes toward use of verbal de-escalation instead of behavior modification. Rates and type of PRN use controlling for length of stay and five predictors were examined: 1) age; 2) gender; 3) admission for outbursts; 4) percent of attending time; and 5) loss of behavior modification program. Chi-square/odds ratio, Mann–Whitney U and t-tests were used for data analysis. Results: Children [mean age ¼ 9.7 years (2.1); 75% male] were admitted for severe outbursts; median length of stay was 16 days, and 56.7 percent had any PRNs. Eighty percent of children had ADHD and ODD. Number of children needing PRNs increased from 48.3 to 69.3 percent (P ¼ 0.000) when attending time decreased to 50 percent and the number of PRNs they received increased from a median of 112 of 1,000 patient days to 315 of 1,000 patient days (P ¼ 0.000). Without a behavior modification program, PRNs increased from 52.0 to 78.7 percent, and PRN use increased from a median of 143 to 532 patient days (P < 0.000 for both). PRN diphenhydramine use increased sixfold (P ¼ 0.000); neuroleptic use did not. Young age (9.5 2 vs. 10.1 2, P < 0.005) but not gender or admission for outbursts was associated with more PRN use.


Conclusions: Decreased physician oversight and loss of the behavior program increased PRN use. Verbal de-escalation procedures inadvertently appeared to positively reinforce the need for PRN medications. Changes in electronic medical record prompts to use diphenhydramine as the first PRN choice probably accounted for its preferential increase.

AGG, APS, ICP http://dx.doi.org/10.1016/j.jaac.2017.09.074

1.61 CHILD AND ADOLESCENT INPATIENT TREATMENT USING TELEPSYCHIATRY: A STUDY OF QUALITY METRICS David Rubin, MD, Massachusetts General Hospital and McLean Hospital, [email protected]; Mahdieh Bodaghi, MD, Acadia Hospital, mbodaghi@emhs. org; Mark Allen, MD, Acadia Hospital, [email protected]; Jason Shorey, Acadia Hospital, [email protected]; Tim Stormann, MBA, Acadia Hospital, [email protected]; Brent Scobie, PhD, Acadia Hospital, [email protected]; Robert R. Althoff, MD, PhD, Larner College of Medicine at the University of Vermont, [email protected]; Anthony T. Ng, MD, Acadia Hospital, [email protected] Objectives: There has been an increase in the use of telepsychiatry to provide care for rural communities. This has mostly been examined in adult populations and almost exclusively in the outpatient setting, with scant literature on inpatient child and adolescent telepsychiatric care and none on the level of quality care provided. The present study was conducted to examine quality metrics when inpatient child and adolescent psychiatric care is provided by the same mental health provider either face-to-face or via telepsychiatry. Methods: Quality metrics of total length of stay and number of restraint/ seclusion episodes was examined for 126 patients admitted to an inpatient child and adolescent psychiatry unit in rural Maine. Assessment and treatment were provided on one of three units by the same child and adolescent psychiatrist. Approximately half of the cases (47%) were seen face to face, and half (53%) were assessed and treated remotely over telepsychiatric connection. Total length of stay (days, square root transformed to reduce skew) was placed as the dependent variable into a linear regression, and number of restraint/ seclusion episodes (count) was placed as a dependent variable into a Poisson regression with type of treatment (face to face or telepsychiatric) and unit as independent fixed-effects predictors in SPSS statistical program. Results: Although numerically there was a slightly longer length of stay in the telepsychiatry group (14.84 days) compared with the face-to-face group (14.24 days), this was not statistically significant (b ¼ 0.962, P ¼ 0.509), despite adequate power to detect medium effect sizes. Restraint/seclusion episodes were numerically higher in the telepsychiatry group (1.63 per admission) than in the face-to-face group (0.86 per admission), and this was significantly different (b ¼ 1.291, P < 0.001). Conclusions: These data suggest that delivery of rural inpatient child and adolescent psychiatric care using telepsychiatry technology does not increase the length of stay. However, the number of restraint/seclusion episodes may be higher in inpatients where care is delivered via telepsychiatry, although this may be accounted for by a disproportionate number of restraints in a few individuals admitted during the telepsychiatry period. More research with larger sample groups is necessary to understand this burgeoning field.

QA, ICP, TVM http://dx.doi.org/10.1016/j.jaac.2017.09.075

1.62 WHAT’S THE ALTERNATIVE WHEN A CHILD AND ADOLESCENT INPATIENT PSYCHIATRIC UNIT IS NOT AVAILABLE? Maira Aguiar Werneck, MD, ABC Medical School, maira_ [email protected]; Leonardo Peroni De Jesus, MD, ABC Medical School, [email protected]; Cintia de Azevedo Marques P erico, PhD, ABC Medical School, [email protected]

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Objectives: The main objective of this study is to assess the prevalence of child and adolescent admission to a general inpatient psychiatric unit and this group profile. The secondary objective is to describe the role of this hospital internment. Methods: A retrospective medical chart review was conducted at a general inpatient psychiatric unit on Mario Covas State Hospital from July 31, 2008 to July 30, 2016. During this period, subjects under age 18 years on the day of their admission were selected. The sample data were obtained from the hospital electronic medical record database, and the variables were assessed (age, gender, religion, race, hospital internment type, and diagnosis). A descriptive analysis of the data was conducted. Results: Among the 2,662 admissions during this eight-year period, 193 patients (7.25%) were between ages 11 and 17 years. Males represented 66 percent of the sample group, and 18 percent were younger than age 15 years. Psychotic episode required 48 percent (n ¼ 92) of hospitalizations, and 51 percent (n ¼ 99) had SUD as the primary diagnosis or comorbidity. Catholic and Caucasian were the most prevalent religion and race, 38 and 55 percent, respectively. Only 24 admissions were voluntary. Thirty-one patients of 153 (20%) required at least another admission before they were age 18 years. No serious incidents due to the coexistence of adults and adolescents in the same environment were reported. Conclusions: We found an unexpected high rate of child and adolescent hospitalizations and readmissions in this unit, with half of admissions related to a psychotic episode. Our findings suggest that this population requires a specific multidisciplinary inpatient and outpatient intervention. However, further research is needed to identify risk factors and establish the safety of this admission for children and adolescents.

ICP, RCR, EPI http://dx.doi.org/10.1016/j.jaac.2017.09.076

1.63 DELAY DISCOUNTING PREDICTS INPATIENT CHILD AND ADOLESCENT PSYCHIATRY READMISSION Jeffrey Wilson, MD, Virginia Tech Carilion School of Medicine, [email protected]; Richard D. Ha, DO, Virginia Tech Carilion Clinic, [email protected]; Tahnee Wong-Okafor, MD, Virginia Tech Carilion Clinic, [email protected]; Petronella Mbu, MD, Carilion Clinic, [email protected]; Kevin K. Lee, MA, Virginia Tech School of Medicine, [email protected]; Chudi Okafor, MD, Virginia Tech Carilion Clinic, [email protected]; Vandana L. Kumar, BS, Virginia Tech Carilion School of Medicine, [email protected]; Lisa M. Dishner, RN, Carilion Clinic, LMDISHNER@ carilionclinic.org; Brooke M. Burns, DO, Virginia Tech Carilion Clinic, [email protected]; Emma L. Beneke, MSW, Carilion Clinic, [email protected]; Warren K. Bickel, PhD, Virginia Tech Carilion Research Institute, [email protected] Objectives: Delay discounting (DD) is a quantifiable neurobehavioral process with substantial support in addiction treatment of adolescents and adults. Little is known about DD in adolescent inpatient psychiatric hospitalization. The objective of this pilot study is to assess the feasibility of a larger prospective study of DD as a predictor of readmission rates and high-risk behaviors following discharge from adolescent inpatient psychiatric hospitalization. Methods: Following institutional review board-approved assent and consent procedures, 30 adolescent boys and girls (ages 11–17.6 years) admitted voluntarily to the adolescent inpatient psychiatry unit were included. A brief measure of DD was used to determine whether DD predicts readmission up to one year after discharge. During admission, adolescents and parents/guardians completed four variations of a five-trial DD task, the Achenbach Youth Self-Report (YSR), or Child Behavior Checklist (CBCL), the 12-item Grit scale of resilience, and two questions regarding perceived parent economic

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pressures. Additional data collected from adolescents during admission included the following: 1) readmission rates; 2) length of stay; 3) inpatient restraints; and 4) PRN use for agitation. Results: Two of the four variations of the baseline DD tasks (DD Future Implicit ED50 and DD Past Explicit ED50) predicted readmission over up to one year after discharge, after controlling for economic pressures. Additional correlates of DD and readmission are reported, including Achenbach externalizing scores, adolescent and parent resilience, length of stay, inpatient restraints, and prn use for agitation. Challenges involved in prospective study of this population will be elucidated for possible solutions and further study. Conclusions: If replicated, a five-item, brief DD task may be useful for predicting risk of readmission and possibly high-risk behaviors following discharge from adolescent inpatient psychiatric hospitalization.

ICP, RF, S Supported by the Virginia Tech Carilion Department of Psychiatry http://dx.doi.org/10.1016/j.jaac.2017.09.077

1.64 PREDICTIVE FACTORS FOR LENGTH OF HOSPITAL STAY IN AN ADOLESCENT INPATIENT PSYCHIATRIC UNIT Muhammad Zeshan, MD, Boston Children’s Hospital, zeshan. [email protected]; Ahmed Waqas, MD, KVC Hospitals, [email protected]; Sadiq Naveed, MD, KVC Hospitals, [email protected]; Pankaj Manocha, MD, Bronx-Lebanon Hospital Center at Icahn School of Medicine at Mount Sinai, pmanocha@ bronxleb.org; Raminder Pal Cheema, Bronx-Lebanon Hospital Center at Icahn School of Medicine at Mount Sinai, [email protected]; Arturo Sanchez, MD, Bronx-Lebanon Hospital Center at Icahn School of Medicine at Mount Sinai, [email protected] Objectives: According to the Health Care Cost and Utilization Project (HCUP) data, inpatient hospital stay costs are approximately 33 percent of all health care spending in the United States. One of the top five causes of inpatient cost and utilization is mental health (MH) disorders. This study examined the factors/predictors impacting the length of stay (LOS) in an adolescent inpatient psychiatric unit in a community hospital in South Bronx, NY. Methods: This is an institutional review board-approved, retrospective chart review of 300 adolescents (ages 13–18 years) who were admitted to an inpatient psychiatric unit in a community hospital in the South Bronx during the years 2011 and 2015. Backward linear regression analysis was run to identify predictors of increasing LOS among adolescents at the Bronx-Lebanon Hospital. All data were analyzed in SPSS (Statistical Package for the Social Sciences), version 20. Results: The mean (SD) age of adolescents admitted to the hospital was 14.10 (3.50) years, with a mean (SD) number of psychiatric diagnoses of 2.10 (0.74), and mean (SD) LOS of 21.17 (18.50) days. A higher proportion of these adolescents were males (n ¼ 155, 51.7%) and Hispanic (n ¼ 177; 59.0%), with a diagnosis of disruptive disorder [n ¼ 123 (41.0%)], neurodevelopmental disorder [n ¼ 69 (23.0%)], and mood disorder [n ¼ 190 (63.3%)]. Multiple regression analysis (adjusted R2¼ 25.30%, P < 0.001) revealed that increasing LOS among adolescents was associated with an increasing number of psychiatric diagnoses, medical diagnosis, seclusions and restraints, not living with biological parents, family history of mental illness, legal and substance use, and schizophrenia. However, the diagnosis of disruptive disorders was associated with decreased LOS at the hospital. Conclusions: The adolescents presenting at Bronx-Lebanon Hospital had a high LOS, associated with disease severity, family structure, history of mental illnesses, and stability.

ADOL, ICP, RF http://dx.doi.org/10.1016/j.jaac.2017.09.078

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1.65 USE OF POST-ACUTE CARE FOLLOWING ACUTE CARE HOSPITALIZATION FOR MENTAL HEALTH CONDITIONS IN CHILDREN AND ADOLESCENTS James Gay, MD, Vanderbilt University Medical Center, james. [email protected]; Bonnie T. Zima, MD, MPH, University of California, Los Angeles Health Services Research Center, [email protected]; Stephanie Doupnik, MD, MS, Children’s Hospital of Philadelphia, [email protected]. edu; Tumaini R. Coker, MD, MBA, University of Washington School of Medicine, [email protected]; Matt Hall, PhD, Children’s Hospital Association, Matt.Hall@ childrenshospitals.org; Jonathan Rodean, PhD, Children’s Hospital Association, Jonathan.Rodean@childrenshospitals. org; Margaret O’Neill, BS, Boston Children’s Hospital, [email protected]; Jay G. Berry, MD, MPH, Boston Children’s Hospital, Jay.Berry@childrens. harvard.edu; Kris Rehm, MD, Vanderbilt University Medical Center, [email protected]; Naomi S. Bardach, MD, University of California, San Francisco, Naomi.Bardach@ ucsf.edu Objectives: The objectives of this study are the following: 1) to determine the proportion of US hospitalizations for children aged 2-20 years with primary mental health diagnoses with discharge to post-acute care (PAC) facilities; 2) to identify predictors of PAC discharge for this patient population; and 3) to examine variation in PAC discharge status by sociodemographic, clinical and hospital characteristics. Methods: This retrospective cohort study included a nationally representative sample of US acute care hospitalizations of children aged 2-20 years with a principal diagnosis of a mental health condition, using the 2009 and 2012 Kids’ Inpatient Databases. Likelihood of discharge to PAC was assessed using a generalized linear mixed effects model with fixed effects for demographic, clinical, and hospitalization characteristics. Results: Among children admitted to US hospitals in 2012 with a principal mental health diagnosis (N ¼ 248,459), 13,068 (5.3%) were discharged to PAC. Two-thirds (n ¼ 8,696; 66.5%) of all PAC discharges were for BD (n ¼ 3,625; 27.7%), depression (n ¼ 3,220; 24.6%), or psychosis (n ¼ 1,851; 14.2%). However, predictors of PAC discharge were homicidal ideation [adjusted OR (AOR) ¼24.9; (4.1, 150.4)], suicide and self-injury [AOR¼15.1; (11.7, 19.4)], substance abuse-related medical illness [AOR¼5.0; (4.5, 5.6)], and personality disorder [AOR¼2.4; (1.8, 3.0)]. PAC use also varied by the state where the discharging hospital was located (range ¼ 2.2%-36.3%). Conclusions: The percentage of patients with primary mental health conditions who were discharged to PAC facilities varied by diagnosis with the strongest predictors being conditions associated with unsafe or high-risk behaviors. Substantial state-to-state variation suggests a lack of standardized PAC use. Understanding PAC use variability may benefit children admitted with mental health conditions and inform interventions to improve the quality of post-discharge care and access to appropriate mental health resources, including PAC.

RF, SIB, S Supported by the Children's Hospital Association http://dx.doi.org/10.1016/j.jaac.2017.09.079

1.66 ASSESSING THE EFFECT OF FOOD ON THE PHARMACOKINETICS OF A NOVEL EXTENDEDRELEASE AMPHETAMINE ORAL SUSPENSION IN HEALTHY ADULTS: A RANDOMIZED-CONTROLLED STUDY Carolyn Sikes, PhD, Neos Therapeutics Inc., sikesc1@verizon. net; Jeffrey Stark, PhD, Worldwide Clinical Trials, Jeff.Stark@


worldwide.com; Russ Mcmahen, Neos Therapeutics Inc., [email protected]; Dorothy Engelking, Neos Therapeutics Inc., [email protected] Objectives: An extended-release amphetamine (AMP) oral suspension (AMP XR-OS) with a pharmacokinetic (PK) profile, comparable to that of an extended-release AMP mixed salts product (MAS ER), has been developed for the treatment of ADHD. This study assessed the effect of food on the rate of absorption and oral bioavailability of this new formulation. Methods: This was an open-label, randomized, three-treatment crossover study. We report the two treatments evaluating the effect of food on AMP XR-OS. The study enrolled 48 healthy adults, who received a single 15-ml dose of AMP XR-OS (equivalent to 30 mg of MAS ER) under fasted or fed conditions in randomized sequences. Blood samples were collected at prespecified time points and analyzed for d- and l-AMP concentrations. Key PK parameters included maximum plasma concentration (Cmax), time to maximum plasma concentration (Tmax ), and area under the curve from zero to last quantifiable concentration (AUC last) and to infinity (AUCinf). No significant food effect was concluded if the 90 percent confidence intervals (CI) around the geometric mean ratios (fed/fasted) for log-transformed Cmax, AUC last, and AUC inf were within the 80- to 125-percent range. Area under the curves from zero to five hours after dose (AUC0-5) and from five hours to last quantifiable concentration (AUC 5-last) were analyzed as exploratory endpoints. Safety was also assessed. Results: Of the 48 participants enrolled, 47 completed the study. For dand l-AMP, Tmax was not affected by food; the 90 percent CI for Cmax , AUC 0-5, AUC5-last, AUClast, and AUCinf fell within the accepted 80- to 125percent range, demonstrating no significant food effect on the PK profile of AMP. Adverse events (AE) were mild to moderate and consistent with the AE profile of AMP. Conclusions: Food had no clinically relevant effect on the PK profile of AMP XR-OS.

PKS, RCT, STIM Supported by Neos Therapeutics, Inc. http://dx.doi.org/10.1016/j.jaac.2017.09.378

1.67 EFFECT OF LURASIDONE ON NEUROCOGNITIVE PERFORMANCE IN ADOLESCENTS WITH SCHIZOPHRENIA: RESULTS FROM A PLACEBO-CONTROLLED SHORT-TERM STUDY AND AN OPEN-LABEL EXTENSION STUDY Philip D. Harvey, PhD, University of Miami Miller School of Medicine, [email protected]; Robert Goldman, PhD, Sunovion Pharmaceuticals Inc., Robert.Goldman@sunovion. com; Michael Tocco, PhD, Sunovion Pharmaceuticals Inc., [email protected]; Ling Deng, PhD, Sunovion Pharmaceuticals Inc., [email protected]; Josephine Cucchiaro, PhD, Sunovion Pharmaceuticals Inc., [email protected]; Antony Loebel, MD, Sunovion Pharmaceuticals Inc., Antony.Loebel@ sunovion.com Objectives: The objective of this study is to evaluate the short- and long-term effects of lurasidone on cognitive performance in adolescents with schizophrenia. Methods: Patients aged 13-17 years with a diagnosis of schizophrenia and a Positive and Negative Symptom Scale (PANSS) total score 70, were randomized to six weeks of double-blind, fixed-dose treatment with lurasidone 40 mg/day, 80 mg/day, or placebo. Patients who completed this study were eligible to enroll in a two-year, open-label extension study in which patients were continued on lurasidone, or switched from placebo to lurasidone. We report data from a Week 52 interim analysis. Cognitive performance was evaluated (as a safety outcome) by the computerized Brief Cogstate Battery, which assesses four cognitive domains: processing speed, attention/vigilance, visual learning, and working memory. Based

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on normative data for children and adolescents, an overall cognitive composite Z-score was calculated as the average of the standardized Zscores for each of the four cognitive domains. Results: A total of 302 patients were randomized to six weeks of double-blind treatment with lurasidone 40 mg/day, 80 mg/day, or placebo. At week six, least squares (LS) mean change from baseline on the Cogstate composite Zscore was not significantly different for the lurasidone 40 mg/day and 80 mg/ day groups versus placebo (-0.09 and +0.11 vs -0.10; endpoint). Numerically greater improvement was observed on three of the four Cogstate cognitive domain scores, with the difference achieving statistical significance on the processing speed and working memory speed tasks. For the subgroup of patients (n ¼ 267) who continued in the open-label extension phase, and for whom Cogstate data were available, the mean change on the composite Zscore from double-blind baseline was +0.04 at open-label baseline and +0.20 at week 52. No reduction in cognitive performance was observed at week 52 in the four Cogstate domains. Conclusions: In adolescents with schizophrenia, short-term lurasidone therapy was not significantly different from placebo on a measure of cognitive performance, with the 80 mg/day dose of lurasidone showing numerical improvement compared to the 40 mg/day dose. Treatment with lurasidone for an additional 52 weeks was not associated with deleterious cognitive effects as measured by the Cogstate battery. The extension phase study is ongoing.

COG, APS, SZ Supported by Sunovion Pharmaceuticals Inc. http://dx.doi.org/10.1016/j.jaac.2017.09.264

NEW RESEARCH POSTER SESSION 2 2.1 KETAMINE AS A TREATMENT FOR ADOLESCENT MAJOR DEPRESSIVE DISORDER Jennifer B. Dwyer, MD, PhD, Child Study Center, jennfier. [email protected]; Michael H. Bloch, MD, MS, Yale University School of Medicine, [email protected] Objectives: Nearly one in four adolescents will experience MDD. Suicide is the second leading cause of death in youth ages 15–24 years. Adolescents (40%) with MDD fail to respond to initial treatment with SSRIs. Of the SSRI-resistant population, nearly half remain depressed despite alternate medication and psychotherapy. Thus, better treatments for adolescent depression are urgently needed. Subanesthetic doses of ketamine, a glutamatergic modulator, produce rapid antidepressant and antisuicidal effects in depressed adults. There are few case reports and no prospective controlled trials of ketamine for the treatment of MDD in adolescents. Methods: We are conducting a midazolam-controlled crossover trial to evaluate the effects of ketamine in treatment-refractory adolescent MDD over four weeks. Adolescents must have failed at least one adequate trial of a standard antidepressant to enroll. Adolescents seeking ketamine treatment who do not meet inclusion criteria are referred to our Interventional Psychiatry Service on a case-by-case basis. Results: We describe our recruitment procedures and experimental design for the clinical trial. We also report a case of successful treatment of an adolescent, with severe medication-refractory MDD with suicidality, who did not meet trial criteria but was treated with ketamine through our interventional service. We describe the side-effect profile of ketamine in this subject and show a rapid reduction of depressive symptoms and suicidality that was sustained with a multiple infusion paradigm. Conclusions: Given the potential therapeutic benefits of ketamine and the burden of treatment-refractory adolescent MDD, ketamine deserves further study as a potential form of treatment in adolescents in appropriately supervised settings with informed consent.

ADOL, ADP, DDD Supported by the AACAP Pilot Research Award for General Psychiatry Residents, supported by Pfizer and PhRMA, the Thrasher Pediatric Research Foundation, and the Yale Child Study Center Pilot Research Fund http://dx.doi.org/10.1016/j.jaac.2017.09.081

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2.2 TRIAL OF POSITIVE PSYCHIATRY IN COMORBID ATTENTION-DEFICIT HYPERACTIVE/ DISORDER (ADHD) WITH POSTTRAUMATIC STRESS DISORDER (PTSD) Naser Ahmadi, MD, PhD, University of California, Los Angeles and VA Greater Los Angeles Healthcare System, [email protected]; Shahzad Chaudhry, MFT, University of California, Los Angeles Kern Medical, [email protected]; Towhid Salam, MD, University of California, Los Angeles Kern Medical, [email protected]; John Rodriguez, BS, University of California, Los Angeles Kern Medical, [email protected]; Chandan Samra, MD, University of California, Los Angeles Kern Medical, [email protected]; Alex Dragic, BS, University of California, Los Angeles Kern Medical, [email protected]; Michelle Zamorano, BS, University of California, Los Angeles Kern Medical, michellezamorano@ students.aucmed.edu; Samantha Madziarski, MD, University of California, Los Angeles Kern Medical, Samantha. [email protected]; Kiran Malhi, BS, University of California, Los Angeles Kern Medical, [email protected]; Michael Kase, MD, University of California, Los Angeles Kern Medical, [email protected]; Garth Olango, MD, University of California, Los Angeles Kern Medical, olangog@ kernmedctr.com; Mohammed Molla, MD, University of California, Los Angeles Kern Medical, shahriarmolla@gmail. com; James T. McCracken, MD, University of California, Los Angeles, [email protected]; Robert S. Pynoos, MD, University of California, Los Angeles Semel Institute for Neuroscience and Human Behavior, rpynoos@ mednet.ucla.edu Objectives: ADHD is associated with higher levels of morbidity and dysfunction, especially in those with PTSD. Recent studies revealed that positive psychiatry (PP) can decrease symptoms of adversity and psychopathology and increase the well-being in youth. This study investigates the impact of PP on vascular function, inflammation, well-being, and ADHD and PTSD symptoms in adolescents with comorbid ADHD and PTSD. Methods: Eleven adolescents (age ¼ 11 3 years; range ¼ 10–15 years; 50% female), after obtaining informed consent, were randomized to the PP group (n ¼ 5) or CBT group (n ¼ 6). Eight participants (PP, n ¼ 4; CBT, n ¼ 4) completed a six-week trial. Vascular function measured as temperature rebound by reactive hyperemia, C-reactive protein (CRP), homocysteine, and neuropsychiatric measures [i.e., SNAP (Special Needs and Autism Project) questionnaire; PERMA (positive emotion, engagement, relationships, meaning and accomplishment); gratitude; posttraumatic growth inventory; Connor-Davidson Resilience Scale; and ClinicianAdministered PTSD Scale (CAPS), children version] were measured at baseline and at week six. Results: At follow-up, a significant improvement in CAPS-CA, SNAP, and vascular function of both PP and CBT groups was noted compared with baseline that was more robust in the PP group (P < 0.01). At week six, a significant decrease in homocysteine and CRP, as well as an increase in PERMA, gratitude, resilience, and posttraumatic growth inventory scores in PP group, but not in CBT group, was noted (P < 0.01). A significant relationship between a decrease in CAPS and SNAP scores and an increase in vascular function, as well as a decrease in homocysteine, were noted (P < 0.01). Furthermore, A direct relationship between increase in PERMA, gratitude, resilience, and posttraumatic growth inventory scores, with increase in vascular function and decrease in homocysteine, was noted (P < 0.01). The most robust improvement was noted in positive connectedness, including new possibilities, appreciation of life, personal strength, and relating to others (P < 0.01). Conclusions: PP is associated with improving PTSD and ADHD symptoms, as well as increase in well-being and vascular function, and reducing

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inflammation in adolescents with comorbid ADHD and PTSD. This highlights the importance the dual role of PP in addressing vulnerable symptoms, as well as enhancing well-being in youth with ADHD and PTSD.

P, ADHD Supported by the AACAP Pilot Research Award for Attention Disorders, supported by AACAP's Elaine Schlosser Lewis Fund http://dx.doi.org/10.1016/j.jaac.2017.09.082

problem behaviors may provide avenues to engaging this vulnerable population.

FCP, JJS, SUD Supported by the AACAP Jeanne Spurlock Research Fellowship in Substance Abuse and Addiction for Minority Medical Students, which is supported by NIDA and AACAP's Campaign for America's Kids, and Supported by the AACAP Physician Scientist Program in Substance Abuse, supported by NIDA http://dx.doi.org/10.1016/j.jaac.2017.09.083

2.3 UNDERSTANDING THE MENTAL HEALTH AND SUBSTANCE USE DISORDER TREATMENT NEEDS OF COMMERCIALLY SEXUALLY EXPLOITED GIRLS: A PARTNERSHIP WITH THE STAR COURT Mikaela A. Kelly, BA, UCLA/Charles Drew University, [email protected]; Elizabeth Barnert, MD, MPH, MS, David Geffen School of Medicine at UCLA, Ebarnert@ mednet.ucla.edu; Sarah Godoy, MSW, David Geffen School of Medicine at UCLA, [email protected]; Lindsey Thompson, MPH, MS, David Geffen School of Medicine at UCLA, [email protected]; Mekeila Cook, PhD, Los Angeles County Department of Mental Health, [email protected]; Kayleen Ports, BS, David Geffen School of Medicine at UCLA, [email protected]. edu; Roya Ijadi-Maghsoodi, MD, MS, David Geffen School of Medicine at UCLA, [email protected]; Shushana Goboian, MSW, Los Angeles County Department of Mental Health, [email protected]; Eraka Bath, MD, University of California, Los Angeles Semel Institute for Neuroscience and Human Behavior, [email protected] Objectives: Commercially sexually exploited youth (CSEY) represent an underserved subset of the female juvenile delinquency population, with high need for substance use disorder (SUD) and mental health (MH) treatment. The Succeeding Through Achievement and Resilience (STAR) Court, a specialty diversion court in Los Angeles, provides MH and SUD referrals to CSEY on probation for trafficking related charges. Our objective was to better understand the SUD and MH characteristics of CSEY in order to inform future service planning. Methods: We conducted an exhaustive chart review of health-related data from the court files of 297 STAR Court CSEY. The observation period spanned from 2012-2017. Domains included sociodemographics, MH and SUD diagnoses, child welfare involvement, and court petition history. Two team members systematically transferred the data from CSEY’s court files to a computerized database. Data was summarized using descriptive statistics and chi-squared tests were performed to explore associations between SUD and potentially related factors. Results: Of the 297 CSEY, 72 percent identified as African American, 20 percent Hispanic, five percent White, two percent Asian, and one percent other. Sixty-two percent had a documented MH condition; of those, 79 percent reported two or more MH conditions. Over 90 percent reported lifetime use of one or more illicit substances, including 20 percent who reported using methamphetamine. Lifetime methamphetamine use was marginally associated with having at least one sexually transmitted infection (STI), accounting for 11 percent of methamphetamine users and 5.4 percent of non-methamphetamine users (p ¼ 0.07). There was a strong relationship between methamphetamine use and suicide attempts, with methamphetamine users being significantly more likely than non-methamphetamine users to report any prior suicide attempts (38% versus 12%, respectively; p < 0.001). Substance use overall was not predictive of either STIs or suicide attempts. Conclusions: CSEY participants in the STAR Court have extremely high levels of MH and SUD problems. Methamphetamine users were more likely to report previous suicide attempts and higher rates of STIs compared to non-methamphetamine users. Partnerships with specialty court-based programs that can address MH and SUD needs and related


2.4 EFFECTIVENESS OF UNDERGRADUATE AND GRADUATE MEDICAL EDUCATION IN PREPARING PEDIATRICIANS TO MANAGE PSYCHIATRIC PROBLEMS Ashley M. Moreno, BS, Rush University Medical College/ Northwestern University, [email protected]; Amandeep S. Jutla, MD, Northwestern University Feinberg School of Medicine, [email protected]; Alison Greenfeder Weiss, MD, University of Illinois at Chicago, [email protected]; James G. MacKenzie, DO, Rush University Medical Center, James_ [email protected] Objectives: Prior studies have alluded to the need for improved training in child psychiatry to meet the growing mental health demands of youth patients. This preliminary study surveys pediatrician trainees to determine 1) the extent of their education in children and adolescent psychiatry; 2) whether the type of psychiatry exposure residents receive during UGME and GME training correlates with willingness to treat noncomplex mental health disorders; and 3) the training enhancements that would best prepare them to manage mental health concerns. Methods: An optional survey was sent to all pediatric trainees at Rush University and Northwestern University. Trainees were asked to characterize the setting in which they completed their psychiatry clerkship, describe their highest level of immersion in children and adolescent psychiatry, assess comfort level and future willingness to engage in treatment of mental health disorders, and recognize the most beneficial ways of improving children and adolescent psychiatry training. Results: Nineteen participants (73%) acknowledged that they only saw adults during their medical school psychiatry clerkship. Eight trainees (32%; 3 PGY1s, 2 PGY2s, 2 PGY3s and 1 PGY4) noted that they have had no significant exposure to children and adolescent psychiatry. Eight trainees (35%) stated that they had low confidence in managing pediatric patients with noncomplex mental health disorders. Twenty-four trainees (90%) expressed willingness to treat future patient’s noncomplex mental health disorders. Greater didactics on children and adolescent psychiatry-related subject areas were identified as likely to most improve training for medical students (58%, n ¼ 15), whereas greater access to children and adolescent psychiatry was isolated as likely to most enhance future residency training (69%, n ¼ 18). Conclusions: These preliminary findings suggest that exposure to children and adolescent psychiatry during the pre- and post-clinical medical school years would improve resident preparedness to manage noncomplex mental health disorders. To curtail this training gap, pediatric residency program requirements may need to be re-examined and modified to foster greater interaction/collaboration amongst pediatrician trainees and mental health specialists. Future studies should assess the effectiveness of novel training schemes in improving pediatrician competency in child and adolescent behavioral and mental health.

REST Supported by the AACAP Summer Medical Student Fellowship Program, which is supported by AACAP's Endowment Fund and partially supported by the Ruth and Peter Metz Family Foundation http://dx.doi.org/10.1016/j.jaac.2017.09.084

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2.5 THE ROLE OF AFFECT MANAGEMENT FOR HUMAN IMMUNODEFICIENCY (HIV) RISK REDUCTION FOR YOUTH IN ALTERNATIVE SCHOOLS Larry K. Brown, MD, Brown University Alpert Medical School and Rhode Island Hospital, [email protected]; Laura Whiteley, MD, Rhode Island Hospital, lwhiteley@ Lifespan.org; Christopher Houck, PhD, Rhode Island Hospital, [email protected]; Lacey Craker, MPH, Rhode Island Hospital, [email protected]; Ashley D. Lowery, MS, Rhode Island Hospital, [email protected]; Nancy Beausoleil, MS, Rhode Island Hospital, NBeausoleil@ Lifespan.org; Geri Donenberg, PhD, University of Illinois at Chicago, [email protected] Objectives: Adolescents in alternative schools are at greater risk for HIV and other sexually transmitted infections (STIs) than their peers because of earlier sexual onset, higher rates of sexual risk, higher rates of psychiatric disorders, and difficulty managing strong emotions. Although traditional HIV prevention education interventions have been shown to be effective in mainstream school settings, these same interventions may not address the specific needs of adolescents in alternative schools. Methods: This project assessed the six-month impact of a three-arm RCT comparing a skills-based HIV prevention intervention with affect management (AM) to a standard, skills-based (SB) HIV prevention intervention and a general health promotion (HP) intervention. Sexual risk outcomes, HIV prevention knowledge and attitudes, and affect dysregulation were assessed among 377 youth (ages 13–19 years) living in two US cities and attending alternative schools. Independent F-tests and Chi-square analyses were conducted to examine the differences between conditions. Logistic regression and analysis of covariance, adjusted for baseline and significant demographic variables, were conducted to assess proportional and scale outcomes, respectively. Intervention effect sizes were calculated using Cohen’s d. Results: Multiple logistic regression analyses, adjusted for the baseline scores and age, found that adolescents in AM were significantly less likely to report being sexually active in the past six months than those in the HP group (0.74 vs. 0.83, P ¼ 0.03), and there was a trend toward more consistent use of condoms in AM than in HP (0.62 vs. 0.39, P ¼ 0.06), whereas SB outcomes did not differ from HP. Analyses of covariance, with similar adjustments, also showed that those in the HIV-specific interventions (AM and SB) had greater HIV knowledge (F ¼ 4.55, P ¼ 0.03) and showed improved attitudes toward condom use (F ¼ 4.00, P ¼ 0.05) compared with those in HP group. Conclusions: These data suggest that focusing on affect management in sexual situations might improve the sexual health of adolescents in alternative schools. The affect management techniques used in this intervention are similar to those that are commonly used in clinical practices, although they are focused on situations and thus may be used to guide clinicians.

AIDS, ADOL, PRE Supported by NIMH Grant R01 MH066641 and Lifespan/Brown/Tufts Center for AIDS Research Grant P30 AI042853 http://dx.doi.org/10.1016/j.jaac.2017.09.085

2.6 UTILIZATION OF MOBILE CLINICS TO DELIVER PREVENTION AND EARLY INTERVENTION MENTAL HEALTH SERVICES IN A COUNTY POPULATION Julia Hoang, MD, University of California, Riverside School of Medicine, [email protected]; Emma Girard, PsyD, University of California, Riverside School of Medicine, [email protected]; Shalin Patel, MD, University of California, Riverside School of Medicine, shalin03@gmail. com; Richard J. Lee, MD, Riverside County Dept of Mental

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Health, [email protected]; Anna Loza, LCSW, University of California, Riverside School of Medicine, [email protected] Objectives: The Prevention and Early Intervention Mobile Services (PEIMS) is an approach to overcome obstacles of access to mental health services in underserved communities. Mobile units are able to optimize care with delivery of Parent–Child Interaction Therapy (PCIT), Incredible Years (IY), Positive Parenting Program (Triple P), and Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). Methods: Mobile clinics provide services at different school settings and were recorded in an electronic health record in the fiscal year of 2015–2016. The outcome measure used scales such as the following: Eyberg Child Behavior Inventory (ECBI); Sutter-Eyberg Student Behavior Inventory (SESBI); Child Behavior Checklist (CBCL); Parent Stress Index (PSI); and Therapy Attitude Inventory (TAI). Results: A total of 103 children received PCIT/mental health services, of which 69 percent were male, 56.3 percent were Hispanic/Latino, and 63.1 percent were ages 4–5 years. Countywide, there was a statistically significant decrease in the frequency of child problem behaviors. For TF-CBT, two of the three children showed improvement in mental health functioning. In the Strong Kid’s Group, four children were enrolled; CBCL scores decreased for internalized and externalized behaviors. In the Incredible Years Dinosaur School, 18 children were enrolled; ECBI problem score showed a 51.4 percent decrease, the SESBI score had decreased 23.6 percent for problem score, and 6.8 percent for intensity score. For PEIMS (parental consultations), there were 86 parent consultations, where listening problems and tantrums were the two frequently discussed concerns encountered during these sessions. For PEIMS (provider consultations), there were a total of 19 provider consultations, with 79 percent involving a child of focus. For Teacher–Child Interaction Therapy (TCIT) provider training, coaching was provided to eight teachers and seven teacher assistants. SESBI scores indicate that there was a decrease in the perception and frequency of child’s behavior in the classroom after teachers received TCIT coaching. A total of 18 events occurred throughout the community; six of 17 events were presentations, six were community meetings, and five were public events, such as National Alliance on Mental Illness walk and two mental health fairs. Conclusions: PEIMS are able to increase outreach to targeted families that include those who have not been able to receive services because of transportation issues, geographical barriers, or the fact that their concerns do not meet mental health clinic criteria.

PRE, CC, PAT http://dx.doi.org/10.1016/j.jaac.2017.09.086

2.7 LONG-TERM EFFECTS OF A PREVENTIVE INTERVENTION FOR PARENTAL DEPRESSION Matias Irarrazaval, MD, MPH, University of Chile, mirarraz@ mail.harvard.edu; Fernanda Prieto, PsyD, Universidad del Desarrollo, [email protected]; Lily Arriagada, MD, University of Chile, [email protected]; Tracy Gladstone, PhD, Wellesley College/WCW, tgladsto@ wellesley.edu; William R. Beardslee, MD, Boston Children’s Hospital, [email protected] Objectives: Family Talk is a preventive intervention for families with parental depression that has shown sustained benefits in parents’ behaviors and attitudes about the illness and a greater understanding of parental depression among children. The objective of this study is to evaluate the maintenance of the effect of the Family Talk intervention in Chilean families between initial time and follow-up. Methods: A sample group of 17 families, in which at least one parent suffered from a mood disorder and at least one nondepressed child was within the age range of 6–15 years, was recruited. Families were randomized to treatment groups. Parents and children were assessed at baseline and every three to eight months thereafter on behavioral functioning, psychopathology, and in response to intervention. Results: At baseline, the sample group consisted of 17 families. Of these, 13 (76.4%) completed the intervention, with gradual sample loss over the follow-

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up assessments. Of the participants at follow-up, 100 percent were mothers and 53.9 percent were parents. The average ages of mothers and fathers were 43.3 and 47.7 years, respectively. The average age of the children was 9.5 years. A significant decrease in maternal depressive symptoms was found after the intervention and in the follow up assessments P < 0.01). Likewise, a significant increase in maternal parenting skills (P < 0.01), particularly in maternal reflexive skills (P < 0.05), as well as in family adaptability, was observed after the intervention, which remained significant in the follow-up assessments (P < 0.05). The children did not report depressive symptoms after the intervention or in the follow-up assessments. In addition, there was a significant decrease in the behavioral problems of the children reported by the mothers in the follow-up, compared with those presented before the intervention (P < 0.05). Conclusions: These findings demonstrate that Famila Activa, a brief familycentered preventive intervention for parental depression, may contribute to long-term, sustained improvements in family functioning.

EBP, PRE, DDD Supported by the National Commission for Scientific and Technological Research and the Chilean Government http://dx.doi.org/10.1016/j.jaac.2017.09.087

2.8 THE DEVELOPMENT, IMPLEMENTATION, AND EVALUATION OF A SUICIDE PREVENTION GATEKEEPER TRAINING CURRICULUM FOR HIGH SCHOOL STUDENTS Laura R. Ledvora, BA, Medical College of Wisconsin, [email protected]; Kathy J. Russeth, MD, Medical College of Wisconsin, [email protected]; Alexandra A. Lynch, BS, Medical College of Wisconsin, [email protected] Objectives: Ample research supports the efficacy of suicide prevention gatekeeper-training programs for adults, but little research evaluates their use with adolescents. This study modified an adult gatekeeper-training program to create a suicide prevention curriculum appropriate for adolescents and evaluated its feasibility and efficacy. Methods: The Question, Persuade, Refer (QPR) Suicide Prevention Gatekeeper Training was modified to include statistics and examples relevant to adolescents and a suicidality screening [Patient Health Questionnaire-9 (PHQ-9) for teenagers]. A total of 118 high school students (ages 13–18 years) were invited to participate. All students were offered screening. Students who screened positive were removed from the study, and their guidance counselors were asked to speak with them before the day ended. Students and their parents (n ¼ 77) actively consented to students’ participation. Those who did not consent were removed from the study. After exclusion criteria, 63 students were eligible to participate. Half of these students were randomized to the modified QPR curriculum, and half were removed from the study to maintain the anonymity of students who had screened positive. Students removed from the study participated in their regular curriculum. Thus, 32 students completed a pretest, the modified QPR curriculum, and a posttest (n ¼ 32). Results: Feasibility was demonstrated qualitatively by school staff members’ support and quantitatively by an active consent rate, comparable with that for other school prevention programs. Efficacy was evaluated using paired sample t-tests comparing participants’ pre- and posttest scores. Posttest scores were significantly higher compared with pretest scores in the categories of declarative knowledge about suicide and suicide prevention behaviors [(mean ¼ 1.22, SD ¼ 1.75); t(32) ¼ 4.01, P < 0.001], self-perceived confidence in enacting suicide prevention behaviors [(mean ¼ 0.72, SD ¼ 0.58); t(32) ¼ 7.22, P < 0.001], and self-perceived comfort in enacting suicide prevention behaviors [(mean ¼ 0.45, SD ¼ 0.75); t(32) ¼ 3.39, P ¼ 0.002]. Conclusions: Resultsindicate that it is feasible to implement a suicide prevention gatekeeper-training program with a suicidality screen in classes of high school students. The significant improvements in participants’ scores show that such a program is effective.


PRE, SC, S http://dx.doi.org/10.1016/j.jaac.2017.09.088

2.9 ELECTRONIC COGNITIVE-BEHAVIORAL THERAPY (ECBT) SMARTPHONE APPLICATIONS: A COMPARATIVE ANALYSIS AMONG ADOLESCENTS Aditya Sareen, MBBS, Northwell Health- Zucker Hillside Hospital, [email protected]; Venkatesh Sreeram, MBBS, Northwell Health- Zucker Hillside Hospital, [email protected]; Inmaculada Pe~ nuelasCalvo, MD, PhD, Hospital Clınico Fundaci on Jimenez Diaz, [email protected] Objectives: Several electronic CBT (eCBT) smartphone applications (apps) have been designed and made available to the general public, including children and adolescents for self-help. However, the advantages and disadvantages of such applications have not been explored. Our aim is to compare such apps, find out the pros and cons of such applications while also focusing on the applications that are helpful for adolescents. Methods: We conducted a thorough search of Google play for Android devices and iTunes for Apple devices on CBT applications. Ten of the most used applications were assessed under five parameters regarding feasibility, cost, confidentiality, communication, and user ratings by two separate investigators. Results: Evaluating the CBT apps available would assist us for future development of smartphone-delivered intervention. Thus, we collected the most used apps among children and compared them based on their feasibility, privacy, and cost. Most of the apps cost an average of four to five dollars. Privacywise, not many apps were designed to provide password protection. Few apps were also devised with auxiliary features such as transferable data, scheduling follow-up appointments, and sending reports to the therapist. We found that three apps performed well with most of the features listed above: 1) iCouch CBT; 2) Mood Kit; and 3) My Mood Tracker. Based on user reviews, two major concerns of apps were technical issues and apps hanging inappropriately in Android, compared with iOS, that require investigation for future development. Conclusions: CBT has become an effective therapeutic tool for various problems. Several electronic apps are available today that help the clients deal with their problems at home. However, not a single app is available for children with all of the features at a reasonable cost, which makes it difficult for everyone to get the benefit out of it. Furthermore, the app does not take the place of CBT performed by the therapist. They only act as an added advantage to control the stress in between the CBT sessions with therapists. Our review suggests the necessity of more apps with reasonable cost and features. Many clients’ complaints about technical issues with Android need to be addressed.

ADOL, MED http://dx.doi.org/10.1016/j.jaac.2017.09.089

2.10 DOES CLINICAL EXPERIENCE, FORMAL COGNITIVE-BEHAVIORAL THERAPY (CBT) TRAINING, ADHERENCE, AND COMPETENCE PREDICT OUTCOME IN CBT FOR ANXIETY DISORDERS IN YOUTH? Gro Janne H. Wergeland, MD, PhD, Haukeland University Hospital, [email protected]; Jon F. Bjaastad, PhD, Stavanger University Hospital, [email protected]; Bente SM Haugland, PhD, University Research Health, Bente. [email protected]; Rolf Gjestad, PhD, Haukeland University Hospital, [email protected]; Odd E. Havik, PhD, University of Bergen, [email protected]; Einar R.

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Heiervang, MD, PhD, University of Oslo, einar.heiervang@ € PhD, Karolinska Institute, ost@ medisin.uio.no; Lars G. Ost, psychology.su.se Objectives: The aim of the present study was to investigate whether therapist factors, such as clinical experience, formal CBT training, adherences, and competence, predict outcome in CBT for anxiety disorders in youth. Methods: A total of 181 videotapes from the sessions in a randomized controlled effectiveness trial comprising youth (N ¼ 182, mean age ¼ 11.5 years) with mixed anxiety disorders were assessed. Participants were assessed with a diagnostic interview [Anxiety Disorders Interview Schedule for Children—Child and Parent (ADIS C/P) versions] and an anxiety symptom measure [Spence Children’s Anxiety Scale—Child and Parent (SCAS C/P) versions] at pretreatment, posttreatment, and at one-year follow-up. Information was collected on the therapists’ (N ¼ 17) clinical experience and educational backgroundTreatment adherence and competence were rated from videotapes using the Cognitive and Adherence Scale for Cognitive Behavioral Therapy (CAS-CBT) for anxiety disorders in youth. Outcomes were defined as complete remission (i.e., the remission of all three principal anxiety disorders—separation anxiety disorder, social phobia, generalized anxiety disorder), remission of the principal anxiety disorder, or anxiety symptom improvement (i.e., decrease in the child and parent ratings of child anxiety symptoms), measured at posttreatment and at one-year follow-up. Associations between therapist factors and outcomes were analyzed using logistic regression or latent growth curve modeling. Results: The findings suggested that higher therapist adherence was related to recovery from both the primary inclusion anxiety disorder [OR 2.62 (95% CI 1.44, 4.74), P ¼ 0.002] and all-inclusion anxiety disorders at follow-up [OR 2.33 (95% CI 1.05, 5.14), P ¼ 0.037]. The number of years of clinical experience [OR 0.92 (95% CI 0.88, 0.95), P < 0.001] and competence [OR 0.38 (95% CI 0.17, 0.83), P ¼ 0.015] was related to reduced likelihood of diagnostic recovery after treatment. However, results were not consistent across reporters and the time points for the assessments. Interaction effects suggested that competence among therapists with formal CBT training was related to better patient outcomes. Conclusions: Adherence to the manual seems to be important to produce good outcomes, whereas clinical experience seems to be related to worse outcomes. Clinical implications of the findings will be discussed.

AD, TREAT Supported by the Western Regional Health Authority, Norway, Grants 911366 and 911253 http://dx.doi.org/10.1016/j.jaac.2017.09.090

2.11 EFFECTIVENESS OF GROUP COGNITIVEBEHAVIORAL THERAPY FOR PEDIATRIC OBSESSIVE-COMPULSIVE DISORDER Ariz Rojas, PhD, Icahn School of Medicine at Mount Sinai, ariz. [email protected]; Shannon Gair, BA, Icahn School of Medicine at Mount Sinai, [email protected] Objectives: CBT with exposure and response prevention (ERP) is the first-line treatment for pediatric OCD, yet the availability of this treatment is limited. Applying ERP in a group format offers a way to increase accessibility to care. This study evaluated the effectiveness and treatment acceptability of group treatment. Methods: A total of 26 children were enrolled over seven therapy sequences. The sample group had a mean severity of 24.67 on the Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS); median age was 11 years; more boys (58%) than girls participated; and the sample group was predominantly Caucasian (79%). The intervention included a 12-session, 90-minute CBT/ERP protocol developed for delivery in a group format. The protocol covered psychoeducation,

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cognitive interventions, fear hierarchies, exposures, habit reversal, relaxation, and relapse prevention. Results: A paired samples t-test revealed that the group treatment was effective [t(23) ¼ 5.9; P < 0.001]. Pre CY-BOCS scores (mean ¼ 24.67; SD ¼ 5.6) were statistically lower at posttest (mean ¼ 15.17; SD ¼ 5.1). All parent-reported indicators revealed clinically significant reductions from pre- to posttest, including parental accommodation [t(19) ¼ 4.31, P < 0.001], interference [t(20) ¼ 4.12, P < 0.001], behavior [t(23) ¼ 2.30, P < 0.05], and anxiety [t(20) ¼ 3.68, P < 0.001]. Children’s self-reports elicited clinically significant improvement from pre- to posttest on interference [t(20) ¼ 2.34, P < 0.05] but not for general anxiety. On average, both children and their parents found the group treatment to be “very helpful.” Open-ended responses indicated that children found the group to help them fight OCD, increase self-confidence, and socialize better. More than half of parents (58%) “strongly agreed” that the group treatment was “as effective or more effective than individual treatment.” Conclusions: The data obtained from this effectiveness study suggest that ERP delivered in group format elicits clinically significant reductions in symptomology. Additionally, parents and children found the group program to increase self-esteem, motivation, and acceptance. Further investigation is warranted and may present novel opportunities for treatment.

SAC, OCD Supported by a private donor http://dx.doi.org/10.1016/j.jaac.2017.09.091

2.12 MINDFULNESS TRAINING IN PREGNANCY, AND POSTPARTUM INTERNALIZING SYMPTOMS Sarah Guth, MD, University of Vermont, [email protected]; Sandra Wood, APRN, University of Vermont, sandra.wood@ uvmhealth.org; Masha Ivanova, PhD, Larner College of Medicine at the University of Vermont, masha.ivanova@med. uvm.edu; James J. Hudziak, MD, Vermont Center For Children, Youth, & Families, [email protected] Objectives: Depression and anxiety in the prenatal and postpartum period are related to long-term physical and behavioral outcomes for offspring. Because of the potential immediate and long-term risks of medicine during pregnancy, there is growing interest in nonpharmacologic strategies to promote women’s’ mental health. Mindfulness may be an ideal intervention to consider as a low-risk intervention, which has been associated with decreased stress and anxiety, as well as improved mood and quality of life. This study evaluates the impact of mindfulness training for women presenting to a general obstetrics practice. Methods: Women were recruited between 12 and 26 weeks of gestation to attend an 8-week “Mindful Motherhood” course. Women enrolled in the course were compared with women who indicated interest in the intervention but were unable to attend because of the timing of the courses offered. Women were assessed between 12 and 26 weeks of pregnancy and six weeks postpartum. The primary outcome of interest was postpartum-internalizing symptoms. Results: Participants (n ¼ 30) and control subjects (n ¼ 24) completed followup evaluations. At baseline, there were no significant differences in education, income, and perceived stress between the intervention and control groups. Using a repeated-measures general linear model, there was an interaction between participation and time where women who participated in the mindfulness course realized a significantly larger decrease in internalizing symptoms from baseline to postpartum (P < 0.01). Conclusions: Mindfulness training was associated with significant reduction of internalizing symptoms. Women who received the intervention experienced a significant reduction in internalizing symptoms, whereas women in the control group did not. The limitations in this study were small sample size and use of a convenience-based control group. Future trials should include a larger sample size and randomized design.

FT, PRE, INF http://dx.doi.org/10.1016/j.jaac.2017.09.092

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2.13 A FOLLOW-UP STUDY OF ADOLESCENTS TREATED WITH ELECTROCONVULSIVE THERAPY (ECT) Shanti Mitchell, MD, University of Michigan, shanti1shanti@ hotmail.com; Ehmer Hassan, University of Michigan, [email protected]; Neera Ghaziuddin, MD, University of Michigan, [email protected] Objectives: Electroconvulsive therapy (ECT) is an effective and a safe form of treatment across the age span but remains controversial and stigmatized. We examined current functioning, attitude, and perception of former patients treated with ECT when they were age 6; CGI-Global Improvement (I) > 6; and CGI side effects > 2], and any positive item on a harm risk assessment checklist. In year 1 (September 2015–August 2016), a monthly audit of at-risk patients was derived from the caseload of a class of child psychiatry fellows and shared with the clinic’s medical director, who distributed the summary report to supervisors. Based upon feedback, in year 2 (September 2016–April 2017), the monthly audit was redesigned to be a customized report given directly to each fellow and supervisor. Results: We designed, tested, and implemented a custom EMR-based approach of identifying at-risk patients, using a quality improvement framework for improved practice. In year 1, 221 visits were identified (96 unique patients; 30% of total visits) according to at-risk criteria for fellows (N ¼ 5). Approximately 40 percent were identified on more than two visits. The majority of at-risk assessments were CGAS scores (57%), followed by CGI (32%), and harm risk assessments (11%). Within the harm risk assessment, the majority identified suicidal ideation (48%), and one patient/visit endorsed a suicide plan. In year 2, 116 visits were identified (62 unique patients; 13% of total visits). Approximately 50 percent were identified on more than two visits. The majority of at-risk assessments were harm risk assessments (42%), followed by CGAS (32%), and CGI (26%). Within the harm risk assessment, the majority identified suicidal ideation (53%) but none with a suicide plan. Conclusions: Systematic data extraction from an EMR is a plausible means for delivering feedback on patient risk within a child psychiatry fellow outpatient clinic. The creation of such a system has the potential to identify patients based on current severity of illness, relative worsening from initial presentation, and risk of harm to self or others. Timely data-driven feedback can inform supervision regarding clinical decision making and promote quality assurance and performance improvement in delivery of care.

QA, REST, RF

2.17 A PEDIATRIC PSYCHOPHARMACOLOGY FEASIBILITY TRIAL OF THE NATIONAL PROJECT ECHO APPROACH IN RURAL PRIMARY CARE Sharon E. Cain, MD, University of Kansas Medical Center, [email protected]; Susan Sharp, DO, University of Kansas, [email protected]; Eve-Lynn Nelson, DrPH, University of Kansas, [email protected]; Shawna Wright, DrPH, University of Kansas Center for Telemedicine, swright6@ kumc.edu; Julie Laverack, Community Health Center of Southeast Kansas, [email protected] Objectives: Our Health Resources and Service Administration (HRSA)funded project uses technology to extend child behavioral access to eight rural Kansas counties, with approximately 30 percent of children in poverty and no child psychiatrists based in the region. Using secure videoconferencing, the Project ECHO (Extension for Community Healthcare Outcomes) comanagement model links rural primary care providers with child psychiatrists and psychologists for one-hour accredited telementoring sessions, including de-identified cases and brief didactics. Methods: As one of the first pediatric psychopharmacology ECHOs in the country, the feasibility trial will summarize findings from surveys and interviews. It will describe the following: 1) developing an accredited curriculum and case format, leveraging community feedback, AACAP practice standards, and Riddle’s Pediatric Psychopharmacology book; 2) adapting training protocols, including reminders to follow HIPAA best practices; and 3) recruiting and retaining sites. Results: Across eight one-hour sessions, there were 14 total participants and 4 presenters on the ECHO expert panel. Attendance per session ranged from four to 13 participants. All elements of the national ECHO model were feasibly implemented. Finding a consistent meeting time across sites and expert panelists was the largest challenge. There were minimal challenges with the secure videoconferencing solution, likely due to pre-training and ongoing technical support. Preliminary findings suggest that the greater the number of sessions attended, the greater impact on self-reported knowledge and confidence around best practices. Didactic topic areas of highest interest were assessing hallucinations/delusions and disruptive mood dysregulation disorder. Conclusions: The results indicate the pediatric psychopharmacology ECHO was feasible and well received by rural practitioners and the expert panel. Utilizing a quality improvement approach, the lessons learned strengthened upcoming ECHO series. Updates include: 1) inviting a broader audience, including primary care, community mental health, and school personnel; 2) linking ECHO telementoring with telemedicine follow-up; and 3) linking participation in ECHO with patient outcomes, including incorporating claims data.

RP, CC, CON Supported by the Health Resources and Services Administration http://dx.doi.org/10.1016/j.jaac.2017.09.097

2.18 MANDATORY MEDICATION CONSULTATION SERVICES AND ANTIPSYCHOTIC PRESCRIBING PRACTICES FOR MEDICAID-INSURED YOUTH IN WASHINGTON STATE Erin Dillon-Naftolin, MD, University of Washington and Seattle Children’s Hospital, erin.dillon-naftolin@ seattlechildrens.org; Aditi Sharma, MD, University of Washington and Seattle Children’s Hospital, aditi.sharma@ seattlechildrens.org; Douglas Russell, MD, University of Washington and Seattle Children’s Hospital, doug.russell@ seattlechildrens.org; William P. French, MD, University of Washington and Seattle Children’s Hospital, william.french@ seattlechildrens.org; Robert J. Hilt, MD, University of Washington, [email protected]


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Objectives: Washington State Medicaid operates a medication consultation service for youth, requiring provider of psychosis treatment to offer telephone consultations with a clinical record review based on age/dose/combination criteria. This study examines predictors of the most restrictive version of consultant feedback (to require a prescription change for continued authorization) and documents changes in Medicaid antipsychotic drug use rates over the timeframe under consideration. Methods: A total of 1,750 mandatory antipsychotic medication reviews completed from January 2009 to June 2017 were analyzed by child age at time of review, number of antipsychotic drugs prescribed, and specific antipsychotic drug prescribed. Statewide antipsychotic drug use rate trends across the first four years of this time period were evaluated. Results: Antipsychotic drug denial recommendations varied by age. For children under age 5 years, a prescription “change required” outcome of review (essentially a denial) occurred in 11.6 percent of reviews; between ages 5 and 12 years, a change required outcome occurred in 9.5 percent of reviews; and for ages 13 years and up, a change required outcome occurred in 8.3 percent of reviews. The rate of change required recommendations were higher (10.2%) when two or more antipsychotic drugs were part of the review compared with when just one antipsychotic drug as triggered by young age or high dose was reviewed (9.3%). Specific antipsychotic drugs associated with change required recommendations varied from a low of 6.25 percent for paliperidone and 6.33 percent for firstgeneration antipsychotic drugs to a high of 11.4 percent for lurasidone. Statewide antipsychotic drug use rates declined from 0.53 percent in January 2009 to 0.25 percent in December 2013. Conclusions: Child psychiatrists performing provider-to-provider medication review consultations were more likely to make antipsychotic prescription drug change recommendations when children were of a younger age and when children were being prescribed more than one antipsychotic drug. Over the first four years of the mandatory antipsychotic drug review system, there was a nearly 50 percent reduction in all antipsychotic drug prescribing for Medicaidinsured youth in Washington State.

APS, PUP, CON http://dx.doi.org/10.1016/j.jaac.2017.09.098

2.19 A CRITICAL INTERVENTION AT A CRITICAL TIME: PROVIDING ACCESS TO PEDIATRIC MENTAL HEALTH CARE THROUGH A COLLABORATIVE CARE MODEL Scott B. Falkowitz, DO, Northwell Health, sfalkowitz@ northwell.edu; Rajvee P. Vora, MD, Northwell Health Care Solutions, [email protected]; Carla Gabris, PhD, Northwell Health, [email protected]; Andrew Tucci, Northwell Health Care Solutions, [email protected]; Christina D. Gerdes, MD, Northwell Health, cgerdes1@ northwell.edu Objectives: Half of all lifetime mental illnesses begin by age 14 years, with early intervention providing an opportunity to reduce long-term morbidity. Approximately 75 percent of children and adolescents with psychiatric disorders are seen in the pediatrician’s office, but multiple barriers impede execution of mental healthcare delivery. At present, the collaborative care model has the most robust research evidence base for improving quality of care, health outcomes, lowering costs, and increasing satisfaction for both patients and pediatricians. This project used the collaborative care model in a primary care pediatric clinic to demonstrate effective treatment of mild to moderate depression and anxiety. Methods: Following the collaborative care model, a behavioral healthcare manager (BHCM) was integrated into a primary care clinic five days a week. The BHCM assists the primary care provider (PCP) with the identification and treatment of patients with behavioral health conditions. The BHCM provides a range of services, including patient education, short-term evidence-based psychotherapy, monitoring of treatment response, and facilitating psychiatric consultation between the PCP and their supervising


psychiatrist. The BHCM tracks each patient in a HIPAA-protected registry, which was used to monitor clinical outcomes, including the number of patients seen, office visits, emergency department diversions, outside behavioral health referrals, initiation of psychotropic medications, and average change in PHQ-9 (Patient Health Questionnaire) scores. All of the outcome measures reflect collaborative care provided from September 2016 to November 2016. Results: The BHCM saw a total of 126 patients over a total of 246 office visits. There were 14 emergency department diversions. The BHCM assisted with 31 outside behavioral health referrals. A total of 20 patients were started on a psychotropic medication by the PCP, with consultation from the psychiatrist. The average PHQ-9 decreased by nine percent during this period. Conclusions: Implementation of the collaborative care model in this setting was successful at enhancing access to effective evidence-based behavioral health treatment, decreasing the number of avoidable emergency department visits, and helping to deliver efficient mental health care to a population in dire need of it.

EBP, CON, TREAT http://dx.doi.org/10.1016/j.jaac.2017.09.099

2.20 PILOT IMPLEMENTATION OF THE INTERVENTURE MODEL OF INTEGRATED TARGETED PREVENTION AND COLLABORATIVE MENTAL HEALTH CARE FOR ADOLESCENTS Kristine Gagnon Lafond, MS, CHU Sainte-Justine Research Center, [email protected]; Olive Mukamana, MSc, CHU Sainte-Justine Research Center, [email protected]; Radhia Ben Amor, CHU SainteJustine Research Center, [email protected]. ca; Mohammad H. Afzali, PhD, Universit e de Montr eal, [email protected]; Patricia Conrod, PhD, CHU SainteJustine Research Center, [email protected] Objectives: The Inter-Venture model consists of three intervention modalities: 1) systematic school-based screening and personality-targeted interventions for students most at risk of mental health problems and substance misuse (Preventure program); 2) parent program designed to strengthen parenting skills and to improve the management of child behavior problems (Cope/ EQUIPE program); and 3) integrated services provided by a multidisciplinary team of professionals (Inter-Action services) for youth with significant symptoms of mental health problems, substance misuse and/or psychosocial difficulties. We present the preliminary results of a pilot implementation of the model aimed at assessing its feasibility and informing its scale-up. The later will involve a cluster-randomised trial to assess the effectiveness of the model across the Montreal area Methods: Based on their scores on the Substance Use Risk Profile Scale, atrisk students in seventh grade were invited to participate in the Preventure program. Parents of seventh grade students reporting discord at home were also invited to participate in the parent program. Participating students with clinically significant internalizing and externalizing problems were invited to receive Inter-Action services. Activity logs, observations, and satisfaction surveys are also used to assess the implementation of the model. Results: Thirty-three students and six parents participated in the first phase of the ongoing pilot study. The low participation rate was mainly due to the timing of program delivery which coincided with the end of the school year. The screening showed that 41.6 percent of participating seventh grade students were at risk for substance use and mental health problems and 70 percent participated in the Preventure program. Eight out of 10 students with clinically significant problems received Inter-Action services, while two declined services. T-test comparing pre- and post-care scores indicated significant reductions of self-report internalizing (t ¼ 3.3, p 24 hours without significant developmental delay or neurologic injury were recruited. Daily screens for delirium were conducted with the Cornell Assessment of Pediatric Delirium (CAPD) and Pediatric Confusion Assessment Method for the ICU (PCAM). Delirium positive children were referred to psychiatry. All children had cognitive testing done at time of transfer with the Children’s Memory Scale (CMS). Other medical data were collected via chart review. Results: Children (N ¼ 53) were recruited (mean age ¼ 11 years, 51% male), with a variety of ethnic backgrounds. Forty-two percent of children screened positive for delirium. Psychiatry confirmed the diagnosis in 54 percent of them (23% of the total number). Children performed at 0.05). Conclusions: Our results suggest that connectivity between the amygdala and DLPFC, a region critical to behavioral regulation, may be important to treatment response. These findings provide new insight in the neural circuits involved in adolescent MDD and the way treatment may impact those circuits needed to yield symptom improvement. This preliminary evidence suggests the presence of a neuroimaging-based biomarker of treatment response in adolescent depression.

ADOL, IMAGS, DDD Supported by NIMH Grant R01MH085734 and Veteran’s Affairs Merit Award I01-CX000715 http://dx.doi.org/10.1016/j.jaac.2017.09.137

2.58 METHYLENE TETRAHYDROFOLATE REDUCTASE (MTHFR) ALLELE FREQUENCY IN A REFRACTORY MAJOR DISRUPTIVE DISORDER POPULATION Thomas J. Zimmer, MD, University of Pittsburgh School of Medicine, [email protected]; Lisa Pan, MD, Western Psychiatric

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Institute and Clinic, [email protected]; Lora L. Mcclain, PhD, University of Pittsburgh, mcclainll2@mwri. magee.edu; Anna M. Segreti, MA, Western Psychiatric Institute and Clinic, [email protected]; David A. Brent, MD, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, [email protected]; Gerard Vockley, PhD, Children’s Hospital of Pittsburgh, gerard, [email protected]; David Peters, PhD, MageeWomens Research Institute, [email protected]; David N. Finegold, MD, University of Pittsburgh, [email protected] Objectives: An estimated 15 percent of depressed individuals do not respond to current pharmacotherapy, psychotherapy, and even electroconvulsive treatment. A preliminary metabolomic study of patients undergoing treatment for refractory major depressive disorder (TR-MDD) implicated CNSspecific errors of metabolism as a potential factor of treatment refractory depression. It is significant that these errors of metabolism may be targeted by existing therapies. Continuation of this research includes whole-exome analysis to identify genetic factors that may contribute to these errors. The goal of this poster is to characterize the methylene tetrahydrofolate reductase (MFTHR) allelic frequencies within this population, which previously has been used to guide treatment decisions regarding L-methylfolate supplementation. Methods: Urine, blood serum, and cerebrospinal fluid samples were gathered from 64 adolescent and young adult participants with wellcharacterized histories of treatment refractory depression (at least three maximum-dose, adequate-duration medication treatments). Metabolomic and whole-exome testing were performed. Methylenetetrahydrofolate reductase genotypes analyzed for the variant single polymorphism nucleotides of C677T and A1305C. Results: For position 667, 25 (39%) participants were homozygous for the wild type, 33 (51%) were heterozygous for C667T, and six (9%) were homozygous for C667T. For position 1305, 35 (55%) were homozygous for wild type, 24 (38%) were heterozygous for A1305C, and five (8%) were homozygous for A1305C. Eleven participants (17%) demonstrated with heterozygosity for both sites. Conclusions: Medicine practitioners (including psychiatrists) are becoming increasingly adroit with the use of pharmacogenetics in the pursuit of “personalized medicine.” Given the relatively low cost and very low risk of harm with L-methylfolate treatment, its broader use for patients undergoing TR-MDD should be considered, especially in light of the ready availability of clinical pharmacogenetic assays and the prevalence of MTHFR loss-of-function mutations in the TR-MDD population.

NECHEM, DDD, S Children's Hospital of Pittsburgh Foundation Grant 00999982077-9500 http://dx.doi.org/10.1016/j.jaac.2017.09.138

2.59 CHANGES IN RESTING-STATE FUNCTIONAL CONNECTIVITY AFTER TWELVE WEEKS OF SERTRALINE IN YOUTH WITH OBSESSIVECOMPULSIVE DISORDER (OCD) Gail A. Bernstein, MD, University of Minnesota, berns001@ umn.edu; Kathryn R. Cullen, MD, University of Minnesota Medical School, [email protected]; Elizabeth C. Harris, MA, University of Minnesota, [email protected]; Alexandra Zagoloff, PhD, University of Minnesota Medical Center, [email protected]; Christine Conelea, PhD, University of Minnesota Department of Psychiatry, cconolea@ umn.edu; Patricia Carstedt, BA, University of Minnesota, [email protected]; Susanne Lee, PhD, University of Minnesota,

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[email protected]; Bryon A. Mueller, PhD, University of Minnesota, [email protected] Objectives: Although frontal-striatal-thalamic-cortical (FSTC) circuitry has been implicated in OCD, no studies have examined the effects of psychopharmacological treatment on functional connectivity in FSTC circuitry in pediatric OCD. This study investigates how sertraline, a selective serotonin reuptake inhibitor, impacts resting-state functional connectivity (RSFC) in medication-free youths with OCD. Methods: Participants (n ¼ 14 with OCD, 14 control subjects) completed two fMRI scan sessions (baseline, 12 weeks). Between scan sessions, participants with OCD received 12 weeks of sertraline (control subjects received no intervention). RSFC was examined using a seed-based, whole-brain analysis with six striatal regions of interest (ROIs) determined by FreeSurfer (bilateral caudate, putamen, nucleus accumbens). Voxelwise z threshold ¼ 2.3 and cluster threshold of P < 0.008 (Bonferroni corrected for six analyses) were used for testing significance. Within-groups RSFC change for each ROI was examined with pairedsample t-tests. Subsequently, two-way repeated measures ANOVAs (voxelwise z threshold ¼ 2.3 and cluster threshold of P < 0.008) were used to identify (at the whole-brain level) group differences in the pattern of change in connectivity for each ROI. Results: Within OCD, comparison of pre- to postsertraline revealed a significant increase in RSFC between right putamen and a cluster in the left hemisphere, including insula, frontal pole, and parts of temporal, parietal, and opercular cortices. Insula showed the greatest increase in connectivity with putamen. ANOVA results showed significant increase in connectivity between pre- and posttreatment in OCD compared with control subjects between right putamen and left insula and left frontal cortex. Similar findings were found for left putamen. For right caudate, there was increase in connectivity with pre- and postcentral cortex over time in subjects with OCD. Conclusions: Following sertraline, participants with OCD showed increase in RSFC in FSTC circuitry (i.e., putamen with frontal area) and between the putamen and parts of the salience network (e.g., insula and operculum). These preliminary findings suggest that FSTC circuitry and salience network are important in pediatric OCD and identify brain areas and connections that could be targets for developing novel interventions for pediatric OCD.

PPC, IMAGS, OCD Supported by P41EB015894

NIH

Grants

5R21MH101395-02,

1P30NS076408,

and


2.60 AUTISM TRAITS IN PEDIATRIC OBSESSIVE-COMPULSIVE DISORDER: ASSOCIATION WITH ORDERING, HOARDING, AND WASHING Sai Phani Sree Cherukuri, MD, Sri Manakula Vinayagar Medical College and Hospital, [email protected]; Diksha Yadav, Maulana Azad Medical College, [email protected]; Meghan McCan, Colgate University, [email protected]; Marco Grados, MD, MPH, Johns Hopkins University, [email protected] Objectives: Traits of autism are present in neurotypical children, yet can be increased in neurodevelopmental disorders, such as Tourette’s disorder and pediatric OCD. Autism traits can include deficits in social cognition, communication, motivation, and repetitive movements (mannerisms). A refined understanding of the range of autism traits and their phenomenological pediatric OCD correlates can lead to more targeted treatments for these features in children with OCD. Methods: A sample group of pediatric patients with OCD (n ¼ 87) was assessed through institutional review board-approved clinical and

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research pediatric OCD studies. Caretakers completed the Social Responsive Scale (SRS-1), a population-normed instrument, to catalog the presence of autism traits. t-tests and linear regressions tested the association between OCD phenomenology (OCD symptom factors such as contamination/washing, obsessional worries, aggressive-somatic, checking-counting-repeating, ordering-hoarding) and t-scores for autism traits (global score, social cognition, mannerisms, social communication, social awareness, social motivation). Results: Of the 87 children with OCD, 55 were male (63%) and 32 were female (37%), whereas the mean age was 12.22 3.46 years. In this sample group of pediatric patients with OCD, females had worse social cognition (59 2.8 vs. 51 1.8; P ¼ 0.02), social motivation (59.5 2.5 vs. 52.7 1.9; P ¼ 0.03), and social communication (57.1 3.2 vs. 48.9 1.5; P ¼ 0.01) than males. Among the five OCD factors, the contamination/washing factor was associated with more mannerisms (P ¼ 0.04), whereas the hoarding-ordering factor was associated with higher total SRS scores (P ¼ 0.01). Among the symptoms, aggressive obsessions (fear of harm) (P ¼ 0.02) and ordering compulsions (P ¼ 0.002) were associated with total SRS scores. For SRS subscales, washing compulsions, but not contamination obsessions, were associated with poor social cognition (P ¼ 0.03), low social motivation (P ¼ 0.008), and more mannerisms (P ¼ 0.007). Conclusions: Children with OCD, especially females, with eminently compulsive symptoms (ordering-hoarding, washing), have an excess of broad autism traits. Children who predominantly exhibit compulsive symptoms and higher autism traits may benefit from more behaviorally based interventions than those who mostly show obsessional symptoms.

ASD, DEMF, OCD http://dx.doi.org/10.1016/j.jaac.2017.09.140

2.61 IMMUNOGLOBULIN DEFICIENCIES IN PEDIATRIC OBSESSIVE-COMPULSIVE DISORDER Jennifer Fehring, BA, Massachusetts General Hospital, [email protected]; Kyle Allen Williams, MD, Massachusetts General Hospital, [email protected]; Suraj Srvode Mothi, MPH, Massachusetts General Hospital, [email protected]; Leag Shorser-Gentile, BA, Massachusetts General Hospital, lshorser-gentile@ partners.org Objectives: Previous investigations suggest that children with pediatric OCD may have an increased rate of immunoglobulin deficiencies. Methods: This retrospective cohort study, conducted using electronic health records of a large New England hospital system, identified 381 children and 2,667 adults diagnosed with OCD who also had undergone testing for serum levels of either IgA, IgG, or IgM immunoglobulin. The rate of immunoglobulin deficiencies and serum immunoglobulin levels in pediatric OCD were compared with children diagnosed with autism spectrum disorder (ASD), tic disorder, ADHD, anxiety disorder, and celiac disease. Results: Compared with the pediatric OCD cohort, the ASD and anxiety disorder cohorts displayed a significantly lower likelihood of IgA deficiency [OR ¼ 0.39 (95% CI ¼ 0.19–0.76) and OR ¼ 0.44 (95% CI ¼ 0.25– 0.78), respectively]. Children with OCD also displayed significantly lower likelihood of IgG deficiency compared with cohorts with tic disorder, celiac disease, ASD, and ADHD. Adults with OCD were also significantly less likely than children with OCD to display deficient IgA [OR ¼ 0.24 (95% CI ¼ 0.13–0.43)]. Conclusions: Children with pediatric OCD display increased rates of immunoglobulin deficiencies and lower serum immunoglobulin levels compared with children with other neuropsychiatric disorders. Future research is needed to expand and replicate these results, as well as understand whether this impacts the clinical course of pediatric OCD.

TICS, TD, OCD http://dx.doi.org/10.1016/j.jaac.2017.09.141


2.62 THE DISGUST PROPENSITY AND SENSITIVITY SCALE-REVISED: PSYCHOMETRIC PROPERTIES IN A SAMPLE OF YOUTH WITH OBSESSIVE-COMPULSIVE DISORDER AND ANXIETY Christopher F. Georgiadis, BA, Brown University Alpert Medical School, [email protected]; Meghan Schreck, PhD, Brown University Alpert Medical School, [email protected]; Joshua Kemp, PhD, Brown University Alpert Medical School, Joshua.Kemp@ Lifespan.org; Jennifer Freeman, PhD, Brown University Alpert Medical School, [email protected]; Abbe Garcia, PhD, Brown University Alpert Medical School, AGarcia2@Lifespan. org; Brady G. Case, MD, Brown University Alpert Medical School, [email protected] Objectives: Disgust is a negative emotional response to a physically or morally offensive stimulus. Studies that examine disgust within the context of OCD and anxiety have identified disgust propensity (DP) and sensitivity (DS) as two constructs that are differentially associated with diagnoses. DP has been defined as the likelihood an individual will feel disgust, and DS has been defined as the degree to which an individual is distressed by disgust. Although existing instruments tend to assess DP and DS in the context of specific diagnoses, only the Disgust Propensity and Sensitivity Scale-Revised (DPSS-R) transdiagnostically measures both constructs. To date, it has only been validated with an adult, nonclinical sample group. We aimed to validate the DPSS-R for youth with OCD and anxiety disorders and hypothesized that its two-factor structure would be confirmed. Methods: Participants were youth (N ¼ 145; aged 7–18 years) receiving treatment for OCD or showing anxiety at the intensive program for OCD. Patients completed the DPSS-R and the Obsessive-Compulsive Index– Child Version (OCI-CV) at admission. A two-factor confirmatory factor analysis using Mplus, version 7.3 was used to test the fit of the DPSS-R. All models were evaluated using five fit statistics, including the Chi-square test, root mean square error of approximation (RMSEA), comparative fit index (CFI), Tucker-Lewis Index (TLI), and standardized root mean square residual (SRMR). Results: The model was shown to have adequate fit, c2 (85) ¼ 162.46, P < 0.01; RMSEA ¼ 0.079 (90% CI ¼ 0.061, 0.098); CFI ¼ 0.91; TLI ¼ 0.89; SRMR ¼ 0.066, and good convergent and discriminant validity (P < 0.01). Differences from previous findings were found with respect to items within each factor. In the current study, item 13 (“I worry that I might swallow a disgusting thing”) loaded onto DP and item 6 (“disgusting things make my stomach rumbly or feel funny”) loaded onto DS. Item 7 (“I scrunch up my face in disgust”), which loaded onto DP in the original study, did not load highly on either factor in the present study. Conclusions: These findings support the two-factor structure of the DPSS-R. The validation of this measure in a pediatric clinical sample group may provide more specific information about disgust levels across anxiety disorders. The small sample size may be a limitation of this study and may have contributed to item discrepancies within factors.

AD, OCD Supported by Bradley Hospital Intensive Program for OCD http://dx.doi.org/10.1016/j.jaac.2017.09.142

2.63 A FACTOR ANALYSIS OF THE LEYTON OBSESSIONAL INVENTORY–CHILD VERSION (LOI-CV) IN A POPULATION GREEK NATIONAL SCHOOL-BASED SURVEY Chang Kim, BA, Seoul National University College of Medicine, [email protected]; Mustafa Hassan Alvi, Jinnah Sindh Medical University, [email protected]; Katherine Ballen, Johns Hopkins University, katherinelballen@

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gmail.com; Marco Grados, MD, MPH, Johns Hopkins University, [email protected] Objectives: OCD traits measured in pediatric population sample groups can better define the phenotype of obsessive-compulsive disorder and obsessive-compulsive personality disorder (OCPD). The current study aims to delineate the adolescent population phenotypic profile of OC traits, using model-fitting procedures that include a bifactor model. Methods: A sample group of 2,552 adolescents from a Greek national sample group were surveyed using the Leyton Obsessional Inventory– Child Version (LOI-CV). The LOI-CV is a 20-item quantitative measure of obsessive-compulsive traits; positive answers are scored by a 0–3 severity index. An exploratory factor analysis (EFA) on half of the sample group (n ¼ 1,276) with varimax rotation yielded the test model. A confirmatory factor analysis (CFA) on the other half of the group (n ¼ 1,276) tested the fit of the EFA and alternative models as follows: 1) a unidimensional model (single factor influences every symptom); 2) correlated symptom factor model; 3) a higher-order factor model (symptom factors correlate with higher-order factors, with compulsions and obsessions being the higher-order factors); and 4) a bifactor model (a general factor covaries with every symptom but is independent [orthogonal of (nuisance) symptom factors]. The best-fit model in the CFA was also tested on the whole sample group (N ¼ 2,552). Fit parameters were as follows: c2, P > 0.05; Comparative Fit Index (CFI) > 0.95; Tucker Lewis Index (TLI) > 0.95; and root mean square error of approximation (RMSEA) < 0.06. Results: The EFA yielded a four-factor model: 1) obsessions/worries; 2) contamination/washing; 3) counting/superstitions; and 4) checking. In the CFA, the unidimensional model had the least optimal fit (CFI ¼ 0.77; TLI ¼ 0.75; RMSEA ¼ 0.092), whereas the four-factor model had a better fit (CFI ¼ 0.92; TLI ¼ 0.91; RMSEA ¼ 0.055). The higher-order factor model had a comparable fit to the four-factor model (CFI ¼ 0.92; TLI ¼ 0.90; RMSEA ¼ 0.057), but the bifactor model had the best fit (CFI ¼ 0.94; TLI ¼ 0.93; RMSEA ¼ 0.05). The symptoms that contributed the most to the bifactor can be labeled as perfectionism (items: 9, 3, and 11), and the symptoms that contributed the least to the bifactor were related to counting/superstitions (items: 19, 14, and 20). Conclusions: Perfectionism is a general trait that underlies other more specific obsessive-compulsive symptoms, such as contamination/washing, worries/ obsessions, and compulsive behaviors in adolescents, and may be a general risk factor for OCD/OCPD.

EPI, OCD Supported by NIH K23MH066284 http://dx.doi.org/10.1016/j.jaac.2017.09.143

2.64 PARENT AND CHILD STRESS REACTIVITY AND FAMILY FUNCTIONING IN PEDIATRIC OBSESSIVE-COMPULSIVE DISORDER Jocelyn P erez, BA, University of California, Los Angeles, [email protected]; Michelle Rozenman, PhD, University of California, Los Angeles, [email protected]; Hardian Thamrin, BA, University of California, Los Angeles, [email protected]; Tara S. Peris, PhD, University of California, Los Angeles, [email protected] Objectives: Poor family functioning is a common correlate of pediatric OCD, and it predicts diminished treatment response to CBT. Despite these links, understanding how poor family functioning undermines treatment outcome is limited. Building on work in related fields, we examine the possibility that poor family functioning is associated with alterations in both parent and child stress reactivity, as measured via multiple markers of arousal. We then test these markers as predictors of change in family functioning following intervention.

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Methods: A total of 25 youth (ages 8–17 years, mean ¼ 13.08 years, SD ¼ 2.78) with a primary OCD diagnosis were recruited via a larger RCT comparing two different family-based CBT interventions [standard treatment and positive family interaction therapy]. Electrodermal activity, heart rate (HR), respiratory sinus arrhythmia (RSA) were obtained from parent and child at rest during the pretreatment assessment. Family functioning domains were assessed via clinical interview and selfreport (accommodation, blame, conflict, and cohesion) at pre- and posttreatment. Results: Partial correlations controlling for OCD severity revealed that, at pretreatment, higher child HR was associated with poorer family cohesion (r ¼ 0.56, P ¼ 0.005) and blame (r ¼ 0.47, P ¼ 0.02), and higher parent RSA was associated with greater parental accommodation (r ¼ 0.48, P ¼ 0.02). Controlling for the effects of treatment, child HR was a significant predictor of improvements in family cohesion (P ¼ 0.03) and blame (P ¼ 0.02), parent RSA did not predict reduction in accommodation (P ¼ 0.07). Conclusions: Findings provide preliminary support for a relationship between child and parent autonomic arousal and poor family functioning and point to psychophysiology as a potential predictor of change in family functioning following intervention. Implications for tailoring treatment to better address both parent and child arousal are discussed.

FT, STRESS, OCD Supported by NIMH Grants K23MH085058 and R03MH099199 http://dx.doi.org/10.1016/j.jaac.2017.09.144

2.65 NEURAL CORRELATES OF INHIBITORY CONTROL IN YOUTH WITH TRICHOTILLOMANIA AND OBSESSIVE-COMPULSIVE DISORDER Giulia C. Salgari, MS, University of California, Los Angeles, [email protected]; Joseph O’Neill, PhD, University of California, Los Angeles, [email protected]; Susanna Chang, PhD, University of California, Los Angeles, [email protected]; John Piacentini, PhD, University of California, Los Angeles, [email protected]; Tara S. Peris, PhD, University of California, Los Angeles, tperis@ mednet.ucla.edu; Sandra K. Loo, PhD, University of California, Los Angeles, [email protected] Objectives: Trichotillomania (TTM) is characterized by recurrent hair pulling, resulting in hair loss, and clinically significant distress or impairment in important areas of functioning. TTM shares several clinical characteristics with OCD; however, little is known about the neural mechanisms underlying TTM and OCD. In this study, we compare OCD, TTM, and healthy control (HC) subjects in error-related negativity (ERN), a neural correlate thought to represent performance monitoring. Methods: Age-matched groups of females (ages 9–17 years; mean ¼ 13.5 years) with DSM-5-diagnosed TTM (n ¼ 8) and OCD (n ¼ 8) were compared with healthy control (n ¼ 8) subjects. ERN activity at a frontocentral midline channel (FCz) was recorded while participants performed an Eriksen flanker task. Consistent with previous research, ERN was scored as the mean negative amplitude at 0–100 ms after incorrect responses. Pairwise differences between diagnostic groups were tested via subject’s t-test. Results: The ERN amplitudes were larger (i.e., more negative) in the OCD (mean ¼ 7.6 mV, SE ¼ 2.7) and TTM (mean ¼ 3.8 mV, SE ¼ 1.2) groups relative to the HC [mean ¼ 0.3 mV, SE ¼ 0.9; t(14) ¼ 2.5, P < 0.05] subjects, with a trend toward significance between the OCD and TTM groups [t(14) ¼ 2.0, P ¼ 0.06]. Performance on the flanker task did not differ by diagnostic group for accuracy (mean ¼ 77%; P > 0.1) and reaction time (mean ¼ 677 ms; P > 0.1). The OCD group exhibited less reaction time (RT) variability (mean ¼109 ms) compared with the

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HC group [mean ¼ 153 ms; t(14) ¼ 3.0, P ¼ 0.01] and trended toward significance compared with TTM [mean ¼ 136 ms; t(14) ¼ 1.96, P ¼ 0.07]. TTM and HC groups were not significantly different in RT variability. Conclusions: This is the first study to compare cognitive and neurophysiological mechanisms among children with trichotillomania and OCD and healthy control subjects and the first study to measure the ERN in TTM. Overall, the TTM group appears to be a milder phenotype compared with OCD, with ERN amplitudes and reaction time variability intermediate between HC and OCD groups. The ERN results suggest hyperactive error monitoring, consistent with the characteristic compulsive behaviors of OCD and TTM. Lower RT variability in the OCD relative to the HC and TTM groups suggests a more rigid, less adaptable response style among girls with OCD. These preliminary findings require replication in larger sample groups.

IMAGS, OCD, TRIC Supported by NIH Grant NS97484 http://dx.doi.org/10.1016/j.jaac.2017.09.145

2.66 REDUCING DIFFERENT TYPES OF FAMILY ACCOMMODATION FOR FAMILIES OF YOUTH WITH OBSESSIVE-COMPULSIVE DISORDER: COMPARISON OF TWO FAMILY INTERVENTION APPROACHES Hardian Thamrin, BA, University of California, Los Angeles, [email protected]; Jocelyn Perez, BA, University of California, Los Angeles, [email protected]; Michelle Rozenman, PhD, University of California, Los Angeles, [email protected]; Tara S. Peris, PhD, University of California, Los Angeles, [email protected] Objectives: Accommodation is common among families of youth with OCD and predicts poorer response to treatment. Although often treated as a global construct, accommodation encompasses a variety of maladaptive responses to OCD (e.g., providing reassurance, enabling avoidance, participating in rituals). Few studies examine how treatment impacts specific domains of symptom involvement. Methods: We draw on data from a randomized controlled trial comparing standard family treatment (ST) to positive family interaction therapy (PFIT). Eligible youth (N ¼ 62, mean age ¼ 12.69 years; 57% male) had a primary diagnosis is OCD and indicators of poor family functioning. They completed the Family Accommodation Scale (FAS) at regular intervals throughout treatment. It contains four subscales: ritual participation; routine modification; distress; and consequences when refraining. Results: Linear mixed models (LMM) analyses revealed significant group x time interactions for participation, modification and consequences subscales (p ¼ 0.016, 0.013, and 0.047, respectively), with significantly lower participation (mean difference ¼ -3.42, SE ¼ 1.38, p ¼ 0.016), modification (mean difference ¼ -3.00, SE ¼ 1.17, p ¼ 0.013), and consequences (mean difference ¼ -1.82, SE ¼ 1.38, p ¼ 0.047) in the PFIT, compared to ST group at post-treatment. There was a group x time interaction that approached significance for the distress subscale (p ¼ 0.067). Conclusions: Results suggest that PFIT produces greater reductions across multiple domains of accommodation compared to ST. Future work is needed to identify predictors of change in accommodation as well as specific therapeutic techniques associated with these changes.


FT, OCD Supported by NIMH Grants K23MH085058 and R03MH099199 http://dx.doi.org/10.1016/j.jaac.2017.09.146

2.67 IMMUNE-MEDIATED COMORBIDITIES IN CHILDREN WITH OBSESSIVE-COMPULSIVE DISORDER AND THEIR FIRST-DEGREE RELATIVES Clara Westwell-Roper, MD, PhD, British Columbia Children’s Hospital Research Institute and University of British Columbia, [email protected]; Fern Jaspers-Fayer, PhD, British Columbia Children’s Hospital Research Institute and University of British Columbia, [email protected]; S. Evelyn Stewart, MD, British Columbia Children’s Hospital Research Institute and University of British Columbia, [email protected] Objectives: Immune-mediated neuronal dysfunction may contribute to the pathogenesis of OCD in a subset of patients with childhood-onset disease. Despite speculation about shared genetic or environmental risks, little is known about autoimmune and inflammatory disease comorbidities in patients with OCD. We determined the prevalence of immune-related disorders in a large cohort of children with OCD and their first-degree relatives. Methods: Medical questionnaires were completed by parents of consecutive consenting patients attending a baseline assessment at the British Columbia Children’s Hospital OCD clinic between October 2011 and March 2017. OCD diagnosis was determined by the Anxiety Disorders Interview Schedule-IV. OCD severity was assessed with the Children’s Yale-Brown Obsessive-Compulsive Scale (CYBOCS) and Florida Obsessive-Compulsive Inventory (FOCI). Data were analyzed with one- or two-sample t-tests and Spearman’s rank correlation and are reported as prevalence with 95 percent adjusted Wald interval or mean 95 percent confidence interval. P values were adjusted for multiple comparisons using the Bonferroni method. Results: Compared with age-matched Canadian survey data, our clinic population reported a higher prevalence of Crohn’s disease (1.9 [0.4–5.8]% vs. 0.5–0.1%, P ¼ 0.008, n ¼ 155), eczema (36.5 [29.4–44.3]% vs. 10–20%, P < 0.001, n ¼ 156), and chronic urticaria (9.9 [5.9–16.0]% vs. 0.5-1%, P < 0.001, n ¼ 142) but not allergies (28.2 [21.6–36.1]% vs. 10-30%, p ¼ 1.000, n ¼ 142), asthma (15.9 [11.0–22.5] vs. 8-20%, P ¼ 1.000, n ¼ 157), or infections. Disease prevalence among first-degree relatives was consistent with population rates. There was a modest correlation between age at onset of OCD and eczema (rs ¼ 0.405, P ¼ 0.042, n ¼ 36) but not with other atopic diseases. Children with eczema also reported higher FOCI severity (22.5 1.7 vs. 18.1 1.8, P ¼ 0.020, n ¼ 70). There was no association with CYBOCS or OCD symptom content. Conclusions: These data provide preliminary evidence for high rates of specific systemic inflammatory conditions in children with OCD but not first-degree relatives. Further multicenter-controlled studies are needed to characterize medical comorbidities in this population and may aid in the development of therapeutic strategies targeting the skingut-brain axis.

PYI, CM, OCD http://dx.doi.org/10.1016/j.jaac.2017.09.147

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P, RTX, EA Supported by the AACAP Summer Medical Student Fellowship, which is supported by AACAP's Endowment Fund, and the University of Nebraska Medical Center College of Medicine Research Scholarship http://dx.doi.org/10.1016/j.jaac.2017.09.149

3.2 DIFFERENTIAL EFFECTS OF FOOD INSECURITY AND SOCIOECONOMIC STATUS (SES) ON THE DEVELOPMENT AND TRANSMISSION OF PSYCHIATRIC SYMPTOMS Merelise Ametti, BA, Larner College of Medicine at the University of Vermont, [email protected]; Masha Ivanova, PhD, Larner College of Medicine at the University of Vermont, [email protected]; Robert R. Althoff, MD, PhD, Larner College of Medicine at the University of Vermont, [email protected] Objectives: The present study was conducted to isolate and compare the effects of food insecurity (FI) and socioeconomic status (SES) on child emotional–behavioral health. More specifically, this study examines FI and SES both as direct predictors of child-internalizing and -externalizing symptoms and as mediators of the effects of parental symptomatology. Methods: Participants were 155 clinically referred and community children [aged 7–17 years (mean age ¼ 11.41 years, 63% male] who were accompanied by at least one biological parent. Parent report on the US

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RF, DEV, STRESS Supported by the National Institute of General Medical Sciences Grant P20GM103644 http://dx.doi.org/10.1016/j.jaac.2017.09.150

3.3 DEVELOPMENTAL TIMING OF EXPOSURE TO ADVERSITY PREDICTS DNA METHYLATION IN LATE CHILDHOOD MORE THAN RECENCY OR ACCUMULATION OF EXPOSURE Erin C. Dunn, MPH, ScD, Harvard Medical School, edunn2@ mgh.harvard.edu

ED

Objectives: The aim of this study was to determine location and number of residential treatment centers (RTCs) in the United States, range of treatments offered, patient population characteristics, and health insurance acceptance for children, adolescents, and adults with eating disorders. Methods: RTCs were located from programs listed under residential treatment on the websites of the National Eating Disorders Association (NEDA) and eating disorder (ED) referral in May 2017. RTCs were included if they listed an ED on their website under the DSM-5. The webpage for each program was audited for treatments offered, patient population, health insurance acceptance, and location. After webpage analysis, descriptive statistics were generated. Results: A total of 75 RTCs were listed by NEDA and ED referral (n ¼ 75). Based on data from RTCs, which listed patient population characteristics, all of them treated females, 49 percent treated males and females, 70 percent treated adolescents, and 73 percent treated adults. Nearly all (93%) reported accepting health insurance. The most cited treatment methods were family-involved therapy (88%), CBT (68%), and DBT (65%). Activities such as equine therapy and yoga were offered by 23 and 63 percent of RTCs, respectively. RTCs were represented in 27 states, with California having the highest proportion of RTCs in the United States (19%), followed by Florida (11%). Conclusions: Availability of RTCs treating adolescents and adults seemed to be similar. The lower number of RTCs treating men may be attributed to the higher prevalence of eating disorders in women. Although some evidencebased forms of treatment, such as DBT and CBT, were used by a high proportion of RTCs, other empirically supported treatments, such as familybased/Maudsley therapy and interpersonal therapy, appeared to be underrepresented. Furthermore, the fourth most represented treatment was yoga, which has little empirical support compared with other treatment methods in this study. The high representation of these methods raises the need for further study and effectiveness in settings such as RTCs.

Objectives: Exposure to early life adversity (e.g., in the first two decades of life) is known to predict DNA methylation (DNAm). However, few studies have investigated whether adversity has time-dependent effects based on the age at exposure. Using an innovative two-stage structured lifecourse modeling approach (SLCMA) grounded in least angle regression (LARs), we tested the central hypothesis that there are sensitive periods associated with DNAm, or life stages when adversity induced greater DNAm changes. We tested this sensitive period hypothesis in relation to two alternative explanations: an accumulation hypothesis, in which the effect of adversity on DNAm increases with the number of occasions exposed, regardless of timing, and a recency hypothesis, in which the effect of adversity on DNAm is stronger for more proximal events. Methods: Data for our prospective study came from the Accessible Resource for Integrated Epigenomics Studies (ARIES), a subsample of 1,018 motherchild pairs from the Avon Longitudinal Study of Parents and Children (ALSPAC). Results: After covariate and cell-type adjustment and Bonferroni correction for multiple testing, we identified 40 CpG sites that were differentially methylated following exposure to adversity. Nearly all of these loci (n ¼ 38) were related to adversity exposure in infancy. Financial stress, maternal psychopathology, and neighborhood disadvantage predicted the greatest number of epigenome-wide DNAm changes. Conclusions: These results suggest that the developmental timing of adversity explains more variability in DNAm than the accumulation or recency of exposure. Infancy appears to be a sensitive period when exposure to adversity predicts differential DNAm patterns.

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Jessica B. Thai, BA, University of Nebraska, jessica.thai@ unmc.edu; Daniel E. Gih, MD, Department of Psychiatry, [email protected]

NC

3.1 REVIEW OF THERAPEUTIC OFFERINGS BY RESIDENTIAL TREATMENT CENTERS FOR EATING DISORDERS IN THE UNITED STATES

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NEW RESEARCH POSTER SESSION 3

Department of Agriculture Household Food Security Survey was used to assess FI during the past 12 months. Demographic characteristics and internalizing and externalizing psychiatric symptoms were collected using the Adult Self-Report (ASR) for parents and the Youth Self-Report (YSR) for children. A series of multilevel structural equation models with FI as a latent variable and child age, sex, and IQ as covariates were tested in MPlus v6.0. Results: After controlling for the effects of child age, sex, and IQ, greater FI was related to higher levels of both child-internalizing and -externalizing symptoms, whereas SES was negatively associated only with child-externalizing symptoms. Additionally, FI mediated the pathway between parentinternalizing symptoms and child-internalizing symptoms. SES mediated the effect of parent-externalizing symptoms on both child-internalizing and -externalizing symptoms and the effect of parent-internalizing symptoms on child-externalizing symptoms. Conclusions: Although SES and FI are related concepts, these findings suggest that they have differential effects on child emotional–behavioral wellbeing. In general, FI was a more robust predictor of child psychiatric symptoms, whereas the effects of SES were specific to only child-externalizing problems. However, FI was only related to the intergenerational transmission of internalizing problems, whereas SES mediated the transmission in all other pathways examined. Given that FI has a role separable from SES in the development and transmission of psychiatric symptoms, it is important for mental health clinicians to be educated and trained to assess for FI and for researchers to continue specifically examining the effects of FI and further refining their knowledge of these relationships.

PSP, GS, STRESS

Supported by NIH Grant K01MH102403 and Harvard Catalyst Pilot Grant http://dx.doi.org/10.1016/j.jaac.2017.09.151

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3.4 COMPARISON OF SUBSTANCE TREATMENT OUTCOMES FOR YOUTH WITH AND WITHOUT POSTTRAUMATIC STRESS DISORDER (PTSD) Sean LeNoue, MD, University of Colorado School of Medicine and Denver Health and Hospital Authority, sean. [email protected]; Kristie Ladegard, MD, Denver Health and Hospital Authority, [email protected]; Madelyne Hull, MPH, Denver Health and Hospital Authority, [email protected]; Christian Thurstone, MD, Denver Health and the University of Colorado, Christian.Thurstone@ dhha.org Objectives: Up to 60 percent of youth in substance treatment have a history of emotional, physical, or sexual abuse. Little is known about substance treatment outcomes for youth with PTSD compared with those without PTSD. Such information might inform the need for and type of specific interventions for youth with co-occurring PTSD and substance use disorders. Methods: Participants comprised 82 youths (mean age ¼ 16.6 years) enrolled in four outpatient substance treatment sites in Denver, Colorado from May 2016 to January 2017. All youths were offered 12 weeks of manual-standardized, individual treatment consisting of the following: 1) motivational interviewing; 2) acceptance and commitment therapy; 3) contingency management; 4) family sessions; and 5) medication-assisted treatment. Sessions were audio-recorded monthly for fidelity monitoring. Outcome measures included the following: 1) number of sessions attended (maximum ¼ 12); 2) proportion of days used substances in the past seven days; and 3) urine drug screens. Statistical analyses included descriptive statistics and comparison of those with and without PTSD, with respect to change in the proportion of days used, number of negative urine drug screens, and number of sessions completed in 16 weeks using independent t-test or nonparametric equivalent. The proportion of youths achieving at least a week of abstinence during treatment was compared using a Chi-square analysis. This study was approved by the Colorado Multiple Institutional Review Board. Results: For youths with and without PTSD, 63 versus 59 percent (P ¼ 0.6885) achieved a week of abstinence during treatment, respectively. The median decrease in the proportion of days of substance use was 0.1 for youth with PTSD versus 0.2 for those without PTSD (P ¼ 0.5384). The median number of negative urine drug screens in treatment for those with PTSD versus those without PTSD was 8.0 versus 7.5 (P ¼ 0.8201), respectively. Finally, the number of sessions completed for those with PTSD was 7.3 3.6 versus 7.8 3.6 for those without PTSD (P ¼ 0.5371). Conclusions: There were no statistically significant findings in treatment outcomes between patients diagnosed with and without PTSD who were in substance treatment. This study included a small sample size. Further investigation with more patients is warranted to determine whether substance treatment outcomes are affected by the presence of co-occurring trauma and/ or PTSD.

SUD, TREAT http://dx.doi.org/10.1016/j.jaac.2017.09.394

3.5 TEEN MOTHERHOOD IN CONTEXT: EXAMINING THE RELATIONSHIP BETWEEN TEEN MOTHERHOOD AND CHILDREN’S ANTISOCIAL BEHAVIORS IN PUERTO RICAN YOUTH LIVING IN DIFFERENT SOCIAL CONTEXTS Maria A. Ramos-Olazagasti, Columbia University and the New York State Psychiatry Institute, [email protected]; Glorisa J. Canino, University of Puerto Rico Medical Campus, [email protected]; Hector R. Bird, MD, Columbia University, [email protected]; Cristiane S. Duarte, PhD, Columbia University, [email protected] Objectives: Latinas have the highest teen birth rate in the United States. While considered a public health concern in our society, the implications of teen motherhood for mothers and their children might not be homogenous across racial and ethnic groups or social contexts that vary in


terms of values, norms, and access to opportunities. This study examined the relationship between teen motherhood and children’s antisocial behaviors in a homogenous Latino subgroup of Puerto Ricans in two social contexts. In this study, we tested: 1) whether associations are similar across contexts; and 2) if so, whether children’s exposure to socioeconomic adversity, family dysfunction, and child maltreatment accounts for associations between having a teen mother and children’s antisocial behaviors. Methods: The Boricua Youth Study is a two-site, longitudinal study of Puerto Rican youth ages 5-15 years at baseline (N ¼ 2,491). The samples are representatives of Puerto Rican youth in the South Bronx (SB), New York, and the metropolitan area in San Juan and Caguas, Puerto Rico (PR). Up to three children were sampled per household. Mother’s age at first birth was used to determine teenage (< 19 years) motherhood. Children’s antisocial behaviors were assessed annually over three waves through parental and child report. Explanatory variables were assessed at baseline. We used multilevel models to adjust for the nested structure of the data. Results: Across contexts, teen motherhood was associated with children’s exposure to sociodemographic risks (low maternal education, poverty, divorce/ separation), and overall more risks, but not maltreatment. In PR only, teen motherhood was associated with family dysfunction (intimate-partner violence, parental substance abuse, and parental antisocial personality) and children’s antisocial behaviors (b(SE) ¼ 0.15(0.06), p ¼ 0.01). The accumulation of risks, divorce/separation, and parental antisocial personality, accounted for the association between teen motherhood and children’s antisocial behaviors in PR. Conclusions: The implications of having a teen mother for children’s home environment and their development of antisocial behavior varies depending on the social context within which it occurs. The accumulation of risks among children of teen mothers is what appears to contribute to their relative disadvantage.

LONG, RF, DEMF Supported by NIH Grants MH56401, DA033172, AA020191, MH098374, HD060072, HL125761, UG3OD023328-01, and the Robert Wood Johnson Foundation New Connections Junior Investigator Award http://dx.doi.org/10.1016/j.jaac.2017.09.153

3.6 PRENATAL STRESS IN MICE REDUCES BRAIN AND PERIPHERAL TELOMERE LENGTH IN FEMALES AND INCREASES BRAIN TELOMERE LENGTH IN MALES Stephanie J. Lussier, BS, MS, University of Iowa, lussisj0@ sewanee.edu; Allison Momany, MA, University of Iowa, [email protected]; Monisa Saravanan, BS, University of Iowa, [email protected]; Hanna Stevens, MD, PhD, University of Iowa, hanna-stevens@ uiowa.edu Objectives: Stress is a risk factor for neuropsychiatric disorders, potentially through its deleterious effects on cellular health and survival. Telomere length (TL) is a peripheral biomarker of cellular health and aging and a proposed biomarker of neuropsychiatric disease, which may reflect the connection between stress and illness, particularly within the brain. Prenatal stress may have distinct influences on telomere length; embryonic cells rapidly divide and differentiate, changing telomere length in a way that may supersede the effects of stress. Therefore, we used a mouse model to determine whether prenatal stress affects telomere biology and another biomarker of cellular stress, mitochondrial DNA copy number (mtDNA CN). Methods: TL and mtDNA CN were measured by quantitative polymerase chain reaction in brain and spleen tissue from mice of different ages exposed to prenatal stress during embryonic development—three times daily restraint stress from embryonic day 12 until birth. Telomerase reverse transcriptase (TERT) protein expression was measured by densitometry in sections of brain, and telomerase activity was measured by Telomeric Repeat Amplification Protocol in protein isolates from brain. Results: TL in the brain initially had a trend decrease one day after prenatal stress onset. Two days after prenatal stress onset, telomerase

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activity and TERT protein were increased in males only. Male and female offspring response to prenatal stress was distinctly different at all subsequent time points of analysis into adulthood, with an increase in TL and TERT levels in males and a decrease in TL with no TERT increase in females. We also found that neonatal peripheral TL was correlated with CNS TL in females but not in males. mtDNA copy number in neonatal brain was decreased regardless of sex in dorsal but not ventral telencephalon, suggesting that this measure assessed a process distinct from TL after prenatal stress. Conclusions: These findings demonstrate that prenatal stress affected telomere biology differently, depending on offspring sex, tissue type, and developmental stage or chronicity of stress, but persisted after the termination of stress into adulthood. Because telomere length is reflective of different stages of cell maturation, these data may demonstrate a distinct impact of prenatal stress on brain maturation in males versus females.

ANI, NEURODEV, STRESS http://dx.doi.org/10.1016/j.jaac.2017.09.154

3.7 PSYCHOSOCIAL PROTECTIVE FACTORS MODERATE THE RELATIONSHIP BETWEEN DEPRESSIVE SYMPTOMS AND HEALTHCARE UTILIZATION IN HEALTHY ADOLESCENTS Vandana L. Kumar, BS, Virginia Tech Carilion School of Medicine, [email protected]; Katherine A. Shaver, MS, Carilion Clinic, [email protected]; Jeri L. Lantz, MD, Carilion Clinic, [email protected]; John Eric Vance, MD, Carilion Clinic, [email protected] Objectives: Thirty percent of adolescents have symptoms of depression, and these adolescents use more healthcare resources than asymptomatic adolescents. Certain psychosocial protective factors (PPFs) moderate the development of depression in high-risk, traumatized adolescents. It is unknown how PPFs and depressive symptoms interact and relate to adolescent healthcare utilization. This exploratory study examines whether psychosocial protective factors moderate the known relationship between depressive symptoms and healthcare utilization. Methods: Data were collected from 227 adolescents (aged 11–17 years) presenting for wellness visits at three clinics. Depressive symptoms were assessed using the Patient Health Questionnaire (PHQ)-9, and PPFs were assessed using the Youth Resiliency Checklist (YRC). Healthcare encounters over the last three years were obtained from the electronic medical record and organized into preventative outpatient (PO), medical illness outpatient (IO), psychiatric outpatient, and total emergency department (ED) visits; ED visits for accidents, sports injuries, medical illness, and mental illness; and total healthcare encounters. Poisson and negative binomial multivariable regression models were used to examine healthcare encounters. Predictors included PHQ-9 score, total YRC and subscale scores, and the interaction between these two sets of variables. Sex and age were included as covariates. Results: Female sex was associated with more IO (P ¼ 0.0147) and total healthcare (P ¼ 0.0241) visits. Higher PHQ-9 scores decreased PO visits (P ¼ 0.0063), increased ED visits for accidents (P ¼ 0.0018), and increased total ED visits (P ¼ 0.0345). Higher YRC-Involvement subscale scores moderated the relationship between PHQ-9 score and PO visits (P ¼ 0.0051) and increased PO visits (P ¼ 0.0020). The following YRC subscales were associated with more PO visits as follows: school (P ¼ 0.0126), social (P ¼ 0.0479), and outlook (P ¼ 0.0270). Conclusions: The results suggest that involvement in structured activities may play a role in the use of preventative healthcare by all teenagers, including those with depression. This study supports the use of depression and resiliency assessments as a means to identify depression and protective factors to positively impact healthcare outcomes in adolescents.

ADOL, PRE, DDD http://dx.doi.org/10.1016/j.jaac.2017.09.155

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3.8 ARE WE REALLY MEASURING RESILIENCE? ANALYSIS OF A COLOMBIAN HIGH-RISK ADOLESCENT SAMPLE Daniel E. Suarez, MD, MSC, Universidad de los Andes, [email protected]; Andres C. Cardozo, MD, MPH, Pontificia Universidad Javeriana, andrescardozo@javeriana. edu.co; Elena M. Trujillo, MD, MSC, Universidad de los Andes, [email protected]; Lorena A. Bejarano, BS, Universidad de los Andes, [email protected]; Oscar A. Bernal, MD, DrPH, MPH, Universidad de los Andes, [email protected]; Anna E. Ordonez, MD, MSC, National Institute of Mental Health, [email protected] Objectives: The goal of this presentation is to compare the performance of two resilience evaluation measures in a Colombian high-risk adolescent school sample group and their association with mental disorder-screening scores. Methods: Adolescents attending sixth grade in schools in a low-resource neighborhood in Bogota (Colombia) completed a self-administered electronic survey carried out within a trial of a resilience-enhancing intervention. With written informed consent from caregivers and participant’s assent, adolescents completed the Individual Protective Factors Index (IPFI) and the Adolescent Resilience Scale (ARS) to measure psychological resilience levels. The survey also included demographic information and economic indicators, as well as screening instruments for family dysfunction, psychopathology symptoms (general), depression, and anxiety disorders, as well as substance use and abuse. Results: A total of 326 adolescents agreed to participate and completed the survey. Almost half of them were male (58%), and the mean age was 12 years (SD ¼ 1). Internal consistency of resilience measures was acceptable (Cronbach’s alpha, 0.87 IPFI; 0.82 ARS) and their standardized distributions did not show significant differences by school or gender. There was a low but significant correlation between the two resilience measures (Lin’s coefficient, 0.344; P < 0.0001); correlation analysis and regression models using subscales of both measures showed significant associations between the self-control IPFI subscale and the emotional regulation ARS subscale (P < 0.001). Regression models showed statistically significant associations (P < 0.0001 in F-test) with family functioning and psychopathology symptoms (general) screening tools in both IPFI and ARS after controlling for school, age, and gender; the depression screening tool was also associated with the IPFI. Conclusions: These results are consistent with findings in other national and international studies using the same measures, and they highlight the importance of the resilience construct in the study of mental disorders in the youth. Based on differences in the results, different instruments of resilience are possibly measuring divergent aspects of the same construct, and complementary methods may be needed to understand the clinical implications of our findings.

ADOL, PRE, SC Supported by Universidad de los Andes http://dx.doi.org/10.1016/j.jaac.2017.09.156

3.9 REACTIVE ATTACHMENT/DISINHIBITED SOCIAL ENGAGEMENT DISORDERS: CALLOUS UNEMOTIONAL TRAITS AND COMORBID DISORDERS Susan D. Mayes, Penn State Health Milton S. Hershey Medical Center, [email protected]; Susan Calhoun, PhD, Penn State Health Milton S. Hershey Medical Center, [email protected]; Daniel Waschbusch, PhD, Penn State College of Medicine, [email protected]; Rosanna Breaux, MS, Penn State Health Milton S. Hershey Medical Center, [email protected]; Raman Baweja, MD, MS, Penn State Health Milton S. Hershey Medical Center, [email protected]

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Objectives: The DSM-5 divides DSM-IV reactive attachment disorder (RAD) into RAD (formerly RAD-inhibited type) and disinhibited social engagement disorder (DSED, formerly RAD-disinhibited type). RAD and DSED are rare, understudied, and controversial disorders. Research demonstrates considerable comorbidity and conduct problems in RAD, which strikingly is not mentioned in the DSM-5. Our study determines comorbidity in children who are rigorously diagnosed with RAD and DSED and compares findings with those for children with ADHD and autism spectrum disorder (ASD) to determine whether comorbidity associated with RAD/DSED differs from that for the two most common disorders in child psychiatric clinics. Methods: Sample groups included the following: 1) 20 children with RAD and/or DSED; 2) 933 children with autism; and 3) 895 children with ADHD and no ASD (ages 4–17 years). All underwent an evaluation by a psychologist with a doctorate degree that included a parent interview, observations of the child during testing, a review of records, and scores on parent- and teacher-rating scales (Pediatric Behavior Scale and Checklist for Autism Spectrum Disorder, both of which have high diagnostic validity and agreement with other established measures). Children with RAD/DSED were removed from their abusive/neglectful environments at a mean age of four years and had a mean age of 10 years when studied. Mothers rated the children on the 165-item Pediatric Behavior Scale assessing oppositional behavior, conduct problems, ADHD, anxiety, depression, and other symptoms. Results: Five of the 20 children with RAD/DSED had DSED without RAD, 15 had RAD with DSED, and none had RAD without DSED. All children with RAD had callous-unemotional (CU) traits, and 73 percent had conduct disorder (CD). None of the children with DSED-no RAD had CU or CD, which differed significantly from the percentages for the RAD group (c2 ¼ 20.0, P < 0.001 and c2 ¼ 8.1, P ¼ 0.008). Children with RAD were considerably more impaired than children with DSED-no RAD, ASD, ADHD-combined (ADHD-C), and ADHDinattentive (ADHD-I). The RAD group had more elevated conduct problem scores than ASD, ADHD-C, and ADHD-I (c2 ¼ 15.6, 11.8, and 71.0, P < 0.001) and the highest symptom frequencies on 12 of the 18 Pediatric Behavior Scale symptom scores. Conclusions: Findings are consistent with other studies indicating high CD/ CU comorbidity in RAD and extreme rarity of RAD without DSED, which should be, but are not noted, in the DSM-5.

ATTACH, CM http://dx.doi.org/10.1016/j.jaac.2017.09.157

3.10 CONCOMITANT USE OF ATYPICAL ANTIPSYCHOTICS WITH LEADING PSYCHOTROPIC MEDICATION CLASSES AND THE RISK OF TYPE 2 DIABETES MELLITUS: A POPULATION-BASED STUDY OF MEDICAID-INSURED YOUTH Mehmet Burcu, MS, PhD, University of Maryland, Baltimore, [email protected]; Julie Zito, PhD, University of Maryland, Baltimore, [email protected]; Daniel J. Safer, MD, Johns Hopkins University, [email protected] Objectives: More than half of Medicaid-insured youth treated with atypical antipsychotic (AAP) medications are also treated with concomitant antidepressants or stimulants, although the metabolic effects of such combinations are largely unknown. This study assessed the association between antidepressant or stimulant use concomitant with AAPs and the risk of incident type 2 diabetes mellitus (T2DM). Methods: Medicaid Analytic eXtract data were used to conduct a retrospective cohort study of youth (aged 5-20 years) who initiated AAP treatment. In youth treated with AAP, concomitant antidepressant [(SSRI/SNRIs), tricyclic/ other cyclic antidepressants (TCAs), and other antidepressants] or stimulant use was assessed. Medication use was operationalized using three timedependent measures: 1) current/former/nonuse; 2) duration of use; and 3) cumulative dose exposure. The risk of incident T2DM was assessed using a previously validated algorithm and was estimated using discrete time failure models, adjusting for disease risk score based on >125 baseline and timedependent covariates.


Results: Among the sample group (N ¼ 73,224) of AAP initiators, 43.0 percent had concomitant antidepressant use (of these, 76.4% were SSRI/SNRIs) and 43.8 percent had concomitant stimulant use. In current AAP-treated youth, concomitant SSRI/SNRI (relative risk [RR] ¼ 1.84, 95% CI ¼ 1.30 - 2.59) or TCA use (RR ¼ 2.75, 95% CI ¼ 1.28 - 5.87) was associated with an increased risk of T2DM. By contrast, concomitant use of other antidepressants or stimulants was not associated with an increased risk of T2DM. In concomitant users of AAPs and SSRI/SNRIs, the risk of T2DM increased with the duration of SSRI/ SNRI use (RR ¼ 2.35, 95% CI ¼ 1.15 - 4.83 for 180 days vs 1 - 180 days) as well as with the cumulative SSRI/SNRI dose (RR ¼ 1.99, 95% CI ¼ 1.08 - 3.67 for > 2,700 mg vs 1-2,700 mg fluoxetine dose equivalents) after adjusting for the duration and cumulative dose of AAP use. By contrast, in concomitant users of AAPs and stimulants, neither duration nor cumulative dose of stimulants was associated with an increased risk of T2DM. Conclusions: In Medicaid-insured youth treated with AAP, concomitant SSRI/ SNRI use was associated with a heightened risk of T2DM that intensified with increasing duration and dose.

EPI, ADP, APS Supported by the University of Maryland, Baltimore and an FDA University of Maryland-CERSI grant http://dx.doi.org/10.1016/j.jaac.2017.09.158

3.11 OVERVIEW OF CHILD AND ADOLESCENT PSYCHIATRY ACROSS COUNTRIES IN THE EURASIAN CHILD MENTAL HEALTH STUDY Roshan Chudal, MBBS, MPH, PhD, University of Turku, roshan.chudal@utu.fi; Norbert Skokauskas, MD, PhD, Norwegian University of Science and Technology, norbert. [email protected]; Ahmed Al Ansari, FRCP, Arabian Gulf University, [email protected]; Anat BrunsteinKlomek, PhD, School of Psychology, Interdisciplinary Center (IDC), [email protected]; Chanvit Pornnoppadol, MD, Faculty of Medicine Siriraj Hospital, Mahidol University, chanvit.por@ mahidol.edu; Gerasimos A. Kolaitis, MD, Medical School, National and Kapodistrian University of Athens, gkolaitis@ med.uoa.gr; Hans-Christoph Steinhausen, MD, University of Zurich, Switzerland, [email protected]; Helena R. Slobodskaya, MD, PhD, Institute of Physiology and Basic Medicine, [email protected]; Hitoshi Kaneko, Ph D, Nagoya University, [email protected]; Jaya Regmee, MD, Child Workers in Nepal Concerned Centre (CWIN), [email protected]; Li Ping LI, MD, Shantou University Medical College, [email protected]; Mai Huong Nguyen, MD, National Hospital of Pediatrics, [email protected]; Meytal Grimland, MA, Tel Aviv University, [email protected]. ac.il Objectives: Majority of existing research in child and adolescent psychiatry comes from the Western countries, and these findings have long been considered to be valid also for the rest of the world. This extrapolation without comparable data is unlikely to present the true picture. The aim of this study is to report the distribution of general and child and adolescent psychiatrists, training schedules, and clinical practices among the countries in Eurasian Child Mental Health Study (EACMHS) group. Methods: The EACMHS includes leading child and adolescent psychiatrists and psychology experts from the following 17 countries: Bahrain, China, Finland, Greece, India, Indonesia, Israel, Japan, Lithuania, Nepal, Norway, Russia, Singapore, Switzerland, Thailand, Ukraine, and Vietnam. The overall aim of the group is to conduct cross-cultural, multisite research on well-being and mental health among children and adolescents. This study is based on a survey among participant countries on various aspects of child and adolescent psychiatry, including the available workforce, training, and clinical practices. Results: The ratio of adult psychiatrists per 100,000 individuals in the population aged 14+ years ranged from 0.43 (India) to 52.09 (Norway). The ratio of child and adolescent psychiatrists per 100,000 individuals in the population

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aged 7,000 in each cohort). Analyses on prevalence of internalizing symptoms across birth cohorts were computed with multiple linear regressions followed by linear trend tests. Analyses on proportions of participants above clinical cut-offs across birth cohorts were conducted with Cochrane Armitage Tests. To investigate differences in proportions of participants above clinical cutoffs, chi-square analyses were used. Results: At age 15 years, there was a significant increase in self-rated internalizing symptoms across birth cohorts. Even though girls had higher levels of internalizing symptoms than boys, the effects in boys drove this increase. At age nine years, there was a marginal increase in internalizing symptoms across birth cohorts. Unexpectedly, the mean levels of depression were slightly higher in boys than in girls. Resultswere similar when studying trends in proportions of participants with symptom ratings over clinical cut-off. Conclusions: These findings indicate that more attention may be needed not exclusively to internalizing symptoms in girls, but also in boys, both at young ages and in adolescence.

EPI, AD, DDD http://dx.doi.org/10.1016/j.jaac.2017.09.162

3.15 PARENT-REPORTED BENEFITS AND SIDE EFFECTS FROM ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER (ADHD) MEDICATION IN A NATIONALLY DRAWN SAMPLE OF SCHOOL-AGED CHILDREN DIAGNOSED WITH ADHD Joseph Holbrook, PhD, Centers for Disease Control and Prevention, [email protected]; Melissa Danielson, MSPH, Centers for Disease Control and Prevention, [email protected]; Rebecca H. Bitsko, PhD, Centers for Disease Control and Prevention, [email protected]; Steven P. Cuffe, MD, University of Florida College of Medicine - Jacksonville, [email protected]fl.edu; David O’Banion, MD, Emory University School of Medicine, [email protected]; Robert E. McKeown, PhD, University of South Carolina, [email protected] Objectives: The purpose of this study is to characterize the magnitude of perceived benefits and side effects associated with ADHD medication use in a nationally drawn sample of school-aged children with ADHD. Methods: We analyzed data from the National Survey of the Diagnosis and Treatment of ADHD and Tourette Syndrome (NS-DATA; N ¼ 2,980). Among children with parent-reported ADHD, parents reported on side effects for those who had ever taken ADHD medication; parents also reported on benefits of medication for children currently taking ADHD medication. SUDAAN version 11.0.1 was used for all analyses to account for the complex sampling design and sampling weights. Results: Among children with a parent-reported ADHD diagnosis, 88 percent (n ¼ 2,647) had ever used ADHD medication; 74 percent


(n ¼ 1,752) were currently taking medication. Most children who had ever taken a medication (92%) had experienced one or more of the 11 types of side effects specified in the survey; 68 percent had experienced at least three side effects. The most commonly reported side effects were change in personality or mood (56%) and sleep problems (54%). Side effects were more common in boys, children diagnosed before age six years, children with severe ADHD, and those with a co-occurring condition. Although 48 percent of medication users had experienced side effects troublesome enough for the parent to discontinue the child’s medication, 56 percent of children whose medication use was discontinued due to side effects were currently using medication. Among children currently taking ADHD medication, most parents reported at least some improvement with academics (91%), behavior (89%), and interactions with others (79%); 72 percent reported at least some improvement in all three domains. Parents not reporting a side effect were more likely to report “a lot” of improvement (compared to “some,” “a little,” or “none”) in academics (81% vs 68%; p ¼ 0.02), behavior (73% vs 56%; p < 0.01), and interactions (62% vs 41%; p < 0.01). Conclusions: This study quantifies the proportion of children experiencing benefits and side effects of ADHD medication in a nationally drawn sample. The vast majority of children taking ADHD medication experience significant benefit across areas of daily life, but most also experience multiple side effects. These data can be used by clinicians and shared with families to help balance the benefits of medication with the risks of known side effects.

EPI, ADHD, TREAT http://dx.doi.org/10.1016/j.jaac.2017.09.163

3.16 HEADACHE AND PSYCHIATRIC DISORDERS IN A NATIONALLY REPRESENTATIVE SAMPLE OF AMERICAN YOUTH Rebecca Hommer, MD, National Institute of Mental Health, [email protected]; Tarannum Lateef, MD, MPH, National Institute of Mental Health, tlateef@childrensnational. org; Jian-Ping He, MS, National Institute of Mental Health, [email protected]; Kathleen Merikangas, PhD, National Institute of Mental Health, [email protected] Objectives: The goal of this presentation is to examine the association between headache and psychiatric disorders in a nationally representative sample group of American youth. Methods: We used the National Comorbidity Survey–Adolescent Supplement (NCS-A) to assess associations between past-year headache and pastyear mental disorders in a population-based sample group of youths ages 13 to 18 years. Adolescent report (n ¼ 10,123) was used to identify anxiety, mood, eating, and substance use disorders, as well as headache subtypes. Parent report (n ¼ 6,483) informed ADHD and behavior disorder (ODD and CD) diagnoses. Psychiatric diagnoses were based on DSM-IV criteria, and headache subtypes were defined using modified International Headache Society (IHS) criteria. Logistic regression analyses, controlling for key demographic characteristics (age, sex, race/ethnicity, family income), were used to examine the associations between headache and psychiatric disorders. Results: Headache was endorsed by 12.5 percent of the full sample group. Youths with headache were three times more likely to meet criteria for any past-year mental disorder [OR 3.00 (95% CI 2.17–4.15)]. After adjustment for key demographic characteristics and co-occurring DSM-IV disorders, adolescents with headache were found to have higher odds of anxiety [OR 2.53; 95% CI 1.79–3.57], mood [OR 2.47 (95% CI 1.49–4.11)], and behavior [OR 1.88 (95% CI 1.40–2.52)] disorders than those without headache. Anxiety disorders were more common in youth with migraines than in youth with other types of headache [OR 2.06 (95% CI 1.17–3.61)]. Conclusions: Adolescent headache is associated with anxiety, mood, and behavior disorders in a nationally representative sample group of US youth. Migraines, compared with other headache type, is associated with increased odds for anxiety disorders. These findings are in keeping with associations observed in previous population-based sample groups of adults and clinical sample groups of children and suggest that pediatricians, neurologists, and

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other adolescent care providers should be vigilant and assess for psychiatric comorbidities when caring for youth with headache. Future research is needed to identify possible shared etiologic pathways between headache and psychiatric disorders and to explore associations between comorbidity and treatment response.

EPI, ADOL, PYI Supported by NIMH Intramural Research Program, NIMH Grant U01MH60220, National Institute on Drug Abuse Grant R01-DA12058-05, Substance Abuse and Mental Health Services Administration, the Robert Wood Johnson Foundation Grant 044780, and the John W. Alden Trust http://dx.doi.org/10.1016/j.jaac.2017.09.164

3.17 LEARNING CONTEXT AND UNDESIRED BEHAVIORS AMONG JUNIOR HIGH SCHOOL STUDENTS IN JAPAN Sachiko Inoue, PhD, Okayama Prefectural University, sinoue@ fhw.oka-pu.ac.jp Objectives: The National Survey on Academic Performance and Learning Context is conducted annually in Japan. This survey covers students’ study habits at home, study perspectives, and family support for studying at home. At school, the frequency of students’ undesired behaviors, such as violence, smoking, and class truancy, is a combination of persisting issues that must be addressed. We demonstrate the relationship between students’ learning context and undesired behaviors at school in the current study. Methods: We used data from the National Survey on Academic Performance and Learning Context in 2015. In particular, we collected information from 5,969 participants enrolled in 38 municipal junior high schools located in western Japan, with the exception of academic scores. These data were combined with the students’ records of undesired behaviors, such as violence, smoking, and class truancy. The relationship between students’ learning context and undesired behaviors were evaluated using a logistic regression model and then calculated odds ratios (ORs) and confidence intervals (CIs). This study was approved by the Okayama Prefectural University Institutional Review Board in 2014. Results: Although several negative attitudes toward studying were affected by class truancy, they were not associated with violence and smoking behaviors. However, an overall association was found between students’ negative perspective of class and undesired behaviors. Students who felt that class rules were not decided in class meetings were associated with acts of violence (OR 2.95, CI 1.40–6.20), smoking (OR 3.40, CI 1.61–7.17), and class truancy (OR 4.01, CI 2.17–7.53). Furthermore, students who did not feel glad when they made an achievement together with classmates were also associated with acts of violence (OR 3.66, CI 1.69–7.90), smoking (OR 2.99, CI 1.31– 6.76), and class truancy (OR 3.33, CI 1.74–6.38). With regard to daily life habits, students who skipped breakfast were clearly associated with the same behaviors (OR 5.80, CI 2.54–13.27; OR 3.93, CI 1.59–9.76; OR 4.85, CI 2.35–10.01, respectively). Conclusions: From this study, we found that students’ perspectives and attitudes toward studying may influence their behaviors at school. Teachers and families are recommended to be aware of students’ perspectives toward class and studying.

EPI, SAC Supported by the Japan Society for the Promotion of Science, KAKENHI Grant 16K21295 http://dx.doi.org/10.1016/j.jaac.2017.09.165

3.18 EXAMINING TRENDS AND INTERACTIONS IN THE DIAGNOSES OF PEDIATRIC BIPOLAR DISORDERS AND DISRUPTIVE MOOD DYSREGULATION DISORDER (DMDD) IN KENTUCKY CHILDREN AND ADOLESCENTS RECEIVING MEDICAID Jennifer F. Le, MD, University of Louisville, jennifer.le@ louisville.edu; William David Lohr, MD, University of

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Louisville, Bingham Clinic, [email protected]; Yana B. Feygin, MS, University of Louisville, yana.feygin@louisville. edu; Liza M. Creel, MPH, PhD, University of Louisville, Liza. [email protected]; Natalie Pasquenza, MBA, RN, University of Louisville, [email protected]; Allan Mark Josephson, MD, Bingham Clinic, University of Louisville, [email protected]; Deborah W. Davis, PhD, University of Louisville, [email protected] Objectives: We aim to assess the trends in the use of bipolar disorders and disruptive mood dysregulation disorder (DMDD) in a population of children and adolescents in Kentucky covered by Medicaid. Additionally, we plan to assess whether prior diagnoses of bipolar disorders, mood disorder NOS, or ODD predicts a diagnosis of DMDD following the recent implementation of DSM-5 diagnostic criteria. Methods: Using Kentucky Medicaid claims data from 2012 to 2015, we developed a detailed demographic, behavioral, clinical, and diagnostic dataset for all children under the age of 18 years (2012, n ¼ 473,389; 2013, n ¼ 470,918; 2014, n ¼ 499,094; 2015, n ¼ 517,199) to determine trends in the diagnoses of bipolar disorders, ODD, mood disorder NOS, and DMDD. A logistic regression model was used to analyze a second sample group of children who had at least one of the diagnoses and were represented in each year from 2012 to 2015 (n ¼ 7,268) to determine whether early diagnoses were predictive of a diagnosis of DMDD in 2015. Results: Rates of diagnosis of bipolar disorders have remained stable since 2012, whereas there was a steady increase in the use of DMDD after 2013. Furthermore, a diagnosis of mood disorder NOS in 2012 predicted a diagnosis of DMDD in 2015 (OR ¼ 1.55, P 0.05). Conclusions: Our results support the other findings of similar studies and will help in applying suitable screening procedures for identification and subsequent management of psychiatric conditions, thereby minimizing the service gap through hospital-based, pediatric–psychiatric liaison service.

EPI, R, SII http://dx.doi.org/10.1016/j.jaac.2017.09.168

3.21 CYBERBULLYING AND PSYCHIATRIC DISORDERS IN MEXICAN ADOLESCENTS Enrique Navarro-Luna, MD, Hospital Psiquiatrico Infantil Dr. Juan N Navarro, [email protected]; Victor Noguera-Navas, Hospital Psiquiatrico Infantil Dr. Juan N Navraro, [email protected]; Olga MartinezAguilar, Hospital Psiquiatrico Infantil Dr. Juan N Navarro, [email protected]; Yassel Flores-Rodriguez, MD, Hospital Psiquiatrico Infantil Dr. Juan N Navarro, avellanafr@ hotmail.com; Yariela Delgadillo-Gonzalez, MD, Hospital Psiquiatrico Infantil Dr. Juan N Navarro, yarieladg@hotmail. com; Jose L. Mendez-Santos, MD, Hospital Psiquiatrico Infantil Dr. Juan N Navarro, [email protected]; Carlos I. Chavez-Flores, MD, Hospital Psiquiatrico Infantil Dr. Juan N Navarro, [email protected]; Adriana GarcıaLuna, MD, Hospital Psiquiatrico Infantil Dr. Juan N Navarro, [email protected]; Tania Vargas-Rizo, MD, Hospital Psiquiatrico Infantil Dr. Juan N Navarro, taniavr86@hotmail. com; Lilia Albores-Gallo, MD, DrPH, Hospital Psiquiatrico Infantil Dr. Juan N Navarro, [email protected] Objectives: The goal of this presentation is to determine the frequency of cyberbullying and its association with psychiatric disorders in high school Mexican adolescents. Methods: Adolescents (aged 11–17 years) were recruited from three city secondary schools in Mexico. The parents completed the Mexican version of the Child Behavior Checklist for Ages 6–18 years (CBCL/6–18), and adolescents answered the instrument VEA (Valoraci on Escolar de Acoso), which identifies the cyberbully, the cyber victim, and the neutral students. Results: Participants included 829 students; only 555 (47.3%) answered the instruments. The prevalence of cyberbullying was 23.9 percent. Using the self-report, 7.9 percent of cyberbullies and 18.0 percent of cyber victims were identified, in contrast to peer nominations, through which only 0.4 percent of cyberbullies and cyber victims were identified. The cyberbullies showed a higher risk for externalized symptoms, such as breaking rules [OR 2.08 (CI 95% 1.04–4.16); P ¼ 0.03]; attentional problems [OR 2.23 (CI 95% 1.08–4.63); P ¼ 0.02]; conduct problems [OR 2.20, (95% CI 1.27–3.80); P ¼ 0.00]; and affective problems [OR 2.13 (95% CI 1.07–4.24); P ¼ 0.02]. The cyber victims show a higher risk of social symptoms [OR 2.14 (95% CI 1.22–3.74); P ¼ 0.00]; thought problems [OR 2.01 (95% CI 1.07–3.78); P ¼ 0.02]; attention problems [OR 1.98 (95% CI 1.09–3.59); P ¼ 0.02]; breaking rules [OR 2.28 (95% CI 1.32–3.95); P ¼ 0.00]; and conduct problems [OR 2.20 (95% CI 1.27–3.80); P ¼ 0.00]. Cyberbullies–victims show a higher risk for breaking rules [OR 2.57 (95% CI 1.09–6.06); P ¼ 0.02] and conduct problems [OR 2.35 (95% CI 1.00–5.51); P ¼ 0.04]. In addition, 69 percent of adolescents have computers at home, 50.7 percent have internet, and 17.8 percent have public internet access. Adolescent females spend on average 2.01 (SD ¼ 2.33) hours a day using a computer and 1.90 hours

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(SD ¼ 2.36) online, whereas adolescent males spend an average of 1.7 (SD ¼ 1.84) hours using a computer and 1.64 hours online (SD ¼ 2.36). Conclusions: The prevalence of cyberbullying in Mexican adolescents is similar to those reported in the world literature. Cyberbullying is associated with psychiatric disorders in all those involved, with higher risk of conduct and externalized problems. Cyberbullying is better identified through self-report.

BLY, COMP, CD http://dx.doi.org/10.1016/j.jaac.2017.09.169

3.22 PSYCHIATRIC SYMPTOMS OF EARTHQUAKE-AFFECTED SCHOOL CHILDREN IN NEPAL Sanju Silwal, MPhil, University of Turku, sanju.silwal@utu.fi; Lars Lien, Norwegian Centre for Addiction Research, lars. [email protected]; Ragnhild Dybdahl, Oslo and Akesrhus University College of Applied Sciences, ragnhild.dybdahl@ hioa.no; Roshan Chudal, MBBS, MPH, PhD, University of Turku, roshan.chudal@utu.fi; Andre Sourander, MD, PhD, University of Turku, andsou@utu.fi Objectives: In 2015, two major earthquakes hit Nepal and caused widespread destruction. In general, there are limited studies on mental health consequences among children after an earthquake. The present study aims to assess prevalence of PTSD and depressive symptoms and to explore potential risk factors among school children in two sample groups: 1) severely damaged area; and 2) less severely damaged areas. Methods: Cross-sectional data were conducted to enroll 893 participants from grades 7 to 10 across two earthquake-affected districts: Sindhupalchok and Kathmandu. Psychiatric symptoms were assessed by self-report Child PTSD Symptom Scale (CPSS) and Depression Self-Rating Scale (DSRS). Multiple logistic regression analysis was used to examine the association between demographic and earthquake-related factors and symptoms of mental illness. Results: The prevalence of PTSD in Sindhupalchok and Kathmandu districts was 39.5 and 10.7 percent, and that of depression was 40.4 and 23.2 percent, respectively. Moderating effect of gender on the relationship between age and PTSD was significant (P < 0.01). In multivariate logistic analyses, factors associated with PTSD and depressive symptoms were as follows: female; prior exposure to trauma; and directly affected by earthquake. Conclusions: Children living in Sindhupalchok had higher prevalence of PTSD and depressive symptoms compared with the Kathmandu district. Demographic and earthquake-related factors were associated with psychiatric outcomes. This study highlights need of early interventions to reduce mental health symptoms progress into disorders among children and adolescents of affected communities.

RF, SAC Supported by Academy of Finland Grant 820/211/2012 http://dx.doi.org/10.1016/j.jaac.2017.09.170

3.23 PRENATAL RISK FACTORS ASSOCIATED WITH ATTACHMENT DISORDER IN CHILDREN: A NATIONWIDE REGISTER-BASED STUDY Subina Upadhyaya, MPH, University of Turku, subina. upadhyaya@utu.fi; Roshan Chudal, MBBS, MPH, PhD, University of Turku, roshan.chudal@utu.fi; Susanna Hinkka-YliSalom€ aki, MSc, University of Turku, sushys@utu.fi; Andre Sourander, MD, PhD, University of Turku, andsou@ utu.fi Objectives: Attachment disorder is a condition characterized by an abnormal pattern of social functioning and is associated with behavioral and emotional disturbances in children. There are no population-based studies to date that have identified the prenatal risk factors for attachment disorder. The aim of this study was to examine the association between prenatal risk factors and attachment disorder in children.

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Methods: In this nested case-control study design, 775 individuals born in Finland between January 1, 1996, and December 31, 2012, and diagnosed and registered in Finnish Hospital Discharge Register (FHDR) as attachment disorder by the end of 2012 were included. Each case was matched with four controls (n ¼ 3,087) without any diagnosis of attachment disorder, severe or profound intellectual disability, or anxiety disorder. Control subjects were matched by the date of birth (30 days), sex, and place of birth as identified from Finnish Population Register. A conditional logistic regression model was used to examine the association between exposures and attachment disorder, adjusting for potential confounding attributed to parental age, maternal socioeconomic status, and maternal smoking. Results: In the adjusted analysis, mothers younger than age 20 years had a 1.9-fold [OR ¼ 1.97 (95% CI 1.22-3.19); P ¼ 0.005] increased risk of having offspring with attachment disorder compared with mothers aged 25–29 years. Likewise, fathers older than age 45 years had a 4.4-fold [OR ¼ 4.49 (95% CI 2.69–7.49); P < 0.001] increased risk of having offspring with attachment disorder. Maternal smoking was associated with 4.9-fold [OR ¼ 4.97 (95% CI 4.01– 6.18); P < 0.001] increased risk. In addition, blue collar workers had 3.7-fold [OR ¼ 3.75 (95% CI 2.36–5.97); P < 0.001] increased risk compared with white collar workers. Conclusions: The increased risk of attachment disorder in offspring of youngest mothers and older fathers suggests the involvement of some biological and psychosocial factors associated with parental age. Furthermore, findings on maternal smoking and socioeconomic status point towards the possible role of biological and socioeconomic factors in causation of attachment disorder.

ATTACH, RF, EC Supported by the Academy of Finland Dnro 820/211/2012 http://dx.doi.org/10.1016/j.jaac.2017.09.171

3.24 PREVALENCE OF SUBSTANCE USE IN EARLY-PSYCHOSIS PATIENTS TREATED IN A SPECIALIZED FIRST-EPISODE PSYCHOSIS UNIT IN A CITY HOSPITAL OF NEW YORK Gaurav Vishnoi, MD, SUNY Downstate Medical Center, [email protected]; Nitin Toteja, MD, Kings County Hospital Center, [email protected] Objectives: Mentally ill patients have a high prevalence of co-occurring substance use disorder (SUD). Approximately 100,000 adolescents and young adults in the United States experience first episode psychosis (FEP) each year. The data related to prevalence of baseline substance use when these patient present early for inpatient treatment is relatively scarce. The aims of this study are to: 1) find the prevalence and pattern of use of various SUDs in FEP patients; and 2) study the relationship of SUD with demographic factors and duration of untreated psychosis in these patients. Methods: Data for early psychosis patients (with a DSM-5 diagnosis) admitted to a specialized first episode psychosis inpatient unit at KCHC (Kings County Hospital Center) was collected and analyzed for prevalence of various SUD in these patients. All participants had experienced only one episode of psychosis (individuals with a psychotic episode followed by full symptom remission and relapse to another psychotic episode and those with > 6 months of lifetime antipsychotic medications were excluded). Mean standard deviation was calculated for the duration of untreated psychosis. Results: Eighty patients (aged 16-23 years; 73 males) were included in the study. Patients (n ¼ 9) had lifetime prevalence of alcohol use disorder, patients (n ¼ 39) had lifetime prevalence of cannabis use of which 17 patients already had the diagnosis of cannabis use disorder on presentation for treatment. Patients (n ¼ 6) had self-reported history of K2 (synthetic cannabis) use presentation. Median duration of untreated psychosis was 165 days (range ¼ 1 day to 12 years, on first admission). Drug use was associated with younger age of onset of psychosis, male gender and African American and Caribbean ethnicity. Conclusions: Poly-substance use (alcohol, marijuana, and synthetic cannabis) is highly prevalent at baseline/presentation early during the course of

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psychotic illness. Such epidemiological data may be helpful in planning services that are responsive to the target population’s needs.

EPI, PSY, SUD http://dx.doi.org/10.1016/j.jaac.2017.09.172

3.25 SEASONAL PATTERNS OF CHILD AND ADOLESCENT PSYCHIATRIC DISORDERS Katelin J. Williamson, DO, Palmetto Health and the University of South Carolina School of Medicine, katelin.krummrey@ gmail.com Objectives: There is a widely held belief in child and adolescent psychiatry that there is a decrease in mental illnesses during the summer months. It has been postulated that the stressors and demands of school contribute to an increase in psychiatric symptoms outside of the summer months. In existing literature, there are currently no objective data to support or disprove this observation. If a seasonal pattern is identified, further investigation can be pursued to determine factors driving admission patterns. This, in turn, would allow for an area of intervention to aid in decreasing psychiatric admissions and ultimately healthcare costs. Methods: A total of 159,629 hospitalizations, with primary mental health discharge diagnoses for children ages 3–20 years, were sampled in the Kids’ Inpatient Database (KID). The population proportion was estimated by year for children and adolescents meeting inclusion criteria who were admitted during the summer months. In addition to population estimates, we computed 95 percent confidence intervals and determined whether the null value is included in this interval. Results: All psychiatric diagnoses from the DSM-IV-Text Revision were categorized in three broad groups as follows: 1) mood; 2) psychotic; and 3) behavioral. The data showed that across all three groups, primary psychiatric discharge diagnoses for children and adolescents were less than the expected null value during the summer. The data showed the largest difference from the null to be in the mood category. Conclusions: Statistically significant evidence was found to support that, during the summer months, there are fewer primary psychiatric discharge diagnoses made in children and adolescents. Mood disorders had the largest difference from the expected null value. These data statistically support the observational belief that there is a decrease in admission rates for treatment of mental illnesses in children and adolescents during the summer months. It should be noted, however, that the absolute difference from the expected null is shown to be quite small in all datasets. The largest difference from the expected null was found to be a decrease of 8.58 percent (mood disorders in 2003). The average difference from the expected null was found to be a 4.09 percent decrease in primary psychiatric discharge diagnoses compared with the rest of the year. How clinically significant a decrease of four percent is debatable.

EPI, RCR, MCS Supported by the Department of Neuropsychiatry at the University of South Carolina School of Medicine http://dx.doi.org/10.1016/j.jaac.2017.09.173

3.26 DEVELOPMENT OF THE EXTENDED STRENGTHS AND WEAKNESSES ASSESSMENT OF NORMAL BEHAVIOR RATING SCALE (E-SWAN) Lindsay Alexander, MPH, Child Mind Institute, lindsay. [email protected]; Giovanni A. Salum, MD, PhD, Universidade Federal do Rio Grande do Sul, gsalumjr@gmail. com; James M. Swanson, PhD, University of California, Irvine Child Development Center, [email protected]; Michael P. Milham, MD, PhD, Child Mind Institute, michael.milham@ childmind.org Objectives: The Strengths and Weakness of ADHD-symptoms and Normalbehavior (SWAN) rating scale assesses behavior on a dimensional scale of strengths and weaknesses. A number of studies have demonstrated the ability of this method to capture more variance within populations and yield more


normally distributed data than traditional ADHD scales. Here we present the preliminary findings from the Extended Strengths and Weaknesses Assessment of Normal Behavior (E-SWAN)—an open effort focused on the extension of the SWAN methodology. Initial efforts presented here focus on the following: panic disorder, social anxiety, major depression, and disruptive mood dysregulation disorder. Methods: Data were collected from 500 participants from the Child Mind Institute Healthy Brain Network, a community-based sample group focused on the generation and open sharing of data from 10,000 children and adolescents (ages 5–21 years) in the New York City area. Parents completed each of the four E-SWAN scales and their traditional counterparts (i.e., Mood and Feelings Questionnaire, Screen for Childhood Anxiety and Related Disorders, Affective Reactivity Index). Distributional properties were examined for all scales. Item response theory (IRT) analysis was used to explore the performance of each item of the scales. Results: In contrast to the traditional scales, which exhibited truncated distributions (as expected), all four E-SWAN scales were found to have near-normal, bipolar distributions, spanning from those with substantive strengths to those with clinically significant weaknesses. IRT analyses indicate that the E-SWAN subscales provided reliable information on respondents lying at any place of the latent trait (z-scores from 3 to +3; reliabilities range from 0.77 to 0.96); in contrast, the traditional scales only provided reliable information at the high end of the latent trait (z-scores from 0 to +3). Conclusions: Building on the wisdom of the SWAN, the E-SWAN was developed to capture the full spectrum of the latent trait of several DSMclassified disorders. This type of scale has the potential to capture more variance and information on participants in a population-based study or epidemiological sample group. This is useful for both research and clinical practice. It is noteworthy that, by capturing information on strengths, there is greater potential to provide insight into factors related to resiliency.

ADOL, RI http://dx.doi.org/10.1016/j.jaac.2017.09.174

3.27 ASSESSING WHITE MATTER CORRELATES OF COGNITIVE AND VISUOMOTOR CONTROL DEFICITS IN CHILDREN WITH SENSORY PROCESSING DISORDERS Annie Brandes-Aitken, BS, University of California, San Francisco, [email protected]; Joaquin A. Anguera, PhD, University of California, San Francisco, Joaquin.Anguera@ ucsf.edu; Yi-Shin Chang, University of California, San Francisco, [email protected]; Julia P. Owen, PhD, University of California, San Francisco, [email protected]; Pratik Mukherjee, MD, PhD, University of California, San Francisco, [email protected]; Elysa J. Marco, MD, University of California, San Francisco, [email protected] Objectives: Children with sensory processing dysfunction (SPD) are reported to have challenges with cognitive and visuomotor control. In this study, we aimed to quantitatively determine whether children with SPD show deficits in their cognitive control and visuomotor control abilities using a combination of clinical and experimental direct assessments. We then used these behavioral metrics in conjunction with measures of white matter integrity via diffusion tensor imaging (DTI) to better understand the structural underpinnings of these neural processes. Methods: Here we characterized cognitive and visuomotor control and collected DTI neuroimaging data in 14 children with SPD, 13 children with SPD and comorbid attention deficits (SPD+IA), and 16 typically developing control (TDC) subjects. The cognitive control battery included a validated measure of attention (Test of Variables of Attention, TOVA), and a perceptual discrimination and goal management assessment, each presented with a novel diagnostic video game-like platform called Project:EVOTM. The visuomotor battery included the Beery TM VMI copying, matching, and tracing subtests, as well as the EVOTM navigation

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assessment. Finally, we assessed for correlations between our behavioral measures and mean fractional anisotropy (FA) in six bilateral regions of interest. Results: Our findings suggest that the SPD+IA group shows deficits in assessments of cognitive control and visuomotor control. The brain-behavior correlational analysis revealed a relationship between the white matter integrity of the anterior limb of the internal capsule, the cingulate gyrus, and the superior longitudinal fasciculus with both cognitive and visuomotor control abilities. These correlations suggest a disruption in the information transfer between cortical and subcortical structures to the frontal cortex for the orchestration of both cognitive and visuomotor control. Conclusions: These findings suggest that children with SPD+IA show visuomotor and cognitive control deficits. Furthermore, these behavioral deficits may result from anomalous connections to the frontal cortex. These findings provide new insight into the biological implications for cognitive and visuomotor deficits observed in children with neurodevelopmental disorders on the whole and suggest detailed clinical assessment of these domains of function in at-risk children.

COG, NEURODEV, ND Supported by the Wallace Research Foundation http://dx.doi.org/10.1016/j.jaac.2017.09.175

3.28 AT-HOME FUNCTIONAL IMPAIRMENT IN YOUTH WITH ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER (ADHD): FACTOR STRUCTURE AND NORM-REFERENCED CUT-OFF POINTS FOR THE BEFORE SCHOOL FUNCTIONING QUESTIONNAIRE AND PARENT RATING OF EVENING AND MORNING BEHAVIOR SCALE, REVISED Stephen V. Faraone, PhD, SUNY Upstate Medical University, [email protected]; Norberto J. DeSousa, MA, Ironshore Pharmaceuticals & Development, Inc., bert@ ironshorepharma.com; Rick Nullmeier, BA, Ironshore Pharmaceuticals & Development, Inc., rick@ironshorepharma. com; F. Randy Sallee, MD, PhD, Ironshore Pharmaceuticals & Development, Inc., [email protected]; Bev Incledon, PhD, Ironshore Pharmaceuticals & Development, Inc., [email protected]; Timothy E. Wilens, MD, Massachusetts General Hospital, twilens@ partners.org Objectives: Two validated rating scales provide measures of temporal athome functional impairment for clinical trials in children with ADHD: 1) Before School Functioning Questionnaire (BSFQ), which assesses early morning functional (EMF) impairment; and 2) Parent Rating of Evening and Morning Behavior Scale, Revised (PREMB-R), which evaluates EMF and late afternoon/ evening functional impairment. The objectives of this study were to determine the factor structure and define norm-referenced cut-off points for both instruments. Methods: A survey was conducted with 1,200 respondents derived from a representative US sample of primary caregivers of youth (aged 6-17 years; n ¼ 50 per age/gender category). Caregivers were enrolled if their child never had ADHD or had a history of ADHD (past or current untreated). Using a severity scale of 0 to 3 (higher score indicating greater severity), caregivers rated their child’s at-home functional impairment on the 20-item BSFQ and 11-item PREMB-R. Factor analyses were conducted, and percentile cut-off points were calculated for screening risk (80th) and for identifying mild (90th), moderate (93rd), and severe (97th) functional impairment. Results: Of the 700 children (aged 6-12 years) and 500 adolescents (aged 1317 years) rated by a caregiver, 1,079 had no history of ADHD and 121 had a history of ADHD. As expected, BSFQ fit a 1-factor model, which explained 91.7 percent of the variance, and PREMB-R fit a 2-factor model, with one factor containing three morning items (PREMB-R AM subscale) and the other accounting for eight late afternoon/evening items (PREMB-R PM subscale). Age

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and comorbidities, but not gender, had significant effects on scores. Youth with ADHD had significantly higher scores than those without ADHD, even after adjusting for comorbidities. Norm-referenced cut-off points were defined for screening risk (BSFQ: 24; PREMB-R AM: 4; PREMB-R PM: 10), and for mild (BSFQ: 32; PREMB-R AM: 6; PREMB-R PM: 14), moderate (BSFQ: 36; PREMB-R AM: 6; PREMB-R PM: 16), and severe (BSFQ: 41; PREMB-R AM: 7; PREMB-R PM: 18) functional impairment. Cut-offs are also presented by age. Conclusions: Percentile cut-off points derived from norm-referenced data are defined to guide clinicians in determining the severity of ADHD-related athome functional impairment among youth.

ADHD, RI, DIAG Supported by Ironshore Inc. http://dx.doi.org/10.1016/j.jaac.2017.09.176

3.29 PSYCHOMETRIC VALIDATION OF THE BEFORE SCHOOL FUNCTIONING QUESTIONNAIRE AND PARENT RATING OF EVENING AND MORNING BEHAVIOR SCALE, REVISED IN CHILDREN WITH ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER (ADHD) Stephen V. Faraone, PhD, SUNY Upstate Medical University, [email protected]; Norberto J. DeSousa, MA, Ironshore Pharmaceuticals & Development, Inc., bert@ ironshorepharma.com; F. Randy Sallee, MD, PhD, Ironshore Pharmaceuticals & Development, Inc., randy@ ironshorepharma.com; Bev Incledon, PhD, Ironshore Pharmaceuticals & Development, Inc., bev@ ironshorepharma.com; Timothy E. Wilens, MD, Massachusetts General Hospital, [email protected] Objectives: The goals of this session are to assess the psychometric properties of the Before School Functioning Questionnaire (BSFQ) and Parent Rating of Evening and Morning Behavior Scale, Revised (PREMB-R) and determine the following: 1) whether the previously validated BSFQ and PREMB-R morning (ante meridiem, AM) subscales are measuring the same construct [early morning functional (EMF) impairment]; and 2) whether the PREMB-R evening (post meridiem, PM) subscale is a valid and reliable measure of late afternoon/evening functional impairment in children with ADHD. Methods: Using data from two randomized, placebo-controlled phase 3 trials of HLD200 in children (ages 6–12 years) with ADHD, reliability (internal consistency and test-retest) and construct validity (convergent/divergent and known groups) were evaluated by correlating or comparing BSFQ, PREMB-R AM, and PREMB-R PM scores with other instruments [ADHD Rating Scale-IV (ADHD-RS-IV); ADHD-RS-IV between 6:00 AM and 9:00 AM (ADHD-AM-RS); Clinical Global Impression-Improvement (CGI-I) and Clinical Global Impression-Severity (CGI-S); Connors’ Global Index-Parent (CGI-P); Swanson, Kotkin, Agler, M-Flynn, and Pelham (SKAMP); and Permanent Product Measurement of Performance (PERMP)]. Results: BSFQ and PREMB-R AM/PM scales demonstrated strong internal consistency (Cronbach’s a >0.7) and at least good test-retest reliability (intraclass correlation coefficient >0.7, except 0.59 for PREMB-R AM scale in one trial). BSFQ and PREMB-R AM had moderate to large correlations with ADHD-AM-RS and with one another, small to moderate correlations with ADHD-RS-IV, and no correlations with SKAMP and PERMP. PREMB-R PM scales had moderate correlations with ADHD-RS-IV, ADHD-AM-RS, and BSFQ and no correlations with SKAMP or PERMP. With increasing ADHD severity (measured by CGI-S, CGI-P, and ADHD-RS-IV), mean BSFQ (P < 0.0005), PREMB-R AM (P < 0.03), and PREMB-R PM (P < 0.0001) scores were higher (worse) with significant linear trends across the groups. Significant positive correlations between mean change scores from baselines in BSFQ, PREMB-R AM, and PREMB-R PM and other measures (ADHD-RS-IV, ADHD-AM-RS, CGIP, CGI-I) were found in both trials (all P < 0.0001). Conclusions: These findings psychometrically support the use of BSFQ and PREMB-R AM/PM scales in clinical trials of children with ADHD and demonstrate that BSFQ and PREMB-R AM scales measure the same underlying construct (EMF impairment).

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ADHD, RI, DIAG Supported by Ironshore Pharmaceuticals & Development, Inc. http://dx.doi.org/10.1016/j.jaac.2017.09.177

3.30 PARENT-CHILD AGREEMENT IN ASSESSMENT OF ANXIETY, MOOD, AND SLEEP DISORDER SYMPTOMS IN OFFSPRING OF BIPOLAR PARENTS Tomas Novak, MD, National Institute of Mental Health, [email protected]; Antonin Sebela, MD, Charles University in Prague, 1st Medical Faculty, antonin.sebela@ nudz.cz; Michal Goetz, MD, PhD, Charles University in Prague, 2nd Faculty of Medicine, [email protected] Objectives: Anxiety symptoms, sleep impairment, and transient mood symptoms are among the often described antecedents of full mood episodes in offspring of parents with bipolar disorder (BD). Creating a method for its evidence-based assessment is crucial for staging a risk of developing mood disorder. The aim of this study is to evaluate both the cross-informant (parentchild) agreement in assessment of symptoms of mood, anxiety, and sleep impairment and agreement between self-report and objective assessment. Methods: Forty-three offspring of a parent with BD (OBP; age 12.5 3.2 years; 40% girls) and 43 gender- and age-matched offspring of healthy parents (OHP) were assessed using the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) for the presence of DSM-5 diagnoses and, subsequently, parent and self-report versions of General Behavior Inventory (GBI)— depression, hypomania/biphasic, and sleep modules and the Screen for Child Anxiety-Related Emotional Disorders (SCARED) were administered. Crossinformant agreement and parent-child agreement on DSM-5 diagnoses were calculated as Kendall’s rank correlation coefficient, concordance correlation coefficient (CCC), and Cohen’s k. Regression analyses were applied to identify factors associated with higher agreement. Results: Thirty-three OBP (77%) and 10 control subjects (23%) met the criteria for at least one current DSM-5 diagnosis (P < 0.001; OR ¼ 8.10; 95% CI 2.74– 24.01) with mood disorders, anxiety disorders, and ADHD as the most frequent diagnoses. Parent-child agreement was low in hypomania/biphasic and sleep symptoms, moderate in mood symptoms, and satisfactory in case of anxiety symptoms. Higher agreement was found in families with a parent with BD, in younger children (age < 13 years), in girls, and in the absence of current depression in offspring. Agreement with the DSM-5 diagnosis was fair to moderate (k 0.29-0.43) and similar in both parents and children, with a high positive (up to 92%) but low negative predictive value in parents, and balanced but moderate predictive values in children. Conclusions: Weak cross-informant agreement impedes application of questionnaires as a method for detection of mood disorder prodromal stages in high-risk children and adolescents.

PSP, RI, DIAG Supported by the Agency for the Czech Republic Health Research Grant 1732478A and the Ministry of Health, Czech Republic Grant 00064203 http://dx.doi.org/10.1016/j.jaac.2017.09.178

3.31 BUILDING PREDICTIVE MODELS FOR AUTISM SPECTRUM DISORDER BASED ON BIOSENSOR DATA S. Jagannatha, PhD, Janssen Research & Development, LLC, [email protected]; D. Sargsyan, MS, Janssen Research & Development, LLC, [email protected]; N.V. Manyakov, PhD, Janssen Research & Development, LLC, [email protected]. com; A. Skalkin, MS, Janssen Research & Development, LLC, [email protected]; A. Bangerter, MA, Janssen Research & Development, LLC, [email protected]; S. Ness, MD, Janssen Research & Development, LLC, [email protected]; D. Lewin, PhD, Janssen Research & Development, LLC, [email protected]; Geraldine Dawson, PhD, Duke Center


for Autism and Brain Development, geraldine.dawson@duke. edu; F. Shic, PhD, Seattle Children’s Hospital, [email protected]; M.S. Goodwin, PhD, Northeastern University, m.goodwin@ neu.edu; R. Hendren, DO, University of California, San Francisco, [email protected]; Bennett L. Leventhal, MD, University of California, San Francisco, [email protected]; G. Pandina, PhD, Janssen Research & Development, LLC, [email protected] Objectives: The goal of this presentation is to demonstrate the utility of applying data mining to biosensor data from the Janssen Autism Knowledge Engine (JAKEä) system by identifying biosensor variables, in combination or individually, that can discriminate between autism spectrum disorder (ASD) and typically developing (TD) participants. Methods: A total of 144 participants with ASD [median age (range): 12.5 (6–54) years; male ¼ 77.8%] and 41 TD individuals [median age (range): 11 (6–63) years; male ¼ 65.9%] were exposed to a battery of tasks consisting of 11 different experimental audiovisual tasks; data were collected from readings from EEG, ECG, and electrodermal activity (EDA), as well as observations from eye tracking and facial expressions (ClinicalTrials.gov NCT02668991). This resulted in approximately 31,000 data features. Features were eliminated because of nearzero variance, missingness, and collinearity, leaving 2,569 features for analysis. Correlations with Autism Behavior Inventory (ABI) score and Social Responsiveness Scale (SRS) were evaluated. The data were split into training (80%) and validation (20%) sets. A group of participants with moderate and severe ASD (105 subjects based on SRS total score), along with 41 TD individuals, were used to build models using repeated cross-validation to identify features contributing to predictive diagnosis at baseline visit. For diagnostic classifier, four models (partial least squares, random forest, elastic net, and C5.0) were built using the training set and tested on the validation set. We then compared performance, efficacy, and important features from the four models. Results: A total of 125 biosensor features were moderately correlated (jrj 0.4) with ABI domains and subdomains, but only four features with SRS treatment subscales, suggesting that ABI parent-reported behavioral constructs can capture directly assessed biosensor variance. Model performance, based on receiver operating characteristic (ROC), was moderate (AUC ROC ¼ 0.61–0.72), and model efficacy based on kappa statistic for the validation set was between 0.40 and 0.46 across the four models. The 20 most important features for each model were extracted. Ninety percent of these features were novel and have never been reported to discriminate ASD from TD. Fifty percent of important features were drawn from FACET; 42 percent were drawn from eye-tracking, and 8 percent were drawn from ECG. Conclusions: Data mining methods applied to baseline biosensor data can lead to models that discriminate ASD from TD. This method may prove useful in creating new diagnostic tests.

ASD, DIAG, OTH Supported by Janssen Research & Development, LLC http://dx.doi.org/10.1016/j.jaac.2017.09.179

3.32 CORRESPONDENCE OF THE MASSACHUSETTS GENERAL HOSPITAL AUTISM SPECTRUM DISORDER SYMPTOM CHECKLIST WITH THE AUTISM DIAGNOSTIC OBSERVATION SCHEDULE Gagan Joshi, MD, Massachusetts General Hospital, joshi. [email protected]; Abigail H. Belser, BA, Massachusetts General Hospital, [email protected]; Maura Fitzgerald, MPH, Massachusetts General Hospital, mfi[email protected]; Ronna S. Fried, EdD, Massachusetts General Hospital, [email protected]; Maribel Galdo, LICSW, Massachusetts General Hospital, [email protected]; Barbora Hoskova, BA, Massachusetts General Hospital, [email protected]. edu; Haley Tornberg, Massachusetts General Hospital, [email protected]; Joseph Biederman, MD,

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Massachusetts General Hospital, jbiederman@mgh. harvard.edu Objectives: Diagnosing autism spectrum disorder (ASD) can be a lengthy and expensive process. There is a need for a simplified and accurate assessment to aid in the diagnosis of ASD. This study assessed the validity of a DSMbased diagnostic symptom checklist for the assessment of ASD in psychiatrically referred populations. Methods: Assessment data from 86 children and adults (aged 8–57 years), with a clinical diagnosis of ASD, were collected to assess the validity of a DSM-based Autism Spectrum Disorder Symptom Checklist (ASD-SCL). The assessments included the Autism Diagnostic Observation Schedule (ADOS), Social Responsiveness Scale-2 (SRS-2), and the DSM-based ASD-SCL. We assessed the agreement of an expert clinician-administered ASD-SCL with the ADOS and SRS-2, both reliable measures to aid in diagnosing ASD. Results: There is a strong agreement between the ASD-SCL and the ADOS (86%), as well as the ASD-SCL and the SRS-2 (80%). Conclusions: A DSM-based ASD-SCL could serve as a useful diagnostic aid in the assessment of ASD in psychiatrically referred populations. Further assessment of the psychometric properties is warranted.

ASD, DIAG, OTH Supported by NIMH Grant K23MH100450 http://dx.doi.org/10.1016/j.jaac.2017.09.180

3.33 PROCESSING SPEED: COMMONALITIES AND DISCREPANCIES BETWEEN CLINICIAN AND COMPUTERIZED ASSESSMENT TOOLS Eliza L. Kramer, BA, Child Mind Institute, eliza.kramer@ childmind.org; Rebecca Neuhaus, PsyD, Child Mind Institute, [email protected]; Aki Nikolaidis, PhD, Child Mind Institute, [email protected]; Lindsay Alexander, MPH, Child Mind Institute, lindsay. [email protected]; Anna Yeo, MA, Child Mind Institute, [email protected]; Charissa Andreotti, PhD, Child Mind Institute, [email protected]; Batya Bronstein, PsyD, Child Mind Institute, batya.bronstein@ childmind.org; Danielle Citera, BA, Child Mind Institute, [email protected]; Emily Hart, PhD, Child Mind Institute, [email protected]; Camille Gregory, BS, Child Mind Institute, [email protected]; Anastasia Bui, BA, Child Mind Institute, anastasia.bui@ childmind.org; Bonhwang Koo, BS, Child Mind Institute, [email protected]; Michael P. Milham, MD, PhD, Child Mind Institute, [email protected] Objectives: Though computerized cognitive batteries are ideal for large-scale studies due to increased reliability and ease of administration, the exact ways in which they differ from examiner-administered tests remain unknown. Clinician-administered assessments may be advantageous for developing and clinical populations, as the structure provided can be helpful for those with difficulties with language, attention, or behavior regulation. This study examined differences between processing speed scores obtained from clinician administration of the Wechsler Intelligence Scale for Children (WISCV) and those from computerized administration of the NIH Toolbox Pattern Comparison (NIH PC) task, as well as examined potential contributing factors. Methods: Data were obtained from the Child Mind Institute Healthy Brain Biobank, which used a community-referred recruitment model (N¼323; ages 7-21). Measures collected include the WISC-V, the NIH PC, the Wechsler Individual Achievement Test (WIAT-III), and the Social Communication Questionnaire (SCQ). In addition to assessing the reliability of the two instruments, we tested for the presence of associations with other variables, in order to generate hypotheses about potential contributing factors (e.g., verbal ability, affect, ADHD, and neurodevelopmental disorders). Results: Moderate inter-rater reliability was observed between the two assessment tools (intraclass correlation coefficient ¼ 0.48). Higher estimates of processing speed index (PSI) by the WISC-V, relative to the NIH PC, were

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significantly associated (false discovery rate q < 0.05) with higher autistic traits (i.e., SCQ). Higher estimates of PSI by the NIH PC, relative to the WISC-V, were associated with higher WIAT-III listening comprehension composite scores, as well as with the WISC-V verbal comprehension index and the WISCV subtests of coding and symbol search. Conclusions: Our findings suggest that NIH PC and the WISC-V PSI appear to be assessing related but unique aspects of processing speed. This raises cautions about the substitution of one for another in the clinical domain, and the potential for disparities in findings across studies, if the mode of administration is not considered.

RI, NEPSYC, DIAG http://dx.doi.org/10.1016/j.jaac.2017.09.181

3.34 ASSESSING BARRIERS TO ENGAGEMENT IN A COMMUNITY MENTAL HEALTH CENTER USING THE PSYCHOSOCIAL ASSESSMENT TOOL (PAT) Melina Sevlever, PhD, Columbia University Medical Center, [email protected]; Liora Hoffman, PhD, Columbia University Medical Center, [email protected]; Josefina Toso Salman, MA, Columbia University Medical Center, [email protected] Objectives: Barriers in access to care prevent many individuals from benefitting from mental health services. The purpose of the current project was to assess the feasibility and utility of incorporating the Psychosocial Assessment Tool (PAT) into evaluation procedures at a community mental health clinic for children and adolescents. The PAT is a well-researched measure with strong reliability and validity. As a secondary objective, PAT results were used to develop case management interventions to address potential barriers with families during initial treatment sessions. Methods: Over six months, the PAT was administered to 58 families during evaluation. Families in targeted range (moderate risk) received a one-time case management meeting to address barriers (e.g., transportation issues), whereas families in clinical range (high risk) received intensive case management services to ensure continued support for chronic barriers to care. Treatment engagement (i.e., number of sessions attended in first treatment quarter) was used as an outcome measure of the effectiveness of the current intervention. Number of sessions attended in first quarter was also compared in a control sample group (no case management intervention at intake). Results: Approximately 28 percent of our sample group fell in the universal range; however, 62 and 10 percent of our sample group fell in the targeted and clinical range, respectively. Average PAT score fell in the targeted range (mean ¼ 1.36, SD ¼ 0.66). PAT subscore analysis indicated that majority of patients in our clinic identified barriers related to caregiver mental health (i.e., with own mental health needs) and lack of resources (e.g., finances, unemployment, child care). Initial outcome measures for families who completed the PAT and participated in the present intervention indicate high engagement in mental health services. Attendance for first psychotherapy appointment following evaluation and case management intervention was 90 percent. Conclusions: The PAT is an easily implemented and evidence-based measure that facilitates assessment of potential barriers to treatment engagement. Because a majority of families presenting to community mental health clinics endorse at least one significant barrier to care, addressing initial engagement issues may lead to improved outcomes throughout psychotherapy.

EBP, PRE, RF http://dx.doi.org/10.1016/j.jaac.2017.09.182

3.35 PSYCHOPHARMACOLOGY CONSULTATION FACILITATED BY INTEGRATED PSYCHOLOGY RESIDENTS IN A PEDIATRIC CONTINUITY CARE CLINIC: A FEASIBILITY STUDY Raman Marwaha, MD, Case Western Reserve University School of Medicine and MetroHealth Medical Center, [email protected]; Julie A. Pajek, PhD, Case Western

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Reserve University School of Medicine and MetroHealth Medical Center, [email protected]; Kelsy Newton, MS, Case Western Reserve University School of Medicine and MetroHealth Medical Center, [email protected]; Elizabeth Machado, MS, Case Western Reserve University School of Medicine and MetroHealth Medical Center, elizabethm.machado@gmail. com; Maixner W. Rae, MS, Case Western Reserve University School of Medicine and MetroHealth Medical Center, [email protected]; Terry Stancin, PhD, Case Western Reserve University School of Medicine and MetroHealth Medical Center, [email protected] Objectives: Primary care pediatricians (PCPs) are often tasked with prescribing psychotropic medications without access to a psychologist (PSY) or child and adolescent psychiatrist. The purposes of this study were: 1) to determine the feasibility of adapting an integrated care model that already incorporates PSY residents in a pediatric continuity care clinic to include child and adolescent psychiatrist consultation; and 2) to enhance knowledge of pediatric residents in psychopharmacology. Methods: Subjective and objective assessments of knowledge and comfort with prescribing psychotropic medications were conducted with pediatric residents prior to program implementation and again four months later. PSY doctoral residents who are embedded in a pediatric continuity care clinic at an urban academic health center collaborated with pediatric residents to identify patients for child and adolescent psychiatrist consultation. PSY residents assessed patients and reviewed cases with the child and adolescent psychiatrist who then messaged recommendations to the pediatric resident and attending PCP through electronic health records. Monthly child and adolescent psychiatrist-led educational conferences were conducted with pediatric and PSY residents. Patient diagnosis, medications prescribed, and time spent on consults were tracked within the four month pilot feasibility phase. Results: Cases receiving consultation (17/19) were started on psychotropic medications. Mean time spent by the child and adolescent psychiatrist on consultations was 20 minutes. Most common diagnoses were ADHD (42%), MDD (26%) and anxiety disorders (21%). 52 percent were prescribed SSRIs; 35 percent were prescribed ADHD medications. Total resident objective knowledge score (possible range 0 - 10) improved from pre- (M ¼ 5.1, SD ¼ 1.55) to post-intervention (M ¼ 8.1, SD ¼ 1.04; t ¼ -8.70, p < 0.05). Resident subjective assessment of knowledge/comfort improved (p < 0.05) on 20/21 items. No patient would have had access to a child and adolescent psychiatrist without the intervention. Conclusions: Availability of child and adolescent psychiatric or developmental behavioral pediatric psychopharmacology consultation is feasible within an integrated care model when facilitated by an embedded collaborating mental health professional. This approach may increase access to care and offer interprofessional educational opportunities.

REST, CC, CON Supported by the MEDTAPP Healthcare Access Initiative and the Ohio Department of Medicaid http://dx.doi.org/10.1016/j.jaac.2017.09.183

3.36 TEN YEARS OF TELEMENTAL HEALTH (TMH) COLLABORATION WITH BEHAVIORAL HEALTH ORGANIZATIONS L. Lee Carlisle, MD, Child Study and Treatment Center, [email protected]; William P. French, MD, University of Washington and Seattle Children’s Hospital, william.french@ seattlechildrens.org; Ian Kodish, MD, PhD, University of Washington and Seattle Children’s Hospital, ian.kodish@ seattlechildrens.org; Katherine Lo, ARNP, Seattle Children’s Hospital, [email protected]; Lisa Chui, ARNP, Seattle Children’s Hospital, [email protected]; Erin Dillon-Naftolin, MD, University of Washington and


Seattle Children’s Hospital, erin.dillon-naftolin@ seattlechildrens.org; Kathleen Myers, MD, DFAACAP, MPH, MS, University of Washington and Seattle Children’s Hospital, [email protected] Objectives: We describe the experience of seven telemental health (TMH) providers in collaborating with 11 behavioral health organizations (BHOs) in Washington and Alaska in the context of the newly published Practice Guidelines for Telemental Health with Children and Adolescents. Methods: We obtained utilization statistics, demographics, and clinical characteristics of patients treated at the BHOs from 2007 to 2017. We surveyed BHO therapists, administration, and families regarding their satisfaction. TMH providers summarized their experiences and outlined approaches for providing “best practices” for collaboration with BHOs. Results: The TMH providers collaborated in the care of over 3,000 youth (ages 4–21 years) across diagnoses with over 9,000 sessions. Most patients were prescribed medication. Parents reported high satisfaction (36 of 40 points). Therapists and administrative staff were also highly satisfied and wanted more time from the TMH providers for direct services and patient discussion. TMH providers appreciated working with underserved and vulnerable youth. Technology did not impede their delivery of evidencebased treatment. They noted facilitation of treatment by inclusion in sessions of a therapist or case manager (“telepresenter”). The lack of a shared electronic health record impeded efficiency and precluded understanding the therapists’ expertise and patients’ progress. Therapists’ turnover was frustrating. TMH providers noted the need for assistance in obtaining rating scales to establish measurement-based practice and to coordinate youths’ system of care (e.g., TMH providers, primary care physicians, and teachers). Conclusions: This presentation delineates best practices for meeting the challenges of collaborating with BHOs through TMH. Five top best practices include the following: 1) a telepresenter; 2) shared electronic records and tracking methods to document progress; 3) integration across the youth’s system of care; 4) time for interdisciplinary conferences, not just direct service; and 5) establishing criteria for discharge back to primary care. Our findings will guide aspiring TMH providers in collaborating with BHOs and establishing an enjoyable career in TMH.

EBP, CC, TVM http://dx.doi.org/10.1016/j.jaac.2017.09.184

3.37 ASSOCIATION OF RECENT CYBERBULLYING WITH OTHER FORMS OF MALTREATMENT, ANXIETY, AND DEPRESSION AMONG ADOLESCENTS IN AN OUTPATIENT SETTING Samantha B. Saltz, MD, University of Miami Miller School of Medicine and Jackson Memorial Hospital, samantha.saltz@ jhsmiami.org; Nils C. Westfall, MD, University of Miami Miller School of Medicine and Jackson Memorial Hospital, nils. [email protected]; Gabrielle E. Hodgins, University of Miami Miller School of Medicine, [email protected]; Rolando Gonzalez, MD, University of Miami Miller School of Medicine and Jackson Memorial Hospital, rolando. [email protected]; Piotr Pelc, MD, University of Miami Miller School of Medicine and Jackson Memorial Hospital, [email protected]; Alodia Diaz de Villegas, MD, University of Miami Miller School of Medicine and Jackson Memorial Hospital, [email protected]; Nicole Mavrides, MD, University of Miami Miller School of Medicine, [email protected]; Philip D. Harvey, PhD, University of Miami Miller School of Medicine, pharvey@med. miami.edu Objectives: Cyberbullying is a major public health threat associated with increased psychiatric morbidity and mortality in youths. We have previously shown that adolescent inpatients with psychiatric disorders who endorsed recent cyberbullying victimhood reported higher levels of

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emotional abuse, anger, depression, and dissociation. In this follow-up study, we investigated the association between recent cyberbullying, child abuse and neglect, anxiety, and depression among adolescent outpatients. Methods: We administered questionnaires assessing social media usage and cyberbullying in the previous two months [the Childhood Trauma Questionnaire (CTQ), the Children’s Depression Inventory 2 (CDI2), and the Screen for Child Anxiety Related Disorders (SCARED)] to patients ages 12–17 years presenting to an outpatient psychiatric clinic. The study protocol was approved by the institutional review board. Results: Subjects (N ¼ 50; 46% male, 54% female; mean age ¼ 14.18 1.71 years) were recruited. All subjects reported frequent access to the internet, and most reported using one or more types of social media at least daily. Ten percent of subjects reported being victims of cyberbullying compared with 20 percent in our previous inpatient study. Females were more likely to report cyberbullying victimhood than males (14.8 vs. 4.3%). Whereas in our previous inpatient study cyberbullying was associated with higher emotional abuse scores on the CTQ, there were no significant differences between cyberbullying victims and nonvictims in the CTQ subscale scores of this study. Cyberbullying victims had 1.25-fold higher CDI2 T-scores compared with nonvictims (P ¼ 0.03). On the SCARED, female cyberbullying victims had twofold higher (P ¼ 0.02) panic/somatic symptom and 2.3-fold (P ¼ 0.03) higher school avoidance scores than female nonvictims. Conclusions: Recent cyberbullying victimhood appears to be common among adolescent females, substantially more common among adolescent females than males, associated with higher levels of panic/somatic and school-related anxiety symptoms in adolescent females, and associated with higher levels of depression in adolescents in the psychiatric outpatient setting. Cyberbullying may be less common and less strongly associated with emotional abuse among adolescents in the psychiatric outpatient setting compared with the inpatient setting.

ADOL, BLY, MED http://dx.doi.org/10.1016/j.jaac.2017.09.185

3.38 UNDERSTANDING THE ROLE OF REWARD PROCESSING AND DEPRESSION IN COMPULSIVE INTERNET USE AMONG VIETNAMESE ADOLESCENTS Kunmi Sobowale, MD, Yale University, kunmi.sobowale@yale. edu; Hoang Anh Ngo, BA, Danang Psychiatric Hospital, [email protected]; Lam Tu Trung, MD, Danang Psychiatric Hospital, [email protected] Objectives: Previous studies find that depression, as a broad construct, is commonly comorbid with compulsive internet use. Therefore, in this crosssectional study, we examine the relationship between compulsive internet use and specific constructs of depression: behavioral activation and anhedonia. Methods: We surveyed students from two high schools in Vietnam. Selfreport measures of internet use, depressive symptoms, behavioral activation goal-oriented/avoidance behavior, and anhedonia system were collected. We used multivariate linear regression, controlling for gender, socioeconomic status, depressive symptoms, and patterns of internet use to determine which constructs were associated with compulsive internet use. Results: A total of 306 students [mean age ¼ 16.7 years (SD ¼ 0.9); 54.6% female] were included in the study. Most students had access to the internet at home (94.5%) and owned a smartphone (76.8%). Girls and those of lower socioeconomic status were more likely to use the internet compulsively. In multivariate linear regression, we find that compulsive internet use was associated with depression (b ¼ 0.14, P ¼ 0.008), as well as certain activities, including visiting social networking sites (b ¼ 0.41, P < 0.001), chatting (b ¼ 0.17, P ¼ 0.003), and online gambling (b ¼ 0.11, P ¼ 0.03). Furthermore, both behavioral activation goal-oriented (b ¼ 0.20, P < 0.001) and avoidance behavior (b ¼ 0.19, P < 0.001) were the strongly associated with compulsive internet use, whereas anhedonia had no association. This model explained a significant proportion of the variance in compulsive internet use [R2 ¼ 0.44,

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F(13, 280) ¼ 18.76, P < 0.001]. Avoidance behavior mediated the relationship between compulsive internet use and depressive symptoms. Conclusions: Our results suggest that behavioral activation, particularly avoidance behavior, is an important target for curtailing compulsive internet use. In addition, restricting certain activities, such as excessive use of social networking sites, may reduce compulsive internet use among Vietnamese adolescents.

ADOL, COMP, DDD Supported by the Yale Global Mental Health Scholarship http://dx.doi.org/10.1016/j.jaac.2017.09.186

3.39 SMARTPHONE AND ONLINE USAGE-BASED EVALUATION IN TEENS (SOLVD-TEEN): CAN AN APP HELP TEENS AND THEIR PARENTS WITH DEPRESSION? Anh L. Truong, MD, Baylor College of Medicine, altruong@ bcm.edu; Sophia Banu, MD, Baylor College of Medicine, [email protected]; Jian Cao, MS, Rice University, [email protected]; Asim Shah, MD, Baylor College of Medicine, aashah@bcm. edu; Nidal Moukaddam, MD, PhD, Baylor College of Medicine, [email protected]; Ashu Sabharwal, PhD, Rice University, [email protected] Objectives: The study aims to evaluate whether the Smartphone and Online Usage Based Evaluation for Depression (SOLVD) smartphone application can be useful in monitoring and classifying depression symptoms in a clinically depressed adolescent population by tracking daily moods and monitoring smartphone usage compared to standard clinician psychometric instruments including Patient Health Questionnaire-9 (PHQ-9), Hamilton Rating Scale for Depression (HAM-D), and Hamilton Anxiety Rating Scale (HAM-A). Methods: Thirteen patients with major depressive disorder with or without comorbid anxiety disorder and their parents or primary caregivers were recruited. Patients (aged 12-17 years) of both genders, with the diagnosis of major depressive disorder, and ownership of an Android smartphone were included. Patients were excluded if they had other comorbid psychiatric disorders. Patients and parents were prompted by the application to report daily moods for eight weeks, and parents were also asked to rate how they felt their teens were doing daily. Sensor data including GPS location and usage data were also collected. Patients and parents were evaluated biweekly by research clinician to assess for depression and anxiety symptoms through use of HAMD, HAM-A, and PHQ-9 scales. The clinician was blinded to smartphone data. Results: Pearson’s coefficient was used as indicator of correlations between self-reported moods and sensor data to clinician psychometric instruments. Adherence rate to daily self-reported moods was 79 percent for adolescents and 95.7 percent for their caregiver. Teen self-reported mood correlated to PHQ-9 scores (p < 0.01). Sensor data also correlated to PHQ-9 scores as well as HAM-A scores. This was reflected as fewer calls (r ¼ 0.44), fewer text messages (r ¼ 0.55) and fewer steps taken (r ¼ 0.65) in individuals with higher PHQ-9 scores and HAM-A scores. Conclusions: This study showed that self-input data correlated with clinical assessment of depression in the adolescent population. Parent and teen depression levels also correlated. The study was well tolerated with no privacy or operability concerns and results suggest that a well-designed app can be used to track mood and anxiety levels reliably and that data may be useful if integrated into clinical assessment.

ADOL, MED, OTH http://dx.doi.org/10.1016/j.jaac.2017.09.187

3.40 LENGTH OF STAY MAY NOT CORRELATE WITH IQ: PREDICTION CHALLENGES OF IQ ASSESSMENT IN THE CHILD AND ADOLESCENT PSYCHIATRIC INPATIENT SETTING Maria E. Reynoso, MD, Bronx-Lebanon Hospital Center, [email protected]; Robert Dugger, MD,

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Bronx-Lebanon Hospital Center, [email protected]; Amelia Mcintosh, MD, Bronx-Lebanon Hospital Center, [email protected]; Sylvia Boules, MD, BronxLebanon Hospital Center, [email protected]; Monica Badillo, MD, Bronx-Lebanon Hospital Center at Icahn School of Medicine at Mount Sinai, [email protected]; Aos Mohammed Ameen, MD, Bronx-Lebanon Hospital Center at Icahn School of Medicine at Mount Sinai, [email protected]; Wen Gu, PhD, Bronx-Lebanon Hospital Center, [email protected]; Marilena A. Jennings, MD, Bronx-Lebanon Hospital Center, [email protected]; Arturo Sanchez, MD, BronxLebanon Hospital Center at Icahn School of Medicine at Mount Sinai, [email protected]; Jeffrey M. Levine, MD, Bronx-Lebanon Hospital Center, [email protected] Objectives: Intellectual disability has been defined as “the impairment of general mental abilities that impact adaptive functioning.” It is prevalent in approximately one percent of the US population. The aim of our study was to investigate whether IQ is associated with clinical outcomes relevant for inpatient psychiatric hospitals, including duration of psychiatric admission, medication selection, crises management on the unit, and comorbidity with other medical and substance use disorders. Methods: This is an institutional review board-approved study. We conducted a retrospective chart review of child and adolescent patients in an inner city psychiatric hospital in New York City from December 3, 2012, to April 3, 2017. In order to better identify modifiable treatment targets, variables reviewed include: 1) length of stay; 2) number of admissions; 3) episodes of seclusion and restraint; 4) medications prescribed; and 5) substance use. Our sample consisted of 160 patients, with a mean age of 13.6 year (SD ¼ 2.8). The average IQ was 79.2 (SD ¼ 16.4). Results: Full-scale intelligence quotient (FSIQ) was inversely correlated with a history of sexual abuse at a statistically significant level. There was also a trend for IQ being inversely correlated with receiving emergent intramuscular medication. Patients with higher IQ were more likely to be prescribed antidepressants and less likely to be prescribed mood stabilizers, but not significantly correlated with prescription of alpha agonists, stimulants, antipsychotics, or other medication classes. Interestingly, IQ was not significantly associated with length of stay, number of intramuscular medication administrations, number of seclusions or restraints, or use of different classes of illicit substances. Conclusions: The mean IQ of our population was 79. The prevalence of trauma in our sample, as measured by history of physical abuse (28%), sexual abuse (18%), and neglect (18%) was high, which likely impacted normal development of verbal reasoning, attention, and processing speed. IQ may not correlate with length of stay or indirect measures of aggression in the inpatient child and adolescent setting. Moreover, our findings echo the vulnerability of the intellectually disabled population as our findings demonstrate inverse correlation between IQ and history of sexual abuse.

AGG, ID http://dx.doi.org/10.1016/j.jaac.2017.09.188

3.41 SCHOOL PERFORMANCE ON CHILDREN AND ADOLESCENTS EXPOSED TO MALTREATMENT Fernanda M. Saraiva, MD, Psychiatric Institute, Medical School, University of S~ao Paulo – Brazil, fernandamsaraiva2@ gmail.com; Anne F.M. Brito, MD, Psychiatric Institute, Medical School, University of S~ ao Paulo – Brazil, annefmbrito@gmail. com; Sandra Scivoletto, PhD, Psychiatric Institute, Medical School, University of S~ ao Paulo – Brazil, sscivoletto@gmail. com; Luciene Stivanin, PhD, Medical School, University of S~ ao Paulo – Brazil, [email protected]; Gisele Fao, BS, Psychiatric Institute, Medical School, University of S~ao Paulo – Brazil,


[email protected]; Vinıcius Silva, BS, Psychiatric Institute, Medical School, University of S~ ao Paulo – Brazil, [email protected]; Bernardo Santos, MSC, Nursing School, University of S~ ao Paulo – Brazil, bernardo.estat@ gmail.com Objectives: The aim of this study is to analyze the association of maltreatment (type, intensity, age of first shelter, and length of sheltering) with school performance of children and adolescents living in shelters. Methods: A total of 104 maltreated children from ages seven to 14 years were evaluated from February 2016 to March 2017. The tests applied were as follows: cognitive-linguistic skills evaluation protocol, reading comprehension test, phonological skills profile, arithmetic test, school motivation assessment scale, questionnaire of difficulties and potentialities (SDQ), Childhood Traumas Questionnaire, Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL), and Wechsler Intelligence Scale for Children (WISC-IV). To analyze the results, the following tests were used: t-test and ANOVA to associate numerical with categorical variables, Pearson correlation for two numerical variables, and Chi-square test, or Fisher Exact test for two categorical variables. Results: Seventy-five percent presented written language problems. Difficulties in writing had statistically significant association with the following: lower age (P ¼ 0.003); lower schooling (P ¼ 0.002); more deficits on phonological skills (P ¼ 0.000) and operational memory index (P ¼ 0.002); higher scores on total SDQ (P ¼ 0.031); higher hyperactivity (P ¼ 0.046); and intermediate levels of extrinsic motivation (P ¼ 0.004). In arithmetic, 48.5 percent children presented problems, which had statistically significant association with lower IQ (P ¼ 0.001), lower verbal comprehension index (P ¼ 0.000), altered operational memory indexes (P ¼ 0.016), higher scores on total SDQ (P ¼ 0.023), and more emotional symptoms (P ¼ 0.027). With regard to school motivation, lower total school motivation had statistically significant association with older age (P ¼ 0.000), higher schooling (P ¼ 0.000), older age at first sheltering (P ¼ 0.001), higher intensity of maltreatment (P ¼ 0.033), greater occurrence of physical neglect (P ¼ 0.005), physical (p ¼ 0.031) and emotional abuse (P ¼ 0.045), and oral coherence (P ¼ 0.025). Conclusions: Different types of maltreatment were associated with impacts on different school skills and were associated with specific behavioral problems. Furthermore, age of first sheltering also affected the school skills. These results demonstrate that different school approaches must be developed to enhance abilities and overcome deficits in maltreated children.

LD Supported by S~ ao Paulo Research Foundation http://dx.doi.org/10.1016/j.jaac.2017.09.189

3.42 THE FEASIBILITY OF A NOVEL COGNITIVE ASSESSMENT AND MONITORING TOOL WITHIN A NATURALISTIC SETTING Nirmaliz Colon, BS, Columbia University, nirmalizc@gmail. com; Jimmy Zhou, BS, Akili Interactive Labs, jzhou@ akiliinteractive.com; Jeffrey D. Bower, PhD, Akili Interactive Labs, [email protected]; Rachel Flynn, PhD, New York University, fl[email protected] Objectives: A pilot study was conducted to assess the feasibility, reliability, and assessment sensitivity of a novel video game-like repeat-assessment monitor (Akili Interactive). Methods: A total of 100 participants (mean age ¼ 13.62 years; 74% male) were recruited from a special needs summer camp (Camp Ramapo, New York). Parents reported on the participants’ cognitive and behavioral diagnoses [ADHD ¼ 32; autism spectrum disorder (ASD) ¼ 31; ADHD + ASD ¼ 20; other ¼ 17]. Participants completed up to eight assessments using the monitor tool over two weeks. An acceptance survey and the Test of Variables of Attention (TOVA) were administered on entrance and exit. Results: There were no treatment-related adverse events. The rate of completion was 75 percent (5.97 sessions). On the exit tolerability survey, 85

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percent of participants indicated they enjoyed using the monitor tool. Monitor metrics were assessed for repeated assessment stability by calculating an interclass correlation coefficient (ICC). The most reliable measure produced an ICC of 0.90, indicating high test-retest reliability. Additional metrics from distinct components of the monitor’s tasks showed similar high levels of reliability (ICC > 0.70). For assessment, monitor metrics were analyzed for associated signals that were related to diagnostic group. The most sensitive metric was Reaction Time Standard Deviation (RTSD). An ANOVA showed a main effect of the diagnostic group of scores on RTSD [F(3,55) ¼ 11.08, P < 0.00001]. In post hoc analyses, significant differences between the ASD and all other groups were found (P < 0.01). In addition, single and multivariate models were examined for association with baseline TOVA Attention Performance Index (API) scores. A three-factor multivariate model was found to offer the most explanatory power with the fewest number of factors. The threefactor model was strongly associated with baseline TOVA API [F(4,19) ¼ 9.615, P ¼ 0.0002]. Conclusions: This pilot study provides initial support for the feasibility of Akili Interactive’s novel video game-like repeat-assessment monitor. In addition, the findings suggest that it is highly reliable, is sensitive to attention dysfunction, and may have diagnostic specificity for specific disorders such as ASD, potentially filling a gap in practice for cognitive assessment and monitoring tools that are tolerable, accessible, and affordable.

RI, COG, SAC http://dx.doi.org/10.1016/j.jaac.2017.09.190

3.43 THE RELATION OF PARENT-CHILD INTERACTION THERAPY (PCIT) IN WELL-BEING OF YOUNG CHILDREN WITH ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) AND OPPOSITIONAL DEFIANT DISORDER Naser Ahmadi, MD, PhD, University of California, Los Angeles, [email protected]; Shahzad Chaudhry, MFT, University of California, Los Angeles Kern Medical, [email protected]; Garth Olango, MD, University of California, Los Angeles Kern Medical, olangog@ kernmedctr.com; Mohammed Molla, MD, University of California, Los Angeles Kern Medical, shahriarmolla@ gmail.com Objectives: Previous studies have demonstrated effectiveness of Parent-Child Interaction Therapy (PCIT) in improving children’s disruptive behavioral problems. This study investigates the effect of PCIT on the well-being of young children with ADHD and ODD. Methods: Eleven consecutive children (ages 5–8 years, 7 males) who scored 120 on the Eyberg Child Behavior Inventory (ECBI) received PCIT. The child and families were assessed at baseline and at four months after beginning treatment. Parenting skills were measured using the Dyadic Parent-Child Interaction Coding System (DPICS), and child behavior problems were measured using the ECBI and the Child Behavior Checklist (CBCL). Well-being was measured using multidimensional PERMA model (positive emotions, engagement, positive relationships, meaning, and accomplishment). Wellbeing was defined as low (PERMA score 3), average (PERMA score 4–5), and high (PERMA score 6). Results: At follow up, after PCIT intervention, a significant improvement in children’s behavior (ECBI baseline: 147 22 vs. follow-up: 80 15, P ¼ 0.001) and parents’ do and don’t skills, measured by observer rating on DPICS (d ¼ 2.9, d ¼ 1.6, respectively, P ¼ 0.01), were noted. The total PERMA score, as well as scores in each dimension, were significantly improved at follow-up in both children and parents compared with baseline (P ¼ 0.01). The most robust improvement was noted in positive relationships, engagements, and accomplishments (P < 0.05). Conclusions: The current findings reveal that PCIT is associated with an increase in well-being of both children and parents, in addition to significant reduction of children’s disruptive behavior. This highlights the importance of

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simultaneous intervention to address vulnerable symptoms, as well as enhancing well-being in youth with ADHD and ODD.

ADHD, ODD, PAT http://dx.doi.org/10.1016/j.jaac.2017.09.191

3.44 A COMPARISON OF MOTHER-CHILD INTERACTIONS DURING FEEDING AND PLAY IN THE ASSESSMENT OF FEEDING DISORDERS Irene Chatoor, MD, Children’s National Medical Center, [email protected]; Cristina Sechi, PhD, University of Cagliari, Italy, [email protected]; Loredana Lucarelli, PsyD, University of Cagliari, Italy, [email protected] Objectives: The assessment of the quality of the parent-infant/toddler relationship in children with feeding disorders is crucial, not only to observe parent-child interactions in settings where the child and his/her mother are distressed but also in settings where activities can be pleasurable. Most observational tools for assessing parent-child interactions suffered from a lack of empirical research, and the psychometric properties of these tools should be considered more carefully. Therefore, this work explores the factor structure and validity of the Parent-Child Play Scale. It is a complement to the Feeding Scale to evaluate mother-child interactions in children with feeding disturbances and disorders. The Play Scale can be used with children ranging in age from one month to three years and provides ratings of mother-child interactions during 10 minutes of videotaped free-play observations. The scale consists of 32 mother and child interactive behaviors, which are rated by trained observers. Methods: This study examines the factor structure and the ability of the Play Scale to differentiate between healthy children and children with three subtypes of developmental feeding disorders; the relationship between the mother-infant/toddler interactions measured on the Feeding Scale versus the Play Scale. A sample group of 124 mother-child dyads (74 children with feeding disorders; 50 children who were typically developing) participated in the study. Children ranged in age from one to 36 months. Results: The factor analysis extracted four factors, which we labeled: dyadic reciprocity, maternal unresponsiveness to infant/toddler’s cues, dyadic conflict, and maternal intrusiveness. All four factors together explain 57.7 percent of the total variance. The Play Scale discriminates between children with and without feeding disorders, as well as between children with different subtypes of feeding disorders. Significant correlations (P < 0.05; P < 0.01) between the subscales of the Feeding Scale and the Play Scale were found for mothers and children who had feeding disorders. Conclusions: The Play Scale can be used for research or clinical practice to enhance observational skills, to assess the pervasiveness of mother-infant/ toddler difficulties, and to monitor changes following therapy.

R, EC, EA http://dx.doi.org/10.1016/j.jaac.2017.09.192

3.45 CHARACTERISTICS AND POTENTIAL SUBTYPES OF CHILD AND ADOLESCENT PSYCHIATRIC PATIENTS WITH AVOIDANT RESTRICTIVE FOOD INTAKE DISORDER THAT PRESENTED TO A TERTIARY CARE PSYCHIATRIC FACILITY Mili Khandheria, MD, University of Texas Southwestern Medical Center, [email protected]; Kinjal Patel, DO, University of Texas Southwestern Medical Center, kinjal6891@ gmail.com; Briana Sacco, MD, University of Texas Southwestern Medical Center, [email protected]; Graham J. Emslie, MD, University of Texas Southwestern Medical Center, [email protected] Objectives: Few studies have been done on avoidant-restrictive food intake disorder, which is a relatively new diagnosis in DSM-5. This retrospective chart

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review was done to determine clinical characteristics and subtypes within patients with avoidant-restrictive food intake disorder presenting to a tertiary care eating disorder facility. Methods: A retrospective chart review was performed on adolescents (ages 6–17 years) who were admitted to an inpatient and partial tertiary care facility and diagnosed with avoidant-restrictive food intake disorder between October 2014 and October 2015. Demographics and psychiatric comorbidity information was collected from the chart review. Based on clinical information in the chart, patients were divided into four subtypes within the avoidantrestrictive food intake disorder population. The four subtypes were compared in terms of comorbidities using Chi-square tests. ANOVA was used to compare the subtypes in terms of age, length of stay, and ideal body weight percentage. Results: Patients (46 of 222; 21.6%) met criteria for avoidant-restrictive food intake disorder at the tertiary care facility during this time period. Within the patient population diagnosed with avoidant-restrictive food intake disorder, 39.1 percent were male and 60.9 percent were females (mean age ¼ 11.6 years). The cohort in terms of ethnicity was 58.7 percent Caucasian, 34.8 percent Hispanic, 4.3 percent Indian, and 2.2 percent African American. Fifteen percent of patients changed diagnosis to anorexia nervosa. Anxiety was the primary comorbidity present in this population at 54.3 percent, which was nearing significance (P ¼ 0.07). Of this population, 19.5 percent had depression and 2.17 percent had autism spectrum disorder (ASD). Unfortunately, no significance was found between subtypes and variables on Chisquare and ANOVA tests. Conclusions: Patients with avoidant-restrictive food intake disorder presenting at this tertiary care facility for inpatient and partial hospitalization had a greater proportion of females and tended to be older compared with patients with avoidant-restrictive food intake disorder as discussed in the literature. The fear of an eating subtype had a high level of comorbid anxiety that could approach significance if a higher sample group size was present.

RCR, EA http://dx.doi.org/10.1016/j.jaac.2017.09.193

3.46 AVOIDANT/RESTRICTIVE FOOD INTAKE DISORDER IN DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, FIFTH EDITION (DSM-5), RESTRICTIVE SUBTYPE IN EARLY CHILDHOOD: THE ASSESSMENT OF PARENT-CHILD FEEDING INTERACTIONS AND THE USE OF THE LAUSANNE TRIADIC PLAY Loredana Lucarelli, PsyD, University of Cagliari, Italy, [email protected]; Alessio Porreca, PhD, University of Padua, [email protected]; Alessandra Simonelli, PhD, University of Padua, [email protected] Objectives: The main aim of this research was to investigate early childhood mother-child dyadic interactions and mother-father-child triadic interactions in families with a child diagnosed with DSM-5 avoidant/ restrictive food intake disorder (ARFID), restrictive subtype (“lack of interest in food or eating”). Methods: The study involved five families with children (mean age ¼ 42 months) with a DSM-5 diagnosis of ARFID, restrictive subtype, extracted from a larger group of 51 families with a child diagnosed with ARFID, and compared to non-clinical families. Families were assessed during: 1) dyadic, and 2) triadic interactions, through the Scala di Valutazione dell’Interazione Alimentare Madre-Bambino (SVIA), the Italian validated version of the Feeding Scale, and the Lausanne Trilogue Play procedure. Triadic interactions were evaluated through the Family Alliance Assessment Scales. Results: During dyadic feeding interactions, all the subjects reported scores above clinical normative cut-offs on the SVIA subscales (i.e., mother’s affective state, food refusal, interactive conflict, dyad’s affective state). During triadic feeding interactions, families with children diagnosed with ARFID showed significant differences (p < 0.05) compared to non-clinical families. They presented specific difficulties in the areas concerning posture and gaze, coconstruction of a joint activity, interactive mistakes and their resolution


during activities, family warmth, validation of the child’s emotional experience, and child’s involvement and self-regulation. Conclusions: Findings highlight the importance of considering the family interactions during the assessment of feeding disorders in early childhood. The adoption of a comprehensive perspective, through the investigation of both dyadic and triadic dynamics will be useful in the clinical understanding of the role played by interactive difficulties in the onset and in the maintenance of the restrictive subtype feeding disorder. Dysfunctional family interactions are a critical issue, stressing the importance of an articulated diagnostic assessment in order to target effective treatment.

FAM, EC, EA http://dx.doi.org/10.1016/j.jaac.2017.09.194

3.47 TREATMENT OF EXCESSIVE DAYTIME SLEEPINESS WITH MODAFINIL AND ARMODAFINIL IN EARLY-ONSET NARCOLEPSY COMORBID WITH PSYCHIATRIC DISORDERS Anna Ivanenko, MD, PhD, Northwestern University Feinberg School of Medicine, [email protected]; Laura Kek, AMITA Health, [email protected] Objectives: Limited data are available on the use of modafinil and armodafinil in pediatric patients with narcolepsy and other psychiatric conditions. The aim of this study was to examine a long-term clinical effectiveness and tolerability of modafinil and armodafinil coadministered with other psychopharmacological treatments in children and adolescents with excessive daytime sleepiness associated with narcolepsy. Methods: A retrospective chart review was performed at a pediatric sleep medicine clinic affiliated with a major academic medical center and several large healthcare systems. Pediatric patients under age 18 years who met diagnostic criteria for narcolepsy based on the ICSD-3 criteria were selected and included into data analysis. Medical, psychiatric, demographic and electrophysiological characteristics were examined. Results: Patients (N ¼ 63) were prescribed modafinil and armodafinil at the time of initial diagnosis. Starting dose of modafinil was 50-100 mg/day and of armodafinil was 50-75 mg/day. The average maintenance dose of modafinil was 340mg 162/day, and of armodafinil was 225mg 66.9/day. Twenty-four patients (38%) that received modafinil/armodafinil treatment had additional psychiatric diagnoses and were concomitantly treated with various antidepressants, mood stabilizers and antipsychotic medications. Psychiatric disorders reported in our sample included: mood disorders, anxiety disorders, and ADHD. Clinically significant side effects occurred in three patients and included reduced appetite, headache, nausea, and anxiety. Only one patient discontinued modafinil and armodafinil due to anxiety and agitation. Conclusions: High prevalence of psychiatric disorders was documented in patients with early-onset narcolepsy. Modafinil and armodafinil were effective and well-tolerated among those with comorbid psychiatric disorders over a long period of clinical follow-ups. Future prospective controlled studies are needed of modafinil and armodafinil in pediatric patients with complicated presentation of narcolepsy.

PPC, SLP, TREAT http://dx.doi.org/10.1016/j.jaac.2017.09.195

3.48 PROSPECTIVE PREDICTORS OF THE INTERPERSONAL THEORY OF SUICIDE IN A MULTINATIONAL STUDY OF ADOLESCENTS Shira Barzilay, PhD, Icahn School of Medicine at Mount Sinai, [email protected]; Alan S. Apter, MD, Schneiders Children’s Medical Center of Israel, [email protected]; Vladimir Carli, MD, ational Centre for Suicide Research and Prevention of Mental Ill;Health (NASP), Karolinska Institute, Stockholm, Sweden, [email protected]; Christina Hoven, DrPH, Columbia University and The New

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York State Psychiatric Institute, [email protected]; Camilla Wasserman, PhD, Columbia University and The New York State Psychiatric Institute, camillawasserman@gmail. com; Marco Sarchiapone, MD, Department of Health Sciences, University of Molise, Campobasso, Italy, marco. [email protected]; Danuta Wasserman, MD, National Centre for Suicide Research and Prevention of Mental Ill; Health (NASP), Karolinska Institute, [email protected] Objectives: We aimed to test the interpersonal theory of suicide (IPTS) predictions in a large multi-national sample group of adolescents in a prospective manner. We hypothesized the following: 1) that baseline assumptions of IPTS will be associated with a higher likelihood of incident suicide attempts between baseline and after three- and 12-month followup evaluations; 2) that acquired capability for self-harm, measured by health risk behaviors (HRB) and direct self-injurious behaviors (D-SIB), will be associated with incident suicide attempts during follow-up evaluations beyond suicide ideation; and 3) that the interaction between suicidal ideation and HRB/D-SIB will additionally increase the likelihood of the first suicide attempts. Methods: Data were collected as part of the Saving and Empowering Young Lives in Europe (SEYLE) study. Pupils (N ¼ 7,738) from 10 countries in the European Union who were evaluated at baseline and followed up at three months and 12 months were included in this study. A self-report questionnaire was used to measure perceived burdensomeness, thwarted belongingness, HRB, D-SIB, and suicidal ideation and attempts. We used multilevel mixedeffect logistic regression analyses to examine univariate and multivariate associations between baseline predictors and incident suicide attempt at three and 12 months. Results: In line with IPTS predictions, thwarted peer/parental belongingness and burdensomeness predicted suicide attempts during follow-up (OR ¼ 1.26, 1.16, 1.23, P < 0.001 respectively), but not beyond the effect of suicidal ideation (OR ¼ 1.90, P ¼ 0.002). Acquired capability for self-harm, measured by HRB (OR ¼ 1.20, P ¼ 0.01) and D-SIB (OR ¼ 3.67, P < 0.001), predicted incident suicide attempts beyond suicidal ideation. This effect operated independently from suicidal ideation rather than collectively with it. Conclusions: Direct and indirect acts of self-harm are important predictors in the pathway of suicide attempts in adolescents, regardless of suicidal ideation. Suicide prevention strategies are encouraged to attend to distinguished risk groups, one associated with suicidal ideation and interpersonal vulnerabilities and the other with self-harm practices.

ADOL, SIB, S Supported by the European Union through the Seventh Framework Program Grant HEALTH-F2-2009-223091. http://dx.doi.org/10.1016/j.jaac.2017.09.196

3.49 INTENSIVE CRISIS INTERVENTION (ICI) FOR ADOLESCENT SUICIDALITY: AN OPEN PILOT TRIAL Glenn Thomas, PhD, Nationwide Children’s Hospital, glenn. [email protected]; Ericka M. Bruns, MS, Nationwide Children’s Hospital, Ericka.Bruns@ nationwidechildrens.org; Sandra M. McBee-Strayer, PhD, The Research Institute at Nationwide Children’s Hospital, sandy. [email protected]; Kendra M. Heck, MPH, The Research Institute at Nationwide Children’s Hospital, [email protected]; Jeffrey A. Bridge, PhD, Research Institute at Nationwide Children’s Hospital, [email protected] Objectives: Adolescent suicide is a major public health concern, but evidence regarding the effectiveness of interventions addressing youth suicide risk is limited. The goal of this study was to evaluate the feasibility and acceptability of Intensive Crisis Intervention (ICI) for targeting adolescent suicidal thoughts and behaviors in adolescents at risk for suicide.

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Methods: ICI was piloted over a two-year period, with 50 adolescents admitted to an intensive crisis stabilization unit as a result of suicidal ideation and/or behavior. All subjects had to score in the clinical range on the Suicidal Ideation Questionnaire–Junior (SIQ-Jr) upon admission to participate (score > 31). The Columbia Impairment Scale (CIS) was also administered to assess global functioning. Data were collected upon admission, as well as 30-day (n ¼ 41) and 90-day (n ¼ 39) follow-up. Feasibility and acceptability of ICI were assessed by monitoring treatment adherence, treatment outcome measure completion, consumer satisfaction using the Consumer Satisfaction Questionnaire (CSQ-8), and readiness for care transition upon discharge using the Care Transitions Measure (CTM-15). Exploratory analyses examined potential predictors (e.g., baseline levels of depression, anxiety and suicidal ideation, previous suicide attempts, diagnosis, family conflict) of future suicide events. Results: On the SIQ-Jr, subjects reported significantly lower suicidal ideation at 30 days (mean score ¼ 13.5) and three months (mean score ¼ 12.8) than at baseline (mean score ¼ 54.3; P < 0.0001). On the CIS, parents/guardians reported significantly improved levels of functioning for adolescents at 30 days (mean score ¼ 16.2) and three months (mean score ¼ 15.1) than at baseline (mean score ¼ 19.7; P ¼ 0.003 and P ¼ 0.002, respectively). Very high rates of consumer satisfaction (CSQ-8 mean score ¼ 30.21) and readiness for care transition (CTM-15 mean score ¼ 90.52) were also reported by parents/ guardians. There were no significant findings for potential predictors of suicide events. Conclusions: Findings provide preliminary evidence of the feasibility and acceptability of the ICI model targeting adolescent suicidal ideation and behavior. Significant reductions in suicidal ideation, as well as improvements in functioning, were sustained over the three-month follow-up.

RF, DDD, S Supported by the Research Institute at Nationwide Children's Hospital intramural funding http://dx.doi.org/10.1016/j.jaac.2017.09.197

3.50 FEASIBILITY OF A THERAPEUTIC ASSESSMENT PATHWAY FOR SUICIDAL YOUTH Meredith R. Chapman, MD, University of Texas Southwestern Medical Center, [email protected]; Jane J. Miles, MD, University of Texas Southwestern Medical Center, [email protected]; Syed Sarosh Nizami, MD, University of Texas Southwestern Medical Center, sarosh. [email protected]; Alexandra Moorehead, BS, Children’s Health System of Texas, alexandra.moorehead@ UTSouthwestern.edu; Betsy D. Kennard, PsyD, University of Texas Southwestern Medical Center, beth.kennard@ utsouthwestern.edu; Graham J. Emslie, MD, University of Texas Southwestern Medical Center, graham.emslie@ UTsouthwestern.edu Objectives: The Family Intervention for Suicide Prevention (FISP) is a brief and efficacious CBT approach that aims to increase family support and youth coping and facilitate community care linkage. FISP tasks include individual/ family strengths identification and mood thermometer, followed by safety planning and enhancing motivation for aftercare. This study explored the feasibility of FISP as an assessment tool and treatment intervention in a busy clinical setting. Methods: A therapeutic assessment pathway [clinical interview, FISP, and Concise Health Risk Tracking (CHRT)] was developed to classify medically stable youth ages 10–17 years into low, moderate, and high-risk groups. Low-risk patients had an uneventful CHRT and successfully completed both FISP tasks. Patients in the moderate-risk group scored in the clinically significant range on the CHRT or had difficulty completing either of the two FISP tasks. Youth in the high-risk group had elevated CHRT scores, were unable to complete FISP tasks, and were referred for hospitalization. Patients from low-risk and moderate-risk groups completed safety planning and were discharged home. Clinicians who delivered the FISP completed a checklist measuring satisfaction, influence, and

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effectiveness of FISP components in relation to clinical decision making and patient disposition. Results: FISP was used in 29 patients from September 2016 through March 2017. Average duration was 82 minutes (range 32–180 minutes); 13 patients were seen on medical floors and 16 were seen in emergency departments. Suicidal youths (65.5%) were safely discharged to lower levels of care (intensive outpatient/partial hospital/outpatient). Disposition recommendation was most impacted by clinical interview, safety plan, and CHRT. The two FISP tasks were equally effective, and if completed, safety planning was the most helpful intervention. FISP was overall effective, reported somewhat helpful in clinician’s decision making for 37.9 percent of patients and very helpful for 24.1 percent of patients. Conclusions: FISP is feasible in clinical settings. In this sample group, the majority of suicidal youths did not require hospitalization. Clinical interview, safety planning, and CHRT mostly influenced disposition. Time involved and patient backlog were identified as barriers to using FISP.

FT, S, TREAT http://dx.doi.org/10.1016/j.jaac.2017.09.198

3.51 IDENTIFICATION OF AT-RISK PREADOLESCENTS THROUGH SUICIDE SCREENING IN PEDIATRIC EMERGENCY DEPARTMENTS Sarah Edwards, DO, University of Maryland, sedwards@psych. umaryland.edu; Mary Cwik, PhD, John Hopkins University, [email protected]; Samantha Y. Jay, BS, Johns Hopkins University, [email protected]; Mary Ellen Wilson, RN, Charlotte R. Bloomberg Children’s Center, [email protected]; Karen Baddoura, Johns Hopkins University School of Medicine, [email protected]; Sharon Hoover, PhD, University of Maryland, [email protected]; Jane Virden, MS, RN, Johns Hopkins Hospital, jvirden1@jhmi. edu; Mitchell Goldstein, MD, MBA, Johns Hopkins Hospital, [email protected]; Holly Wilcox, PhD, Johns Hopkins University, [email protected] Objectives: Suicide is the second leading cause of death among youth (ages 10–24 years), accounting for 5,504 deaths in this age-group. Although limited research on preadolescent suicide exists, some research indicates that an at-risk subset of children ages 11 years and younger have suicidal ideations and behaviors. However, there is a gap in knowledge about the value of suicide screening in children younger than age 10 years. Methods: To improve identification of suicidal youth in the emergency department (ED) setting, the ASQ (Ask Suicide-Screening Questions) screen was implemented as routine care in the Johns Hopkins Hospital (JHH) Pediatric ED in March 2013 and at University of Maryland Medical Center (UMMC) Pediatric ED in July 2015. Data on a retrospective cohort of patients between the ages of eight and 21 years, who presented with a psychiatric chief complaint in the JHH and UMMC Pediatric EDs from March 2013 through December 2016 (195 weeks) and who were administered the ASQ by nursing staff, were extracted from the ED’s electronic health records. Characteristics examined included patient’s arrival date, gender, age, race, chief complaint, discharge diagnosis, disposition, ASQ responses, and medical history. In addition, nursing compliance, answers to individual items, and psychometrics (i.e., sensitivity and specificity) will be compared across age-groups. Results: Preliminary statistical analyses compared the characteristics of the younger (ages 8–9; n ¼ 81) and older (ages 10–21 years; n ¼ 1,057) patients (with more data to be included by the time of the presentation). Sixty-nine percent of patients ages eight to nine years, who screened positive for the ASQ, did not present to the ED for suicide. Initial analyses revealed that there was a significantly higher proportion of older females who screened positive on the ASQ than the younger females but no significant differences for the presenting complaint of suicide ideation or suicide attempt, disposition of admit/transfer versus discharge, or with regard to any of the individual ASQ screening form items.


Conclusions: The ASQ successfully identified patients ages eight to nine years at risk of suicide who may not have been identified otherwise. Further research should be done to validate the ASQ for children younger than age 10 years.

RCR, SAC, S Supported by Substance Abuse and Mental Health Administration Grant U79SM061751 http://dx.doi.org/10.1016/j.jaac.2017.09.199

3.52 PROSPECTIVE ASSOCIATION OF RUMINATION AND HOPELESSNESS WITH ONSET, REMISSION, AND PERSISTENCE OF SUICIDAL IDEATION AMONG YOUNG ADULTS Ana Ortin, PhD, Hunter College, City University of New York (CUNY), [email protected]; Hannah Ellerbeck, Hunter College, City University of New York (CUNY), hannah. [email protected]; Regina Miranda, PhD, Hunter College, City University of New York (CUNY), regina. [email protected] Objectives: Little is known about risk factors that predict different temporal courses of suicidal ideation (SI) in young adults. The aim of this study is to examine the prospective association of different forms of ruminative thinking and hopelessness on the temporal course of SI—operationalized as no SI, onset of SI, remitted SI, and persistent SI among young adults. We expected that rumination and hopelessness would be independently associated with different SI courses, especially with persistent SI, after adjusting for depressive symptoms. Methods: Participants comprised 289 young adults (ages 18–34 years; mean ¼ 19.0 years; 74% female) oversampled for baseline SI (40%). Young adults were classified into four SI courses based on the presence/absence of SI in three subsequent assessments over an 18-month follow-up period. Rumination was assessed via the Ruminative Responses Scale (subscales: brooding and reflection) and the Future-Oriented Repetitive Thought Scale (subscales: pessimistic future thinking and goal-oriented repetitive thought). Hopelessness-related cognitions were assessed via the Beck Hopelessness Scale (BHS) and Future Events Questionnaire (to examine depressive-predictive certainty). Depressive symptoms were measured with the Beck Depression Inventory (excluding the SI item). Results: Rates of SI courses were determined as follows: 1) 52 percent no SI; 2) eight percent onset (i.e., no SI at baseline but SI at follow-up); 3) 24 percent remission (SI at baseline but none at follow-up); and 4) 16 percent persistence (SI at baseline and follow-up). In multinomial regressions, reflection was associated with significantly higher odds of all three SI courses (vs. no SI), brooding was associated with higher odds of remitted and persistent SI, and hopelessness (BHS) was associated with higher odds of persistent SI only (vs. no SI). After adjusting for depressive symptoms, only reflection remained significantly associated with SI courses. Conclusions: Cognitive variables predicted different courses of SI. Depressive symptoms explained the effect of hopelessness and brooding, but not of reflection, on remitted and persistent SI. Depressive symptoms may be a potential mediator of the association of hopelessness and brooding with SI courses. This possibility aligns with previous findings that depressive symptoms mediated the effect of brooding, but not reflection, on future SI.

S, LONG, COLST Supported by NIH Grant 5 SC1 MH 091873 http://dx.doi.org/10.1016/j.jaac.2017.09.200

3.53 INVESTIGATION OF THE CONTRIBUTION OF INVOLUNTARY COMMITMENT LAWS TO SUICIDE RATES IN ADOLESCENTS Jennifer Jacobson, MD, University of Texas at Austin Dell Medical School, [email protected] Objectives: Suicide is a significant concern in the adolescent population, and limited data exist exploring the role of admission laws on suicide risk. The

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purpose of this investigation was to determine whether the rates of suicide in this population in each state are affected by the restrictive or lenient quality of involuntary commitment laws. Methods: Suicide statistics from each state were obtained from the CDC Web-based Inquiry Statistics Query and Reporting System Fatal Injury Report for the population of youth ages 10–24 years. States were stratified as having either higher or lower rates of suicide completion than the national average for this age group. Legal statutes for involuntary psychiatric hospitalization were obtained and scored on a five-point scale for restrictive criteria. Results: The restrictive or lenient nature of psychiatric involuntary commitment laws in each state was found to have a nonstatistically significant impact on suicide completion rates in the child and adolescent patient population. The Chi-square value for the analysis of the contribution of law quality on suicide rates in all 50 states was calculated as 0.095 (P ¼ 0.758). For the 15 and 10 states with the highest and lowest suicide rates, the Chi square values were 0.5357 (P ¼ 0.464) and 0.202 (P ¼ 0.653), respectively. The Chi square value for comparison based on suicide rates in states with the most and least restrictive laws was 0.170 (P ¼ 0.680). Conclusions: The restrictive or lenient quality of involuntary commitment laws does not significantly affect suicide rates in the child and adolescent population of each state. The distribution of states with higher and lower suicide risk, with either more or less restrictive admission laws, was nearly equally split. Multiple factors contribute to both mitigating and exacerbating suicide risk, of which inpatient laws are only a single component. Such results should be reassuring to providers considering involuntary hospitalization.

ADOL, ICP, S http://dx.doi.org/10.1016/j.jaac.2017.09.201

3.54 A PAINFUL DISTRACTION? NONSUICIDAL SELF-INJURY IN PEDIATRIC INPATIENTS AND ITS RELATIONSHIP WITH CAREGIVER STRESS Isha R. Jalnapurkar, MD, University of Texas Health Science Center at Houston, [email protected]; Anastasia M. Pemberton, MD, University of Texas Health Science Center at Houston, [email protected]. edu; Pratikkumar Desai, MD, MPH, University of Texas Health Science Center at Houston, [email protected]. edu; Serena Mammen, University of Texas Health Science Center at Houston, [email protected]; Mary Clare Bruce, BA, The Harris Center for Mental Health and IDD, [email protected]; Zachary J. Sullivan, DO, University of Texas Health Science Center at Houson, zachary. [email protected]; Dana W. Hipp, MD, University of Texas Health Science Center at Houston, Dana.W.Hipp@uth. tmc.edu; Alexandra N. Duran, University of Texas Health Science Center at Houston, [email protected]; Iram Kazimi, MD, University of Texas Health Science Center at Houston, [email protected]; Cristian Zeni, MD, PhD, University of Texas Health Science Center at Houston, [email protected]; Teresa Pigott, MD, University of Texas Health Science Center at Houston, teresa.a.pigott@ uth.tmc.edu Objectives: Nonsuicidal self-injury (NSSI) is defined as the deliberate, selfinflicted destruction of body tissue without suicidal intent and for purposes not socially sanctioned. It includes behaviors such as cutting, burning, biting, and scratching skin. Clinical sample groups (40–80%) of adolescents report NSSI and are more likely to meet criteria for a major mood disorder. Poor family functioning is associated with exacerbation of mood disorders and is a strong predictor of later hospitalization. However, the association between familial stress, as measured by expressed emotion (EE) and NSSI, has been scarcely studied. Hence, the current research examines the prevalence of NSSI and explores its relationship with EE and other demographic and clinical factors in youth hospitalized for mood disorders.

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Methods: The current analysis includes 77 children and adolescents (ages 8–17 years; 63.6% female) admitted to an acute psychiatric facility with a primary mood disorder. Current and past NSSIs were evaluated during intake assessment. A standardized interview was conducted with a primary caregiver, and EE was determined using the Five-Minute Speech Sample (FMSS). Independent sample t-tests and Chi-square analyses were used to compare NSSI with sociodemographic and clinical variables and EE (high/low). Results: Prevalence of NSSI in the inpatient pediatric mood disorder sample group was 59.7 percent (46 of 77). Female subjects were more likely to demonstrate NSSI (P ¼ 0.001), as were individuals of Caucasian and Hispanic descent (P ¼ 0.03). Furthermore, individuals diagnosed with MDD and an unspecified mood disorder had a higher incidence of NSSI reaching marginal statistical significance (P ¼ 0.08). NSSI was also strongly associated with high caregiver EE (P ¼ 0.02). Conclusions: Resultsfrom this cross-sectional study are consistent with prior reports and highlight the prevalence of NSSI in hospitalized youth with mood disorders. We found that elevated caregiver EE is significantly related to NSSI. Although the direction of the effect remains to be determined, this finding serves as a platform for future work aimed at reducing caregiver EE and studying its effect on reducing the incidence of these harmful behaviors.

FAM, SIB, S Supported by an APA Resident Research Psychiatric Scholars Fellowship http://dx.doi.org/10.1016/j.jaac.2017.09.202

3.55 ASSESSMENT OF SUICIDE RISK IN CHILDREN AND ADOLESCENTS WITH AUTISM SPECTRUM DISORDER PRESENTING TO A PEDIATRIC EMERGENCY DEPARTMENT Roma Vasa, MD, Johns Hopkins University School of Medicine, [email protected]; Samantha Y. Jay, BS, Johns Hopkins University, [email protected]; Parvathy Nair, MD, PhD, Alexian Brothers Medical Group, [email protected]; Karen Baddoura, Johns Hopkins University School of Medicine, [email protected]; Mitchell Goldstein, MD, MBA, Johns Hopkins Hospital, [email protected]; Sarah Edwards, DO, University of Maryland, sedwards@psych. umaryland.edu; Sharon Hoover, PhD, University of Maryland, [email protected]; Mary Cwik, PhD, John Hopkins University, [email protected]; Holly Wilcox, PhD, Johns Hopkins University, [email protected] Objectives: Recent research indicates that those with autism spectrum disorder (ASD) are at an elevated risk for suicidal thoughts and behaviors. Given the challenges of identifying suicidality in youth with ASD and the high rates of emergency department (ED) visits in this population, developing methods to assess suicidal ideation in patients with ASD in ED settings is essential to determine the patient’s safest disposition plan. This study compared the efficacy of eliciting the presenting chief concern upon presenting to the ED versus the Ask Suicide-Screening Questions (ASQ), which was administered at triage, in detecting suicidality in children and adolescents with ASD in the ED setting. Additionally, characteristics of children and adolescents with ASD who reported suicidal ideation in the ED were examined. Methods: This study is a retrospective chart review of 104 children and young adults with ASD (ages 8–21 years), who presented to the Johns Hopkins Pediatric ED between March 2013 and April 2016. All participants were administered the ASQ, a suicide screening tool, as part of their standard of care during triage. Results: Among the 104 participants with ASD, 31 screened positive on the ASQ for suicide risk. Sixty-five percent of patients with ASD were uniquely identified as experiencing suicidal ideation by the ASQ (X2 ¼ 13.61 P < 0.01). Descriptive characteristics of the ASQ were examined for 21 of the 31 patients with ASD who screened positive for suicide risk on the ASQ. The most common comorbid psychiatric diagnoses were anxiety disorders (n ¼ 11, 52%), mood disorders (n ¼ 8, 38%), and ADHD/ODD (n ¼ 9, 42%). Suicide

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attempts (ASQ4) were reported among 12 youth and consisted of the following methods: stabbing/cutting (n ¼ 5), jumping from a height (n ¼ 2), choking/holding breath/hanging (n ¼ 3), overdose (n ¼ 1), and firearms (n ¼ 1). Conclusions: This study demonstrates that brief suicide screening instruments, such as the ASQ, can be incorporated into the standard of care in pediatric ED settings to assess suicide risk in children and young adults with ASD. Additional research is needed to examine the validity of the ASQ in ASD populations and to identify specific risk factors and clinical determinants that characterize suicidal behaviors in youth with ASD in acute settings.

ADOL, ASD, S Supported by Substance Abuse and Mental Health Administration Grant U79SM061751 http://dx.doi.org/10.1016/j.jaac.2017.09.203

3.56 SELF-REPORTED ANXIETY PREDICTS POSITIVE SUICIDE RISK SCREENING IN ADOLESCENTS PRESENTING TO THE EMERGENCY DEPARTMENT Samantha Y. Jay, BS, Johns Hopkins University, sjay1@jhmi. edu; Dan Powell, BA, National Institutes of Health, [email protected]; Elizabeth C. Lanzillo, BA, National Institutes of Health, [email protected]; Mira Tanenbaum, National Insitutes of Health, mira. [email protected]; Elizabeth Ballard, PhD, National Institutes of Health, [email protected]; Jeffrey A. Bridge, PhD, The Research Unit at Nationwide Children’s Hospital and The Ohio State University, jeff.bridge@ nationwidechildrens.org; Elizabeth A. Wharff, LCSW, MSW, PhD, Boston Children’s Hospital, Elizabeth.Wharff@childrens. harvard.edu; Maryland Pao, MD, National Institute of Mental Health and the National Institutes of Health, [email protected]. gov; Lisa M. Horowitz, PhD, MPH, National Institute of Mental Health Intramural Research Program, [email protected] Objectives: Recent research has established emergency departments (ED) as essential venues for detecting youth at risk for suicide and suicide attempts. Anxiety disorders can be key risk factors of suicidal thoughts and behaviors. It is noteworthy that subclinical anxiety symptoms are also linked to suicide risk in adolescents. Whereas it may be impractical to provide psychiatric assessments for all patients, identifying recent symptoms of anxiety may help to determine which patients are at elevated risk of suicide and warrant further mental health care. This study aims to assess whether patient-reported symptoms of anxiety are associated with suicide risk in pediatric patients presenting to the ED. Methods: The sample group for this subanalysis consists of pediatric patients (ages 10–21 years) who presented to one of three pediatric EDs and participated in a multisite study that developed the Ask SuicideScreening Questions (ASQ) instrument. Seventeen candidate items, including the four ASQ items and the criterion standard Suicidal Ideation Questionnaire (SIQ), were administered to patients to detect suicide risk. Patients who answered “Yes” to any of the four ASQ items or scored above the SIQ cutoff were considered positive for suicide risk. Self-reported anxiety was assessed using one of the candidate items administered as part of the development of the ASQ. Results: Participants included 524 patients (ages 10–21 years) recruited from three pediatric EDs. Thirty percent of participants endorsed feeling unbearably nervous or worried. Participants who endorsed feeling unbearably nervous or worried were five times more likely to screen positive for suicide risk [OR adjusted ¼ 5.18 (95% CI 3.06–8.76)]. All participants who endorsed symptoms of anxiety were more likely to screen positive for suicide risk, regardless of chief complaint [OR adjusted for medical patients ¼ 4.87 (95% CI 2.09–11.36, P < 0.001; OR adjusted for psychiatric patients ¼ 3.95 (95% CI 1.79–8.72); P < 0.001]. Conclusions: It is noteworthy that youth presenting to the ED reporting recent symptoms of anxiety had a greater likelihood of screening positive for suicide


risk, regardless of whether their chief complaint was medical/surgical or psychiatric. Asking brief questions about recent subclinical mental illness symptoms to all pediatric patients in the ED may allow clinicians to better identify patients at elevated risk for suicide.

ADOL, AD, S Supported by NIMH Intramural Research Program Grant NCT00623493, Protocol ID 08-M-N070 http://dx.doi.org/10.1016/j.jaac.2017.09.204

3.57 CLINICAL CHARACTERISTICS AND ASSOCIATIONS WITH PSYCHIATRIC DISORDERS OF NONSUICIDAL SELF-INJURY IN KOREAN ADOLESCENTS Gyung-Mee Kim, MD, PhD, Inje University Haeundae Paik Hospital, [email protected]; Jong-Min Woo, MD, MPH, PhD, Korea Employee Assistance Professionals Association, Seoul, Korea, [email protected] Objectives: Nonsuicidal self-injury (NSSI) is more common among adolescents than other age-groups and has a high co-occurrence with suicide attempts in adolescents. The purpose of this study is to examine the prevalence, clinical characteristics, and associations with psychiatric disorders of nonsuicidal self-injury in Korean adolescents. Methods: One hundred-forty depressed adolescents (aged 13–18 years; mean age ¼ 15.5 1.5 years) in South Korea were enrolled in this study. The participants of this study were assessed using the Korean version of semistructured diagnostic interviews (Korean-Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime) for DSM-IV diagnoses and various self-reported scales for clinical risk factors, including Child Depression Inventory (CDI), Rosenberg Suicide Ideation Questionnaire (RSIQ), State-Trait Anxiety Inventory (STAI), State-Trait Anger Expression Inventory (STAXI-2), Coping Inventory for Stressful Situations (CISS), and CGAS (Children’s Global Assessment Scale). In a final assessment, 129 participants underwent clinical testing. Demographic and other clinical characteristics of the subjects were compared between NSSI group and non-NSSI group using Chi-squared tests and independent-sample t-tests. Logistic regression analysis was used to determine which variables were independent predicting factors for NSSI. Results: Among 129 depressed participants, 35 (27.1%) adolescents were classified into the NSSI group. In the NSSI group, there were significantly more females, higher RSIQ score, higher-state anger score, less anger expression, and lower CGAS scores than those in the non-NSSI group. In addition, in the NSSI group, MDD was 4.5 times more common (P ¼ 0.007), and bipolar disorder (BD) was 9.6 times more common than in the non-NSSI group (P ¼ 0.002) Conclusions: NSSI is common among female adolescents with MDD and BD, particularly those who present high suicidal ideation and high anger state but difficult anger expression. These results support the importance of evaluation not only about self-injury behavior but also anger and the tendency toward overcontrolling a stressful situation in this clinical population. Teaching adaptive skills for dealing with anger may decrease and prevent NSSI in Korean adolescents with mood disorders.

SIB, DEMF, S Supported by Inje University Research Fund 20110877 http://dx.doi.org/10.1016/j.jaac.2017.09.205

3.58 SUICIDAL BEHAVIOR AND RELATED FACTORS AMONG YOUTH STUDENTS IN SOUTH KOREA Youngsil Kweon, MD, St. Mary’s Hospital, [email protected]. kr; Ah Reum Kim, BA, Institute of Suicide and School Mental Health, [email protected]; Han Nah Cho, Institute of Suicide and School Mental Health, [email protected] Objectives: This study was conducted to examine the traits of suicidal behavior among youth students in South Korea. In addition, its goal was to find the risk and protective factors to investigate their relationship. Finally, this

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study was implemented to propose the school-based strategies for suicide prevention. Methods: The authors designed a survey questionnaire to examine the students’ suicide-related factors. Data were collected by off-line survey for 2,753 middle and high-school students who reside in a Seoul metropolitan and close medium-sized city from September to October 2015. The participants completed the survey, including demographic data, mental health status, suicidal behaviors, school environment, daily lives, and so on. Among all respondents, 56.2 percent (n ¼ 1,543) were males and 43.8 percent (n ¼ 1,202) were females; 45.4 percent were middle-school students, and 54.6 percent were high school students. Data were analyzed using SPSS, version 21.0. Results: Participants (n ¼ 295; 10.7%) had answered questions pertaining to suicide ideation (females ¼ 12.1%; males ¼ 9.4%), of which 89 participants (3.3%) had attempted suicide (females ¼ 2.4%; males ¼ 3.1%) in the past 12 months. Suicide ideation had significant differences in sex and the level of school. There was a significant difference in suicide attempt by sex (P < 0.05). Upon comparing students with and without suicide attempts, most variables such as depressed mood, anxiety, family abuse, poor academic performance, low school attendance, and bullying or being bullied were significantly related to suicide attempts, with the exception of sex. The odds ratios of attempting suicide were 69.2 in suicide plan, 19.9 in school absence for fear of being bullied, 0.24 in parents’ support, and 0.29 in friend’s support. Conclusions: These results are used to understand the traits and related factors of suicidal behaviors among students in Korea. Improving the effective caring system of students with difficulties in school attendance and school violence, such as being bullied, a bullying screening might be one of the most important preventive strategies in schools. In addition, we recommend that schools should provide students opportunities to improve interpersonal relationships.

S Supported by the Republic of Korea's Ministry of Education 2016937557 http://dx.doi.org/10.1016/j.jaac.2017.09.206

3.59 THE IMPORTANCE OF SCREENING PRE-TEENS FOR SUICIDE RISK IN THE EMERGENCY DEPARTMENT Elizabeth C. Lanzillo, BA, National Institutes of Health, [email protected]; Jeffrey A. Bridge, PhD, Research Institute at Nationwide Children’s Hospital, jeff.bridge@ nationwidechildrens.org; Elizabeth A. Wharff, LCSW, MSW, PhD, Boston Children’s Hospital, Elizabeth.Wharff@childrens. harvard.edu; Elizabeth Ballard, PhD, National Institutes of Health, [email protected]; Maryland Pao, MD, National Institute of Mental Health and the National Institutes of Health, [email protected]; Lisa M. Horowitz, PhD, MPH, National Institute of Mental Health Intramural Research Program, [email protected] Objectives: In 2015, more than 5,900 youth died by suicide. The rate of suicidal behavior in youth ages 10–14 years has significantly increased in recent years. In 2014, suicide ranked as the second leading cause of death for this age-group and surpassed the death rate for traffic accidents. A 2016 Joint Commission recommendation to screen all medical patients for suicide risk lacked specific guidance on the appropriate age to begin screening. This study describes the prevalence of positive screens for suicide risk in preteenagers presenting to the emergency department (ED) to determine whether suicide risk screening below age 13 years is warranted in this setting. Methods: This sub-analysis of data from a multisite, cross-sectional study was used to develop the four-item Ask Suicide-Screening Questions (ASQ) instrument. Participants consisted of patients (ages 10–21 years) who presented to ED at three urban hospitals. Patients completed the ASQ and Suicidal Ideation Questionnaire (SIQ). Patients who endorsed any of the ASQ items and/or scored above the SIQ cutoff were considered positive screens. This study examines the positive screen rate among patients admitted to the ED (ages 10–12 years) with psychiatric and medical chief complaints.

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Results: A total of 524 patients admitted to the ED participated in the larger study. This sample group included 79 patients (ages 10–12 years, referred to as preteenagers throughout; mean age 11.2 0.8 years; 61% male; 49% white). The positive screen rate was 29 percent (n ¼ 23). More than half (n ¼ 20 of 37; 54%) of preteenagers with psychiatric complaints screened positive, and seven percent (n ¼ 3 of 42) of the preteenagers with medical complaints screened positive. It is noteworthy that 18 percent (n ¼ 14) of all preteenagers reported a previous attempt, including five children (ages 10 years), indicating that six percent of patients attempted suicide at age 10 or younger. Conclusions: More than one-third of preteen-age patients admitted to the ED screened positive for suicide risk. Although suicide is a low base-rate event in this age-group, preteenagers think about suicide and engage in suicidal behaviors at a concerning rate. Nearly 18 percent of preteen-age patients admitted to the ED previously attempted suicide, and six percent attempted suicide before age 11 years. A previous attempt is the greatest risk factor for future suicidal behavior; thus, identifying patients with past attempts is vital for prevention. It is noteworthy that seven percent of preteenagers with medical chief complaints screened positive, highlighting the importance of screening all preteenagers for suicide risk in the ED regardless of complaint.

ADOL, PRE, S Supported by NIMH Grant NCT00623493 http://dx.doi.org/10.1016/j.jaac.2017.09.207

3.60 SUICIDE RISK PREVALENCE AND CLINICAL CORRELATES IN YOUTH WITH AUTISM SPECTRUM DISORDER Elizabeth C. Lanzillo, BA, National Institutes of Health, [email protected]; Lisa M. Horowitz, PhD, MPH, National Institute of Mental Health Intramural Research Program, [email protected]; Audrey Thurm, PhD, National Institute of Mental Health, [email protected]; Cristan Farmer, PhD, National Institute of Mental Health, [email protected]; Carla Mazefsky, PhD, University of Pittsburgh, [email protected]; Jeffrey A. Bridge, PhD, The Research Unit at Nationwide Children’s Hospital and The Ohio State University, [email protected]; Rachel Greenbaum, PhD, Surrey Place Centre, rachel. [email protected]; Maryland Pao, MD, National Institute of Mental Health and the National Institutes of Health, [email protected]; Matthew Siegel, MD, Maine Medical Research Institute and Tufts University School of Medicine, [email protected] Objectives: Youth with autism spectrum disorder (ASD) are known to be at elevated risk for suicide, yet there is sparse research on suicide risk in the pediatric population with ASD. An understanding of how suicidality develops is expressed, and reliably detected in ASD is critical for reducing morbidity and mortality. Although there have been advances in the development of suicide risk measures for typically developing youth, there are no suicide riskscreening instruments designed specifically for ASD. This study aims to determine a prevalence estimate of thoughts of death or suicide in youth with ASD. Methods: Data were collected from a convenient sample group of psychiatrically hospitalized youth with ASD (aged 4–20 years) as part of a multisite study. A single parent-reported item was used to estimate the prevalence of thoughts of death or suicide. This item asked parents whether their child “has periods lasting at least several days where he/she.talks about death or suicide.” Individual characteristics associated with talking about suicide or death, such as intellectual ability and comorbid psychiatric diagnoses, were also assessed. Results: A total of 107 verbal youth with ASD met inclusion criteria and were included in this subanalysis (77% male; 91% white; mean age 13.6 2.3 years; mean nonverbal IQ 95.56 20.6). Per parent report, 22 percent of youth had periods lasting several days when they talked about death or suicide “often,” or “very often.” Clinical correlates included the presence of a comorbid mood

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(OR ¼ 2.71, 95% CI 1.12–6.55) or anxiety disorder (OR ¼ 2.32, 95% CI 1.10– 4.93). Nonverbal IQ, sex, race, and age did not affect the frequency of talking about death or suicide. Conclusions: This subanalysis reveals that nearly a quarter of verbal, psychiatrically hospitalized youth with ASD reportedly talked often or very often about death or suicide for periods lasting several days. It is critical to consider these findings in the context of the Joint Commission’s recommendation to screen all patients for suicide risk in all medical settings. The pediatric population with ASD presents unique challenges for the medical system given variation and limitations in cognitive, social, emotional, and language skills. These results demonstrate a need to develop and validate suicide screening instruments designed specifically to identify risk in populations with ASD.

PRE, ASD, S Supported by NIMH Intramural Research Program Grant ZIA MH002914, the Simons Foundation Autism Research Initiative, and the Nancy Lurie Marks Family Foundation Grant SFARI #296318 http://dx.doi.org/10.1016/j.jaac.2017.09.208

3.61 DETECTING SUICIDE RISK ON PEDIATRIC INPATIENT MEDICAL UNITS: IS DEPRESSION SCREENING ENOUGH? Elizabeth C. Lanzillo, BA, National Institutes of Health, [email protected]; Dan Powell, BA, National Institutes of Health, [email protected]; Jeffrey A. Bridge, PhD, The Research Unit at Nationwide Children’s Hospital and The Ohio State University, jeff.bridge@ nationwidechildrens.org; Elizabeth A. Wharff, LCSW, MSW, PhD, Boston Children’s Hospital, Elizabeth.Wharff@childrens. harvard.edu; Abigal Ross, PhD, Fordham University Graduate School of Social Service, [email protected]; Martine Solages, MD, Children’s National Health System, [email protected]; Sally Nelson, RN, Boston Children’s Hospital, [email protected]; Maryland Pao, MD, National Institute of Mental Health and the National Institutes of Health, [email protected]; Lisa M. Horowitz, PhD, MPH, National Institute of Mental Health Intramural Research Program, [email protected] Objectives: Medically ill youth are at heightened risk for suicidality. In 2016 the Joint Commission recommended that all medical patients be screened for suicide risk. Without specific guidance, many hospitals are screening for suicide risk using depression screening instruments. The Patient Health Questionnaire for Adolescents (PHQ-A) is a commonly used depression screen that includes an item purported to measure suicidal ideation (item 9). However, studies suggest that depression screening alone may not be adequate to detect suicide risk. This study aims to determine if depression screening can detect suicide risk in pediatric medical inpatients who screen positive on suicide-specific measures. Methods: A convenience sample of medical inpatients aged 10-21 years were recruited as part of a larger instrument validation study. Participants completed the PHQ-A; two suicide risk screening tools: the Ask Suicide-Screening Questions (ASQ) and the Suicidal Ideation Questionnaire (SIQ; patients ages 10-14 completed the SIQ-Junior); and a demographics questionnaire. Patients who scored 11 on the PHQ-A screened positive for depression and those who endorsed any of the ASQ items and/or scored above the SIQ/SIQ-JR cut-off score were positive for suicide risk. Univariate and multivariate statistics were calculated to examine the relationship between screening positive for depression and suicide risk. Results: A total of 400 medical inpatients were included in this analysis (59% female; 47% Caucasian; mean age 15.2 2.9 years). Thirty-nine patients (9.8%) screened positive for depression only, 16 (4.0%) screened positive for suicide risk only, and 36 (9.0%) screened positive for both depression and suicide risk. Of the patients who screened positive for suicide risk, 37.9 percent (22/58) did


not screen positive on the PHQ-A, and nearly half (26/58) did not endorse item 9. Notably, 16 (28%) participants who screened negative for depression and on item 9 were found to be at risk for suicide. Conclusions: In this sample, depression screening alone would have failed to detect over one-quarter of youth at risk for suicide. Although there is clear overlap between depression and suicide risk, some medical patients at risk for suicide may pass through the healthcare system unrecognized if depression screening is used as a proxy for identifying suicide risk.

PRE, DDD, S Supported by NIMH Grant NCT02050867 http://dx.doi.org/10.1016/j.jaac.2017.09.209

3.62 ALTERED ANTERIOR CINGULATE GLUTAMATE IN DEPRESSED ADOLESCENTS WITH AND WITHOUT LIFETIME SUICIDAL BEHAVIOR: A PROTON MAGNETIC RESONANCE SPECTROSCOPY STUDY Charles P. Lewis, MD, Mayo Clinic, [email protected]; John D. Port, MD, PhD, Mayo Clinic, [email protected]; Caren Jacquetta Blacker, MD, Mayo Clinic, blacker.caren@ mayo.edu; Jennifer L. Vande Voort, MD, Mayo Clinic, [email protected]; Magdalena Romanowicz, MD, Mayo Clinic, romanowicz. [email protected]; Mark A. Frye, MD, Mayo Clinic, [email protected]; Paul E. Croarkin, DO, Mayo Clinic, croarkin. [email protected] Objectives: Suicide is the second most common cause of death among young people, yet relatively little is understood about the neurobiological mechanisms of suicidal behavior in this age group. Prior research in adults has implicated disturbances in the excitatory neurotransmitter glutamate in suicidal persons. This study sought to examine glutamatergic metabolites in brains of adolescents with and without histories of suicidal behavior using proton magnetic resonance spectroscopy (1H-MRS). Methods: Fifty-six adolescents (36 females, 20 males; age 11–21 years) were divided into three groups: 1) heathy control subjects (n ¼ 17); 2) those who were depressed with no lifetime history of suicidal behavior (n ¼ 26); and 3) those who were depressed with a lifetime history of suicidal behavior (n ¼ 13). Groups did not differ in sex distribution (P ¼ 0.630) or age (P ¼ 0.170); the two depressed groups did not differ in depression severity (P ¼ 0.090), duration of depressive episode (P ¼ 0.830), overall illness duration (P ¼ 0.477), use of psychotropic medications (P ¼ 0.821), or family history of psychiatric illness (P ¼ 0.456). All participants underwent 1H-MRS of the medial anterior cingulate cortex (mACC) at 3 T. Concentrations of glutamatergic metabolites [glutamate, glutamine, and glutamate + glutamine (Glx), all corrected to creatine] were measured with a two-dimensional J-resolved averaged PRESS sequence. Results: One-way analysis of variance revealed group differences in mACC glutamate (F ¼ 3.846, P ¼ 0.028) and Glx (F ¼ 5.296, P ¼ 0.008). Post hoc tests demonstrated that depressed adolescents with no history of suicidal behavior had lower mACC Glx than healthy controls subjects (P ¼ 0.026) or depressed adolescents with a lifetime of suicidal behavior (P ¼ 0.026). Conclusions: These preliminary data indicate disturbances of glutamatergic neurochemistry in depressed adolescents and suggest that glutamate may have a role in suicidal behavior that is distinct from that of mood state or depressive disorder. Further research, particularly a comparison of acutely suicidal adolescents with adolescents with historical suicidal behavior, is necessary to understand this relationship. Spectroscopy of cortical glutamatergic metabolites may hold promise in the development of biomarkers of suicide risk and the identification of targets for intervention.

IMAGS, NECHEM, S Supported by NIMH Grant K23 MH100266 http://dx.doi.org/10.1016/j.jaac.2017.09.210

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3.63 PREVALENCE AND PREDICTION OF SUICIDE IDEATION IN JAPANESE ADOLESCENTS: RESULTS FROM A POPULATION-BASED QUESTIONNAIRE SURVEY Shinichiro Nagamitsu, MD, Department of Pediatrics and Child Health, Kurume University School of Medicine, kaoru@ med.kurume-u.ac.jp; Masakazu Mimaki, MD, Teikyo University School of Medicine, [email protected]; Kenji Koyanagi, MD, Nagasaki Prefectural Center of Medicine and Welfare for Children, [email protected]; Natsuko Tokita, MD, Keio University School of Medicine, [email protected]; Yoriko Kobayashi, PhD, Clinic of International University of Health and Welfare Mita Hospital, [email protected]; Ritsuko Hattori, PhD, Nara Gakuen University, [email protected]; Yushiro Yamashita, MD, Kurume University School of Medicine, [email protected]; Zentaro Yamagata, MD, University of Yamanashi School of Medicine, [email protected]; Takashi Igarashi, MD, National Center for Child Health and Development, [email protected] Objectives: The prevalence of suicide in Japanese adolescents is increasing, and suicide is the second leading cause of death among that age group. This study aimed to determine the prevalence of suicide ideation and its predictive factors in Japanese school-age children. Methods: A population-based questionnaire survey was performed in 22,419 school-age children (aged 13–18 years) to investigate their recognition of adolescent health promotion. This survey covered representative regions belonging to urban, suburban, and rural areas in Japan. The questionnaire included 28 questions regarding adolescents’ worries related to parents, friends, and siblings, as well as sleep habits, suicide ideation, emotional status, information related to sexual activity (sexually transmitted diseases, pregnancy, contraception), and other information. Results: The prevalence of suicide ideation and suicide attempts are 21.7 and 3.5 percent in male adolescents and 28.7 and 6.7 percent in female adolescents, respectively. The prevalence of both suicide ideation and suicide attempts increases in tandem with the school grade. Suicide ideations were significantly associated with the experience of cyberbullying, lower number of friends, and less communication with family. Furthermore, worries about bullying, friends, sexual identity, and relationship with parents were also associated with ideation. Worries about school achievement and academic career were also associated but not to a great degree. Feelings of happiness, loneliness, and healthiness of adolescents showed significant relations with ideation. Conclusions: These results indicated that suicidal ideation is a common experience among adolescents, and many factors are associated with such ideation. Knowledge and awareness of the associations between these predictors and adolescents’ suicide ideation are important for health providers and adolescents’ families to be able to conduct effective suicide prevention.

BLY, RF, SIB http://dx.doi.org/10.1016/j.jaac.2017.09.211

3.64 ILLICIT SUBSTANCE USE IN TURKISH ADOLESCENTS AND ITS ASSOCIATION WITH SUICIDAL IDEATION BASED ON AGE, GENDER, AND SCHOOL TYPE Parna R. Prajapati, MD, MPH, University of Texas Southwestern Medical Center, [email protected]; Hatice Burakgazi Yilmaz, MD, MS, Cooper University Hospital, [email protected]; Alican Dalkilic, MD, MPH, Cooper University Hospital, [email protected]; Andres J. Pumariega, MD, Cooper Medical School of Rowan University and Cooper University Hospital, Pumariega-Andres@ CooperHealth.edu

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Objectives: The purpose of this study is to examine the association between type of substance use with suicidal ideation based on age group, gender, and type of school in a sample of Turkish youth. Methods: Istanbul Department of Education and Istanbul Police Department collected the data during May and June of 2010. Out of 39 provinces of Istanbul, 28 inner cities were selected for sampling. The schools were divided into three categories in each province as regular, occupational, and Anatolian (college prep) high schools (HS) based on the regulations of the Ministry of Education (based on structure, focus, and curriculum). This study comprised 31,272 participants, which constitutes 20% of the total high school population in Istanbul. SPSS statistical analysis software was used to run logistic regression between dependent variable and independent variables and standardized coefficients were calculated with p-value. Odds ratios were calculated using standardized coefficients. Results: Tobacco and sleeping pill use were significantly associated with suicidal ideation among: 1) all age groups; 2) both genders; 3) regular HS students; and 4) vocational HS students. Young participants using tobacco, sleeping pills, and inhalants were 1.73, 1.76, and 1.57 times at increased odds, respectively, of having suicidal thoughts as compared to participants who did not use them. Male participants using tobacco and sleeping pills were 1.52 and 1.57 times at increased odds, respectively, of having suicidal thoughts as compared to participants who did not use them. Inhalant use was significantly associated with suicidal ideation in female participants and those who were in regular HS. Female participants using tobacco, sleeping pills, and inhalant were 1.86, 1.96, and 2.08 times at increased odds, respectively, of having suicidal thoughts as compared to participants who did not use them. Participants in Anatolian HS who use sleeping pills and ecstasy were 2.53 and 3.23 times at increased odds, respectively, of having suicidal thoughts as compared to participants who did not use them. Conclusions: A pattern of substance use was seen from this study, which specifically highlights the need to develop and implement preventive measures based on gender, age, and type of school.

SUD, S http://dx.doi.org/10.1016/j.jaac.2017.09.212

3.65 DIALECTICAL BEHAVIOR THERAPY VERSUS SUPPORTIVE THERAPY FOR ADOLESCENTS WITH SUICIDAL BEHAVIOR: A RANDOMIZEDCONTROLLED TRIAL

Pilar Santamarina, PhD, Hospital Clınic Barcelona, psantama@ clinic.ub.es; Iria Mendez Blanco, MD, Hospital Clinic of Barcelona, [email protected]; Marisol Picado, PhD, Hospital Clinic of Barcelona, [email protected]; Elena Font, PsyD, Hospital Clinic of Barcelona, efont@clinic. ub.es; Elena Moreno, PsyD, Hospital Clinic of Barcelona, [email protected]; Esteve Martınez, PsyD, Hospital Clinic of Barcelona, [email protected]; Astrid Morer Linan, MD, PhD, Hospital Clinic of Barcelona, [email protected]; Soledad Romero, MD, Hospital Clinic of Barcelona CIBERSAM, [email protected] Objectives: Self-harm in adolescents is a major clinical problem and is strongly associated with suicide. DBT was originally developed for adults with suicidal behavior to improve skills and regulate intense emotions. Evidence has shown that DBT is associated with a substantial reduction in self-harm in that population. Currently, DBT has been adapted for youth with suicidal behavior, and there is little evidence in support of its efficacy. However, to date, none of these RCTs has compared DBT with another group therapy. We examined whether DBT is more effective than a combined individual and group supportive therapy (ST) to reduce self-harm in adolescents. Methods: Thirty-five participants (ages 12–18 years) with recent and repetitive self-harming behavior were selected from a psychiatry outpatient clinic. Patients were randomly assigned to receive either treatment: DBT (n ¼ 18) or ST (n ¼ 17). Both treatments included 16 weekly group sessions with adolescents and families separately, and biweekly individual sessions. Group DBT was carried out following the manualized intervention protocol developed by

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Rathus and Miller. The ST was not manualized and consisted of an eclectic psychotherapy approach, which included psychoeducational and supportive therapy. Assessments of self-harming behavior (number of self-reported selfharm episodes), suicidal ideation (Suicidal Ideation Questionnaire), and Clinical Global Impression (CGI) for suicide were made at baseline and at the end of the trial period. Analyses were conducted using ANCOVA adjusted for baseline measures. Results: The groups did not differ from one another at baseline with respect to sociodemographic and clinical variables. DBT was superior to ST in reducing self-harm and CGI. Analyses indicated large effect sizes for self-harm [0.89 (95% CI 0.7–1.71); P ¼ 0.034] and CGI [0.75 (95% CI 0–1.49); P ¼ 0.049] among adolescents receiving DBT. Although there were no between-group differences in suicidal ideation, we found that it improved after receiving both treatments. Conclusions: This is the first RCT to demonstrate the efficacy of DBT treatment for adolescents with suicidal behavior by comparing it to another group treatment. These findings suggest that DBT is a promising treatment for suicidal behavior in this population.

P, RCT, SIB Supported by Fundaci on Alicia Koplowitz http://dx.doi.org/10.1016/j.jaac.2017.09.213

3.66 DISCLOSURE AND TREATMENT RATES FOR SUBURBAN YOUTH WHO ENDORSE SUICIDAL IDEATION Lauren O. Thomann, BS, Wellesley College/WCW, [email protected]; Tracy Gladstone, PhD, Wellesley College/WCW, [email protected]; Amy Kane, MA, Wellesley College/WCW, [email protected]; Laura Tichner, MSW, Wellesley College/WCW, ltichner@ wellesley.edu; Erica Plunkett, MA, Wellesley College/WCW, [email protected] Objectives: According to the CDC (in 2015), youth suicide is a problem of major proportions. Universal depression/suicide screening programs are effective in identifying at-risk youth and are best conducted by outside personnel, given that students are less likely to express symptoms in school. We explored the disclosure patterns and treatment status of at-risk adolescents in a universal school-based screening initiative. Methods: Students from a suburban public school system (grades 7–11) participated in individual screens conducted by outside mental health assessors, using an adaptation of the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) to assess current and lifetime depression, including suicidal ideation, and a shortened version of the Center for Epidemiologic Studies Depression Scale (CES-D) to evaluate the frequency of depressive symptoms within the past week. Results: Of the full sample group (N ¼ 1,502, 50% female, mean age ¼ 13.96 years), 62 students (66% female, mean age ¼ 14.94 years) endorsed suicidal thinking (5% current, 68% past, and 27% both current and past), and 19 percent reported a past suicide attempt. Only 66 percent of these students reported disclosing their suicidal thinking at the time. Of those who disclosed this state of mind, two percent told school personnel, 29 percent told a parent, 15 percent told a friend, 10 percent told an outside professional, and 12 percent told both a parent and an outside professional. Of the students who endorsed suicidal thinking, 21 percent were currently in treatment, 16 percent reported past treatment, 38 percent received past and current treatment, and 25 percent never received any treatment. Of those who had received treatment, 65 percent received treatment solely outside of the school, two percent received treatment solely within the school, and 33 percent received treatment both within and outside of the school. Conclusions: Nearly one-third of all students who experienced suicidal thinking never disclosed these thoughts to anyone, and 25 percent never received treatment. Furthermore, students rarely disclosed suicidal thinking


to school personnel, and most students who endorsed suicidal thinking did not receive treatment within the school setting. These data suggest that universal screening efforts must support teenagers in receiving treatment and that school-based screening efforts are best conducted by outside specialists.

ADOL, S, TREAT Supported by the MetroWest Health Foundation http://dx.doi.org/10.1016/j.jaac.2017.09.214

3.67 CONTRIBUTION OF NEUROPSYCHIATRIC DIAGNOSES, COMORBIDITY, AND TRANSDIAGNOSTIC TRAITS TO RISK FOR SUICIDAL IDEATION IN A YOUTH CLINICAL SAMPLE Pieter J. Vuijk, PhD, Massachusetts General Hospital, pvuijk@ mgh.harvard.edu; Hillary Bush, PhD, Massachusetts General Hospital, [email protected]; Ellen B. Braaten, PhD, Massachusetts General Hospital and Harvard Medical School, [email protected]; Patrick S. McGuinness, BA, Massachusetts General Hospital, [email protected]. edu; Brenda A. Lee, BS, Massachusetts General Hospital, [email protected]; Anna R. Samkavitz, BA, Massachusetts General Hospital, [email protected]. edu; Alysa E. Doyle, PhD, Massachusetts General Hospital and Harvard Medical School and The Broad Institute, [email protected] Objectives: Previous research on suicide in children has focused on risk conferred by the presence of specific diagnoses, particularly mood disorders, with limited attention to comorbidity and to individual differences on dimensional traits that cut across conditions. A recent study also concluded that ADHD contributes to suicide completion in young children. We aimed to advance this literature by examining the contribution of a range of neuropsychiatric diagnoses, comorbidity, and dimensional traits to risk for suicidal ideation (SI) in a youth clinical cohort. Methods: Data were from 847 children (ages 6–18 years) who were consecutively referred for neuropsychiatric evaluation and enrolled in the Longitudinal Study of Genetic Influences on Cognition (LOGIC). Risk for SI was examined using logistic regression models. First, we used neuropsychiatric diagnoses as predictors while addressing comorbidity. Second, we examined prediction based on dimensional measures of psychopathology. Results: After controlling for comorbidity, having a mood disorder significantly increased SI risk (OR ¼ 4.5) as did having an anxiety disorder, albeit to a smaller extent (OR ¼ 1.6); however, no increased risk was associated with ADHD, autism spectrum disorder (ASD), or the presence of psychosis. Compared with ADHD, comorbid mood plus anxiety disorder had the highest risk for SI (OR ¼ 12.2). Compared with ADHD alone, there was also an increased risk for SI when ADHD was comorbid with a mood disorder. Finally, dimensional measures of depression, aggression, and anxiety (but not of ADHD or ASD) contributed uniquely to SI. Conclusions: After addressing comorbidity, mood and anxiety disorders were the strongest diagnostic contributors to risk for SI in this clinical cohort of youth. The co-occurrence of mood and anxiety disorders conferred a particularly high risk. ADHD only increased SI risk when it was comorbid with a mood disorder. Dimensional symptoms of depression, anxiety, and aggression all contributed uniquely to SI risk. These data support consideration of comorbidity and transdiagnostic traits as potential contributors to SI.

RDoC, CM, S Supported by NIMH Grant R03-MH-106862 and the Stanley Center for Psychiatric Research http://dx.doi.org/10.1016/j.jaac.2017.09.215

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NEW RESEARCH POSTER SESSION 4 4.1 CAN MATERNAL N-ACETYL CYSTEINE RESCUE THE EFFECTS OF PRENATAL STRESS ON BEHAVIOR AND THE BRAIN? James Chambliss, BA, BS, University of Iowa, [email protected]; Jada Bittle, BA, MA, University of Iowa, [email protected]; Hanna Stevens, MD, PhD, University of Iowa, [email protected] Objectives: One of the concepts that makes pediatric psychiatry complex is the interaction of the developing neurological system and mental illnesses. Specifically, inhibitory neuron development must be understood because GABAergic abnormalities have been implicated in the pathogenesis of autism spectrum disorder (ASD), schizophrenia, and Tourette’s disorder. By use of mouse models, our laboratory has found that prenatal stress alters GABAergic neurons, particularly the parvalbumin (PV) subtype, in the medial frontal cortex and hippocampus. We also found that prenatal stress increases anxiety-like behavior and decreases social preference in mice, alterations correlated with inhibitory neuron abnormalities, and mirroring neuropsychiatric symptoms. Thus, if GABAergic neuron changes after prenatal stress could be rescued, this might contribute to the prevention of mental illness. GABAergic neurons are sensitive to oxidative stress, a possible mechanism of prenatal stress, suggesting that the antioxidant N-acetylcysteine (NAC) could rescue GABAergic neuron changes. Methods: We tested this possibility by creating the following four groups of pregnant mouse dams: 1) nonstressed (NS); 2) prenatally stressed (PS); 3) NS with NAC; and 4) PS with NAC provided in drinking water. We then evaluated behavioral outcomes using an open-field test, rotarod, elevated plus maze, and water T maze. We evaluated neurobiological outcomes using fluorescence immunocytochemistry in fixed sections of medial frontal cortex. PV+ and GAD67+ (the enzyme that makes GABA) cells were counted. Results: In PS-exposed offspring, maternal NAC showed a rescue-like effect, eliminating PS increases in anxiety-like behavior in the open field and in procedural learning on the rotarod and water T maze. Increased anxiety on the elevated plus maze was not rescued by NAC. Unexpectedly, NAC exposure alone had significant effects on anxiety-like behavior and procedural learning. PV+ and GAD67+ cell counting is still underway to assess whether NAC rescued PS effects and/or had independent influences on GABAergic neurons. Conclusions: In a mouse model, maternal NAC consumption during pregnancy counteracted some effects in offspring of PS on anxiety-like and procedural learning behavior. Furthermore, NAC exposure alone had an impact on offspring behaviors, suggesting that redox balance during pregnancy has neurodevelopmental significance.

ANI, PRE, STRESS Supported by the Roy J. Carver Trust and the Iowa Neuroscience Institute Junior Research Program of Excellence http://dx.doi.org/10.1016/j.jaac.2017.09.217

4.2 STEREOLOGY OF VON ECONOMO NEURONS (VENS) IN ANTERIOR CINGULATE CORTEX (ACC) AND INSULA OF POST MORTEM BRAINS FROM PERSONS WITH PRADER-WILLI SYNDROME (PWS): A PRELIMINARY REPORT Janice L. Forster, MD, Pittsburgh Partnership, [email protected]; Merina Varghese, PhD, Icahn School of Medicine at Mount Sinai, merinavarghese@mssm. edu; Patrick Hof, MD, Icahn School of Medicine at Mount Sinai, [email protected] Objectives: Von economo neurons (VENs) are large spindle cells located in layer V of the anterior cingulate cortex (ACC) and insula of human brain. VENs appear in the eighth month of gestation, proliferate postnatally and selectively in the right hemisphere, and reach adult numbers by age four years. Their putative function is to relay fast information about social salience, self-awareness, and physiological state that are essential for autonomic nervous system

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modulation. VENs have been examined in post mortem brains from individuals with autism spectrum disorder (ASD), bipolar disorder (BD), schizophrenia, and frontotemporal dementia. This preliminary report describes the number, location, morphology and stereology of VENs in Prader-Willi syndrome (PWS). Methods: The NIH NeuroBioBank provided 20 brains with PWS. Areas of interest (ACC and insula) were dissected as a block from the right hemisphere. Each tissue block was prepared, sectioned, Nissl stained and examined to clarify cytoarchitectural boundaries. VENs were identified; their number, location, morphology, and spatial orientation were documented by stereological methods and compared with ASD and normal controls (NC). Results: VENs were more numerous in the ACC of PWS compared to ASD and NC; morphology and spatial orientation were normal. Stereology completed on two cases showed increased VEN density with age-related decline. In PWS there were fewer VENs in insula; some were oblique in spatial orientation, similar to those in ASD. VENs were found in the mid and posterior insula, a finding unique to PWS. Conclusions: In these preliminary results, VENs in PWS brain (ACC and insula) are abnormal in number, distribution, or spatial orientation. The developmental proliferation and elevated number of VENs may correlate with the onset and intensity of temper tantrums, hyperphagia, autonomic instability and social salience required for both food acquisition and understanding social hierarchy. Stereological data reveals that increased VEN density in ACC declines with age. This is clinically consistent with the fourth nutritional stage of satiety and “mellowing” of behavior. The number, morphology, spatial orientation, and distribution of VENs in insula is comparable to reports in ASD, correlating with abnormalities of interoception. The presence of VENs in the posterior insula is unique to PWS, and may be related to abnormal brain folding and insula closure.

PSP, NEUROA, ND Supported by the Foundation for Prader-Willi Research http://dx.doi.org/10.1016/j.jaac.2017.09.218

4.3 IMPAIRED PROCESSING SPEED: AN UNDERSTUDIED PHENOMENON ACROSS NEUROPSYCHIATRIC DISORDERS IN YOUTH Ellen B. Braaten, PhD, Massachusetts General Hospital and Harvard Medical School, [email protected]; Amanda K. Ward, PhD, Massachusetts General Hospital, [email protected]; Pieter J. Vuijk, PhD, Massachusetts General Hospital, [email protected]; Nathan E. Cook, PhD, Massachusetts General Hospital, [email protected]; Patrick S. McGuinness, BA, Massachusetts General Hospital, [email protected]. edu; Brenda A. Lee, BS, Massachusetts General Hospital, [email protected]; Anna R. Samkavitz, BA, Massachusetts General Hospital, [email protected]. edu; Sheila M. O’Keefe, EdD, Massachusetts General Hospital and Harvard Medical School, [email protected]. edu; Alysa E. Doyle, PhD, Massachusetts General Hospital and Harvard Medical School and The Broad Institute, [email protected] Objectives: Impaired speed of information processing or “processing speed” (PS) is associated with academic and adaptive functioning difficulties. PS has been examined extensively in ADHD, but to a more limited degree in other neuropsychiatric conditions. We aimed to extend the literature by examining PS across a range of conditions in clinically referred youth. Our goals were to elucidate the role of neuropsychiatric diagnosis, psychiatric comorbidity, and transdiagnostic psychopathology traits in the prediction of impaired PS. Methods: Data were from 775 youth (ages 6–21 years) consecutively referred for neuropsychiatric evaluation and enrolled in the Longitudinal Study of Genetic Influences on Cognition (LOGIC). Processing speed was calculated using measures from the Wechsler Intelligence Scale. Data were analyzed using mixed modeling, ANOVA, and logistic regression while controlling for age, sex, and psychotropic medication use. We also used structure equation modeling to explore models of how PS can influence academic achievement in relation to other cognitive constructs. Results: In this clinical cohort, PS was significantly more impaired than either of the other two major domains of functioning on the Wechsler Intelligence Scale,

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including working memory (Mdifference ¼ 1.3, P ¼ 0.03) and general cognitive ability (Mdifference ¼ 9.0, P < 0.001). Youth with psychosis, autism spectrum disorder (ASD), mood disorders, and ADHD all performed below national norms on PS, whereas youth with anxiety disorders did not show PS impairment. Controlling for comorbidity, the presence of psychosis (OR ¼ 3.5), ASD (OR ¼ 1.8), and ADHD (OR ¼ 1.5) increased the risk of having slow PS (operationalized as PSI < 85). Among dimensional measures of the neuropsychiatric conditions we examined, only inattention (OR ¼ 1.4) was a significant predictor of risk for impaired PS across disorders. The influence of PS on reading achievement was fully mediated by Working Memory and General Cognitive Ability. Conclusions: Impaired PS is relevant to neuropsychiatric conditions beyond ADHD. Our data raise the possibilities that inattention accounts for impaired PS across disorders and that working memory plays a role in the impact of PS on reading.

PSP, RDoC, CM Supported by NIMH Grant R03-MH-106862 and the Stanley Center for Psychiatric Research http://dx.doi.org/10.1016/j.jaac.2017.09.219

4.4 TRANSLATING DISCOVERIES IN ATTENTIONDEFICIT/HYPERACTIVITY DISORDER (ADHD) GENOMICS TO THE CLINIC Alysa E. Doyle, PhD, Massachusetts General Hospital and Harvard Medical School and The Broad Institute, doylea@ helix.mgh.harvard.edu; Joanna Martin, PhD, The Broad Institute and Cardiff University, [email protected]; Pieter J. Vuijk, PhD, Massachusetts General Hospital, pvuijk@ mgh.harvard.edu; Michael R. Capawana, PhD, Massachusetts General Hospital, [email protected]; Sheila M. O’Keefe, EdD, Massachusetts General Hospital and Harvard Medical School, [email protected]; Brenda A. Lee, BS, Massachusetts General Hospital, brenda.andi.lee@ gmail.com; Anna R. Samkavitz, BA, Massachusetts General Hospital, [email protected]; Hannah S. Lind, BA, Massachusetts General Hospital, [email protected]; Jordan W. Smoller, MD, Massachusetts General Hospital and Harvard Medical School, [email protected]; Roy H. Perlis, MD, Massachusetts General Hospital and Harvard Medical School, [email protected]; PhD Stephen V. Faraone, SUNY Upstate Medical University, sfaraone@ childpsychresearch.org; Ellen B. Braaten, PhD, Massachusetts General Hospital and Harvard Medical School, ebraaten@ mgh.harvard.edu Objectives: A genome-wide association study has identified susceptibility variants and a substantial polygenic component for ADHD. We aimed to do the following: 1) confirm the convergent validity of ADHD-polygenic risk (PR) with ADHD-related phenotypes in youth presenting for neuropsychiatric evaluation; and 2) determine the extent to which ADHD-PR associates with phenotypes beyond ADHD. Methods: Participants included 470 youths (ages 7–18 years), consecutively referred for neuropsychiatric evaluation and genotyped on the Illumina Infinium PsychArray Beadchip. Diagnoses reflected a range of psychopathology and comorbidity. We determined the burden of ADHD-related common variants in patients at different significance thresholds from the ADHD Psychiatric Genomics Consortium-iPSYCH meta-analysis. We then associated this PR with clinical phenotypes in univariate analyses and genotype-first and phenotypefirst analyses that examined phenotypic profiles beyond DSM categories. Results: The ADHD-PR predicted the ADHD diagnosis at seven discovery sample thresholds after correction for confounds and multiple testing. The strongest association occurred at discovery sample {P < 0.000001 [Wald X2(2) ¼ 13.34, P ¼ 0.0013]}, where an ADHD-PR score increase of 1.0 SD increased the relative risk of having ADHD versus not having ADHD 1.5-fold among youth with a range of diagnoses. Variation in ADHD risk also predicted crossdiagnostic variation in ADHD symptoms, aggression, and working memory. Here, the strongest associations explained 2.3–3.0 percent of the variation.


Youth with high ADHD polygenic burden also showed a distinct clinical profile [Wald X2(2) ¼ 8.15, P ¼ 0.017], with greater severity on measures of inattention, hyperactivity, inhibition, aggression, and anxiety. Finally, among four latent classes of youth, the ADHD-PR scores distinguished the classes with the greatest and least psychopathology severity [F(1,421) ¼ 10.73, P ¼ 0.0011], including differences in ADHD symptoms and dimensions of emotional and behavioral dysregulation. Conclusions: In a multidiagnostic clinical sample group, ADHD polygenic risk showed convergent validity with ADHD phenotypes. Genotype- and phenotype-first analyses also indicated that ADHD polygenic burden associates with traits reflecting cognition and behavioral and emotional dysregulation that extend beyond ADHD and that have implications for functional outcome.

ADHD, RDoC, GS Supported by NIMH Grant R03MH106862 and the Stanley Center for Psychiatric Research http://dx.doi.org/10.1016/j.jaac.2017.09.220

4.5 PRENATAL EXPOSURE TO PESTICIDES AND NEURODEVELOPMENTAL DISORDERS IN CHILDREN Bettina Fage-Larsen, MD, Child and Adolescent Psychiatric Department, [email protected]; Helle Raun Andersen, PhD, University of Southern Denmark, [email protected]; Niels Bilenberg, PhD, Child and Adolescent Psychiatric Department, [email protected] Objectives: Neurodevelopmental disorders, including ADHD, affect millions of children worldwide, leading to severe mental and social impairment in adulthood and large socioeconomic costs. Both genetic and environmental factors influence the development of ADHD. Neurotoxic chemicals, such as insecticides, are suspected to cause permanent damage to the fetal brain, increasing the risk of ADHD. Pesticides are used in large amounts in Denmark and abroad; residues are known to be present in 50 percent of fruit, vegetables, and breakfast cereals; and more than 25 percent contain more than one pesticide. The maximum permissible residue levels are not based on the knowledge of potential neurotoxic effects of insecticides. This study examines how pregnant women’s exposure to low doses of neurotoxic insecticides through the diet can affect their children’s nervous system and increase the risk of ADHD. Methods: Data from 589 children at 2.5 years of age were obtained, assessing symptoms of ADHD using the Child Behavior Checklist (CBCL). Data from children with ADHD and ADHD scores above the 90th percentile (n ¼ 93) were compared with urinary concentrations of insecticides, metabolites, pyrethroids (3-PBA), and organophosphates (3,5,6-trichloro-2-pyridinol, TCPY) collected in their mothers at 28 weeks of gestation. Odds ratios were calculated and adjusted for potential confounders. Odds ratios were calculated separately for boys and girls to detect a possible gender difference. Results: Odds ratio (95% CI) for ADHD CBCL scores above the 90th percentile in boys at age 2.5 years and maternal urinary concentrations of 3-PBA was 3.00 (1.59, 5.66), and for 3-PBA + TCPY, it was 4.25 (1.60, 11.33) (P < 0.001). There was no significant association in girls. Conclusions: Pregnant women’s exposure to low doses of neurotoxic insecticides through food increases the risk for developing ADHD symptoms three to four times in boys.

ADHD, NECHEM, ND Supported by the Psychiatric Research Fund of the Region of Southern Denmark, University of Southern Denmark, and Child and Adolescent Psychiatric Department Odense, Denmark http://dx.doi.org/10.1016/j.jaac.2017.09.221

4.6 THE RELIABILITY AND VALIDITY OF MOTHERS’ FIVE-MINUTE SPEECH SAMPLE ABOUT THEIR CHILDREN: ASSOCIATIONS WITH CHILD PSYCHIATRIC SYMPTOMS COMPARED TO OTHER MEASURES OF PARENTING Kathleen E. Feeney, BA, University of Maryland, kfeeney28@ gmail.com; Maryam Sizar, University of Maryland, maryamsz@

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terpmail.umd.edu; Stephanie M. Merwin, MS, University of Maryland, [email protected]; Lea R. Dougherty, PhD, University of Maryland, [email protected] Objectives: Research demonstrates that parents’ expressed emotion about their child during the Five Minute Speech Sample (FMSS) is associated with child externalizing and internalizing symptoms. The current study examined reliability and validity of the FMSS and tested the unique incremental validity of the FMSS over other common parenting measures, including parent report and observational measures. Methods: Mothers of 98 children aged 5-9 years completed the FMSS, an observational parent-child interaction task (PCI), and the parent-reported Parenting Styles Dimensions Questionnaire (PSDQ). FMSS coders rated mothers’ criticism and warmth, while observed parental hostility and support were rated on the PCI. Maternal-reported authoritarian and authoritative parenting styles were assessed with the PSDQ. Child externalizing and internalizing symptoms were assessed with a clinical interview, after which interviewers rated mothers’ criticism and warmth. Results: The internal consistency and inter-rater reliability of the FMSS was acceptable. FMSS criticism was positively associated with interviewer-rated criticism but not significantly associated with parent-report and observations of parenting behaviors. FMSS warmth was positively associated with parentreported authoritative parenting and interviewer-rated warmth and negatively associated with parent-reported authoritarian parenting and interviewer-rated criticism. FMSS criticism was associated with externalizing and depressive symptoms. FMSS warmth was associated with ODD symptoms. After accounting for all negative parenting measures, FMSS and interviewer-rated criticism were the best predictors of externalizing symptoms. Interviewer-rated criticism was the only significant predictor of internalizing symptoms after accounting for other negative parenting measures. Interviewer-rated warmth was the best predictor of externalizing and depressive symptoms after accounting for all positive parenting measures. Conclusions: These findings support the reliability and validity of the FMSS in school-age children. Both the FMSS and interviewer-rated parenting showed incremental validity over and above parent-report and observational measures of parenting.

RI, PAT, SAC Supported by the University of Maryland College of Behavioral and Social Sciences Dean’s Research Initiative Award and the University of Maryland Research and Scholars Award http://dx.doi.org/10.1016/j.jaac.2017.09.222

4.7 TARGETING MENTAL HEALTH DISPARITIES IN CHILDREN THROUGH FATTY ACID SUPPLEMENTATION DURING PREGNANCY Cherrelle L. Jones, BA, University of Chicago, cherrellejg@ uchicago.edu; Jillianne Fowle, BA, University of Chicago, [email protected]; Rimma Ilyumzhinova, MA, University of Chicago, [email protected]; Kathryn Keenan, PhD, University of Chicago, [email protected]; Kimberley Mbayiwa, MA, University of Chicago, kmbayiwa@ yoda.bsd.uchicago.edu Objectives: Findings from multiple studies support the hypothesis that maternal psychosocial stress is significantly associated with higher risk for child psychiatric disorders. Extant data have shown African American women living in low-income environments have greater exposure to psychosocial stress, a likely common pathway by which health disparities emerge. Thus, it is important to investigate modifiable factors associated with stress to prevent the negative effects of prenatal stress on mothers and their offspring. Studies indicate that docosahexaenoic acid (DHA) improves functioning of the hypothalamic–pituitary–adrenal axis in response to social stressors. We hypothesize that DHA supplementation during pregnancy will improve maternal perceived stress and cortisol reactivity over time for African American women living in low-income areas. Methods: Sixty-four pregnant women were recruited for the Nutrition and Pregnancy Study at the University of Pittsburgh, a randomized,

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placebo-controlled trial, double-blind study of DHA (450 mg) supplementation. Participants were African American (aged 20–30 years) living in low-income areas and between 16 and 21 weeks of gestation. Cortisol reactivity to the Trier Social Stress Test (TSST) was measured via saliva samples collected upon arrival to the laboratory, 20 and 40 minutes poststressor. Data on DHA levels were available for 32 subjects. Given the small sample size, we report effect size in our results. Results: Compared with baseline, DHA levels at 36 weeks’ gestation showed an increase in the active group (n ¼ 20) by +0.355 and a decrease of in the placebo group (n ¼ 12) by 0.333, a difference of moderate magnitude (Cohen’s d ¼ 0.49). DHA levels at 36 weeks were positively associated with cortisol reactivity (rs ¼ 0.261, P ¼ 0.082; Cohen’s d ¼ 0.54), indicating that pregnant women with higher DHA levels had more modulated cortisol response to a controlled stressor. DHA levels were negatively associated with perceived stress (rs ¼ 0.252, P ¼ 0.090; Cohen’s d ¼ 0.52). Conclusions: Our results show an increase in DHA levels for those receiving supplementation, which resulted in decreased levels of perceived stress and a more modulated typical cortisol response to a controlled stressor. Fatty acid supplementation during pregnancy in high stress populations have implications in reducing prenatal stress and improving offspring mental health.

NEURODEV, STRESS, DEV Supported by NIH Grant R21 HD058269 http://dx.doi.org/10.1016/j.jaac.2017.09.223

4.8 PRELIMINARY VALIDATION OF A PARENTREPORT MEASURE OF OVERCONTROL IN YOUNG CHILDREN: ASSOCIATIONS WITH BEHAVIORAL AND NEUROBIOLOGICAL INDICTORS Kirsten Gilbert, PhD, Washington University in St. Louis, [email protected]; Nathan A. Fox, PhD, University of Maryland, [email protected]; Deanna Barch, PhD, Washington University in St. Louis, [email protected]; Joan Luby, MD, Washington University in St. Louis, [email protected] Objectives: Self-control is protective against psychopathology in youth. However, too much self-control, in the form of “overcontrol” is a transdiagnostic risk factor for social impairment and multiple mental disorders in youth, including social anxiety disorder, OCD, and anorexia nervosa (AN). There are currently no parent-reported screening measures to quickly assess this transdiagnostic construct in youth. The current study provides preliminary validation of a parent-report measure of overcontrol in healthy and depressed children ages 4–6 years in relation to behavioral and neurobiological indicators. Methods: Parents of 62 healthy children and children with MDD completed a novel assessment of their child’s overcontrol tendencies and provided executive functioning (Behavior Rating Inventory of Executive Functioning, BRIEF), diagnostic (Kiddie Schedule for Affective Disorders and Schizophrenia, KSADS-Early Childhood), and social functioning (Health Behavior Questionnaire-Parent, HBQ) reports about their child. Children completed an ageappropriate cognitive go/no-go task while an event-related potential (ERP), the error-related negativity (ERN), which is thought to index overcontrol, was recorded in a sample subset (n ¼ 31). Results: Parent-reported overcontrol was associated with deficits in cognitive shifting and cognitive flexibility (r ¼ 0.50, 0.49, P < 0.001) but not in inhibitory control or working memory. Overcontrolled tendencies were elevated in the MDD preschoolers (t ¼ 5.42, P ¼ 0.001). Furthermore, compared with depressed youth with no comorbid anxiety, those with a comorbid anxiety disorder demonstrated even higher overcontrol (t ¼ 2.56, P ¼ 0.026). Overcontrol was also associated with a larger DERN, and using linear regression to control for depression or anxiety disorder status, DERN continued to predict elevated overcontrol (b ¼ 0.60, P ¼ 0.03). Overcontrol was not associated with externalizing disorders or social functioning. Conclusions: Findings demonstrate initial validity of a parent report of overcontrol in relation to cognitive deficits, psychopathology, and neural substrates. Overcontrol appears to be reliably detected and measured during the preschool period and is a marker of risk. Clinicians and researchers can begin to behaviorally identify this transdiagnostic dimensional trait in young children.

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RF, TEMP, EC Supported by NIH Grant T32 MH100019-03 http://dx.doi.org/10.1016/j.jaac.2017.09.224

4.9 PEER VICTIMIZATION IN ADOLESCENCE, AND THE MODERATING ROLE OF PERSONALITY TRAITS ON INTERNALIZING AND EXTERNALIZING PROBLEMS: A LONGITUDINAL STUDY

Flavie Laroque, MSC, University of Montreal, flavie.laroque@ umontreal.ca; Mohammad Afzali, PhD, CHU Sainte-Justine Research Center, [email protected]; Patricia Conrod, PhD, University of Montreal, [email protected] Objectives: There is limited evidence on the role of personality traits in the development of psychopathology among children who are victimized, yet personality plays an important role in the type of victims and in the prediction of mental disorders. Methods: Five-year data from 3,612 seventh grade adolescents of a randomized controlled trial (personality-targeted intervention) were used to determine levels of victimization, depressive, anxiety, and ADHD symptoms, conduct problems, and personality. Multilevel linear modelling analyses assessed general vulnerability and concurrent effect of victimization as the time varying predictor of the four assessed psychopathological domains. Interaction between time and general vulnerability and concurrent effect of victimization were evaluated. To assess the moderating role of personality on the effect of victimization on the four domains, we added the interaction between personality and general vulnerability and concurrent effect. Results: There is a general vulnerability of victimization on conduct problems and ADHD symptoms (b ¼ 0.20, SE ¼ 0.012, P < 0.01; b ¼ 0.22, SE ¼ 0.020, P < 0.01), concurrent effect on conduct problems (b ¼ 0.070, SE ¼ 0.013, P < 0.01), and vulnerability and concurrent effect on anxiety and depressive symptoms (b ¼ 0.48, SE ¼ 0.056, P < 0.01; b ¼ 0.83, SE ¼ 0.078, P < 0.01; b ¼ 0.18, SE ¼ 0.083, P < 0.05; b ¼ 0.36, SE ¼ 0.115, P < 0.01) along with significant time interactions for these effects. Externalizing personality increases general vulnerability and concurrent effect on conduct problems (b ¼ 0.013, SE ¼ 0.006, P < 0.05; b ¼ 0.017, SE ¼ 0.007, P < 0.05), increases general vulnerability on ADHD symptoms (b ¼ 0.034, SE ¼ 0.012, P < 0.01), and decreases general vulnerability on depressive symptoms (b ¼ —0.066, SE ¼ 0.027, P < 0.05). Internalizing personality increases the general vulnerability and concurrent effect on depressive symptoms (b ¼ 0.056, SE ¼ 0.027, P < 0.05; b ¼ 0.058, SE ¼ 0.024, P < 0.05) and increases general vulnerability on anxiety symptoms (b ¼ 0.046, SE ¼ 0.019, P < 0.05). Conclusions: Our findings view victimization as a dynamic experience at high risk for psychiatric disorders that could be partly explained by underlying personality. Our study supports calls within the literature to move away from traditional programs toward personality-targeted programs.

PSP, BLY, LONG Supported by the Canadian Institutes Health Research Grant FRN 114887 http://dx.doi.org/10.1016/j.jaac.2017.09.225

4.10 CHILDREN WITH AUTISM SPECTRUM DISORDER AND COMORBID SPECIFIC LEARNING DISORDER DEMONSTRATE COGNITIVE WEAKNESS COMPARED TO AUTISM SPECTRUM DISORDER ALONE Patrick S. McGuinness, BA, Massachusetts General Hospital, [email protected]; Nathan E. Cook, PhD, Massachusetts General Hospital, [email protected]; Hillary Bush, PhD, Massachusetts General Hospital, hbush@ pchi.partners.org; Hannah Lind, BA, Massachusetts General Hospital, [email protected]; Pieter J. Vuijk, PhD, Massachusetts General Hospital, [email protected];


Alysa E. Doyle, PhD, Massachusetts General Hospital and Harvard Medical School and The Broad Institute, doylea@ helix.mgh.harvard.edu; Ellen B. Braaten, PhD, Massachusetts General Hospital and Harvard Medical School, ebraaten@ mgh.harvard.edu Objectives: Autism spectrum disorder (ASD) and specific learning disorder (SLD) are each associated with neurocognitive weakness. However, to our knowledge, no study has examined whether comorbid SLD confers any additive negative effect on cognition or executive functioning for youth with ASD. The present study aims to identify cognitive and executive functioning weaknesses in a clinically referred sample. In the present study, youth with ASD and comorbid SLD were hypothesized to have lower cognitive scores and elevated executive function ratings. Methods: Participants were 46 youth aged 6-15 years (M ¼ 9.7, SD ¼ 2.4, 75% male) with ASD, referred for neuropsychological evaluation. Youth with ASD and comorbid SLD (ASD+LD; n ¼ 23) were individually matched to youth with ASD only (n ¼ 23) based on age, sex, race, autism severity, ADHD severity, and comorbid psychiatric diagnosis. Working memory index (WMI), processing speed index (PSI) and general ability index (GAI) of the Wechsler Intelligence Scales for Children, Fourth Edition (WISC-IV) were compared using ANCOVA (controlling for medication status) and Behavior Rating Inventory of Executive Function (BRIEF) parent report scale scores were compared using ANOVA. Group differences on all indices and subscales were further analyzed with post-hoc paired sample t-tests. Results: The ASD+LD group had a significant deficit in the overall WISC-IV profile, F(1, 131) ¼ 6.17, p ¼ 0.014. When looking at specific index scores in the WISC-IV, WMI was significantly lower in the ASD+LD group (M ¼ 89.7, SD ¼ 18.1) as compared to the ASD only group (M ¼ 97.5, SD ¼ 13.5), [t(21) ¼ -1.72, p ¼ 0.05], representing a medium effect size (Cohen’s d ¼ 0.49). Groups did not differ on PSI or GAI. Overall parent-rated executive functioning scores were not significantly different, F(1, 350) ¼ 1.44, p ¼ 0.23. Post-hoc analyses revealed that the planning/organizing subscale was significantly weaker in ASD+LD [t(21) ¼ 2.6, p ¼ 0.01], (d ¼ 0.60). Conclusions: Youth with ASD+LD may be at greater risk for working memory, processing speed and planning challenges compared to youth with ASD only. Understanding and identifying potential sources of, or contributors to, cognitive difficulties is critical for clinical care and supporting development.

ASD, LD, CM http://dx.doi.org/10.1016/j.jaac.2017.09.226

4.11 THE DEVELOPMENTAL PROPENSITY MODEL EXTENDS TO OPPOSITIONAL DEFIANT DISORDER Amy J. Mikolajewski, PhD, Tulane University School of Medicine, [email protected]; Sara A. Hart, PhD, Florida State University, [email protected]; Jeanette Taylor, PhD, Florida State University, [email protected] Objectives: Previous research has provided support for the developmental propensity model in which three socio-emotional dispositions (prosociality, negative emotionality, and daring) lead to increased risk for the development of conduct disorder (CD). The current study extends this research by examining the developmental propensity model in relation to ODD, which is often conceptualized as a precursor to CD. Based on previous research, prosociality was divided into two factors (dispositional sympathy and respect for rules) rather than being examined as a unitary construct. Methods: Parents of 694 same-sex twins (ages 7–13 years) from the Florida State Twin Registry provided ratings of their children’s dispositions and oppositional defiant behaviors as part of a larger project. Structural equation modeling was used to examine the relationships among the dispositions and ODD (while taking nonindependence of twins into account using clustering). Because several models of ODD have recently been proposed in the literature, a confirmatory factor analysis was used to compare a one-factor (ODD), two-factor (irritability, headstrong/hurtful), three-factor (negative affect, oppositional, antagonistic), and a second three-factor (irritable, headstrong, and hurtful) model of ODD. The final model, which is consistent with the conceptualization of

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ODD in the DSM-5, was the best-fitting model. As such, the structural equation model was also run with the dispositions predicting the three factors of ODD from the best-fitting model (irritable, headstrong, and hurtful). Results: Resultsshowed that dispositional sympathy, respect for rules, negative emotionality, and daring were significantly (P < 0.05) related to ODD. Furthermore, each disposition was also significantly related to each factor of ODD (irritable, headstrong, and hurtful), with one exception; daring was not a significant predictor of the irritable dimension. Conclusions: These findings provide initial support for using the developmental propensity model to explain the development of ODD.

DEV, TEMP, ODD Supported by Eunice Kennedy Shriver National Institute of Child Health and Human Development Grant P50 HD052120 http://dx.doi.org/10.1016/j.jaac.2017.09.227

4.12 MATERNAL WHOLE BLOOD SEROTONIN LEVELS PREDICT VERBAL ABILITY AND CORE SYMPTOMS IN CHILDREN WITH AUTISM SPECTRUM DISORDER Alicia K. Montgomery, BMe, Columbia University, akm2206@ cumc.columbia.edu; Lauren C. Shuffrey, PhD, Columbia University, [email protected]; Stephen J. Guter, MA, Institute for Juvenile Research, University of Illinois at Chicago, [email protected]; George M. Anderson, PhD, Yale University, [email protected]; Suma Jacob, PhD, University of Minnesota, [email protected]; James S. Sutcliffe, PhD, Vanderbilt University, james.s. [email protected]; J. Blake Turner, PhD, Columbia University, College of Physicians and Surgeons, TurnerB@ nyspi.columbia.edu; Edwin H. Cook, MD, University of Illinois at Chicago, [email protected]; Jeremy VeenstraVanderWeele, MD, Columbia University, veenstr@nyspi. columbia.edu Objectives: Biomarker, neuroimaging, and genetic findings implicate the serotonin (5-HT) system in autism spectrum disorder (ASD). Several groups have investigated clinical correlates of 5-HT in ASD, with minimal and inconsistent findings across studies. The maternal 5-HT system influences embryonic forebrain 5-HT levels and neurodevelopment in mice. Given emerging evidence pointing to maternal genotype as a contributor to offspring risk of neurodevelopmental abnormalities, we evaluated whether the maternal 5-HT system is associated with phenotype in children with ASD. Methods: Whole-blood serotonin (WB5-HT) levels were obtained from 181 children diagnosed with ASD, Asperger Syndrome, or pervasive developmental disorder NOS based on DSM-IV-Text Revision criteria. WB5-HT levels (93 paternal and 106 maternal) were also collected, and behavioral, language, and cognitive phenotypes were evaluated using a range of standardized assessments. Results: Maternal WB5-HT levels were associated with lower impairment in social and repetitive behavior and increased cognitive and language abilities in children with ASD. Multiple regression predicted maternal 5-HT from summary outcome measures on the Autism Diagnostic Observation Schedule-2, Autism Diagnostic Interview-Revised (ADI-R), Vineland Adaptive Behavior Scales-Second Edition, and cognitive testing [F(13, 81) ¼ 2.119, P ¼ 0.021, R2 ¼ 0.134]. Variables adding statistically significantly to the prediction included total reciprocal social interaction and total nonverbal communication on the ADI-R and nonverbal IQ and self-injurious behavior on the Repetitive Behavior Scale-Revised (P < 0.05). Latent class analysis supported a threeclass structure to the behavioral dataset, describing children with low, intermediate, and high severity across measures of behavior, cognition, and adaptive function. Mean maternal 5-HT differed across classes, with the lowest levels seen in the highest severity group [Welch’s t-test: F(2, 32.457) ¼ 16.948, P < 0.001]. Conclusions: Work is ongoing to replicate these findings and assess whether maternal 5-HT levels define a specific subgroup of children with ASD. Further

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studies are needed to understand the mechanisms underlying these associations.

ASD, RF, NEURODEV Supported by NIH Grants HD055751, MH094604, MH016434, the Simons Foundation Autism Research Initiative Simplex Project, National Center for Research Resources, Vanderbilt Clinical and Translational Science Award 5UL1 RR024975, the New York State Psychiatric Institute, and the Mortimer D. Sackler, MD, Foundation http://dx.doi.org/10.1016/j.jaac.2017.09.228

4.13 VALIDITY OF AUTOMATED METHODS FOR ASSESSING CHILD COMMUNICATION ABILITIES (LENA) IN AN AUTISM CLINICAL TRIAL Maura Sabatos-DeVito, PhD, Duke University Medical Center, [email protected]; Megan McVea, PhD, Duke University Medical Center, [email protected]; Lauren Franz, MBChB, MPH, Duke University Medical Center, [email protected]; Jesse Troy, PhD, Duke University School of Medicine, [email protected]; Geraldine Dawson, PhD, Duke Center for Autism and Brain Development, [email protected] Objectives: Few objective measures of social communication deficits in autism spectrum disorder (ASD) exist. We examined the validity of a computerized measure of vocalizations, the Language Environment Analysis (LENA) system, in relation to standardized social communication measures over time in preschoolers with ASD. Methods: Preschoolers (N ¼ 25; mean age ¼ 4.47 years; nonverbal IQ ¼ 64.3 24.6) with ASD participated in a safety trial assessing a single intravenous infusion of autologous umbilical cord blood. Language at home (Language Environment Analysis; LENA) and social communication (Pervasive Developmental Disorder Behavior Inventory, PDDBI) were assessed at baseline, three and six months. Adaptive functioning (Vineland Adaptive Behaviors Scales-II; VABS-II) and language (Expressive One-Word Picture Vocabulary Test; EOW) were assessed at baseline and six months. Correlations and group differences between LENA (Conversational Turn Count, CTC; Adult Word Count, AWC; Child Vocalization Count/Duration, CVC/CVD; and Block Duration, BD) and standardized social communication measures were explored across time. Results: LENA variables (not AWC) were significantly correlated with PDBBI Expressive Language (rs ¼ 0.45 - 0.71, 0.001< p < 0.05) and Expressive Social Communication (rs = 0.45 - 0.68, 0.001 < p < 0.05) at baseline, three, and six months. CVC, CVD, and BD were significantly, positively correlated with EOW raw scores at baseline and six months (rs ¼ 0.42 - 0.67, 0.001 < p < 0.05). All LENA variables were significantly correlated with VABS-II Communication (rs ¼ 0.41 - 0.49, 0.001 < p < 0.05) and Socialization (rs ¼ 0.55 - 0.68, 0.001 < p < 0.01) at baseline, and remained significantly correlated (except AWC) at six months (VABS-II Communication, rs ¼ 0.43 - 0.56, 0.01 < p < 0.05; Socialization, rs ¼ 0.53 - 0.56, ps < 0.01). CVC was greater at six months for subjects with improved EOW raw scores (M ¼ 14.84, SD ¼ 8.73) compared to those whose EOW score did not change (M ¼ 8.42, SD ¼ 4.49) (t (20) ¼ -2.10, p < 0.05). Conclusions: LENA correlated with standardized social communication measures in preschoolers with ASD across time points. Children with EOW language gains at six months had greater LENA-measured vocalizations compared to children with no EOW language gains. LENA shows promise as a valid, objective measure of language in clinical trials for preschoolers with ASD.

ASD, DIAG, OLT Supported by the Marcus Foundation http://dx.doi.org/10.1016/j.jaac.2017.09.229

4.14 NEUROBIOLOGY, COGNITION, AND BEHAVIOR IN TWO POPULATIONS WITH HISTORY OF NEGLECT Eve G. Spratt, MD, MSCR, Medical University of South Carolina Children’s Hospital, [email protected]; Kathleen T.

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Brady, MD, Medical University of South Carolina, Bradyk@ musc.edu; ScD Thomas C. Hulsey, West Virginia University, [email protected]; Myla Ebeling, Medical University of South Carolina, [email protected]; Michael DeBellis, MD, Duke, [email protected]; Teri Lynn Herbert, MS, Medical University of South Carolina, [email protected]; Carrie Papa, Medical University of South Carolina, papa@ musc.edu; Amy H. Wahlquist, MS, Medical University of South Carolina, [email protected]; Richard W. Furlanetto, MD, Medical University of South Carolina and Quest Diagnostics, [email protected] Objectives: Preschoolers with a history of inconsistent caretaking, living in an orphanage, or social deprivation are at an increased risk for behavioral disorders and delays in cognitive development. This study was designed to examine cognitive, behavioral, and neurobiological systems (hypothalamicpituitary-adrenal axis and posterior pituitary hormones) in youth with two different types of neglect and to compare these relationships to an age- and gender-matched control group. Methods: This prospective cohort study of 60 children aged three to 10 years had three groups based on histories: 1) 17 (mean age ¼ 5.3) with a history of physical neglect living with a relative or non offending parent (USN); 2) 15 (mean age ¼ 5.9) with a history of international adoption (IA) from an orphanage (14/15 from Russia); and 3) 28 (mean age 5.2) with biologic parents and no known history of maltreatment (controls). Cognitive (Differential Abilities Scale) and behavioral (Child Behavioral Checklist) measures were obtained. Morning urinary oxytocin and vasopressin were collected and salivary cortisol was collected at four time points in response to a mild stressor (blood draw). Results: There were no significant group differences based on race, age, or gender. Children with a history of USN spent a larger proportion of time in an unstable environment than the group with a history of IA (35 vs 21 months). Children in the IA group had spent 44 months versus 36 months in a stable adoptive home environment. As expected, the two groups of children with a history of neglect had more behavior problems and lower cognitive scores than children with no history of neglect, with the most behavior problems and lower cognitive abilities in the children with USN. Children with an IA history had the greatest and most prolonged cortisol response (p ¼ 0.01). Controls and USN had a similar minimal cortisol response. Early morning urinary oxytocin levels were similar in all groups. However, vasopressin which can be coreleased with oxytocin was lowest in the IA group (p ¼ 0.01). Conclusions: Children with a history of USN demonstrated more behavioral and cognitive impairment than those with a history of IA, yet biologic stress and attachment measures were most remarkable for the group of children with a history of early life in an orphanage.

NEURODEV, NEURO Supported by NIMH Grant K23MH064111 http://dx.doi.org/10.1016/j.jaac.2017.09.230

4.15 EXPLORE-EXPLOIT DECISION MAKING: DIFFERENCES IN INFORMATION-SEEKING BEHAVIOR IN PEDIATRIC PSYCHOPATHOLOGY Caroline Swetlitz, BA, National Institute of Mental Health, [email protected]; Bruno Averbeck, PhD, National Institute of Mental Health, [email protected]; Ellen Leibenluft, MD, National Institute of Mental Health, [email protected]; Daniel S. Pine, MD, National Institute of Mental Health, [email protected]; David Pagliaccio, PhD, National Institute of Mental Health, [email protected] Objectives: Impairments in decision making are often associated with various types of pediatric psychopathology. Such perturbations may impact one’s ability to resolve explore-exploit dilemmas, i.e., choosing to pursue a known reward (exploitation) versus a lesser-known option (exploration). The exploreexploit dilemma has begun to be mapped using both behavioral paradigms and neuroimaging data. However, exploratory decision-making strategies have not yet been studied in a clinical pediatric sample group using the


present reward choice task. The present study aims to use an explore-exploit paradigm to examine group differences in information-seeking behavior. Methods: Healthy youth and youth with a variety of psychiatric diagnoses (N ¼ 48; 26 healthy volunteers, 22 with primary diagnoses of ADHD, anxiety, bipolar disorder, disruptive mood dysregulation disorder, or depression) completed a forced-choice reward task as well as a battery of self-report measures to assess anxiety, irritability, and reward sensitivity. Data were split as a function of information about the reward environment given to examine different behavioral outcomes. The percentage of times selecting each option was examined as a function of the number of decision-making opportunities and the magnitude of the difference between the two options presented. Repeated-measure ANCOVAs were used to evaluate differences in behavior. The number of choices on each trial and reward differential between options were examined as the within-subject factors. Age and symptoms of anxiety and irritability were examined as continuous predictors of interest. Results: Preliminary results suggest that children with high levels of self-reported anxiety and irritability display greater levels of information-seeking behavior on high-conflict trials with more decision-making opportunities. However, these children do not select the high information/high reward options as much as other diagnostic groups. Conclusions: Decision making may be a valuable way of examining transdiagnostic symptomology. Future work should continue to probe various aspects of the explore-exploit dilemma across clinically diverse sample groups.

PSP, AD, DEV Supported by NIMH Grant ZIAMH002781 http://dx.doi.org/10.1016/j.jaac.2017.09.231

4.16 NEUROPSYCHOLOGICAL PROFILE DIFFERENCES BETWEEN CHILDREN WITH DISRUPTIVE MOOD DYSREGULATION DISORDER (DMDD) AND ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD): A PRELIMINARY STUDY Sarper Taskiran, MD, Koc University School of Medicine, [email protected]; Tuba Mutluer, MD, Koc University Hospital, [email protected]; Isil Necef, MA, Koc University Hospital, [email protected] Objectives: Disruptive mood dysregulation disorder (DMDD), characterized by severe irritability, and ADHD are highly comorbid. Clinical observation suggests that patients with DMDD have greater impairment in functioning at school. We compared the neuropsychological assessment scores across three groups of participants to test whether any cognitive differences exist among children with ADHD, DMDD and healthy control (HC) subjects. Methods: The study sample group consisted of 43 participants (14 DMDD, 14 ADHD and 15 age-matched HC, mean age ¼ 9.51; SD ¼ 2.10). All the subjects diagnosed with DMDD had comorbid ADHD. Subjects underwent extensive diagnostic measures including Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS). We applied the following tests: trail making test (TMT), symbol cancellation task (SCT), single letter cancellation task (SLCT), digit span learning (DSL), benton judgment of line orientation (JLO), Rey-Osterrieth complex figure test (CFT), letter and symbol cancellation test (LCT, SCT), Stroop color word (TBAG), and Wisconsin card sorting test (WCST). Results: There were statistically significant differences between these three groups on the TMS, F(2,41) ¼ 5.270, p ¼ 0.009, structured SLCT, F(2,41) ¼ 3.376, p ¼ 0.044, unstructured SLCT, F(2,41) ¼ 5.142, p ¼ 0.010, unstructured SCT, F(2,41) ¼ 5.282, p ¼ 0.009, the ROCFT, F(2,40) ¼ 6.622, p ¼ 0.003, the ROCFT: delayed recall condition score, F(2,40) ¼ 3.647, p ¼ 0.035), the ROCFT: delayed condition time, F(2,40) ¼ 9.195, p ¼ 0.001), Stroop test: incongruent color words condition, F(2,40) ¼ 4.522, p ¼ 0.017), Stroop test: naming the color of random words condition, F(2,40) ¼ 3.647, p ¼ 0.035). Post hoc analyses revealed little difference between ADHD and ADHD and DMDD groups except for the TMT. Conclusions: Neuropsychological properties for children with DMDD are very similar to those of ADHD. Selective and sustained attentional impairment,

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working memory, and set shifting difficulties are prominent in both ADHD and DMDD. Although results did not yield a significant difference, we observed more impaired performance in all tests, likely due to greater impulsivity and poorer frustration tolerance. Larger sample size is required to confirm this notion.

ADHD, NEPSYC, DMDD http://dx.doi.org/10.1016/j.jaac.2017.09.232

4.17 FACE EMOTION RECOGNITION DIFFERENCES WITH RESPECT TO FRUSTRATION IN DISRUPTIVE MOOD DYSREGULATION DISORDER (DMDD) AND ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER (ADHD) Sarper Taskiran, MD, Koc University School of Medicine, [email protected]; Esin Turkakin, BS, Koc University, [email protected]; Ceyla Karamanci, PhD, Koc University, [email protected]; Tuba Mutluer, MD, Koc University Hospital, [email protected]; Isil Necef, MA, Koc University Hospital, [email protected]; Fuat Balci, PhD, Koc University, [email protected] Objectives: We examined the effect of frustration in emotion recognition across children with ADHD and disruptive mood dysregulation disorder (DMDD) and healthy control (HC) subjects. Methods: Sample group consisted of 43 participants (14 DMDD + ADHD, 14 ADHD, 15 HC subjects, mean ¼ 9.51; SD ¼ 2.10), who completed a novel emotion recognition task with a frustration component that we developed using happy, angry, and neutral faces from the FACES database of Max Planck Institute for Human Development. The task was a two-alternative forced choice paradigm in which participants were asked to identify if a face was happy versus neutral or if a face was angry versus neutral. Frustration, in some blocks, was elicited by providing conflicting feedback and holding back deserved points after some correct answers. Results: In the frustration blocks of the emotion recognition task, there were statistically significant main effects of emotion on accuracy [F(1,39) ¼ 18.886, P < 0.001, h2 ¼ 0.326] and the type of feedback in previous trial on the response time [F(1,39) ¼ 11.019, P < 0.002, h2 ¼ 0.220], as well as a between-subjects effect of diagnosis on accuracy [F(2,39) ¼ 6.384, P ¼ 0.004, h2 ¼ 0.247]. Post hoc analyses revealed that participants were more accurate recognizing happy faces as opposed to angry faces (P < 0.001), slower after frustrating trials (P ¼ 0.002), and that participants with DMDD were less accurate than control subjects (P ¼ 0.017) and participants with ADHD (P ¼ 0.007). Linear integrated speed-accuracy scores (LISAS), interpreted as reaction time adjusted by error rate, showed a main effect of emotion [F(1,39) ¼ 12.389, P ¼ 0.001, h2 ¼ 0.241] and feedback type in previous trial [F(1,39) ¼ 6.350, P ¼ 0.016, h2 ¼ 0.140], but there was no between-subjects effect of diagnosis group on LISAS. The post hoc analyses revealed that the reaction time adjusted for error rates when recognizing happy faces were found to be faster as opposed to angry faces (P ¼ 0.001) and slower in postfrustration trials (P ¼ 0.016). Conclusions: Children with DMDD are less accurate overall compared with healthy control subjects and children with ADHD in the novel task that involves emotion recognition. Their impairment becomes more pronounced after frustrating trials, which emerge as a distinctive feature between participants with pure ADHD and those with ADHD/DMDD comorbidity.

ADHD, NEPSYC, DMDD http://dx.doi.org/10.1016/j.jaac.2017.09.233

4.18 SPECIFICITY OF THE ASSOCIATIONS BETWEEN PSYCHOPATHOLOGY AND EXECUTIVE FUNCTION IMPAIRMENT IN YOUTH Lauren K. White, PhD, Children’s Hospital of Philadelphia, [email protected]; Tyler M. Moore, PhD, University of

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Pennsylvania, [email protected]; Monica E. Calkins, PhD, University of Pennsylvania, [email protected]. upenn.edu; Daniel H. Wolf, MD, University of Pennsylvania, [email protected]; Theodore D. Satterthwaite, MD, University of Pennsylvania, sattertt@mail. med.upenn.edu; Ruben C. Gur, PhD, University of Pennsylvania, [email protected]; Raquel E. Gur, MD, University of Pennsylvania, [email protected] Objectives: Deficits in executive function (EF) are a hallmark of many clinical disorders. However, it is unclear whether the type and degree of EF dysfunction is common across neuropsychiatric disorders, indicative of a general psychopathology marker, or whether disorder-specific EF impairments exist. To address this gap, the current study assessed multiple subcomponents of EF and clinical domains in a large sample group of youth (N ¼ 8,856). Methods: Participants (ages 8–21 years) were from the Philadelphia Neurodevelopmental Cohort. Using the Penn Computerized Neurocognitive Battery, four EF components were assessed: 1) attentional vigilance; 2) response inhibition; 3) cognitive flexibility, and 4) working memory. Based on Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) adapted clinical assessment, five factor scores were calculated: 1) general psychopathology; 2) anxious-misery; 3) fear; 4) externalizing; and 5) psychosis. Analyses examined how differences in general EF ability (performance on all EF tasks) related to symptoms across the clinical domains using a repeated-measures ANCOVA. Hierarchical multiple regression analyses were conducted to examine specific relations between separate EF components and clinical domains. Results: General EF ability differentially related to symptom levels across clinical domains [F(8,35396) ¼ 26.34, P < 0.001]. Overall, psychopathology symptoms differed the most as a function of general EF ability (d ¼ 0.39), followed by externalizing symptoms (d ¼ 0.34). EF ability had the smallest impact on fear (d ¼ 0.17) and psychosis (d ¼ 0.23). Notably, although higher EF abilities generally served as a protective factor, they were associated with higher anxious-misery symptoms (d ¼ 0.29). Resultsexamining relations between the separate EF components and psychopathology found both common and disparate patterns of association. For example, attentional vigilance significantly predicted symptoms across all five domains; cognitive flexibility significantly predicted symptoms on all domains, with the exception of psychosis and anxious-misery. Conclusions: The current study found evidence of a general behavioral EF deficit common to an overall psychopathology factor. However, distinct associations between the separate clinical factors and EF also emerged, suggesting that unique EF dysfunction may also underlie specific clinical phenotypes.

PSP, COG, DEV http://dx.doi.org/10.1016/j.jaac.2017.09.234

4.19 ACCESS TO CARE FOR TRANSGENDER YOUTH Laura R. Campbell, BA, Tufts University School of Medicine, [email protected]; Neha Sharma, MD, Tufts Medical Center, [email protected] Objectives: A growing body of research shows that transgender- and gender-nonconforming youths experience more harassment, violence, and abuse than peers. A vulnerable population, “gender-expansive” youth, face a higher risk of substance abuse, depression, and suicidality and are disproportionately represented among homeless youth. These patients experience significant barriers to access for gender-affirming healthcare. Given the unique needs of this population, clinics have been developed with the intent of improving and integrating services for gender-expansive youth. This study aims to explore gender clinic models currently in place, with the intent of building a framework for development of future clinics. Methods: Eighteen clinics providing care to transgender youth younger than age 18 years were identified in nine northeastern states and asked to

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complete an online survey. Twelve programs (n ¼ 12) responded to the survey, with questions divided into the following: 1) objective data on clinic structure and population characteristics; and 2) subjective responses regarding challenges, strengths, and areas for growth. Results: All 12 clinics offer care coordination and hormone therapy. A majority offer primary care, sexual health, and HIV services, endocrinology, gynecology, nutrition, peer support, and individual therapy. A smaller number offer legal services, housing support, crisis intervention, family groups, substance abuse treatment, and surgical support. Among challenges identified were the alignment of goals between parents and children and the structural concerns (e.g., embedding within larger institutions, lack of resources, access to transportation, and lack of shelters). Strengths included the integration of multidisciplinary services, ongoing collection of patient feedback, family-centered care, group information sessions, institution-wide support and trainings, and 24-hour crisis services. Respondents hope to expand to more providers, more support groups, younger patients, wider specialist networks, enhanced websites, and improved medical records. Conclusions: Clinics throughout the Northeast have taken creative, multidisciplinary approaches to improve integration and delivery of services for transgender youth that can serve as an inspiration for other institutions nationwide.

ADOL, GID, TREAT http://dx.doi.org/10.1016/j.jaac.2017.09.235

4.20 HEIGHTENED ACTIVITY IN SOCIAL REWARD NETWORKS IS ASSOCIATED WITH ADOLESCENTS’ RISKY SEXUAL BEHAVIORS Kristen Eckstrand, MD, PhD, Western Psychiatric Institute and Clinic, University of Pittsburgh, [email protected]; Sophia Choukas-Bradley, PhD, University of Pittsburgh, [email protected]; Marissa Cross, BA, University of Pittsburgh, [email protected]; Jennifer Silk, PhD, University of Pittsburgh, [email protected]; Nicholas Allen, PhD, University of Oregon, [email protected]; Neil P. Jones, PhD, University of Pittsburgh, [email protected]; Erika E. Forbes, PhD, University of Pittsburgh, [email protected] Objectives: Adolescent sexual risk behavior can lead to serious health consequences, yet few investigations have addressed its neurodevelopmental mechanisms. Social neurocircuitry is postulated to underlie the development of risky sexual behavior, and response to social reward may be especially relevant. Methods: Typically developing adolescents (N¼47; 18 male, 29 female; 16.31.4 years; 42.5% sexual intercourse experience) completed a social reward fMRI task and reported their sexual risk behaviors (e.g., lifetime sexual partners) on the Youth Risk Behavior Survey (YRBS). Neural response and functional connectivity to social reward were compared for adolescents with higher- and lower-risk sexual behavior. All results were corrected at p < 0.05 with age and gender included as covariates. Results: Adolescents with higher-risk sexual behaviors demonstrated increased activation in the right precuneus and the right temporoparietal junction during receipt of social reward. Adolescents with higher-risk sexual behaviors also demonstrated greater functional connectivity between the precuneus and the temporoparietal junction bilaterally, dorsal medial prefrontal cortex, and left anterior insula/ventrolateral prefrontal cortex. Conclusions: The greater activation and functional connectivity in self-referential, social reward, and affective processing regions among higher sexual risk adolescents underscores the importance of social influence underlying sexual risk behaviors. Furthermore, results suggest an orientation towards and sensitivity to social rewards among youth engaging in higher-risk sexual behavior, perhaps as a consequence of or vulnerability to such behavior.

ADOL, IMAGS, SEX Supported by NIMH Grant R21 DA033612 http://dx.doi.org/10.1016/j.jaac.2017.09.236


4.21 DEPRESSION, SUICIDALITY, SUBSTANCE USE, AND ABUSE HISTORY AMONG LESBIAN, GAY, BISEXUAL, TRANSGENDER, QUEER (LGBTQ) ADOLESCENTS WHO ARE PSYCHIATRICALLY HOSPITALIZED Sara B. VanBronkhorst, MD, MPH, Pine Rest Christian Mental Health Services, [email protected]; Evonne M. Edwards, PhD, Pine Rest Christian Mental Health Services, [email protected]; Daniel E. Roberts, MSW, Michigan State University, [email protected]; Katie Kist, DO, Pine Rest Christian Mental Health Services, [email protected]; Darci L. Evans, DO, MSW, Pine Rest Christian Mental Health Services, darci.evans-tracey@ pinerest.org; Alexandra Mahdasian, Michigan State University, [email protected]; Kelly Blankenship, DO, Pine Rest Christian Mental Health Services, [email protected] Objectives: Lesbian, gay, bisexual, transgender, and/or questioning (LGBTQ) youth have higher rates of suicidality, but few studies have examined psychiatrically hospitalized LGBTQ youth. This study compared the prevalence of LGBTQ identification by psychiatrically hospitalized adolescents with rates in the general population and compared self-reported suicidality, depression, substance use, and abuse history between LGBTQ and cisgender/heterosexual patients. Methods: Adolescents (ages 13–17 years) completed surveys upon admission to Pine Rest Christian Mental Health Services (PRCMHS) Inpatient or Partial Hospitalization Programs (n ¼ 201). Depression severity, suicidality, substance use, and abuse history were statistically compared between LGBTQ and cisgender/heterosexual patients using independent samples t-tests and Chisquare statistics. Chi-square analyses also compared the prevalence of LGBTQ identification in this sample group with national rates of LGBTQ identification. Results: The prevalence of heterosexual youth among these psychiatrically hospitalized adolescents (69.7%) was significantly lower than that reported nationally in the 2015 Youth Risk Surveillance System [88.8%, X2 (1, N ¼ 195) ¼ 71.20, P < 0.001]. Transgender adolescents comprised 5.2 percent of the sample group and a total of 30.7 percent of subjects identified as LGBTQ. The mean severity of depression on the Patient Health Questionnaire modified for Adolescents (PHQ-A) was higher in LGBTQ patients than their peers [t(175) ¼ 2.36, P ¼ 0.02], and significantly more LGBTQ patients (93.2%) than their peers (79.7%) indicated having considered suicide in the previous year [X2 (1, N ¼ 187) ¼ 5.49, P ¼ 0.019]. More LGBTQ adolescents (66.1%) than their peers (42.3%) reported a history of abuse [X2 (1, N ¼ 189) ¼ 9.19, P ¼ 0.002]. Substance use in the previous month was similar between groups (P ¼ 0.555). Conclusions: Almost one-third of this sample group of psychiatrically hospitalized adolescents identified as LGBTQ, and these patients had higher PHQA scores, suicidal ideation, and rates of abuse history than their peers.

GID, HO, S http://dx.doi.org/10.1016/j.jaac.2017.09.237

4.22 EDUCATION GAPS IN LESBIAN, GAY, BISEXUAL, TRANSGENDER, QUEER, PLUS (LGBTQ+) HEALTH AMONG RESIDENCY TRAINING PROGRAMS Aylin Saner, MD, University of Florida College of Medicine Jacksonville, [email protected]; Bianca Pinto, MD, University of Florida College of Medicine - Jacksonville, [email protected]fl.edu; Katryne Lukens Bull, MPH, University of Florida College of Medicine - Jacksonville, [email protected]fl.edu; Rita Nathawad, MD, University of Florida College of Medicine - Jacksonville, rita. [email protected]fl.edu Objectives: Currently, residency training curricula lack a standardized model regarding education about lesbian, gay, bisexual, transgender, questioning,

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queer (LGBTQ)+ youth health. The goal of this study is to evaluate residents’ knowledge, learner attitudes, and satisfaction attained from current residency training programs with regard to the healthcare of LGBTQ+ youth. The information gathered from this study will be used to plan specific educational interventions that will close any education gaps discovered. Methods: An anonymous and voluntary survey platform (Qualtrics) was used to assess residents’ perceptions of knowledge, level of skill, learner attitudes, and existing learning opportunities related to LGBTQ+ health. This survey has so far been sent via chief residents to the pediatric and psychiatric residents at University of Florida Health in Jacksonville, Florida. The study is still in process, with plans to disseminate the survey to other residency programs across the country. Results: To date, a total of 27 residents have completed the survey; 30 percent of respondents were postgraduate year (PGY)-1, 48 percent PGY2, 15 percent PGY-3, and seven percent PGY-4. Of these 27 respondents, there were 20 (74%) pediatric residents, six (22%) psychiatric residents, and 1 (4%) medicine and pediatrics resident. Almost all residents agreed that it is important to know a patient’s sexual orientation and gender identity and indicated that unique discrepancies exist with regard to LGBTQ+ youth healthcare. For the most part, however, residents reported minimal training, knowledge, and confidence when it came to providing care to this specific population regardless of training level. Residents as a whole are not familiar with national resources for LGBTQ+ youth and their parents, where 63 percent of residents were not aware of any resources and 78 percent had never recommended resources to patients. However, there is a change noted in some aspects of participants’ attitudes toward providing LGBTQ care between PGY-1 residents and their more senior counterparts (PGY-2 to PGY-4) Conclusions: The vast majority of residents do not believe that they are adequately educated on LGBTQ+ youth health but feel it is important to learn these skills as part of their training. Therefore, there is a clear need for the development of a standardized model on LGBTQ+ youth healthcare; thus, specific interventions will be developed for residency training program curricula based on residents’ perceived needs.

REST, SEX, SP http://dx.doi.org/10.1016/j.jaac.2017.09.238

4.23 A NEUROCOMPUTATIONAL INVESTIGATION OF REINFORCEMENT-BASED DECISION-MAKING AS A CANDIDATE LATENT VULNERABILITY MECHANISM IN MALTREATED CHILDREN Mattia I. Gerin, BS, MS, University College London, mattia. [email protected]; Vanessa B. Gerin, PhD, University College London, [email protected]; James Blair, PhD, Center for Neurobehavioral Research - Boys Town National Research Hospital, [email protected]; Stuart White, PhD, Center for Neurobehavioral Research - Boys Town National Research Hospital, [email protected]; Arjun Sethi, PhD, University College London, [email protected]; Ferdinand Hoffmann, PhD, University College London, [email protected]; Amy Palmer, PhD, University College London, [email protected]; Essi Viding, PhD, University College London, [email protected]. uk; Eamon McCrory, PhD, PsyD, University College London, [email protected] Objectives: Alterations in reinforcement-based decision making are associated with psychiatric disorders commonly associated with maltreatment. This study investigated, for the first time, the computational and neurocognitive basis of these processes in individuals with maltreatment histories. Methods: A probabilistic passive avoidance task and a model-based fMRI analytic approach (based on the Rescorla-Wagner model of conditioning) were implemented to assess the neurocomputational components underlying decision making and measured the following: 1) the estimation of the outcome associated with a stimulus or action [expected value (EV)

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representation]; and 2) the ability to detect the differences between expected and actual outcomes [prediction error (PE) signalling]. Children with documented experiences of maltreatment (n ¼ 20; mean age ¼ 13) were recruited from Social Service (SS) departments; a matched group of comparison children (n ¼ 21; mean age ¼ 13) with no prior SS contact were recruited through schools and advertisement. The region of interest (ROI) statistical analyses (corrected at p < .05 familywise error rate) focused on the striatum and orbitofrontal cortex during EV processing, and on the amygdala, insula, anterior and mid-cingulate cortex during PE signaling. Results: First, the maltreated group relative to non-maltreated peers showed decreased activity during EV processing in a widespread network commonly associated with reinforcement expectancies representation, including the striatum (especially the caudate), the orbitofrontal cortex, and medial temporal structures, including the hippocampus and insula. Second, consistent with previously reported hyperresponsiveness to negative cues in the context of childhood abuse, the maltreated group showed increased PE signaling in the midcingulate gyrus, somatosensory cortex, superior temporal gyrus, and thalamus. Post hoc analyses indicated that reduced activation in the caudate and the lateral orbitofrontal cortex during EV representation was related to higher levels of anxiety and mood-related symptomatology in maltreated individuals. Conclusions: These findings suggest that early adverse environments disrupt the development of decision making processes, which in turn may compromise psychosocial functioning, increasing latent vulnerability to later psychiatric disorder.

IMAGS, ADOL Supported by the UK Economic and Social Research Council ES/K005723/1, University College London, and the Anna Freud National Centre for Children and Families http://dx.doi.org/10.1016/j.jaac.2017.09.239

4.24 PSYCHIATRIC DISORDERS AND TRAUMARELATED PSYCHIATRIC SYMPTOMS IN KOREAN YOUTH AND ADULT VICTIMS OF SEXUAL VIOLENCE Eunji Kim, MD, Seoul National University Hospital, blessed_ [email protected]; Jihye Kwon, Seoul National University Hospital, [email protected]; Jae-Won Kim, MD, PhD, Seoul National University Hospital, [email protected] Objectives: In Korea, few studies have reported on the psychiatric sequelae in victims of sexual violence. The aims of this study were to examine the rate of psychiatric disorders and the effects of the types of sexual violence on traumarelated psychiatric symptoms in Korean youth and adult victims of sexual violence. Methods: A total of 271 female victims (160 youths, age 12.6 4.0 years; 111 adults, 28.7 11.0 years), who visited the Seoul Sunflower Center Serving Victims of Sexual Violence, funded by Ministry of Gender Equality and Family, and received psychiatric care from January 2012 to December 2016, were recruited. Their psychiatric sequelae were evaluated using psychiatric diagnosis of electronic medical record and psychiatric rating scales, including Child Posttraumatic Stress Disorder-Reaction Index (CPTSD-RI), Children’s Depression Inventory (CDI) and Revised Children’s Manifest Anxiety Scale (RCMAS) for youth, and Impact Event Scale-Revised (IES-R-K), Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI) for adults. Results: Regarding psychiatric diagnosis, adjustment disorder was the most common, followed by PTSD and acute stress disorder in both groups. The percentage of trauma and stressor-related disorders of DSM5 was 77.6 percent in youth and 83.7 percent in adults. There was no difference in the percentages of rape (48.8%) and sexual harassment (51.2%) among youth, but among adults, rape was more frequent (80.9 vs. 19.1%, P < 0.001). In youth, CPTSD-RI, CDI, and RCMAS scores were higher in victims of rape than in victims of sexual harassment (P 0.05). Post hoc analysis showed that CPTSD-RI and CDI scores were higher in youth with PTSD than in those with adjustment disorder (P 0.05). In contrast, there were no differences in IES-R-K, BDI, and BAI scores according to the types

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of sexual violence or the diagnosis of trauma and stressor-related disorders among adults. Conclusions: This study suggests that in youth, posttraumatic stress, depressive, and anxiety symptoms are associated with the types of sexual violence and that posttraumatic stress and depressive symptoms may differ according to the diagnosis of trauma and stressor-related disorders. Our findings highlight the importance of more precise evaluation in exploring the association between the types of sexual violence and psychiatric sequelae in youth.

Development, [email protected]; Katarzyna Kordas, PhD, University at Buffalo, kkordas@ buffalo.edu; Hannah Sallis, PhD, University of Bristol, hannah. [email protected]; Marc Bornstein, PhD, Eunice Kennedy Shriver National Institute of Child Health and Human Development, [email protected]; Rebecca M. Pearson, PhD, University of Bristol, rebecca.pearson@bristol. ac.uk

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Objectives: Parenting is complex, and the variation across large populations has rarely been described. It is unclear which components are important for which outcomes. This study aims to describe the different parenting behaviors in a large longitudinal cohort and determine the extent to which different aspects of parenting at age 0–3 years are associated with long-term offspring outcomes at age 16 years. Methods: Data were used retrospectively from the British Avon Longitudinal Study of Parents and Children (ALSPAC). Parenting behaviors at age 0–3 years were extracted from self-reported questionnaires (n ¼ 12,358 mothers). Items were entered into confirmatory factor analysis (CFA) models. Child outcomes at age 16 years included emotional and behavioral problems using the SelfReported Moods and Feelings Questionnaire; parent- and child-reported Development and Well-Being Assessments; and an achieved grade in national English language examinations. Results: CFA confirmed three factors: 1) parent enjoyment; 2) conflictual relationship; and 3) stimulation. Regressions revealed no independent associations between parenting and depressed mood. High stimulation was associated with better grades, even after controlling for maternal education (standardized path compared with beta coefficient ¼ 0.058, P ¼ 0.007). High enjoyment was negatively correlated with academic grades (standardized path compared with beta coefficient ¼ 0.082, P ¼ 0.002). Conflictual relationships were associated with the risk of child behavioral disorders, even after accounting for reverse causality by adjusting for conduct problems at age three years (standardized path compared with beta coefficient ¼ 0.227, P ¼ 0.007). There was also evidence that higher enjoyment reduced the association between conflict and behavioral problems (interaction term ¼ 0.113; P < 0.001). Conclusions: This study provides evidence for the specificity of early parenting and its later impact on adolescent outcomes. Early stimulation promoted later educational achievement, unlike high enjoyment, perhaps indicating a different parenting focus. For emotional and behavioral outcomes, different components appeared relevant. Conflictual relationships were associated with greater risk of behavioral problems, buffered by increased enjoyment. This holds implications for future parenting interventions guiding their focus according to long-term outcomes.

Supported by the Korean Mental Health Technology R&D Project by the Ministry of Health and Welfare Grant HM15C1107 http://dx.doi.org/10.1016/j.jaac.2017.09.240

4.25 EFFECTS OF AN INTENSIVE OUTPATIENT PROGRAM FOR ADOLESCENTS WITH MENTAL ILLNESS ON PARENT AND CHILD PERCEPTION OF THE PARENT-CHILD RELATIONSHIP Katherine G. Mohan, BA, Bay Area Children’s Association, [email protected]; Julia A. Langer, MHS, Bay Area Children’s Association, [email protected]; Olivia Calkins, BA, Bay Area Children’s Association, [email protected] Objectives: This study investigates changes in parent and child perception of their relationship during an intensive outpatient program (IOP) for teenagers with mental illness. Methods: Data were collected from 121 IOP patients (ages 11–18 years; mean age ¼ 15.28 1.71 years) and their parents at two clinics in California. The IOP is manualized and evidence-based, including parent and family therapy, lasting eight weeks or longer if clinically necessary. Parents and children rated their relationship on a self-report, Likert Scale questionnaire, several times a week. Subjects who did not complete questionnaires were excluded. Nontraditional families were included in maternal and paternal groups based on self-identified gender and referred to as parents based on legal guardianship. Mean scores from weeks one and two (baseline) were compared with weeks seven and eight and the final two weeks. Data were analyzed with paired, dependent t-tests. Results: Analysis showed significant improvement in parent perception of the parent–child relationship from baseline to final weeks (t ¼ 2.17, P < 0.05) but not from baseline to weeks seven and eight. Fathers showed significant improvement over eight weeks (t ¼ 2.04, P < 0.05) and entire length of stay (t ¼ 2.10, P < 0.05). Maternal perception did not change significantly. Child perception improved significantly over the entire length of stay (t ¼ 2.06, P < 0.05) but not more than eight weeks; 59.5 percent stayed beyond eight weeks. Baseline scores for all groups did not differ significantly. Conclusions: Resultsindicate that a teenage IOP program with parent involvement significantly improves parent–child relationship from baseline to end of treatment. Only eight weeks may not sufficiently improve parent-child relationships for many families. Significant improvement in paternal perception compared with insignificant change in maternal perception suggests that fathers drive the improvement. This merits further investigation into influences on maternal and paternal parentchild relationships during treatment. Limitations include small sample size.

EBP, DTT, PAT http://dx.doi.org/10.1016/j.jaac.2017.09.241

4.26 SPECIFIC ASPECTS OF EARLY PARENTING DIFFERENTIALLY PREDICT ADOLESCENT BEHAVIORAL DISORDERS AND ACADEMIC ACHIEVEMENT Priya Rajyaguru, MBBCh, University of Bristol, priya. [email protected]; Diane Putnick, PhD, Eunice Kennedy Shriver National Institute of Child Health and Human


ADOL, EC, PAT Supported by the University of Bristol http://dx.doi.org/10.1016/j.jaac.2017.09.242

4.27 GENDER DIFFERENCES IN SERVICE UTILIZATION AMONG YOUTH ADOPTED FROM FOSTER CARE Austin J. Blake, BA, University of California, Los Angeles TIES for Families, [email protected]; Jill Waterman, PhD, University of California, Los Angeles TIES for Families, [email protected]; Audra Langley, PhD, University of California, Los Angeles TIES for Families, alangley@mednet. ucla.edu Objectives: Foster and adopted youth receive more mental health services than the normative. Although research on nonfoster youth has indicated that females use these services to a greater extent than males, contradictory results have emerged from research examining whether male or female foster youth use these services. Given the high overall rates of service use among foster youth, it is imperative to identify a gender gap, if it exists, to ensure that all youth receive the treatment they need. Methods: A total of 82 children adopted from foster care were studied for five years and contacted again in adolescence. We tested whether 1) childhood

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behavior problems and gender predict mental health service use in adolescence; and 2) gender moderates the association of behavior problems and service use. Results: Greater childhood behavior problems (b ¼ 0.035, SE ¼ 0.012, P < .01) predicted greater service use in adolescence, but gender did not predict service use. The interaction between child behavior problems and gender was marginally significant (b ¼ 0.028, SE ¼ 0.016, P ¼ 0.084), suggesting that female adoptees may receive more intensive mental health services in adolescence to treat severe, longstanding mental health problems. Conclusions: The present study suggests that, although the level of childhood behavior problems is the greatest predictor of later mental health treatment among adoptees, slight gender differences may exist in the extent to which childhood psychopathology predicts treatment use in adolescence. Further research should aim to tease apart the possible explanations for these findings, revealing whether symptoms decline more in males after childhood, whether adolescent girls are more willing to use services, or whether girls are referred for services at greater rates than males despite similar levels of symptoms.

ADOL, FOC, RTX http://dx.doi.org/10.1016/j.jaac.2017.09.243

4.28 PREVALENCE OF SUBSTANCE USE AND MENTAL ILLNESS IN FOSTER YOUTH Evan Trager, MD, University of California, Riverside, evan. [email protected]; Howard Moss, MD, University of California, Riverside School of Medicine, howard.moss@ medsch.ucr.edu Objectives: Existing research suggests that current and former foster youth represent an under-studied group that is presumed to be at increased risk for comorbid substance abuse and mental illness. Recent reviews by Braciszewaski and Stout, 2012, and Havlicek et al., 2013, highlight the significant gaps in our knowledge and understanding concerning both the risk and protective factors impacting foster youth. We sought to expand the literature by undertaking a secondary analysis of a large national cohort. Methods: This case control study utilized data collected as part of the National Longitudinal Study of Adolescent Health (Add Health), the largest, and most comprehensive survey of adolescents ever undertaken in the United States. We utilized questions from Wave III to identify individuals who self-reported having spent time in foster care then matched them to similar individuals without a reported history of time spent in foster care. Non-foster care history individuals were matched with foster care history individuals 4:1 utilizing parental income during adolescence as a proxy for socio-economic status, Hispanic ethnicity, gender, race, and birth year. All analyses and algorithmic matchings were run on SPSS v24. Chi-square tests were used for categorical variables and t-tests for continuous variables. Results: In this study foster youth only differed from their matched controls in two of the tested analyses. 1) Foster youth were less likely to have ever smoked an entire cigarette; and 2) were more likely than matched controls to have taken prescription drugs recreationally. The two groups did not differ in their self-reported prevalence of mental illness, use of cannabis, use of alcohol, or history of having met criteria for DSM-IV cannabis or alcohol dependence. Conclusions: These findings run contrary to what would be expected given the available literature on childhood trauma and subsequent substance use. Potential explanations include weaknesses inherent in using cohort data, such as loss to follow up and participation bias, as well as potential recall bias as many of the substance use questions asked individuals to recall use that had occurred over ten years previously. Further research will be needed to elucidate the import of the findings.

FOC, CM, SUD Supported by the NIDA-AACAP Resident Training Award in Substance Use Disorders, supported by NIDA http://dx.doi.org/10.1016/j.jaac.2017.09.244

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4.29 A PILOT MENTAL HEALTH SCREENING INITIATIVE IN THE OUTPATIENT PEDIATRIC SETTING Lindsay Alexander, MPH, Child Mind Institute, lindsay. [email protected]; Ginny Mantello, MD, Office of the Staten Island Borough President, GMantello@ statenislandusa.com; Alexis Alexander, LCSW, Child Mind Institute, [email protected]; Jasmine Escalera, PhD, Child Mind Institute, jasmine. [email protected]; Usha Thomas, MD, Usha Thomas Pediatrics, [email protected]; Brian McMahon, MD, Island Pediatrics, [email protected]; Clifford Mevs, MD, Pediatric Health Care, [email protected]; Patricia Mullen, MD, Island Medical Specialists, [email protected]; Michael P. Milham, MD, PhD, Child Mind Institute, [email protected] Objectives: A core goal of current medical reforms is the integration of physical and mental health care; however, the necessary infrastructure and training for this is lacking. In particular, the primary care setting is struggling with gaps in the knowledge base and resources needed to screen for mental health disorders, as well as the management of patients for whom concerns are identified. Methods: Building from its growing community interactions, the Child Mind Institute/Healthy Brain Network has established a pilot program to test the feasibility and utility of implementing a brief mental health screening at four pediatric practices in Staten Island, New York. An iPadbased screening instrument was constructed from the following: the emotionality and hyperactivity sections and bullying probe of the Strengths and Difficulties Questionnaire (11 questions); eating disorder prompts from the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) (4 questions); and Patient Health Questionnaire (3 questions). Parents completed the screening during well-check visits. Clinicians were provided optional follow-up questionnaires for when a potential clinical concern was detected, as well as a comprehensive referral guide for connecting patients to the next level of care. Initial analyses (n ¼ 209, male-to-female ratio ¼ 111:98) examined the prevalence of psychopathology in this population. Correlation analysis examined the relationship of the various domains with one another. Results: In this sample group, 8.1 percent of patients had clinical levels of depressive symptoms, whereas 12.9 percent had clinical levels of hyperactivity. Correlation analysis showed significant relationships between several domains. It is noteworthy that depressive symptoms were significantly correlated with suicidality (r ¼ 0.5, P ¼ 2.2 1016), bullying (r ¼ 0.23, P ¼ 1.8 103), and pathologic eating behaviors (EB) (r ¼ 0.3, P ¼ 3.8 105). Suicide was significantly correlated to bullying (r ¼ 0.21, P ¼ 0.005) and EB (r ¼ 0.23, P ¼ 1.7 103). Finally, BMI was significantly associated with EB (r ¼ 0.43, P ¼ 1.2 1010). Conclusions: This analysis highlighted associations that are in general alignment with the broader psychiatric literature. This pilot project confirms the feasibility of implementing a low-cost, easy-to-use, mental health assessment that can be administered in pediatric settings. Such a tool has the potential to detect symptoms earlier and connect patients with necessary services.

RI, DIAG, TREAT http://dx.doi.org/10.1016/j.jaac.2017.09.245

4.30 IRRITABILITY AND LIMITED PROSOCIAL EMOTIONS/CALLOUS-UNEMOTIONAL TRAITS IN ELEMENTARY SCHOOL-AGE CHILDREN WITH ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) AND CONDUCT PROBLEMS Raman Baweja, MD, MS, Penn State Health Milton S. Hershey Medical Center, [email protected]; James

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G. Waxmonsky, MD, Penn State College of Medicine, [email protected]; Dara E. Babinski, PhD, Penn State College of Medicine, [email protected]; Susan D. Mayes, Penn State Health Milton S. Hershey Medical Center, [email protected]; Daniel Waschbusch, PhD, Penn State College of Medicine, dwaschbusch@ pennstatehealth.psu.edu Objectives: Conduct problems (CP) are highly heterogeneous within and across children, and numerous efforts have been made to use affective traits to better specify the nature of conduct problems. Two primary approaches in this regard are presence of irritability (IRR) and the presence of limited prosocial emotions/callous-unemotional traits (LPE/CU). This study examined the association between IRR and LPE/CU among elementary school age children with serious conduct problems. Methods: Participants were 123 children (102 boys, mean age ¼ 9.73 years), who met criteria for ODD and ADHD (47.2%) or conduct disorder (CD) and ADHD (52.8%). Diagnoses were assigned using DSM-IV-Text Revision (TR) criteria as assessed by several sources of information, including ratings completed by parents and teachers and a structured diagnostic interview administered to parents. The Antisocial Process Screening Device was completed to assess CU traits. The Disruptive Behavior Disorder Rating Scale was completed to assess symptoms of CD, ODD, and ADHD. The Child Behavior Checklist (CBCL) and Teacher Report Form (TRF) were completed to examine anxious-depressed, withdrawn-depressed, social problems, attention problems, rule breaking, and aggressive behavior outcomes. The Nova Scotia Modified IOWA Conners was completed to measure aggression and peer relationships in children. Results: Within this sample, youth met criteria for both IRR and LPE/CU (30.1% both), IRR but not LPE/CU (26.8% IRR-only), LPE/CU but not IRR (18.7% LPE/CU-only), and neither IRR nor LPE/CU (24.4% neither). Results showed that IRR and LPE/CU were not correlated (r ¼ 0.09, p ¼ 0.306) and categorical analyses showed that only half of the children with IRR had LPE/CU and half of the children with LPE/CU had IRR. Comparisons of LPE/CU-only, IRR-only groups, both LPE/CU and IRR, and neither condition showed groups differed in meaningful ways on measures of psychopathology, aggression, and social functioning. Conclusions: These findings suggest that IRR and LPE/CU may represent distinct phenotypes within children with conduct problems. Results suggest that future research and treatment of children with conduct problems may benefit from simultaneously taking into account IRR and LPE.

IMD, DBD, DMDD Supported by the Nova Scotia Health Research Foundation 304e and the Social Sciences and Humanities Research Council of Canada 839-2000-1061; 410-2004-1272 http://dx.doi.org/10.1016/j.jaac.2017.09.246

4.31 SALIVARY OXYTOCIN IN ADOLESCENTS WITH CONDUCT PROBLEMS AND CALLOUSUNEMOTIONAL TRAITS Tomer Levy, MD, University of Toronto, tomering@gmail. com; Yuval Bloch, MD, Tel Aviv University, [email protected]. il; Meytal Bar-Maisels, MA, Felsenstein Medical Research Center, [email protected]; Galia Gat-Yablonski, PhD, Schneider Children’s Medical Center of Israel, galiagy@post. tau.ac.il; Amir Djalovski, MA, Bar-Ilan University, amir.djv@ gmail.com; Katy Borodkin, PhD, Tel Aviv University, [email protected]; Alan S. Apter, MD, Schneider Children’s Medical Center of Israel, [email protected] Objectives: Callous-unemotional (CU) traits correlate with the severity and prognosis of conduct disorder in youth. The neuropeptide oxytocin (OT) has been linked to prosocial behaviors, including empathy and collaboration with others. This study discusses a possible role for OT in the biology of delinquent behavior. We hypothesized that, in delinquent youth, OT secretion would correlate with the severity of conduct problems and specifically with the level of CU traits.


Methods: The study group included 67 male adolescents (mean age ¼ 16.2 years) undergoing residential treatment, previously assessed by an open clinical interview and history for the psychiatric diagnosis. Staff-based Inventory of Callous-Unemotional traits for psychopathy and Strength and Difficulties Questionnaire (SDQ) were administered, and patients’ medical and social personal files were systematically coded for previous history of antisocial acts using the Brown-Goodwin Questionnaire. Salivary OT was assayed by enzyme-linked immunosorbent assay. Results: Salivary OT levels were inversely correlated with conduct problems severity on SDQ (r ¼ 0.27; P 0.01). Recorded history of antisocial acts did not correlate with current OT levels. Odds ratio (OR) for significant CU traits among subjects with conduct problems was increased in low OT (OR ¼ 14, P 0.05) but not in high OT subjects (OR ¼ 6, P 0.05). Conclusions: Children with conduct problems and low levels of salivary OT are at risk for significant CU traits. These results suggest a possible role for salivary OT as a biomarker for CU traits and conduct problems severity.

CD, NEURO, DBD http://dx.doi.org/10.1016/j.jaac.2017.09.247

4.32 DEVELOPMENT AND IMPLEMENTATION OF A NEW PARENT AND SELF-REPORT TOOL TO IMPROVE THE IDENTIFICATION OF TIC DISORDERS IN CHILDREN Rebecca H. Bitsko, PhD, Centers for Disease Control and Prevention, [email protected]; Melissa Danielson, MSPH, Centers for Disease Control and Prevention, [email protected]; Joseph Holbrook, PhD, Centers for Disease Control and Prevention, [email protected]; Kate Flory, PhD, University of South Carolina, [email protected]; Lorraine F. Kubicek, PhD, University of Colorado School of Medicine, [email protected]; Steven P. Cuffe, MD, University of Florida College of Medicine - Jacksonville, [email protected]fl.edu Objectives: The purpose of this study is to evaluate a new parent- and child-report tool of DSM-5 criteria for tic disorders in a community-based epidemiologic study, the Project to Learn About Youth-Mental Health (PLAY-MH). Methods: A brief parent- and child-report form, the Description of Tic Symptoms (DoTS), was developed to assess DSM-5 criteria for tic disorders. In stage one of PLAY-MH, teachers completed the Proxy Report Questionnaire (PRQ) to screen for tics in students (grades K–12). The stage two assessment included parent and child report on the DoTS. Children at one site (Florida; FL) with tic symptoms reported on the DoTS were invited for a clinical assessment. A preliminary algorithm for the DoTS was used to determine whether children had a persistent tic disorder (PTD), including Tourette’s disorder. Initial validation of the DoTS focused on comparison with the teacher PRQ and clinical assessment, and the report of four characteristics commonly associated with tics as reported on the DoTS: 1) a sense of urgency to tic; 2) tics come and go; 3) tics can be held back; and 4) feel relief following the tic. Weighted analyses were conducted on South Carolina (SC) data, to account for the over-sampling of high screen children. Results: In SC, 42.6 percent (CI: 27.7-59.1) of children who screened positive on the teacher PRQ met criteria for a PTD using the parent-reported DoTS. Among those children with PTD, parents reported an average of 2.5 (CI: 2.0-2.9) characteristics associated with tics; children self-reported an average of 2.8 (CI: 2.4-3.2) characteristics. Of 13 FL children with tics reported on the DoTS, subsequent clinical assessments revealed that 10 (76.9%) had a tic disorder; none of these children had a previous tic disorder diagnosis. Conclusions: The DoTS is a relatively brief form that may assist in the identification of tic disorders. Additional validation work continues, with the goal of producing a freely available, validated tic disorder measure alongside an algorithm appropriate for the calculation of prevalence of tic disorders.

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EPI, TICS, TD http://dx.doi.org/10.1016/j.jaac.2017.09.248

4.33 PSYCHOPATHOLOGY AND TOURETTE’S DISORDER IN TWO COUNTRIES: WHAT DOES THE CHILD BEHAVIOR CHECKLIST (CBCL) TELL US? Saniya Saleem, MS, Icahn School of Medicine at Mount Sinai, [email protected]; Maxwell J. Luber, BA, Icahn School of Medicine at Mount Sinai, maxwell.luber@mssm. edu; Anita de Larrechea, MD, Interdisciplinary Center for Tourette’s, OCD, ADHD and Associated Disorders (Centro Interdisciplinario de Tourette, TOC, TDAH y Trastornos Asociados; CITTTA), [email protected]; Tomas Fazio, MD, Interdisciplinary Center for Tourette’s, OCD, ADHD and Associated Disorders (Centro Interdisciplinario de Tourette, TOC, TDAH y Trastornos Asociados; CITTTA), [email protected]; Luz Maria Zappa, MD, Interdisciplinary Center for Tourette’s, OCD, ADHD and Associated Disorders (Centro Interdisciplinario de Tourette, TOC, TDAH y Trastornos Asociados; CITTTA), [email protected]; Blanca GarciaDelgar, MD, Hospital Clinic of Barcelona, BGARCIAD@clinic. cat; Beatriz Moyano, MD, Interdisciplinary Center for Tourette’s, OCD, ADHD and Associated Disorders (Centro Interdisciplinario de Tourette, TOC, TDAH y Trastornos Asociados; CITTTA), [email protected]; Barbara J. Coffey, MD, MS, Icahn School of Medicine at Mount Sinai, [email protected] Objectives: Early onset psychopathology has been identified in children with Tourette’s disorder (TD). Few studies have examined its prevalence and association with tic severity in children with TD cross-culturally. In this study, we explored the phenomenology of internalizing and externalizing problems in children with TD from an international perspective. Methods: Demographic and clinical data were collected from two specialized clinical sites: the Interdisciplinary Center for Tourette’s, OCD and Related Disorders, Buenos Aires (BA), Argentina; and the National Tourette Center of Excellence at Icahn School of Medicine at Mount Sinai in New York, New York (NY). Comparisons between sites were examined in children with TD (ages 6– 17 years) using the Child Behavior Checklist (CBCL) internalizing and externalizing problems scales, Yale Global Tic Severity Scale (YGTSS), and Tic Severity Self-Report (TSSR) for tic severity. Results: Analysis included 112 patients (NY: n ¼ 62; BA: n ¼ 50), with a mean age of 10.57 years and 80% males (NY: n ¼ 48; BA: n ¼ 42). CBCL internalizing (NY: mean age ¼ 62.21 years, SD ¼ 11.20; BA: mean age ¼ 61.86 years, SD ¼ 9.50) and CBCL externalizing (NY: mean age ¼ 56.77 years, SD ¼ 11.39; BA: mean age ¼ 58.26 years, SD ¼ 10.27) scores were similar across sites, as were the prevalence rates of clinical range of internalizing (NY ¼ 43.5%, BA ¼ 40%) and externalizing (NY ¼ 25.8%, BA ¼ 28%) scores. Boys (ages 6–12 years) had higher externalizing scores in BA (mean age ¼ 59.61 years, SD ¼ 9.23) than NY (mean age ¼ 53.27 years, SD ¼ 12.04) [t(110) ¼ 2.35, P < 0.02]. Tic severity correlated with internalizing [r( 112) ¼ 0.38, P < 0.01] and externalizing [r(112) ¼ 0.28, P < 0.01] scores across sites with higher severity in BA (mean age ¼ 24.60 years, SD ¼ 10.50) than NY (mean age ¼ 17.55, SD ¼ 13.11) [t(110) ¼ 3.08, P < 0.01]. Conclusions: Findings suggest that childhood-onset psychopathology is frequent in children with TD in NY and BA and correlates positively with tic severity across cultures. Higher externalizing scores in preadolescent boys in BA could suggest clinical and/or cultural differences. The CBCL may be a useful cross-cultural tool for identification of children with TD at risk for early onset psychopathology. Further examination of subscales may facilitate identification of affective subtypes in children with TD.

PSP, TICS, TD http://dx.doi.org/10.1016/j.jaac.2017.09.249

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4.34 THE PREMONITORY URGE REVISITED: AN INDIVIDUALIZED PREMONITORY URGE FOR TICS SCALE Joseph McGuire, PhD, University of California, Los Angeles, [email protected]; Nicole McBride, MPH, University of South Florida, [email protected]; John Piacentini, PhD, University of California, Los Angeles, [email protected]; Carly Johnco, Macquarie University, [email protected]; Adam B. Lewin, PhD, Pediatric Neuropsychiatry, [email protected]; Tanya K. Murphy, MD, University of South Florida, [email protected]. edu; Eric A. Storch, PhD, University of South Florida, estorch@ health.usf.edu Objectives: Premonitory urge ratings have advanced our understanding of urge phenomenology among individuals with tic disorders (TDs). However, these ratings have been limited by their reliance on a single global dimension of urge severity. This study examined the psychometric properties of a novel scale called the Individualized Premonitory Urge for Tics Scale (I-PUTS) that assesses urge severity across multiple dimensions (number, frequency, and intensity). Methods: Youths (N ¼ 75) with TDs and their parents participated in the study. Clinicians assessed youth’s tic severity, depression severity, rages, and premonitory urges. Parents completed ratings of youth’s anxiety, affect lability, and general psychopathology. Youths completed self-report ratings of anxiety, urge severity, and distress tolerance. Results: The I-PUTS identified that youths experienced an average of three distinct urges (mean ¼ 2.86, SD ¼ 3.20) but had an average of seven tics over the past week (mean ¼ 7.05, SD ¼ 4.48). Urges were primarily localized in the head/ face, neck/throat, and arm regions. All I-PUTS dimensions exhibited excellent inter-rater reliability (intraclass correlation coefficient ¼ 0.76–0.87). The I-PUTS dimensions exhibited good convergent validity with global urge ratings and tic severity and appropriate divergent validity from other clinical constructs. Youths who exhibited discrepant reports between clinician-administered and selfreport urge ratings had less anxiety and tic severity and greater inattention and externalizing problems compared with youths who exhibited good agreement. Conclusions: The I-PUTS is a reliable and valid assessment of urge phenomenon, which provides additional and complementary information to existing urge scales. It highlights the existence of multiple dimensions of urge severity and presents particular utility when assessing urges in youth with TD who have inattention and externalizing problems.

RI, TICS, TD http://dx.doi.org/10.1016/j.jaac.2017.09.250

4.35 DEVELOPMENT OF A SCREENING INSTRUMENT TO IDENTIFY MOTOR AND VOCAL TICS IN CLINIC POPULATIONS Tanya K. Murphy, MD, University of South Florida, tmurphy@ health.usf.edu; Adam B. Lewin, PhD, Pediatric Neuropsychiatry, [email protected]; Erin M. Brennan, BA, University of South Florida, ebrenna1@health. usf.edu; Akilah Heggs, MA, Centers for Disease Control and Prevention, [email protected]; Rebecca H. Bitsko, PhD, Centers for Disease Control and Prevention, [email protected] Objectives: The identification of tics among children in nonspecialized healthcare settings may improve the timely diagnosis of tic disorders. Thus, a screening instrument to identify tics in children was developed and tested. Methods: Working from existing measures used to identify or characterize tics and tic disorders, items were proposed for inclusion in a tic screener. Following expert review of the proposed items, an initial instrument with parent- and child-report versions was created and tested in a specialty tic disorder clinic. Responses to the questions, as well as qualitative feedback from the families, were reviewed. Items with the highest rates of falsepositives and false-negatives, compared with expert evaluation, were considered for removal. Two revisions of the screener were made, following the same approach to reduce items. The final revision was

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piloted among children with tic disorders and children in a general pediatric clinic. A factor analysis was also conducted on the measure to explore the construct validity and response patterns of the items in relation to motor and vocal tic characteristics. Factor reliability was tested using Cronbach’s a. Results: In total, 80 children (mean age 11.2 years; 60% male) and parents completed the screening instrument; many provided qualitative feedback on specific items. More than half (52.5%, n ¼ 42) had tics based on expert evaluation, and 38 (47.5%) did not. The initial instrument of 25 items was eventually reduced to 14 items. The final 14-item screener had very good psychometric properties for parent report (sensitivity ¼ 0.90, specificity ¼ 0.82) and child report (sensitivity ¼ 0.86, specificity ¼ 0.63). Both sample groups were found to be reliable (r ¼ 0.90). Seven children in the general pediatric office were identified as having tics for the first time and were referred for further evaluation. Conclusions: In a limited sample group for validation, a new screening instrument for tics in children had both high sensitivity and specificity by parent report and had previously identified unrecognized tics in children in a nonspecialty healthcare setting. After additional validation, this instrument has the potential to improve the timely identification of tics and tic disorders in nonspecialty settings and referral for treatment, if needed.

MOVE, TICS, TD Supported by CDC http://dx.doi.org/10.1016/j.jaac.2017.09.251

4.36 A RANDOMIZED, DOUBLE-BLIND, PLACEBOCONTROLLED STUDY OF THE D1 RECEPTOR ANTAGONIST ECOPIPAM FOR CHILDREN AND ADOLESCENTS WITH TOURETTE’S DISORDER Tanya K. Murphy, MD, University of South Florida, tmurphy@ health.usf.edu; Donald Gilbert, MD, MS, Cincinnati Children’s Hospital Medical Center, [email protected]; Cathy L. Budman, MD, North Shore University Hospital, [email protected]; Kevin J. Black, MD, Washington University in St. Louis, [email protected]; Joseph Jankovic, MD, Baylor College of Medicine, josephj@ bcm.edu; Jon Grant, MD, JD, MPH, University of Chicago, [email protected]; James T. McCracken, MD, University of California, Los Angeles, jmccracken@mednet. ucla.edu; Keith A. Coffman, MD, Children’s Mercy Hospitals, Kansas City, [email protected]; Jorge Juncos, MD, Emory University School of Medicine, [email protected]; Roger Kurlan, MD, Atlantic Neuroscience Institute, [email protected]; Richard E. Chipkin, PhD, Psyadon Pharmaceuticals, [email protected] Objectives: The objective of this trial was to investigate the efficacy and safety of the selective dopamine D1 receptor antagonist ecopipam in children and adolescents with Tourette’s disorder (TD). Methods: Forty children aged 7 to 17 years meeting criteria for TD plus severity criteria on the Yale Global Tic Severity Scale (YGTSS) total tic score of 20 were enrolled in a double-blind, placebo-controlled, crossover study. Participants taking any dopaminergic drugs including stimulants for ADHD or D2 receptor blocking agents were excluded as were subjects on alpha2agonists. Children were randomized to receive either ecopipam (50 mg/day orally for subject < 75 lbs; 100 mg/day for subjects weighing >75 lbs) or placebo for four weeks, followed by a twoweek washout and crossover to the other treatment for four weeks. The primary outcome measure was tic severity assessed by YGTSS (motor+phonic scores). Secondary endpoints included Clinical Global Impression of Improvement (CGI-I) scale and age appropriate scales for comorbid ADHD and OCD were also performed. Analysis was intention-to-treat. Adverse events were tabulated. Results: Reduction in YGTSS total tic score was significantly greater for ecopipam treatment (M ¼ -5.6, SD ¼ 8.6) compared to placebo (M¼ -3.4,


SD ¼ 5.8) (p ¼ 0.043). CGI-Severity scores were decreased to a significantly greater extent in ecopipam- versus placebo-treated subjects (-0.78 vs. -0.21, p < 0.01). The difference in reduction of ADHD-Rating Scale total scores between groups was not significant. Adverse events reported were predominantly mild-to-moderate in both groups, with only four rated as “severe” and only one unrelated serious adverse event. Side effects included mild sedation, headache, and gastrointestinal symptoms, and were only marginally greater than placebo. There were no changes in body weight or ECG (e.g., QTc), no renal or hepatic changes, no neurological adverse events, or exacerbation of comorbidities. Conclusions: This is the first double-blind, placebo-controlled study of ecopipam, a D1 receptor antagonist, in TD. Ecopipam appeared to be an efficacious and well-tolerated treatment for Tourette’s disorder in children and adolescents.

RCT, TD, PPC Supported by Psyadon Pharmaceuticals, Inc http://dx.doi.org/10.1016/j.jaac.2017.09.252

4.37 NIGHTS OF SUFFICIENT SLEEP IN CHILDREN WITH TOURETTE’S DISORDER: FINDINGS FROM THE NATIONAL SURVEY OF CHILDREN’S HEALTH Emily J. Ricketts, PhD, University of California, Los Angeles, [email protected]; Michelle Rozenman, PhD, University of California, Los Angeles, mrozenman@mednet. ucla.edu; Caitlin Choy, BA, University of California, Los Angeles, [email protected]; Hannah B. Goldberg, University of California, Los Angeles, HGoldberg@mednet. ucla.edu; Jessica S. Kim, University of California, Los Angeles, [email protected]; Christopher S. Colwell, PhD, University of California, Los Angeles, [email protected]; James T. McCracken, MD, University of California, Los Angeles, [email protected]; John Piacentini, PhD, University of California, Los Angeles, jpiacentini@mednet. ucla.edu Objectives: Sleep disturbance is common in youth with Tourette’s disorder (TD). Reasons for these difficulties are unclear. The present study assessed sufficient sleep in those with TD with matched case control subjects, as well as predictors of sufficient sleep in a United States population-based survey. Methods: Participants were 673 parents or guardians of youth (ages 6–17 years; 298 with current TD, 122 with a history of TD, and 254 matched case control subjects) from 2007 and 2011/2012 National Survey of Children’s Health (NSCH), a large population-based survey of child physical, behavioral, and emotional well-being. Lifetime and current TD; current co-occurring conditions (ADHD, anxiety, and depression); and medication status were assessed via dichotomized yes/no items. TD severity (mild, moderate, or severe) was assessed using multiple choice questions. Sleep was assessed via number of sufficient nights of sleep in the past week. Results: Univariate ANOVA yielded significant group differences in nights of sufficient sleep [F(2,369.70) ¼ 71.53, P < 0.001], with 1.5 more nights per week found in control subjects relative to both current and history of groups with TD (P < 0.001). With respect to predictors of sufficient sleep, ANCOVA yielded a significant age gender TD severity interaction [F(1,15.84) ¼ 4.28, P ¼ 0.04]. Older adolescent males with mild TD had significantly fewer nights of sufficient sleep than children (P ¼ 0.004) and early adolescents [P ¼ 0.002; F(2,54.93) ¼ 7.45, P ¼ 0.001]. Female early adolescents with moderate-to-severe TD had fewer nights of sufficient sleep relative to males (P ¼ 0.008). Comorbidity type and medication status did not significantly predict sufficient sleep in youth with current TD. Conclusions: Insufficient sleep in youth with TD persists independent of comorbidity or medication status, suggesting the importance of clinical sleep monitoring.

SLP, TD http://dx.doi.org/10.1016/j.jaac.2017.09.253

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4.38 PLANNING ABILITY IMPAIRMENT IN CHILDREN AND ADOLESCENTS WITH ANXIETY DISORDER: RESULTS FROM A CONTROLLED TRIAL Camila Luisi Rodrigues, MS, Faculdade de Medicina da Universidade de S~ ao Paulo, [email protected]; Carolina da Costa, MD, Faculdade de Medicina da Universidade de S~ ao Paulo, [email protected]; Cristiana Castanho A. Rocca, PhD, Institute of Psychiatry of University of S~ ao Paulo, [email protected]; Fernando R. Asbahr, MD, Faculdade de Medicina da Universidade de S~ ao Paulo, [email protected] Objectives: A few studies have shown cognitive abnormalities in youngsters with anxiety disorders, particularly impairment in attention and memory processes. The aim of this study was to investigate whether planning ability is compromised in children and adolescents with anxiety disorders. Methods: A sample group of 37 children (ages 7–17 years), diagnosed with at least one anxiety disorder [generalized anxiety disorder (GAD), separation anxiety disorder (SAD), and/or social anxiety; study group], and 34 healthy control subjects were evaluated. The following neuropsychological tests were used: 1) the Tower of Hanoi task (ToH) for the assessment of planning ability; 2) speed processing and problem solving; and 3) the Vocabulary and Matrix Reasoning subtests of the Wechsler Abbreviated Scale of Intelligence (WASI) for measures of the estimated IQ in both groups. The groups were compared with a generalized linear model controlling for age, IQ, and ADHD comorbidity. Results: Compared with the control group, subjects with anxiety disorders made more errors (P ¼ 0.006) and required more time (P ¼ 0.001) to complete the ToH task. Conclusions: Findings from this study suggest that subjects with pediatric anxiety disorder have poorer planning ability than healthy control subjects. Poorer planning ability performances seem to be related to attentional control theory, which suggests that anxiety impairs the efficiency of the inhibition and shifting functions.

AD, COG, NEPSYC

~o de Amparo a Pesquisa do Estado de S~ Supported by Fundaç a ao Paulo - S~ ao Paulo Research Foundation Grants 0851632-9 and 2015/17582-8 http://dx.doi.org/10.1016/j.jaac.2017.09.254

4.39 MEASUREMENT INVARIANCE OF THE SCARED QUESTIONNAIRE: EXAMINING PARENT AND CHILD REPORT OF ANXIETY SYMPTOMS Brigid Behrens, BS, National Institute of Mental Health, [email protected]; Caroline Swetlitz, BA, National Institute of Mental Health, [email protected]; Katharina Kircanski, PhD, National Institute of Mental Health, [email protected]; Daniel S. Pine, MD, National Institute of Mental Health, [email protected]; David Pagliaccio, PhD, National Institute of Mental Health, [email protected] Objectives: The Screen for Child Anxiety Related Disorders (SCARED) is a questionnaire measure widely used to assess childhood anxiety based on parent and child report. However, although SCARED is a reliable, valid, and sensitive measure to screen for pediatric anxiety disorders, informant discrepancy can pose clinical and research challenges. Preliminary research suggests partial threshold invariance among respondents but uses moderate sample sizes. By examining measurement invariance of the SCARED between parent–child dyads and between age-groups, the present study aims to explore psychometric factors that may influence informant discrepancies. Methods: Participants included 1,092 parent–child dyads. Child participants (aged 7–18 years) included both treatment-seeking anxious patients and healthy volunteers. We conducted one longitudinal and two multi-group invariance models in Mplus to explore how informant (parent vs. child) and age of the child at completion related to item interpretation. The first model examined parent and child responses, using a longitudinal method to account for the

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nonindependence of variables. The second and third model examined parent or child responses in young and older children. Ongoing analyses will examine the test-retest reliability of parent and child report on the SCARED as well. Results: Our results indicated that the SCARED shows strict measurement invariance, as evidenced by small changes in confirmatory factor analysis model fit, suggesting similar factor loadings, thresholds, and residuals across informant, as well as age of the child. Evidence of measurement invariance informs the interpretation of the SCARED, suggesting that it is appropriate to compare values across groups. Conclusions: This suggests that item interpretation is not responsible for the discrepancy between raters. However, because of the prevalence of informant discrepancy, further analyses will examine the test-retest reliability of parent and child respondents. Understanding how informants interpret the latent variables informs the validity of the SCARED measure in both research and clinical settings.

AD, NIMH Supported by NIMH Intramural Research Program http://dx.doi.org/10.1016/j.jaac.2017.09.255

4.40 THE EFFECT OF SOCIAL AWARENESS ON ANTICIPATED SOCIAL INTERACTIONS IN ANXIOUS AND NON-ANXIOUS YOUTH: A NEUROIMAGING STUDY Quyen B. Do, BS, National Institute of Mental Health, quyen. [email protected]; Brent I. Rappaport, BA, Washington University in St. Louis, [email protected]; Eric E. Nelson, PhD, Nationwide Children’s Hospital, eric.nelson@ nationwidechildrens.org; Johanna M. Jarcho, PhD, Stony Brook University, [email protected]; Daniel S. Pine, MD, National Institute of Mental Health, pined@mail. nih.gov; Ashley R. Smith, PhD, National Institute of Mental Health, [email protected] Objectives: Adolescence is a period of increased emphasis on peer relationships. Social awareness, the ability to detect social cues, is critical in forming and maintaining such relationships. Anxious youth have difficulty processing social cues, often interpreting social interactions as more negative than their healthy peers. These negative biases may lead to avoidance of and/or withdrawal from social interactions. As such, understanding how individual differences in social awareness influence brain response during anticipation of peer interactions may be critical to our understanding of social anxiety. Methods: Both anxious (N ¼ 44) and healthy (N ¼ 45) youths (ages 8–17) completed a computerized social interaction task while undergoing fMRI. Participants were told they would be the “New Kid” at a virtual school and that a purported group of “Other Students” would provide evaluative feedback about a profile and avatar they created at a previous visit. To examine how youth respond to anticipation of different types of social interactions, each Other Student had a reputation for being “nice” (provided 100% positive feedback), “mean” (provided 100% negative feedback), or “unpredictable” (provided 50% positive and 50% negative feedback). The present analysis focused on the anticipatory period before receiving evaluative feedback. We ran a whole-brain, mixed-effects model with social awareness (as measured by the Social Responsiveness Scale) as a continuous, between-subject variable and student reputation as a repeated, within-subjects variable. Results: A whole-brain analysis (P < 0.005) revealed a main effect of social awareness in the anterior insula (41, 1, 1). In particular, when anticipating evaluative feedback, youth with lower levels of social awareness showed less insula activation, whereas insula activation was higher in youth with higher levels of social awareness. Conclusions: The current study suggests a direct relationship between one’s ability to detect social cues and engagement in the insula, a brain region involved in the detection and interpretation of physiological arousal. These preliminary data demonstrate that both levels of social awareness and insula engagement may play important roles in processing potential social interactions during adolescence.

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ADOL, AD, IMAGS Supported by NIMH Grant ZIAMH002781 http://dx.doi.org/10.1016/j.jaac.2017.09.256

4.41 A PSYCHOPHYSIOLOGY STUDY OF HEAT PAIN CONDITIONING AND INSTRUMENTAL AVOIDANCE IN ANXIOUS AND HEALTHY CHILDREN Chika Matsumoto, BS, National Institute of Mental Health, [email protected]; Elizabeth Steuber, BA, National Institute of Mental Health, [email protected]; Shmuel Lissek, PhD, University of Minnesota, smlissek@umn. edu; Rany Abend, PhD, National Institute of Mental Health, [email protected]; Kalina Michalska, PhD, University of California, Riverside, [email protected]; Lauren Y. Atlas, PhD, National Center for Complementary and Integrative Health, [email protected]; Ellen Leibenluft, MD, National Institute of Mental Health, [email protected]; Daniel S. Pine, MD, National Institute of Mental Health, [email protected]; Andrea L. Gold, PhD, National Institute of Mental Health, [email protected] Objectives: Anxiety disorders are characterized by excessive fears and avoidance. Prior studies examine threat-safety learning using Pavlovian conditioning, predominantly in adults. We developed a pediatric adaptation of a novel paradigm to study Pavlovian and instrumental conditioning in an approach-avoidance conflict task, using heat pain as the unconditioned stimulus (US). We hypothesized discriminative learning and fear generalization across both anxious and healthy groups, with exaggerated avoidance and generalization in anxious youths. Methods: Thirty-five youths (14 anxious, 21 healthy) aged 8-17 years completed the task. Heat pain levels were calibrated for each subject and psychophysiological recordings were collected during the task, which had two phases. In the first phase, subjects viewed two shapes: a threat cue (CS+) paired with the US and a safety cue (CS-) that never predicted the US. In the second phase, subjects also viewed a novel, ambiguous generalized stimulus (GS) that never predicted the US, and chose whether to avoid the US at the risk of compromised performance. Anxiety differences in avoidance, psychophysiological, and self-report measures were tested. Results: Skin conductance response (SCR) and self-report measures revealed discriminative learning across groups. Relative to the CS-, behavioral avoidance was elevated to the CS+, but not to the GS. However, SCR and self-reported anxiety indicated elevated responses to both GS and CS+, relative to CS-. Anxiety diagnosis and severity were unrelated to the dependent measures. Conclusions: Preliminary results support the use of a heat pain US in pediatric fear conditioning. Moreover, the task elicited avoidance to the threat cue but not the GS, and no anxiety-related differences emerged. Although we did not observe the expected generalization in behavior, generalization manifested in SCR and self-reported anxiety. This discrepancy may relate to methodological factors. Preliminary analyses did not show any anxiety differences in avoidance, although data collection is still ongoing. Given that patients were recruited for social and generalized anxiety, future research might examine avoidance using a disorder-relevant US, such as negative interactions or feedback.

AD, R, NIMH Supported by NIMH Intramural Research Program Grant ZIAMH002781 http://dx.doi.org/10.1016/j.jaac.2017.09.257

4.42 PSYCHOTIC-LIKE SYMPTOMS IN PREADOLESCENCE: WHAT PRECEDES THE PRECURSORY SYMPTOMS OF SEVERE MENTAL ILLNESS? Koen Bolhuis, MD, Erasmus Medical Center: Sophia’s Children’s Hospital, [email protected]; Maria Elisabeth Verhoeff, MPhil, Erasmus Medical Center: Sophia’s Children’s Hospital, [email protected];


Manon Hillegers, MD, PhD, Erasmus Medical Center: Sophia’s Children’s Hospital, [email protected]; Henning Tiemeier, MD, PhD, Erasmus Medical Center: Sophia’s Children’s Hospital, [email protected] Objectives: Childhood psychotic-like experiences are predictive of later psychotic disorders but have also been shown to predict later depression, anxiety, and suicidal behavior. To better understand psychotic-like experiences from a developmental life-course perspective, this study examined the association between preadolescent psychotic-like experiences and 1) emotional and behavioral problems at ages three and six years; and 2) childhood adversities, including physical and sexual maltreatment. Methods: This prospective study was embedded in the Generation R study; 3,984 children (mean age ¼ 9.8 years) completed a self-report questionnaire on psychotic-like experiences. Mothers completed the Child Behavior Checklist at ages three and six years. Additionally, mothers were interviewed about their child’s past adversities. Analyses were adjusted for demographic characteristics, maternal psychopathology, and self-reported emotional and behavioral problems to test effects specific to psychotic-like experiences. Results: Auditory and visual hallucinations were reported by 26 and 17 percent of children, respectively. Psychotic-like experiences were significantly predicted by age three years as internalizing problems [e.g., emotionalreactive symptoms: ORadjusted ¼ 1.12 (95% CI 1.02–1.24)] and by age six years as internalizing problems [e.g., anxious/depressed symptoms: ORadjusted ¼ 1.12 (95% CI 1.02–1.23)] but not externalizing symptoms. A dose-response relationship was observed between childhood adversities and psychotic-like experiences [1–2 adversities: ORadjusted ¼ 1.77 (95% CI 1.53–2.04); > 2 adversities: ORadjusted ¼ 2.24 (95% CI 1.72–2.92)]. More specifically, both physical and sexual maltreatment were substantially associated with preadolescent psychotic-like experiences. Conclusions: This study provides evidence for a developmental continuity from early childhood adversities and emotional problems to preadolescent psychotic-like experiences. This might reflect a shared developmental track or etiology, which should be investigated further using neuroimaging and genetic measures. Moreover, the present findings suggest that children at increased risk for psychotic symptoms and subsequent severe mental illness could potentially be identified early in development.

EPI, PSY, DEV Supported by the Erasmus University Medical Center, the Erasmus University, and the Netherlands Organization for Health Research and Development Grant ZonMw http://dx.doi.org/10.1016/j.jaac.2017.09.258

4.43 INTERACTIONS AND NON-LINEAR EFFECTS OF PRENATAL AND PARENTAL FACTORS AS PREDICTORS FOR SCHIZOPHRENIA David Gyllenberg, MD, PhD, University of Turku, david. gyllenberg@utu.fi; Ian W. McKeague, PhD, Columbia University Mailman School of Public Health, im2131@cumc. columbia.edu; Andre Sourander, MD, PhD, University of Turku, andsou@utu.fi; Alan S. Brown, MD, MPH, Columbia University Medical Center, [email protected] Objectives: Both prenatal and parental factors are strongly associated with schizophrenia. However, most studies have evaluated individual risk factors and linear main effects. Our aim was to study whether nonlinear effects and interactions between prenatal and parental factors increase the risk of schizophrenia. Methods: The study is based on the Finnish Prenatal Study of Schizophrenia, a nested case-control study linked to a nationwide biobank of maternal sera from the gestational period, to national registers and to maternity chart data. To predict schizophrenia based on high-dimensional data, including both linear and quadratic effects of prenatal factors, parental psychopathology, and their two-way interactions, we used the machine-learning algorithm, Least Absolute Shrinkage and Selection Operator (LASSO), for logistic regression. The algorithm was first fit in training data (334 cases and 278 control subjects) and then tested in another validation data derived from a separate geographic region (320 cases and 364 control subjects).

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Results: The selected predictive variables included parental psychopathology, quadratic effects of parental age, and interactions with birth in urban areas. The area under the curve (AUC) that measures the discrimination between schizophrenia and control subjects was 0.68 in the training data and 0.66 in the validation data. When the validation data were restricted to persons younger than age 18 years, the AUC was 0.69. Conclusions: By applying modern statistical tools to the large national dataset, we showed that nonlinear effects and interactions of prenatal and parental factors are important in predicting schizophrenia among youth.

LONG, RF, SZ Supported by NIMH Grants 1R01MH082052-05 and K02MH065422-09, Brain and Behavior Research Foundation NARSAD Young Investigator Grant, and the Finnish Academy and the Finnish Medical Foundation http://dx.doi.org/10.1016/j.jaac.2017.09.259

4.45 CLINICAL MANIFESTATIONS OF 22Q11.2 DELETION SYNDROME AND THE ROLE OF PREMATURITY IN THE EMERGENCE OF PSYCHOSIS Yael Kufert, MD, Edmond and Lily Safra Children’s Hospital, Sheba Medical Center, [email protected]; Abraham Weizman, MD, Sackler Faculty of Medicine, Tel Aviv University, [email protected]; Doron Gothelf, MD, Edmond and Lily Safra Children’s Hospital, Sheba Medical Center, [email protected] Objectives: 22q11.2 deletion syndrome (22q11.2DS, also called velocardiofacial syndrome or DiGeorge syndrome) is a genetic syndrome caused by a microdeletion on the long arm of chromosome 22. Psychotic disorders are common in 22q11.2DS, occurring in up to one-third of affected individuals. Multiple reports described the physical, psychiatric, and cognitive phenotype of the syndrome; however, most focused on a specific organ system, and only a few reported the full range of the phenotypical expression. The aim of this study was to comprehensively report the clinical manifestations in a large Israeli cohort of individuals with 22q11.2DS. We hypothesized that there would be an association between preterm birth and psychotic disorders. Methods: The study population consisted of 128 individuals with 22q11.2DS (77 males, 51 females; aged 1–55 years; mean SD 12.9 11.0). All subjects underwent an extensive medical evaluation. Subjects aged >5 years (n ¼ 104) were also evaluated by the Hebrew version of the Schedule for Affective Disorders and Schizophrenia for School-Aged Children, Present and Lifetime (K-SADS-PL) or the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), as appropriate for age. Cognitive evaluation was conducted with age-appropriate versions of the Wechsler Intelligence Scale. Results: Rates of medical manifestations were in accordance with those reported in the literature. Psychotic disorders occurred in 16.3 percent of the psychiatrically evaluated population. An association was found between the expression of psychotic disorders and preterm birth. Conclusions: Our findings suggest that psychosis in 22q11.2DS is related to a neurodevelopmental process, with early obstetric and medical precursors.

GS, PSY, RF Supported by the Basil O'Connor Starter Scholar Research Award of the March of Dimes Grant 5-FY06-590, the Binational Science Foundation Grant 2011378, and NIMH Grant 5U01MH101722-02 http://dx.doi.org/10.1016/j.jaac.2017.09.261

4.46 IMPLEMENTATION OF COORDINATED SPECIALTY CARE FOR FIRST EPISODE PSYCHOSIS IN MAINE, A STATE WITH LIMITED RESOURCES: LESSONS AND CHALLENGES IN THE INITIAL TWO YEARS Douglas R. Robbins, MD, Maine Medical Center and Tufts University School of Medicine, [email protected]; Sarah Lynch, LCSW, Maine Medical Center, [email protected]

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Objectives: Treatment of first-episode psychosis (FEP) presents an important opportunity for secondary prevention or early intervention in severe mental illness. Coordinated Specialty Care (CSC), a team-based model of psychosocial interventions and pharmacotherapy, is effective, and SAMHSA is supporting implementation of this model through two grant initiatives for patients ages 15 to 25 years. Maine began a program implementing CSC in 2015. This report presents outcomes and challenges in the first two years of implementing CSC for FEP in a state with limited resources. Methods: Outcome was assessed using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS) at entry and every 90 days. Family engagement, school and work participation, and service utilization were documented. Education activities necessary to foster referrals and training and in key evidence-based practices are described. Challenges in sustainable funding for these are outlined. Results: In the first two years, the program completed 58 educational presentations reaching 1,615 school and mental health and medical professionals. A total of 48 patients have been assessed and treated, with a mean age of 17.8 years at intake. The group is heterogeneous, including schizophrenia spectrum and affective psychoses. WHODAS outcomes showed a 71 percent decline in total disability and a reduction of days of severe disability from 20 of the past 30 to 4.5. School attendance and employment improved in all diagnostic groups. All patients remained engaged with their families; three of 44 experienced brief periods of homelessness. Substance abuse was prevalent, often complicating recovery significantly. Critical components of the program do not have sustainable funding. Conclusions: The program can be successfully implemented, with initial grant support in a state with limited resources, with positive outcomes consistent with those seen in other FEP programs. Positive outcomes are observed in affective psychoses as well as in schizophrenia. Alliances with family, use of peer mentors, and support for school and employment and care coordination are important tools in reaching many who would otherwise drop out of treatment. An active partnership with payers is needed to develop sustainable funding.

ADOL, PRE, PSY Supported by Substance Abuse and Mental Health Services Administration Grant “Now Is The Time: Healthy Transitions” and Mental Health Block Grant MH4-17-2019 http://dx.doi.org/10.1016/j.jaac.2017.09.262

4.47 PATIENT CHARACTERISTICS AND PATTERNS OF CARE PRIOR TO SCHIZOPHRENIA DIAGNOSIS IN A LARGE COMMERCIALLY-INSURED POPULATION OF ADOLESCENTS AND YOUNG ADULTS IN THE UNITED STATES Anna Wallace, MPH, PhD, HealthCore, Inc., awallace@ healthcore.com; John Barron, PharmD, HealthCore Inc., [email protected]; Whitney York, MS, HealthCore, Inc., [email protected]; Mayura Shinde, DrPH, MPH, HealthCore, Inc, [email protected]; Keith Isenberg, MD, Anthem Insurance Companies, Inc., keith. [email protected]; Matthew Sidovar, MSC, Boehringer Ingelheim Pharmaceuticals, Inc, [email protected]; Jessica Franchino-Elder, MPH, PhD, Boehringer Ingelheim Pharmaceuticals, Inc., [email protected]; Michael Sand, MPH, PhD, Boehringer Ingelheim Pharmaceuticals, Inc., [email protected] Objectives: Schizophrenia, often diagnosed in adolescence, is associated with substantial health care resource utilization (HCRU) and costs. Little is known about patterns of care before diagnosis. We describe clinical and demographic characteristics and HCRU of adolescent patients with and without schizophrenia over a five-year pre-diagnosis period. Methods: This US-based retrospective study used claims data from the HealthCore Integrated Research Database to identify newly diagnosed

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patients with schizophrenia (ICD-9: 295.x, ICD-10: F20.x). Patients aged 15–25 years at diagnosis were compared with a demographically-matched (1:4) non-schizophrenia cohort during pre-diagnosis periods, including 0–6, 7–12, and 0–12 months, and >1–2, >2–3, >3–4 and >4–5 years. Demographics and comorbidities were compared using medical and pharmacy claims and eligibility files. Medications and medical service utilization were compared for each observation period. Results: Patients (N ¼ 2,591) with schizophrenia and 10,362 matched comparators were identified. Patients were mostly male (70%). In the schizophrenia cohort, psychiatric diagnostic examination was the most common behavioral health service used, increasing in frequency closer to diagnosis (16%–46%) versus comparators (3.8%–4.2%). In the 12 months before diagnosis, more patients with schizophrenia filled prescriptions for atypical antipsychotics and antidepressants (55% and 43%) than matched comparators (1% and 7%); usage of these medications increased over each time period in the schizophrenia cohort (13–55% and 18–43%, respectively) but remained fairly stable in the control cohort (1% and 4–7%, respectively). All comorbidities were more prevalent in the schizophrenia cohort than the comparator cohort in the year before diagnosis (p < 0.01). Conclusions: Prior to diagnosis with schizophrenia, adolescents and young adults experience higher rates of comorbidities, psychiatric medication use and HCRU than demographically-matched comparators. Additionally, clinically high-risk patients have more frequent encounters with health care providers compared with comparators, suggesting that early identification, intervention, and optimization of care may be possible and is warranted.

ADOL, MDM, SZ Supported by Boehringer Ingelheim GmbH and Anthem, Inc. http://dx.doi.org/10.1016/j.jaac.2017.09.263

4.48 DEPRESSIVE SYMPTOMS AND SUICIDAL BEHAVIORS OF ADOLESCENT NON-DAILY SMOKERS IN KOREA: NATIONAL CROSSSECTIONAL STUDY Jinhee Lee, MD, Yonsei University Wonju College of Medicine, [email protected]; Joung-Sook Ahn, MD, Yonsei University Wonju College of Medicine, jsahn@yonsei. ac.kr Objectives: Non-daily smoking is common among adolescent smokers. Although smoking has been known as a risk factor for adolescent depression, little has been known about the relationship between adolescent mental health and non-daily smoking. We aimed to investigate the association of non-daily smoking with depressive symptoms and suicidal behaviors among adolescents by analyzing data from the 2016 Korean Youth Risk Behavior Web-based Survey (KYRBWS), a national school-based survey. Methods: Data from adolescent middle and high school students (N ¼ 65,528) in Korea were analyzed. Subjects were classified into three groups according to patterns of cigarette smoking: 1) never smokers; 2) non-daily smokers; and 3) daily smokers. Students replied to a questionnaire on their depressive symptoms, suicide ideation, suicide planning, and suicide attempt. Relationships between depressive symptoms, suicidal behaviors, and patterns of cigarette smoking were tested by chi-square test and logistic regression models after controlling for potential confounding factors by IBM SPSS 21.0. Results: Among the Korean adolescents aged 12-18 years, 93.3 percent (89.4% among boys, 97.2% among girls) was never smoker, 3.5 percent (4.6% among boys, 1.7% among girls) was non-daily smoker, and 3.2 percent (4.7% among boys, 1.0% among girls) was daily smoker. Depressive symptoms were common among never smokers (23.6%), non-daily smokers (39.6%), and daily smokers (38.0%) (p < 0.001), and suicide attempt was common among never smokers (1.9%), non-daily smokers (6.4%), and daily smokers (7.3%) (p < 0.001). After controlling for confounding factors (age, house income, shool grades, parent education level and current alcohol drinking) non-daily smokers were more likely to have depressive symptoms (OR ¼ 1.80, p < 0.001 in girls, OR ¼ 1.49, p < 0.001 in boys) and suicide ideation (OR ¼ 2.03, p < 0.001 in girls, OR ¼ 1.32, p ¼ 0.002 in boys) than daily smokers. Conclusions: The prevalence of depressive symptoms and suicide ideation among non-daily smokers was higher than daily smokers and never smokers.


There may be a difference in clinical features and significances between nondaily and daily smoking adolescents. Health education, including depression and suicide prevention programs, is needed for non-daily smokers.

SUD, DDD, S http://dx.doi.org/10.1016/j.jaac.2017.09.395

4.49 EFFICACY AND SAFETY OF LURASIDONE IN ADOLESCENTS WITH SCHIZOPHRENIA: INTERIM ANALYSIS AT TWELVE MONTHS OF A 24-MONTH, OPEN-LABEL EXTENSION STUDY Christoph Correll, MD, Zucker Hillside Hospital and Hofstra North Shore LIJ School of Medicine, [email protected]; Michael Tocco, PhD, Sunovion Pharmaceuticals Inc., Michael. [email protected]; Robert Goldman, PhD, Sunovion Pharmaceuticals Inc., [email protected]; Andrei A. Pikalov, MD, Sunovion Pharmaceuticals Inc., andrei. [email protected]; Josephine Cucchiaro, PhD, Sunovion Pharmaceuticals Inc., [email protected]; Antony Loebel, MD, Sunovion Pharmaceuticals Inc., Antony. [email protected] Objectives: The goal of this presentation is to evaluate long-term effectiveness and safety of lurasidone in adolescents with schizophrenia. Methods: Patients with schizophrenia (ages 13–17 years) were randomized to six weeks of double-blind (DB) treatment with lurasidone (Lur, 40 mg per day, 80 mg per day combined in the current analysis) or placebo (Pbo). Patients who completed this study were eligible to enroll in a two-year, open-label (OL), flexible-dose (20–80 mg per day) extension study in which patients were continued on lurasidone (Lur-Lur) or switched from placebo to lurasidone (Pbo-Lur). We present here the results of an interim analysis at week 52. Effectiveness measures included the PANSS total score. Results: A total of 326 patients were randomized to lurasidone (40 or 80 mg per day) or placebo. At the primary week 6 endpoint, treatment with lurasidone was associated with statistically significant and clinically meaningful improvement versus placebo in the PANSS total score [40 mg per day (18.6) and 80 mg per day (18.3) vs. placebo (10.5); P < 0.001 for both comparisons]. A total of 271 patients entered the extension study, and 69.7 percent completed 52 weeks of treatment, including 3.3 percent who discontinued because of a lack of efficacy and 8.5 percent who discontinued because of adverse events. For the Lur-Lur and Pbo-Lur groups, respectively, mean PANSS total scores at DB baseline were 93.9 and 92.7; mean improvement from DB to OL baselines was greater for the Lur-Lur group versus the Pbo-Lur group (19.8 vs. 12.9); and mean changes from OL baseline to week 52 observed cases (OC) (last observation carried forward, LOCF) for the Lur-Lur and Pbo-Lur groups were 14.8 (14.1) and 17.7 (9.3), respectively. During OL treatment, the most common adverse events were headache (21.8%), nausea (11.8%), and anxiety (11.8%). Median changes in laboratory parameters from DB baseline to week 52 OC (LOCF) were as follows: total cholesterol, 2.0 (1.5) mg/dl; triglycerides, +3.5 (+1.5) mg/dl; and hemoglobin A1c, 0.0 (0.0%). Mean change in weight at week 52 was +3.83 (+2.73) kg versus an expected weight gain of +3.30 (+2.74) kg, based on normative data from the CDC. Conclusions: In adolescents with schizophrenia, long-term treatment with lurasidone was associated with continued improvement in symptoms of schizophrenia. After one year of lurasidone treatment, minimal effects were observed on body weight, lipids, and glycemic indices.

APS, PPC, SZ Supported by Sunovion Pharmaceuticals Inc. http://dx.doi.org/10.1016/j.jaac.2017.09.265

4.50 FACE EMOTION LABELING IN PEDIATRIC IRRITABILITY: BEHAVIORAL AND NEURAL CORRELATES Gretchen Perhamus, BA, National Institute of Mental Health, [email protected]; Katharina Kircanski, PhD, National Institute of Mental Health, [email protected];

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Jillian Lee Wiggins, PhD, San Diego State University, jillian. [email protected]; Kelsey Stiles, BA, University of California, Los Angeles, [email protected]; Alexa Curhan, BA, Johns Hopkins University, [email protected]; Caroline Wambach, BS, Georgetown Univeristy School of Medicine, [email protected]; Kenneth Towbin, MD, National Institute of Mental Health, Kenneth.Towbin@nih. gov; Daniel S. Pine, MD, National Institute of Mental Health, [email protected]; Melissa A. Brotman, PhD, National Institute of Mental Health, [email protected]; Ellen Leibenluft, MD, National Institute of Mental Health, [email protected] Objectives: Severe irritability in youth has received increasing scientific and clinical attention, as reflected in the addition of disruptive mood dysregulation disorder (DMDD) to the DSM-5. Dimensionally, irritability is distributed continuously in the population and is a transdiagnostic symptom. Children with irritability exhibit deficits in labeling others’ emotional facial expressions, which may relate to their frustration, anger, and impairment in social contexts. This study investigated the relationships of dimensionally assessed irritability to brain and behavioral function during emotion labeling. Methods: Youth (N ¼ 60) diagnosed with DMDD (n ¼ 21), ADHD (n ¼ 18), and healthy volunteers (n ¼ 21) completed an fMRI-based face emotion-labeling paradigm. Participants viewed images of angry, fearful, and happy faces (28 trials per condition), varying in intensity of expression [0 (neutral), 50, 75, and 100%]. The Affective Reactivity Index (ARI) assessed dimensional irritability, averaging youth- and parent-reported scores. For both the behavioral and neural data, three (emotion) by four (intensity) analyses of covariance (ANCOVAs), with irritability as the covariate, were used. Neural activation data were analyzed in Analysis of Functional NeuroImages (AFNI), with in-scanner motion as an additional covariate. Results: Behavioral data showed no significant differences in face emotion labeling as a function of irritability (all F < 2.52; all P > 0.05). Neural data showed a significant three-way interaction of irritability by emotion by intensity across several clusters of activity. Irritability was associated with differences in activation in the bilateral cuneus/middle occipital gyrus, the right lingual gyrus/right inferior occipital gyrus, and several other regions (P < 0.005, uncorrected). Conclusions: Although behavioral accuracy during face emotion labeling did not relate to dimensionally assessed irritability, neuroimaging data showed several interactions of irritability, face emotion, and intensity, including visual processing areas. By the time of this presentation, we expect approximately 10 more participants to have completed the paradigm, which will be added to the present sample group.

IMD, NIMH, DMDD Supported by NIMH Intramural Research Program http://dx.doi.org/10.1016/j.jaac.2017.09.266

4.51 ASSESSMENT AND TREATMENT OF HOSTILE ATTRIBUTION BIAS IN CHILDREN WITH DISRUPTIVE MOOD DYSREGULATION DISORDER James G. Waxmonsky, MD, Penn State College of Medicine, [email protected]; Daniel Waschbusch, PhD, Penn State College of Medicine, dwaschbusch@pennstatehealth. psu.edu; Lysett Babocsai, PhD, University of Hideelberg, [email protected]; Peter Belin, MD, Hofstra Northwell School of Medicine at Hofstra University, [email protected] Objectives: Hostile attribution bias (HAB), the tendency to interpret hostile intent in the actions of others, predicts increased rates of reactive aggression and has been theorized as a mechanism for the temper outbursts seen in disruptive mood dysregulation disorder (DMDD). We examined the intensity, impact, and treatment response for HAB in children with ADHD and DMDD. Methods: HAB was assessed in 56 children (mean age ¼ 9.3) with ADHD who met criteria for DMDD after their stimulant dose was optimized. HAB was measured using a validated measure composed of 10 vignettes (five

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for relational aggression and five for instrumental aggression) describing a hypothetical situation where the intent of the child provocateur is ambiguous. Following established scoring procedures, participants rated the perceived intent of the provocateur and the distress level that they would have experienced if they had been the victim. Given the associations between callous unemotional (CU) traits and HAB, CU trait was also measured at baseline. Participants then were randomly assigned to CNS stimulants plus experimental 11-week group therapy (called AIM) or medication alone. AIM consisted of eleven 90-minute sessions with concurrent parent and child groups and has been found to significantly reduce DMDD symptoms. Child content addressed processing and regulation of emotion plus problem solving, with a focus on interpreting intent and ways intent influences action. Results: Participants manifested significantly greater levels of HAB intent for relational versus instrumental aggression (P < 0.001). CU traits moderated baseline levels of instrumental but not relational HAB. Mean relational intent scores (4.51) were elevated above age-appropriate levels. HAB distress scores were moderately correlated with parent ratings of problem behaviors (r ¼ 0.31, P < 0.05) on the Social Skills Rating System, which covers a range of internalizing and externalizing symptoms. There were no clear effects of treatment on HAB, with the exception for those with elevated CU traits. Conclusions: Children with DMDD and ADHD manifested elevated rates of HAB for relational aggression that were associated with parent ratings of their child’s problematic behaviors. The relatively low intensity focus on HAB (approximately two hours of dedicated content) was not sufficient to meaningfully reduce HAB, suggesting that more intensive intervention may be necessary.

ADHD, IMD, DMDD Supported by NIMH Grant R34080791 http://dx.doi.org/10.1016/j.jaac.2017.09.267

4.52 PRESERVED CORONARY DISTENSIBILITY INDEX IS ASSOCIATED WITH REDUCED ADULTHOOD POSTTRAUMATIC STRESS DISORDER IN YOUTH WITH ADVERSE CHILDHOOD EXPERIENCE Naser Ahmadi, MD, PhD, University of California, Los Angeles, [email protected]; Fereshteh Hajsadeghi, MD, University of California, Los Angeles, [email protected]; Garth Olango, MD, University of California, Los Angeles Kern Medical, olangog@ kernmedctr.com; Robert S. Pynoos, MD, University of California, Los Angeles Semel Institute for Neuroscience and Human Behavior, [email protected]; Mohammed Molla, MD, University of California, Los Angeles Kern Medical, [email protected] Objectives: Impaired coronary distensibility index (CDI) is a marker of vascular dysfunction, measures an endothelial-dependent process, is associated with vulnerable plaque composition, and predicts major adverse cardiovascular event (MACE). We previously reported that impaired CDI is strongly associated with the severity of adverse childhood experiences’ (ACE) symptoms and predicts an increased risk of MACE in subjects with ACE. This study investigated the relationship between ACE and adulthood PTSD in youth with and without preserved CDI. Methods: Two hundred forty-six subjects (age range 18–70 years, 31% women) with (n ¼ 79) and without (n ¼ 167) ACE underwent computed tomography angiography (CTA) for clinical indication, and their CDI was measured. ACE was measured using Childhood Trauma Questionnaire (CTQ) and Dimensions of Stressful Events Rating Scale (DOSE). CDI in left anterior descending artery (LAD) was defined as follows: [(early diastole mid-diastole lumen cross-section area (CSA))/(lumen CSA in mid-diastole central pulse pressure) x 1,000]. Preserved CDI was defined as CDI >2.4. PTSD was measured using Clinician Administered PTSD Scale and PTSD Checklist–Military scores and verified by medical records. Mixed-regression analyses were used to assess the relationship of ACE with and without preserved CDI with adulthood PTSD.

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Results: A significant inverse correlation between CDI and Clinical Global Impression (CGI) Scale of ACE symptoms was noted (r2¼ 0.61, P ¼ 0.001). CDI was significantly lower in subjects with ACE compared with those without ACE (3.1 0.2 vs. 4.6 0.2, P ¼ 0.001). Regression analyses revealed that ACE is independently associated with adulthood PTSD (likelihood ratio: 18.9, 95% CI 8.5–42.2, P ¼ 0.001). The likelihood of adulthood PTSD in ACE without preserved CDI was 10.6-fold (95% CI 5.4–25.6, P ¼ 0.001) higher compared with ACE with preserved CDI. The likelihood of adulthood PTSD was less in ACE with preserved CDI compared with ACE without preserved CDI (6 vs. 45%, P ¼ 0.001), which was comparable to those without ACE (3.5%; P > 0.05). Conclusions: Preserved CDI is strongly associated with the reduced adulthood PTSD in subjects with ACE. This highlights the important role of early intervention and preserving CDI in identifying individuals with ACE at risk for MACE.

PRE http://dx.doi.org/10.1016/j.jaac.2017.09.268

4.53 PRAZOSIN IN CHILDREN AND ADOLESCENTS WITH POSTTRAUMATIC STRESS DISORDER WHO HAVE NIGHTMARES: A CASE SERIES Adefolake Akinsanya, MD, MetroHealth Medical Center, [email protected]; Raman Marwaha, MD, Case Western Reserve University School of Medicine and MetroHealth Medical Center, [email protected]; Florence V. Kimbo, MD, MetroHealth Medical Center, fl[email protected] Objectives: The aim of this retrospective chart review is to identify patients who have been prescribed prazosin for PTSD-related nightmares and review benefits and outcomes from the use of prazosin. Methods: A retrospective chart review was conducted by reviewing medical records on EPIC over the last 20 years in the child psychiatry departments’ patient population. Information on age, sex, medication dosage, diagnosis, and outcome was gathered. Information gathered was limited to just one facility. Inclusion criteria include the following: patients between the ages of 0 and 18 years; diagnosis of PTSD; nightmares; and prescription of prazosin. There was no discrimination between race, sex, or socioeconomic status. Exclusion criteria included diagnosis of PTSD with no nightmares and no prescription of prazosin, as well as ages > 18 years. Results: A total of 25 patient records were identified. Of this population, 22 patients showed significant improvement in frequency of nightmares with administration of prazosin, one patient did not follow up after initiation of prazosin, and two patients had no significant improvement and also reported side effect of sedation. Of the 22 patients with significant improvement, five of them also had improved irritability and two of them had return of nightmares after stopping prazosin use and improvement when prazosin was resumed. The dose administered ranged from a total of one to three milligrams daily, with either nighttime dosing or twice-a-day dosing. Conclusions: Nightmares associated with PTSD have considerable comorbidity. Currently, there are no US Food and Drug Administrationapproved medications for treatment of nightmares associated with PTSD in children and adolescents. Our case series highlights that prazosin helps with pediatric PTSD-related nightmares. This positive outcome gives room for consideration of this medication in the treatment of children and adolescents with PTSD-related nightmares. Given that there are no RCTs in children, we recommend that RCTs be conducted to assess efficacy and safety of prazosin.

PPC, SLP http://dx.doi.org/10.1016/j.jaac.2017.09.269

4.54 INVESTIGATING THE PREVALENCE OF POSTTRAUMATIC SYMPTOMS IN CHILDREN AND ADOLESCENTS Monica Badillo, MD, Bronx-Lebanon Hospital Center at Icahn School of Medicine at Mount Sinai, [email protected];


Aos Mohammed Ameen, MD, Bronx-Lebanon Hospital Center at Icahn School of Medicine at Mount Sinai, [email protected]; Viviana Chiappetta, MD, BronxLebanon Hospital Center, [email protected]; Luisa Gonzalez, MD, Bronx-Lebanon Hospital Center, [email protected]; Panagiota Korenis, MD, BronxLebanon Hospital Center and Albert Einstein College of Medicine, [email protected]; Michelle Kohut, LCSW, Bronx-Lebanon Hospital Center, [email protected]; Wen Gu, PhD, Bronx-Lebanon Hospital Center, WGu@ bronxleb.org Objectives: To appreciate and further understand what traumatic experience is most prevalent in the child and adolescent community, the goal is to improve detection, diagnosis, and management of posttraumatic pathologies. Methods: A performance improvement project was conducted in an urban inner city hospital on all newly admitted child and adolescent patients to inpatient psychiatry service over a two-month period. A total of 54 charts were screened and retrospectively reviewed, of which 42 patients had screened positive for trauma. Baseline data were collected using a modified Harvard screening questionnaire, which identified the prevalence of posttraumatic symptoms (PTS) and clinical characteristics of these young patients. Results: The overall prevalence of positive trauma history was 78 percent. The most prevalent trauma was physical abuse at 30 percent, sexual at 24 percent, emotional at 13 percent, and neglect at six percent. The most prevalent PTS were anger, sleep, detachment, and avoidance. Half of the patients screened resulted with anger symptoms associated with trauma. These symptoms primarily meet DSM-5 criteria B and C for PTSD. Of patients who screened positive for trauma, 83 percent of patients presented with a mood disorder, including bipolar disorder, major depressive disorder (MDD), and disruptive mood dysregulation disorder(DMDD). Based in our findings, there is a higher percentage of patients who present with substance abuse diagnosis, psychotic disorder, and reactive Attachment. Patient with the diagnosis of ADHD and conduct disorder (CD) had the same prevalence in the general population as the trauma population. Our findings indicated that there is a discrepancy in how PTS are treated in the inpatient unit. Only 19 percent of patients who were screened had prior treatment, and only 15 percent of patients’ PTS were addressed upon discharge. Caregiver support also played a major role in patients presenting symptoms. Conclusions: The prevalence of trauma in our population was high at 78 percent. Patients presenting with these symptoms can be treated with a combination of cognitive behavioral therapy and medications. Identifying trauma and addressing it on the in-patient Child and Adolescent unit may have future implications in preventing progression of psychiatric symptoms and improving quality of life.

R Supported by the Bronx Lebanon Hospital Center http://dx.doi.org/10.1016/j.jaac.2017.09.270

4.55 EFFECTS OF TRAUMA ON CHILDREN IN THE GREAT LAKES REGION OF AFRICA Kaitlin Budnik, MD, George Washington University, kaitlin. [email protected]; Suzan Song, MD, MPH, PhD, George Washington University Hospital, [email protected] Objectives: The Great Lakes Region of Africa, specifically Rwanda, The Democratic Republic of Congo, and Burundi, have endured years of conflict beginning with the genocide taking place in 1994 between the Hutus and Tutsis. During that time, estimates of up to one million Rwandese were killed and many were displaced. Studies at the time estimated that 94 percent of people in Rwanda experienced at least one genocide event (witnessing murder of family members, having property or homes destroyed, and having lives threatened). Children became soldiers, and many girls and women were raped. Children were often orphaned as a result of the fighting. HIV became a weapon of war across the region, causing many births of children with the disease. Studies began to emerge soon after demonstrating high prevalence rates of PTSD,

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depression, and prolonged grief. The fighting continues in many parts of the region to this day, which continues to amplify pathological symptoms of trauma. Methods: A literature search of several databases on the key words of mental health and coping combined with each of Rwanda, Burundi, and Democratic Republic of the Congo was conducted. All primary literature sources published after 2000 in English pertaining to these topics were included and analyzed. Results: A review of the literature examines what we know about the posttraumatic symptoms that remain among this population and also highlights the resilience that victims and perpetrators alike have demonstrated. In multiple studies examining this population, the reported prevalence of PTSD ranges from 10 to 54 percent. Conclusions: Based on these results, nearly a quarter of a century later, evidence exists that posttraumatic symptoms among children remain higher in the Great Lakes Region than in many other parts of the world. There is much to learn about trauma and resilience from this area of the world, which has endured such a horrific past.

COPI, OTH http://dx.doi.org/10.1016/j.jaac.2017.09.271

4.56 PREVALENCE OF ANGER IN THE CHILD ADOLESCENT INPATIENT POPULATION WITH POSITIVE TRAUMATIC EXPERIENCE AND ASSOCIATED COMORBIDITIES: PERFORMANCE IMPROVEMENT PROJECT Aos Mohammed Ameen, MD, Bronx-Lebanon Hospital Center at Icahn School of Medicine at Mount Sinai, [email protected]; Monica Badillo, MD, Bronx-Lebanon Hospital Center at Icahn School of Medicine at Mount Sinai, [email protected]; Viviana Chiappetta, MD, BronxLebanon Hospital Center, [email protected]; Wen Gu, PhD, Bronx-Lebanon Hospital Center, WGu@ bronxleb.org; Michelle Kohut, LCSW, Bronx-Lebanon Hospital Center, [email protected]; Muhammad Zeshan, MD, Bronx-Lebanon Hospital Center, [email protected]; Pankaj Manocha, MD, Bronx-Lebanon Hospital Center at Icahn School of Medicine at Mount Sinai, [email protected]; Luisa Gonzalez, MD, Bronx-Lebanon Hospital Center, [email protected]; Panagiota Korenis, MD, BronxLebanon Hospital Center and Albert Einstein College of Medicine, [email protected] Objectives: The goals of this presentation are to determine the prevalence of traumatic experience in a child adolescent inpatient psychiatric unit, to better understand the overlapping anger or hyperarousal state between posttraumatic experience and other psychiatric disorders, and to learn about the most common associated psychosocial comorbidities with anger in the posttraumatic patient population and improve detection and management of posttraumatic pathologies. Methods: A performance improvement project was conducted in an urban inner city hospital on all newly admitted child and adolescent patients to inpatient psychiatry service over a two-month time period; a total of 54 patients were screened using a modified screening tool. Charts were reviewed retrospectively, of which 42 patients screened positive for trauma; baseline data were collected that identified the prevalence of anger severity and commonly associated comorbidities. Results: The screened population (78%) reported positive traumatic experience; physical abuse and sexual abuse were the highest reported forms of trauma, and anger was the highest reported symptom, highly associated with daily level of distress and lack of social and family support. The patients (34%) who reported positive trauma reported a positive suicide history; all of them had reported positive anger with different severity. Patients (41%) who reported positive trauma also had comorbid sleep problems, and all of them

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had reported anger with different severity. Trauma experience was addressed in only four percent of patient before screening. Conclusions: The prevalence of trauma in our child and adolescent population was higher than the national average report at 78 percent; posttraumatic symptomology is highly overlapping with other psychiatric comorbidities and underappreciated in our inpatient population. Anger and sleep problems were the highest and mostly associated with fatal comorbidity such as suicide behavior.

ICP, S http://dx.doi.org/10.1016/j.jaac.2017.09.272

4.57 DESTINED FOR A DREARY COURSE: DOES POSTTRAUMATIC STRESS DISORDER SEVERITY IMPACT LENGTH OF STAY IN PEDIATRIC PSYCHIATRIC INPATIENTS? Anastasia M. Pemberton, MD, University of Texas Health Science Center at Houston, [email protected]. edu; Isha R. Jalnapurkar, MD, University of Texas Health Science Center at Houston, [email protected]; Pratikkumar Desai, MD, MPH, University of Texas Health Science Center at Houston, [email protected]. edu; Alexandra N. Duran, University of Texas Health Science Center at Houston, [email protected]; Zachary J. Sullivan, DO, University of Texas Health Science Center at Houson, [email protected]; Dana W. Hipp, MD, University of Texas Health Science Center at Houston, Dana. [email protected]; Serena Mammen, University of Texas Health Science Center at Houston, serena.mammen@uth. tmc.edu; Mary Clare Bruce, BA, The Harris Center for Mental Health and IDD, [email protected]; Iram Kazimi, MD, University of Texas Health Science Center at Houston, iram.f. [email protected]; Cristian Zeni, MD, PhD, University of Texas Health Science Center at Houston, cristian.p.zeni@uth. tmc.edu; Teresa Pigott, MD, University of Texas Health Science Center at Houston, [email protected] Objectives: Several studies suggest that PTSD symptoms are common in children and adolescents hospitalized for acute mental illness yet relatively few studies have examined the potential impact of PTSD symptoms on hospital course. With this in mind, the current study investigated the prevalence and demographic variables associated with PTSD symptoms in pediatric patients admitted to an acute inpatient unit as well as the potential relationship between PTSD symptom severity and hospital course, recidivism rates, and suicidality. Methods: The study sample consisted of children and adolescents (N ¼ 102, aged 8-17 years) admitted to an acute psychiatric facility with a primary mood, psychotic, or disruptive behavioral disorder. The patients (mean age + SEM, 13.3 + 0.25 yr.) completed the Child PTSD Symptom Scale (CPSS), a 24-item standardized self-report measure of PTSD symptom severity. The total CPSS score range is 0-51 (total score >15 ¼ high; total score < 15 ¼ low). The potential relationship between total PTSD scores (CPSS) and identified demographic (age, race, gender) and clinical course [length of stay (LOS), diagnosis, suicidality, number of previous admissions] variables were then examined using independent sample t-tests and Chi-square tests. An independent sample t-test was also used to investigate the potential association between PTSD severity (High vs. Low group) and the same demographic and clinical course variables. Results: The mean CPSS scores for the children and adolescent patients was 21.1 (R ¼ 0-94; SEM 1.66); moreover, 63.7 percent (65/102) had scores consistent with high PTSD symptom severity. In addition, high PTSD symptom severity was associated with an increased LOS (p ¼ 0.05) compared to low. No significant relationships were detected between total PTSD symptoms scores or PTSD symptom severity and suicidality or the identified demographic or other clinical variables (diagnosis, recidivism). Conclusions: While preliminary, these results suggest that nearly two thirds of children and adolescents acutely hospitalized with a primary mood, psychotic,

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or disruptive behavioral disorder have a high level of PTSD symptom severity and this in turn is associated with an increased LOS.

ICP, S Supported by the 2015 APA Resident Research Psychiatric Scholars Fellowship http://dx.doi.org/10.1016/j.jaac.2017.09.273

4.58 ASTHMA AND OBESITY IN PUERTO RICAN YOUTH WITH POSTTRAUMATIC STRESS DISORDER (PTSD) Nuria A. Sabat e, MD, Ponce Research Institute, nsabate@ psm.edu; Ann Maldonado-Vazquez, MD, Ponce Health Sciences University, [email protected]; James Porter, PhD, Ponce Research Institute, jporter@psm. edu; Elsa B. Cardalda, PhD, Ponce Research Institute, [email protected]; Jos e V. Martınez, PhD, Ponce Research Institute, [email protected]; Pedro A. Castaing, MD, Ponce Research Institute, [email protected] Objectives: PTSD has been linked to the presence of other psychiatric and systemic pathologies. In Puerto Rican children, there is a high rate of both bronchial asthma and obesity, both of which have been associated with trauma exposure. There was a high frequency of reported pediatric pathologies in our previous study done with Puerto Rican youth who had been exposed to trauma and were receiving psychiatric services. The objective of this post hoc analysis is to identify the prevalence of asthma and obesity in a sample group of Puerto Rican youth with PTSD. Methods: A total of 246 medical charts of patients who met criteria for PTSD in our previous study were reviewed for documentation of bronchial asthma. BMI was calculated from data found in the medical charts. The presence of PTSD was defined by a score of 15 or more on the Child PTSD Symptom Scale (CPSS). Results: Bronchial asthma was found in 31 percent of the sample group. The high frequency of bronchial asthma documented contrasted with a previously reported prevalence of asthma (14%) in nonclinical youth population in Puerto Rico. In addition, a high prevalence of obesity was found (24%). This was found by calculating BMI using data documented in charts. However, documentation of a diagnosis of obesity was found in only one chart. An interesting finding was that male subjects presented with significantly more pediatric comorbidities (P < 0.02) than females. Conclusions: Our findings suggest that PTSD commonly occurs with bronchial asthma and obesity in our clinic, thus contributing to health disparities in this underserved population. Our findings of high frequencies of comorbid bronchial asthma and obesity are consistent with previous reports in trauma-exposed youth and testify to the multidimensional nature of trauma effects in the pediatric population. The significantly higher number of comorbidities in males may signal the impact of gender differences in pediatric comorbidities and warrant appropriate screening and preventive interventions in this at-risk population.

CM, OBE Supported by National Institute on Minority Health and Health Disparities Grant G12MD007579, the Ponce Health Sciences University Behavioral Research and Integrative Neuroscience Core, the Ponce Research Institute, the Puerto Rico Clinical and Translational Research Consortium Award 054MD007587-05, and the National Center for Advancing Translational Sciences Grant UL1TR000114 http://dx.doi.org/10.1016/j.jaac.2017.09.274

4.59 IMPROVING OUTCOMES FOR HOSPITALIZED CHILDREN AND ADOLESCENTS WITH SOMATIC SYMPTOM AND RELATED DISORDERS Valentina Cimolai, MD, Children’s National Medical Center, [email protected]; Finza Latif, MD, Children’s National Medical Center, fi[email protected] Objectives: Somatic symptom and related disorders (SSRD) is a clinical presentation where presenting physical symptoms or impairment cannot be fully explained by an identifiable physical disease and are driven by a psychological


process. The research and clinical literature on treatment of these disorders is limited and recommends a multidisciplinary approach with early involvement of psychiatry and/or psychology. However, in the absence of standardized treatment guidelines and published expert opinions, SSRD management varies between clinicians. Children and adolescents admitted to medical units with SSRD can be challenging for medical providers, and often psychiatry or psychology is consulted much later during admission once all medical investigations are completed. As a result, families often feel that they are being “handed off” by their providers and have low buy-in for psychological treatment. We conducted a survey to assess the current practices followed by providers at Children’s National Health System (CNHS) and whether a clinical pathway was needed to standardize the care of these patients. Methods: In February 2016, a 10-question online survey was emailed to the entire staff working at CNHS in Washington, DC. A total of 128 people completed the survey, of which 42 were physicians and 62 were nurses. Results: Providers (37%) were not familiar with the SSRD diagnosis, and 20 percent were only “somewhat familiar” only 11 percent of providers consulted psychiatry or psychology “always,” whereas 50 percent consulted psychiatry “sometimes.” Providers (13%) never communicated with outpatient providers, and 55 percent never communicated with schools before discharge. Ninetytwo percent of those surveyed felt that a protocol to guide management of patients with SSRD would be helpful. Conclusions: Less than half the hospital staff members at CNHS are familiar with the diagnosis of SSRD. Psychology and psychiatry are not always consulted on these cases, and there is lack of care coordination during hospitalization and upon discharge. Majority surveyed felt that a clinical pathway to help educate and guide providers on how to assess and treat SSRD in the inpatient setting effectively would be helpful. Based on this feedback a clinical pathway was developed in collaboration with physical medicine and rehabilitation, psychology, psychiatry, neurology, and child life.

MC, CON, SOM http://dx.doi.org/10.1016/j.jaac.2017.09.275

4.60 BORDERLINE PERSONALITY FEATURES IN ADOLESCENTS AND THEIR IMPACT ON CLINICAL OUTCOME Parna R. Prajapati, MD, MPH, University of Texas Southwestern Medical Center, [email protected]; Brandon Oscarson, University of Texas Southwestern Medical Center, [email protected]; Lindsey Jenkins, BA, University of Texas Southwestern Medical Center, [email protected]; Aleksandra Foxwell, PhD, University of Texas Southwestern Medical Center, [email protected]; Betsy D. Kennard, PsyD, University of Texas Southwestern Medical Center, [email protected]; Graham J. Emslie, MD, University of Texas Southwestern Medical Center, [email protected] Objectives: The current study’s aim is to examine the impact of borderline personality symptoms on clinical characteristics and treatment outcome in a sample group of suicidal adolescents being treated in an intensive outpatient program. Methods: Data were collected from an intensive outpatient program (IOP) for suicidal adolescents. Participants were between the ages of 13 and 17 years and presented for treatment after a recent suicidal attempt or severe worsening of suicidal ideation not meeting the inpatient admission criteria. The sample group for this research study included all participants who completed Borderline Personality Features Scale in Children (BPFSC)-11 between August 2015 and December 2016. BPFSC-11 is a shortened form of the original BPFSC developed from Personality Assessment Inventory (PAI). Demographic data (age, gender, ethnicity, race) and clinical (number of attempts, nonsuicidal selfinjury) characteristics were measured as part of a larger battery of intake measures. At baseline, all patients completed Concise Health Risk Tracking Scale Self-Report (CHRT-SR) and Quick Inventory of Depressive Symptomatology Self-Report (QIDS-SR, 16 items). Borderline personality symptoms as measured

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by the BPFSC-11 scale were divided into two groups, those with a score of 34 and above (BPD+) and those with a score of 33 and below (BPD). Results: In total, 186 participants were included in this study. Of these, 109 were BPD+ and 77 were BPD-. The majority of patients who were BPD+ were female (77.1%, n ¼ 65) and non–Hispanic (89.9%, n ¼ 87). Likewise, the majority of patients who were BPD were female (71.4%, n ¼ 39) and non–Hispanic (77.9%, n ¼ 46). The mean age of those BPD+ was 15.141.35 versus 14.7 1.33 of those BPD-. The average baseline QIDS score for those with BPD+ was 16.70 5.48 versus 10.77 6.19 of those with BPD. The average baseline chart score for those in the BPD+ was 33.19 9.17 versus 20.66 9.56. We will examine outcomes of patients with high and low borderline personality symptoms and the changes in suicidality during the course of treatment. Conclusions: The findings of this study demonstrate the importance of assessing BPD features among adolescents and presents variation in characteristics of patient with and without strong BPD personality traits.

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Objectives: This study was designed to document the two-year course of axis I disorders in children recently (within the last 12 months) diagnosed with epilepsy compared with healthy control subjects. We investigated risk factors associated with these psychiatric comorbidities at baseline and at two-year follow-up. The factors analyzed include gender, family history of psychopathology, age, full-scale IQ, type of epilepsy syndrome, age of onset of seizures, and current antiepileptic drug (AED) treatment. Methods: The sample group consisted of 105 children with recent onset of epilepsy (56 focal and 49 generalized seizures) and 73 healthy control subjects. Participants were ages 8–18 years. The child and parents participated in a psychiatric interview using the Kiddie Schedule for Affective Disorder and Schizophrenia (KSADS) to identify current axis I disorders. Child participants also engaged in cognitive testing at times 1 and 2. Results: Children with epilepsy had higher rates of axis I disorders than healthy control subjects at the time of epilepsy diagnosis, and this pattern held two years later. Healthy control subjects (23%) were diagnosed with an axis I disorder at baseline compared with 59 percent of children with epilepsy. At time 2, 21 percent of healthy control subjects were identified as having an axis I disorder compared with 51 percent of the epilepsy group. Specific breakdowns of each diagnosis will be provided. Risk factors for chronic axis I disorders included epilepsy, younger age, and family history of psychopathology. In the epilepsy group, children with focal epilepsy were at increased risk for axis I disorders compared with children with generalized epilepsy. Age of seizure onset, current use of AEDs, and time since last seizure were not significant predictors for axis I disorders. Conclusions: The course of psychiatric comorbidities in children with recent onset epilepsy is not well understood. It is becoming increasingly clear that these children are at significant risk for axis I disorders, symptoms of these comorbidities are present at time of epilepsy diagnosis, and these symptoms do not alleviate over time or with control of seizures. Consistent with data previously reported in the literature, children with focal epilepsy are at higher risk for any axis I disorder over time.


4.61 STEROID-INDUCED PSYCHOSIS IN THE PEDIATRIC POPULATION: A NEW CASE AND REVIEW OF THE LITERATURE Gabrielle E. Hodgins, University of Miami Miller School of Medicine, [email protected]; Samantha B. Saltz, MD, University of Miami Miller School of Medicine and Jackson Memorial Hospital, [email protected]; Rolando Gonzalez, MD, University of Miami Miller School of Medicine and Jackson Memorial Hospital, rolando. [email protected]; Judith Regan, MD, JD, MBA, University of Miami Miller School of Medicine and Jackson Memorial Hospital, [email protected]; Charles Nemeroff, MD, PhD, University of Miami Miller School of Medicine, [email protected] Objectives: Iatrogenic steroid-induced psychosis is a rare but serious adverse side effect seen largely in the adult population that less commonly affects children and adolescents. Given the significant amount of distress that steroidinduced psychosis causes patients, families, and treating physicians, recommendations are needed for effective management. A systematic review was conducted in the context of reporting a case of steroid-induced psychosis in a child aged 12 years. Methods: A systematic search was performed using Embase, PubMed, Scopus, and PsycInfo. Key terms included the following: “steroid induced” or “corticosteroid induced” or “glucocorticoid induced”; and “psychosis” or “hallucinations” or “delusions”; and “child” or “adolescent” or “pediatric.” Reports of steroid-induced psychosis that did not include treatment were excluded from review. A total of 15 cases of steroid-induced psychosis in children and adolescents were found in the scientific literature. This report includes those cases and a case of steroid-induced psychosis treated at Jackson Memorial Hospital and University of Miami. Results: Children with asthma, autoimmune diseases, and cancer have been reported to experience steroid-induced psychosis. The mean age of children with steroid induced psychosis was 12 3.6 years, and these children were treated with steroids for a broad range of conditions, including autoimmune disease, cancer, and asthma. Our team presents a case of steroid-induced psychosis in a patient (age 12 years) diagnosed with discoid-type lupus erythematosus. Within days of treatment with 40 mg prednisone daily, this patient began to drool, became mute, and was responding to internal stimuli. Treatment was difficult, secondary to the acute exacerbation of lupus requiring ongoing therapy. It was initially unclear whether the acute psychosis was a manifestation of lupus, a side effect of medication, or a combination of the two risk factors. Neurology consultation ruled out lupus cerebritis. Psychosis was treated with 5 mg of haloperidol. Psychosis did not resolve until the steroid taper was complete. Conclusions: Given the common use of glucocorticoid therapy in children, it is important that physicians and parents recognize the signs of steroidinduced psychosis and are aware of the data on treating this complication.

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4.62 PREVALENCE AND RISK FACTORS OF PSYCHIATRIC COMORBIDITIES IN CHILDREN WITH RECENT-ONSET EPILEPSY Alanna Kessler-Jones, PsyD, University of Wisconsin Madison, [email protected]; Jana E. Jones, PhD, University of Wisconsin - Madison, jejones@ neurology.wisc.edu; Dace Almane, BA, University of Wisconsin - Madison, [email protected]; Bruce Hermann, PhD, University of Wisconsin - Madison, [email protected]

EP, AD, DDD Supported by National Institute of Neurological Disorders and Stroke Grant 3RO1 44351 http://dx.doi.org/10.1016/j.jaac.2017.09.278

4.63 OPTIMISM, SHAME-PRONENESS, AND GUILT-PRONENESS: PREDICTORS OF CD4 AND VIRAL LOAD AMONG YOUTH LIVING WITH HUMAN IMMUNODEFICIENCY VIRUS (HIV)? David G. Prado, DO, Drexel University College of Medicine, [email protected]; Jill Hersh, PsyD, St. Joseph Hospital, SCL Health, [email protected]; Jill Foster, MD, Gilead Sciences, Inc., [email protected]; David S. Bennett, PhD, Drexel University College of Medicine, David. [email protected] Objectives: This study examined optimism, shame proneness, and guilt proneness as predictors of physical health biomarkers (CD4 and viral load counts) among youth living with HIV.

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Methods: Participants comprised 99 youths living with HIV (57% male; age 8–24 years, mean age ¼ 17.4 years, SD ¼ 3.8; 62% African American). Youth completed measures of optimism, shame proneness, and guilt proneness during a regularly scheduled HIV clinic visit. CD4 and viral load counts were recorded during the following 12 months to test the hypotheses that: 1) optimism and guilt proneness would predict higher CD4 and lower viral load counts; and 2) shame proneness would predict lower CD4 and viral load counts. Mixed-model analyses were conducted controlling for age, maternal education, medication (highly active antiretroviral therapy) status, and gender to test study hypotheses. Results: Optimism predicted lower viral load (P ¼ 0.006) as hypothesized. The effect of optimism, however, was moderated by time (P ¼ 0.011) as optimism only predicted lower viral load in the first six months following study entry. A nonsignificant trend was observed for guilt proneness to predict lower viral load (P ¼ 0.070). The only significant predictor of CD4 was age, as older youth had lower CD4 counts (P ¼ 0.014). In addition, nonsignificant trends were found for optimism (P ¼ 0.080) and guilt proneness (P ¼ 0.093) to predict higher CD4 counts, consistent with hypotheses. Conclusions: The current findings suggest that, among youth living with HIV, optimism may be an important protective factor for slowing disease progression, perhaps through increasing adherence and support seeking, as well as by providing a buffer against depression. Future research is needed to assess potential mediators and mechanisms that explain this relationship.

AIDS http://dx.doi.org/10.1016/j.jaac.2017.09.279

4.64 THE IRRITABILITY INVENTORY: ASSESSING THE PHASIC ASPECT OF IRRITABILITY TO BETTER PREDICT BEHAVIOR IN THE HOSPITAL Briana Locicero, BA, Stony Brook University School of Medicine, [email protected]; Gabrielle A. Carlson, MD, SUNY at Stony Brook, Gabrielle. [email protected]; Peng Pang, MD, Stony Brook University Hospital, [email protected]; Daniel N. Klein, PhD, Stony Brook University Hospital, daniel.klein@ stonybrook.edu Objectives: With our attempts to understand mania in children, irritability has become an intense focus of research. If there is a tonic aspect of irritability (how a person feels) and a phasic aspect (what he does), the Affective Reactivity Index (ARI) measures the former and has been validated against several other rating scales. There are few measures of what the child does. We developed a brief measure (the Irritability Inventory – IRRI) that specifically targets anger outbursts, and addresses outburst triggers, behavior, duration, and frequency. This study compares parent responses on the IRRI to parent measures of irritability (ARI), oppositional defiance symptoms (ODD), subscales from the Strength and Difficulties Questionnaire (SDQ) and total score on the Child Mania Rating Scale (CMRS), as well as to PRNs that occur on the inpatient unit. Methods: The sample group comprised of psychiatrically hospitalized children (N ¼ 142, mean age ¼ 9.8, 75% male, 72% admitted for outbursts). PRN interventions (seclusions and medication administration) were used as a measure of frequency and severity of outbursts. The IRRI behavior items were correlated with other measures and used to predict outbursts as a reason for admission, as well as number of PRNs in hospital. Results: The IRRI was significantly negatively correlated with age (r ¼ -0.241) and positively correlated with scores on the following rating scales: the ARI (r ¼ 0.667), ODD symptoms (r ¼ 0.553), CMRS (r ¼ 0.519), and SDQ conduct (r ¼ 0.528) and hyperactivity subscales (r ¼ 0.379), whereas it was not correlated with the SDQ emotional subscale (r ¼ 0.133). It was the only measure that correlated with number of PRNs per day (r ¼ 0.223, p ¼ 0.008). Children admitted for outbursts were significantly more likely to have them in hospital (OR 3.868, 95% CI 1.761, 8.498), and the IRRI, not ARI, predicted why a child was hospitalized (p < 0.001); however, none of the measures predicted number of PRNs in hospital. Conclusions: Although irritable mood is an important construct, it does not appear to be as important as the subsequent behavior in terms of what gets a child hospitalized. Lack of prediction of parent measures to actual behavior in the hospital has been observed before and may represent the relatively low


correlation between informant measures, or the impact of hospitalization, on behavior.

ICP, RI, IMD http://dx.doi.org/10.1016/j.jaac.2017.09.280

4.65 DEMOGRAPHIC AND EMOTIONAL BEHAVIORAL PREDICTORS OF EMOTION IDENTIFICATION ACCURACY Hannah E. Frering, BS, Larner College of Medicine at the University of Vermont, [email protected]; Merelise Ametti, BA, Larner College of Medicine at the University of Vermont, [email protected]; Michelle A. Thompson, BA, Larner College of Medicine at the University of Vermont, [email protected]; Robert R. Althoff, MD, PhD, Larner College of Medicine at the University of Vermont, [email protected] Objectives: The purpose of this research is to investigate differences in emotion identification accuracy between children with elevated symptoms on subscales of the Child Behavior Checklist (CBCL)-Dysregulation Profile (DP) as it relates to symptoms of social problems. Methods: Participants (N ¼ 240) aged between seven and 17 years were included in the sample group. A three-step hierarchical linear regression analysis was used to examine the relationship between CBCL–DP and social problems as they relate to emotion identification accuracy, measured using responses to a morphed faces identification task wherein children were instructed to label the faces as happy, disgusted, angry, or scared. We examined accuracy scores summed across these emotions. Step 1 of the model included demographic predictors (age, socioeconomic status, sex, and IQ). The sum of the t-score on subscales that make up CBCL-DP (anxious/ depression, attentional problems, and aggressive behavior) was entered in step 2, and the CBCL-Social Problems scale was included in step 3. Results: The overall model was significant. The demographic information, specifically age and IQ, as well as social problems, were significant predictors of emotion identification accuracy. In particular, older age and higher IQ were associated with greater accuracy, whereas higher scores on the social problems scale were associated with decreased accuracy. The DP scales did not significantly contribute to the model. Conclusions: In this model, age and IQ had positive effects on emotion identification accuracy over CBCL-DP symptoms. However, CBCL social problems predicted poorer performance on the task. Although previous research has confirmed that dysregulated children perform more poorly on emotion identification tasks, this model suggests that the social problems associated with the Dysregulation Profile were the most predictive of poor emotion identification rather than the profile itself.

IMD, DEMF, OTH Supported by NIMH Grant K08MH082116 and National Institute of General Medical Sciences Grant P20GM103644 http://dx.doi.org/10.1016/j.jaac.2017.09.281

4.66 INVESTIGATING HOW IRRITABILITY ACROSS DEVELOPMENT IS RELATED TO BRAIN STRUCTURE IN MIDDLE CHILDHOOD Jessica F. Sachs, BS, National Institutes of Health, jessica. [email protected]; Courtney A. Filippi, PhD, National Institutes of Health, courtney.fi[email protected]; Katharina Kircanski, PhD, National Institutes of Health, [email protected]; Jenni Pacheco, PhD, Neuroimaging National Intrepid Center of Excellence, [email protected]; Andrea L. Gold, PhD, National Institute of Mental Health, andrea.gold@ nih.gov; Chad Michael Sylvester, MD, PhD, Washington University in St. Louis School of Medicine, sylvestc@ psychiatry.wustl.edu; David Pagliaccio, PhD, National Institute of Mental Health, [email protected];

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Rany Abend, PhD, National Institute of Mental Health, rany. [email protected]; Nathan A. Fox, PhD, University of Maryland, [email protected]; Daniel S. Pine, MD, National Institute of Mental Health, [email protected]; Ellen Leibenluft, MD, National Institute of Mental Health, [email protected] Objectives: There has been increasing scientific focus on irritability in youth, as it is a common dimensional trait in both typical and atypical development. However, little is known about the developmental trajectory of irritability or how irritability relates to cortical thickness and gray matter volume (GMV). This study examines irritability trajectories from toddlerhood to middle childhood and the relationship between irritability and brain structure. To date, this is the first study to examine cortical thickness in youth with irritability. Methods: Families (N ¼ 96) reported irritability symptoms at ages 2, 3, 4, 5, 7, 9, and 12 years using an irritability composite score from the Child Behavior Checklist. MRIs were obtained from the youths at either age 9 or 12. Measures obtained from Freesurfer software examined GMV in hippocampal and amygdala regions of interest (ROIs) and cortical thickness in vertex-wise analyses, whole-brain corrected (P < 0.05). Results: Using latent class growth analysis, we tested group models of trajectories of irritability. Based on our requirement of at least one percent of the sample in each trajectory group, a four-group probabilistic model was selected as the best-fitting model, suggesting that there are four developmental trajectories of irritability in our sample. These trajectory groups were as follows: High-Stable (n ¼ 15); High-Low (n ¼ 38); Low-High (n ¼ 2); and LowStable (n ¼ 41). We examined whether cortical thickness (or GMV) varied as a function of irritability controlling for age. We found that the High-Stable group had thicker superior parietal cortex compared with the Low-Stable group. The High-Stable and High-Low groups were not significantly different from one another. There were no differences in GMV. Conclusions: The present study identified four trajectories for the developmental time course of irritability from infancy to middle childhood. We show differences in superior parietal cortex thickness between individuals with highstable irritability compared to those with low-stable irritability. These findings suggest that children with high-stable irritability may show distinct brain morphometry from individuals low in irritability. Replication and extension of these findings could provide novel evidence about the differences between normative and clinical irritability.

IMAGS, IMD, DEV Supported by NIMH Intramural Research Program, NIMH Grant R01 MH074454, and the Eunice Kennedy Shriver National Institute of Child Health and Human Development Grant R01 HD017899 http://dx.doi.org/10.1016/j.jaac.2017.09.282

4.67 POTENTIAL MENTAL HEALTH BENEFITS OF A BREAKDANCING PROGRAM FOR INNER-CITY YOUTH: A PILOT STUDY Marina Post, MD, Stanford University, [email protected]; Christine Blasey, PhD, Stanford University, cblasey@ stanford.edu Objectives: Few studies have examined breakdancing as a feasible mode for improving mental health among inner city youth. This pilot study describes potential health benefits of a breakdancing program offered in an inner-city youth service organization called Youth Advocates (YA). Methods: Young adults (n ¼ 73) completed surveys at a breakdancing event at a YA site on a weekly basis. Surveys included Messer and Harter’s Self-Perception Profile for Adults and Neemann and Harter’s Self-Perception Profile for College Students. Descriptive data regarding benefits of breakdancing and YA were tabulated. Linear regression models tested potential correlates of years of participation in breakdancing and self-reported benefits of breakdancing and YA. Predictor variables included the following: 1) age; 2) ethnicity (Asian, Black, and Hispanic); 3) parent education; 4) self-perception of sociability; 5) athleticism; 6) physical fitness; 7) intelligence; 8) humor; 9) self-worth; and 10) creativity. Results: Respondents (n ¼ 73) were primarily breakdancers (92%), male (78%), Hispanic (40%), Black (23%), and of Asian (15%) ethnicities. The predominant

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age range was 18–23 years; predominant range for the number of years breakdancing was 3–6 years; and predominant range for attending YA was 3–6 years. Reported benefits of breakdancing included enjoyment (on a scale from 1 to 5) as follows: 1) breakdancing (mean ¼ 4.8, SD ¼ 0.7); 2) creating breakdancing moves (mean ¼ 4.5, SD ¼ 1.1); 3) breakdance battles (mean ¼ 4.1, SD ¼ 1.2); 4) breakdancing in front of other people (mean ¼ 4.0, SD ¼ 1.3); and 5) being good at breakdancing (mean ¼ 3.3, SD ¼ 1.3). Reported benefits of YA participation were as follows: 1) helping youth to be creative (mean ¼ 4.6, SD ¼ 0.9); 2) feeling good about themselves (mean ¼ 4.5, SD ¼ 0.9); 3) getting along with others (mean ¼ 4.5, SD ¼ 0.9); 4) exercising more (mean ¼ 4.5, SD ¼ 1.0); 5) performing in front of others (mean ¼ 4.5, SD ¼ 0.9); 6) learning about being healthy (mean ¼ 4.2, SD ¼ 1.1); 7) dealing with difficult feelings (mean ¼ 4.1, SD ¼ 1.2); 8) learning how people think (mean ¼ 3.9, SD ¼ 1.2); and 9) doing better in school (mean ¼ 3.7, SD ¼ 1.4). Higher self-worth (b ¼ 0.47, t ¼3.4) and Black ethnicity (b ¼ 0.37, t ¼ 2.6) were associated with greater perceived breakdancing benefit. Hispanic ethnicity was a positive correlate of years participating in YA (b ¼ 0.44, t ¼ 3.1). Conclusions: Youth adults participate and feel positively about breakdancing and YA. This program exemplifies a feasible program that can potentially enhance the physical and mental health of ethnic minority youth.

ADOL, PRE http://dx.doi.org/10.1016/j.jaac.2017.09.337

4.68 BARRIERS AND FACILITATORS TO MENTAL HEALTH SERVICE ACCESS AMONG YOUNG REFUGEES: A LOOK AT THE LITERATURE Mehvesh Khan, MD, St. George’s University, mehveshk@ gmail.com; Aziz Shafqat, MD, St. George’s University, [email protected] Objectives: There is limited research on the barriers and facilitators to accessing mental health services among refugee youth. This study elucidates the barriers and facilitators to mental health service access among refugee youth in the hope that it will allow clinicians to provide effective mental health care to this population. Methods: A literature search using PsycInfo was conducted. Search terms included “refugees” and “mental health” and “barriers” or “obstacles” or “challenges.” The results were further narrowed down by looking only at articles published from 2010 to 2017. Furthermore, only studies that included or focused on refugees aged 18 years were included. Using these parameters, a total of 10 articles were obtained. Relevant information was also derived from reference lists of the retrieved publications. Results: Although the study methodologies and reviewed results are heterogeneous, they found similar barriers and facilitators to mental health access in our study population. The main barriers to access to mental health services identified across the multiple studies were self stigma, negative portrayal of psychiatry, distrust of authority, financial deterrents to access, lack of mental health literacy, and lack of information concerning mental health services available. Facilitators to mental health services were identified as time spent in host country, community support, mental health literacy, involvement of primary care physicians and schools, perceived expertise of mental health provider, explaining and maintaining confidentiality, allowing time to develop trust, service availability and access, and understanding the ethno-cultural backgroundof the refugees. Conclusions: This review aims to raise awareness of the obstacles to mental health access for youth refugees and facilitators for success. There are numerous barriers which are unique to the youth refugee population and as such requires unique methods to overcome. This population of patients is becoming more prevalent with the current state of unrest in the world. By being aware of the obstacles they face we can be better equipped to handle their unique situation.

ADOL, PUP, RF http://dx.doi.org/10.1016/j.jaac.2017.09.406

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NEW RESEARCH POSTER SESSION 5 5.1 RAGE-CONTROL: TEACHING EMOTIONAL SELF-REGULATION THROUGH VIDEOGAME PLAY Carrie Vaudreuil, MD, Massachusetts General Hospital, [email protected]; Yvonne Chasser, MD, Massachusetts General Hospital, [email protected]; Christian Hoover, BA, Massachusetts General Hospital, [email protected]; Lauren Jacobs, BS, Massachusetts General Hospital, [email protected]; Dina R. Hirshfeld-Becker, PhD, Massachusetts General Hospital, [email protected] Objectives: Relaxation training is used to help youth manage anger; however, skills do not always generalize. RAGE-Control is a videogame intended to help generalize relaxation skills to frustrating situations. The game involves shooting asteroids. The active condition requires youth to keep their heart rate at a relaxed level to be able to shoot. In the sham condition, youth can continue shooting regardless of heart rate. The game was previously found to augment the efficacy of CBT for anger control. Here we examine whether RAGE-Control with basic instruction in relaxation techniques only can reduce symptoms of anger and aggression in youth. Methods: Subjects with high parent-reported anger participated in six 30minute sessions where they learned relaxation techniques and were randomized to play either the active or sham videogame. Data were collected at baseline, two weeks posttreatment (PT), and at three-month follow-up (FU) by a rater blinded to treatment condition. Results: Data are available for the first 27 completers. Youths ranged from 7 to 17 years (mean ¼ 10.76 years, SD ¼ 2.49), and 76 percent were male. Mean Clinical Global Impression (CGI)-Severity score on anger/aggression was 4.0, and mean Child Behavior Checklist (CBCL) externalizing score was 65.5 (SD ¼ 7.2). All but two had ADHD. Groups did not differ in age, gender, CBCL, or CGI-Severity. Youth assigned to sham were more likely to meet full criteria (vs. subthreshold) for ODD, and those assigned to active were more likely to have major depression. At PT, mean CGI-Improvement differed significantly between groups [Active, n ¼ 13, 2.54 (SD ¼ 0.96); sham, n ¼ 14, 3.57 (SD ¼ 2.87); t ¼ 2.42, P ¼ 0.023]. At FU, active maintained their CGI-I [n ¼ 12, 2.75 (SD ¼ 1.29)] but no longer differed significantly from sham [n ¼ 12, 2.25 (SD ¼ 1.14)]. Many youths initiated treatment during the FU period. Parents reported greater decreases in aggression on the Modified Overt Aggression Scale in the active group, which reached only trend significance. Youth-rated Difficulties in Emotion Regulation total scores showed higher decreases in the active group at PT (z ¼ 2.25, P ¼ 0.026 by Wilcoxon Rank Test) and FU (z ¼ 2.07, P ¼ 0.039). Conclusions: Youth who participated in relaxation training and played the active game showed significantly greater improvement in severity of anger at PT compared with youth who played the sham game. Improvement was maintained at FU.

AGG, DBD Supported by the AACAP Pilot Research Award for Junior Faculty and Child and Adolescent Psychiatry Fellows, which is, supported by the Campaign for America's Kids, and by the Harvard University Dupont Warren Fellowship, Harvard University Livingston Award http://dx.doi.org/10.1016/j.jaac.2017.09.284

5.2 CORTICAL EXCITABILITY AND BEHAVIORAL CORRELATES OF COMORBID ADHD IN YOUTH WITH AUTISM SPECTRUM DISORDERS Ernest Pedapati, MD, Cincinnati Children’s Hospital Medical Center, [email protected]; Lindsey Mooney, BS, Cincinnati Children’s Hospital Medical Center, ernest. [email protected]; Steve Wu, MD, Cincinnati Children’s Hospital Medical Center, [email protected];


Lauren Ethridge, University of Oklahoma, lauren-ethridge@ ouhsc.edu; Craig A. Erickson, MD, Cincinnati Children’s Hospital Medical Center, [email protected]; John Sweeney, PhD, University of Cincinnati, John.sweeney@ uc.edu; Donald Gilbert, MD, MS, Cincinnati Children’s Hospital Medical Center, [email protected] Objectives: The neurological correlates distinguishing youth with autism spectrum disorder (ASD) and youth with ASD and co-occurring ADHD (ASD+ADHD) is poorly understood, despite evidence that ASD+ADHD have higher rates of hospitalization, psychopharmacology, and behavioral concerns than ASD alone. Methods: Paired pulse transcranial magnetic stimulation (ppTMS) data and relevant behavioral measures were performed based on standard methods from an age and gender matched sample of ASD and ASD+ADHD. These data are baseline measures from recently completed randomized controlled, single dose methylphenidate study in youth with ADHD+ASD. Results: Twenty-four ASD+ADHD subjects (mean age ¼ 14.5) and 15 ASD only subjects (mean age ¼ 15.1) were included in this analysis. As expected, Conners-3 Parent Rating Scale-Inattention (CPRS-IA), Hyperactivity (CPRS-H), and Executive Functioning (CPRS-EF) scores were significantly higher for the ASD+ADHD group relative to the ASD group. ASD subjects demonstrated significantly enhanced intracortical facilitation (ICF) (M ¼ 1.26, SD ¼ 0.28, n ¼ 15) compared to ASD+ADHD subjects (M ¼ 1.01, SD ¼ 0.22, n ¼ 24; t ¼ 2.6, df ¼ 37, p ¼ 0.01). ICF was significantly inversely correlated with CPRS-EF (r ¼ -0.350; p ¼ 0.029), CPRS-IA (r ¼ -0.394; p ¼ 0.013) but not CPRS-H (r ¼ -0.083; p ¼ 0.61). ICF also correlated with the ADHD-IV Rating Scale (ADHDRS) Inattention scale (r ¼ -0.432; p ¼ 0.007) but not ADHDRS Hyperactivity scale. Conclusions: These data suggest that ICF, a rapidly obtained ppTMS measure which is associated with glutamergic activity, is disturbed in ASD+ADHD. ICF is also associated with clinical variables representing the severity of inattention and executive function in ADHD. Further results are expected from the larger RCT which will clarify the impact of methylphenidate on these TMS measures, but also resting state electroencephalography and high-speed eye tracking.

ND, NM Supported by the AACAP Junior Investigator Award http://dx.doi.org/10.1016/j.jaac.2017.09.285

5.3 QUALITY IMPROVEMENT PROJECT TO DECREASE MEDICATION BURDEN AND IMPROVE MONITORING OF PSYCHOTROPIC MEDICATIONS IN FOSTER YOUTH Evan Trager, MD, University of California, Riverside, [email protected]; Takesha J. Cooper, MD, University of California, Riverside School of Medicine, cooper. [email protected]; Richard J. Lee, MD, Riverside County Dept of Mental Health, [email protected] Objectives: Concern over the increasing prevalence of psychotropic medication use among children and adolescents in the foster care system has led to regulatory and legal changes in a number of states. In California, judicial review is mandated for all psychotropic medications prescribed to youth in the foster care system. Although the question of what medication is appropriate is ultimately driven by clinical needs, state regulators have advised that, when possible, guidelines that are geared toward the minimum number and dosage of medication should be followed. Overseeing metabolic monitoring, medication start dates, and adherence has also been delegated to the counties, leading to their inclusion in this project. Methods: We held meetings with key informants, including quality improvement staff, data analysis and entry staff, treating psychiatrists, reviewing psychiatrists, and reviewing judges. Data were collected to identify steps where data fidelity can be improved. Data on completed medication requests, followup appointments, and metabolic monitoring were extracted from the electronic medical record. Student’s t-tests were used to examine the difference in means. Results: Key informant interviews covered several detailed areas to increase data fidelity. These included the following: 1) provision of guideline documents to treating psychiatrists; and 2) standardization of data entry into

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tracking documents. Comparing rates of adherence with guidelines of medication number, intraclass polypharmacy, and maximum daily dosage, we found a relative decrease of 0.69, 0.51, and 0.43, respectively, across the study period. Our analysis of the electronic medical records revealed that there was no robust way to track metabolic monitoring, adherence, or medication start dates. Conclusions: Implementation of guideline-based prescribing for foster youth decreased the number of requested medications, the frequency of intraclass polypharmacy, and the frequency of requests for medications above recommended daily dosages. With regard to metabolic monitoring, medication adherence, and medication start dates, scattered systems of care appear to be an impediment to successful monitoring.

FOC, MDM http://dx.doi.org/10.1016/j.jaac.2017.09.286

5.4 GENDER AND ETHNO-RACIAL DIFFERENCES IN SYMPTOM EXPRESSION OF POSTTRAUMATIC STRESS DISORDER AND DEPRESSION AMONG CHILD TRAUMA VICTIMS Christina F. Tolbert, MD, Medical University of South Carolina, [email protected]; Colleen A. HallidayBoykins, PhD, Medical University of South Carolina, hallidca@ musc.edu; Kevin M. Gray, MD, Medical University of South Carolina, [email protected] Objectives: Millions of children in the United States suffer the effects of trauma due to physical abuse, sexual assault, witnessing violence, or other events. The purpose of this study is to determine whether race/ethnicity and gender have an impact on symptom expression of PTSD and depression in trauma-exposed children and adolescents. Methods: Data was drawn from the National Survey of Adolescents-Replication (NSA-R), initiated in 2005 as an epidemiological study of youth aged 12–17 years using computer-assisted telephone interviewing technology. Data for the present study were taken from the first wave of the study, which was completed in 2005, and participants were sampled using random digit dialing. Interviews were conducted in English using computer-assisted telephone interviewing technology. Adolescents (N ¼ 3,497) endorsing at least one “potentially traumatic event” (PTE) at wave 1 were studied, which comprised of 50 percent female (n ¼ 1,750) and 50 percent male (n ¼ 1,747). Mean age was 14.82 (SD ¼ 1.64) and five ethnic groups were examined: Caucasian (n ¼ 2,346, 67.1%), African American (n ¼ 557, 15.9%), Hispanic (n ¼ 409, 11.7%), Native American (n ¼ 86, 2.5%), and Asian American (n ¼ 99, 2.8%). Results: The results of multiple univariate ANOVA tests using SPSS indicated that the effects of gender on symptom expression of PTSD and depression was statistically significant (females > males, p < 0.001) and the effect of race/ ethnicity on symptom expression of PTSD and depression was statistically significant (Native American adolescents > all other ethnicities, p < 0.001). Conclusions: In conclusion, females and Native American adolescents exposed to trauma exhibit more symptoms of PTSD and depression than males and other ethnicities exposed to trauma (Caucasian, African American, Hispanic, and Asian American). Reasons for this include greater exposure to trauma, racial stigmatization, culturally-related gender oppression, cultural differences in reporting symptoms, and sample sizes used.

ETHN, ADOL Supported by the ACAAP Pilot Research Award for General Psychiatry Residents, supported by Pfizer http://dx.doi.org/10.1016/j.jaac.2017.09.287

5.5 EXPLORATION OF A SEMI-STRUCTURED TOOL IN THE ASSESSMENT OF HOMICIDAL IDEATION AND THREATS OF VIOLENCE Sophia A. Walker, BS, University of Connecticut, sowalker@ uchc.edu; Kevin P. Young, PhD, Institute of Living at Hartford Hospital, [email protected]; Mirela Loftus, MD, PhD, Institute of Living at Hartford Hospital,

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[email protected]; Salma Malik, MD, DFAACAP, MS, Institute of Living at Hartford Hospital, salma.malik@ hhchealth.org Objectives: This quality improvement study involved pilot testing of a semistructured homicide and violence assessment tool, which was designed to enhance data collection to inform clinical judgment and decision making. In a unique way, it is meant for use in initial evaluation of patients presenting with homicidal ideation or violent threats. Developed based on literature and expert reviews on violence assessment, it encompasses the specific threat, relevant risk factors, and a mental status exam that emphasizes key aspects related to violence. Methods: A needs assessment survey was completed by 39 child and adolescent clinicians [Licensed Clinical Social Worker (LCSWs), PsyD/PhDs, MDs] in various levels of care (outpatient, therapeutic school, partial hospital program, and emergent and inpatient units), examining previous experience and comfort with homicide assessments. After training on the new tool, they completed questionnaires measuring functionality of the tool (i.e., clarity, ease of administration, and usefulness) and changes in their skill appraisal, including clinician knowledge and confidence. Results: Needs assessment strongly favored enhanced approach (82% reported insufficient training, 89% endorsed need for standardization, 94% preferred a tool, and 100% would use one). Baseline discomfort and confidence were moderate, averaging 2.87 (SD ¼ 0.95) and 3.12 (SD ¼ 0.81) on a five-point Likert Scale, respectively. Clinicians agreed that the tool would increase comfort (90%), aid the recollection of essential topics (92%), inform decision making (95%), and improve quality and efficiency (92%); 94 percent would incorporate it into their practice. Nuanced implications, initial experiences/feedback after use in the clinical setting, will be discussed further. Conclusions: There is an undeniable need for structured guides in homicide and violence assessment at the bedside. Evaluation of this novel tool in the clinical setting demonstrated its utility to clinicians and the feasibility of its implementation in clinical practice per the described parameters. It could be of immense help to clinicians across all levels of care, ultimately improving quality and efficiency of care. Future directions include determination of reliability and validity and efforts to widen its dissemination.

AGG, RI, QA Supported by the AACAP Summer Medical Student Fellowship, which is supported by AACAP’s Endowment Fund http://dx.doi.org/10.1016/j.jaac.2017.09.288

5.6 THE IMPLEMENTATION OF THE DEPRESSION AND ANXIETY GUIDELINES BY THE CYSTIC FIBROSIS FOUNDATION Katherine E. Oberhelman, BS, Tulane University, [email protected]; Amie M. Lofton, PsyD, Tulane University, [email protected]; Lisa D. Settles, PsyD, Tulane University, [email protected]; Myo Thwin Myint, MD, Tulane University, [email protected] Objectives: The International Depression Epidemiology Study (TIDES) discovered elevated symptoms of depression and generalized anxiety in adolescents and adults with cystic fibrosis (CF) and their caregivers. This project aims to screen for the depression and generalized anxiety disorder (GAD) in child and adolescent patients with CF using the Patient Health Questionnaire(PHQ-9) and GAD-7 questionnaire and provide the recommended treatment to these patients as part of their integrated care in the Tulane Pediatric CF Clinic. The PHQ-9 and GAD-7 are used to detect both early and late symptoms of depression and GAD so that appropriate treatment or preventative measures can be administered. Methods: The PHQ-9 and GAD-7 screeners are administered to child and adolescent patients in the Tulane Pediatric CF clinic to assess the initial level of depression and anxiety, respectively. The percentage of patients between the ages of 11 and 18 years who score above four qualify for treatment. Patients who receive mild (5–9) or elevated (> 9) scores on the PHQ-9 or GAD-7 are provided with appropriate resources for treatment in their hometown, which includes psychotherapy and medications from providers who are

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educated on the psychological challenges of CF. Patients are continually screened to monitor their progress and adjust treatment. Results: Of the 39 patients with CF who were initially screened with the PHQ-9 and GAD-7, six reported elevated level of depression and two reported elevated level of anxiety. Two patients reported elevated level of both depression and anxiety. Patients with CF who screened mild or elevated for depression and anxiety were provided with resources for appropriate treatment. Conclusions: The results translate to 15.4, 5.1, and 5.1 percent of adolescents between the ages of 11 and 18 years scoring elevated levels of depression, anxiety, or anxiety and depression, respectively. This point prevalence of adolescent depression is significantly higher than the national average of 6.7 percent between 2007 and 2010, according to the Center for Disease Control and Prevention (CDC). Mental health screening and treatment for patients with cystic fibrosis are necessary components of comprehensive care that must be included in the integrative care approach to CF.

AD, CM, DDD Supported by the AACAP Summer Medical Student Fellowship, which is supported by AACAP's Endowment Fund, and the Cystic Fibrosis Foundation Award CMHC020-15 http://dx.doi.org/10.1016/j.jaac.2017.09.289

5.7 IS THE RIGHT RESEARCH BEING DONE TO ADDRESS EVIDENCE GAPS WITHIN AACAP PRACTICE PARAMETERS? Jake X. Checketts, BS, Oklahoma State University, jake. [email protected]; Gretchan B. Moore, BS, Oklahoma State University Center for Health Sciences, gretchan. [email protected]; Kia R. Golmoradi, BS, Oklahoma State University Center for Health Sciences, jared.t.scott@okstate. edu; Tara R. Buck, MD, University of Oklahoma, tara-buck@ ouhsc.edu; Matthew Vassar, PhD, Oklahoma State University Center for Health Sciences, [email protected] Objectives: The objective of this study was to evaluate the extent to which new and ongoing research is being conducted to address research gaps found during development of AACAP’s Practice Parameters for schizophrenia, reactive attachment disorder (RAD)/disinhibited social engagement disorder (DSED), OCD, eating disorders, autism spectrum disorder, and atypical antipsychotic medications. Methods: For each recommendation rated as a clinical option (based on low-quality evidence or expert opinion) in the Parameters, we created participant-, intervention-, comparator-, outcome-formatted questions and search strings using a systematic process. Searches were conducted through ClinicalTrials.gov and the World Health Organization’s International Clinical Trials Registry Platform to locate new and ongoing studies. Each registered study was then screened for inclusion independently by two investigators. Results: Our search returned 2,660 registered or completed studies. Of these studies, 18 studies (0.68%) were relevant to clinical options within the six Parameters. Of the seven clinical options across Parameters, five (71.4%) were being addressed by new or ongoing research. There were no studies contributing to options 3 (observing patients in a structured observational paradigm) and 7 (limiting contacts of those with DSED to familiar adults) of the RAD/DSED parameter. Conclusions: Research related to clinical options in the Parameters is not thoroughly being studied. As such, these options risk maintaining low-quality status in future editions of the Parameters. Resources required to generate high-quality studies to bridge these research gaps are extensive, but we hope our findings may be used in the reallocation of resources and funding when considering future research agendas.

EBP, R, OTH Supported by the AACAP Summer Medical Student Fellowship, which is supported by AACAP's Endowment Fund http://dx.doi.org/10.1016/j.jaac.2017.09.290


5.8 MAPPING REGULATORY NETWORKS OF AUTISM RISK AT CELLULAR RESOLUTION DURING NEURODEVELOPMENT Rebecca Muhle, MD, PhD, Yale University, rebecca.muhle@ yale.edu; Wei Niu, University of Michigan, weiniu@med. umich.edu; Guillermina Hill-Teran, Yale University, [email protected]; Kristina Yim, Yale University, [email protected]; Martina Krenzer, Yale University, [email protected]; Sarah Abdallah, Yale University, [email protected]; Smita Krishnaswamy, Yale University, [email protected]; James Noonan, PhD, Yale University, james.noonan@ yale.edu Objectives: The complexity of the mechanisms underlying autism spectrum disorder (ASD) stands as a major obstacle to novel therapeutics development. ASD is a common neurodevelopmental disorder, typified by deficits in social communication and other behavioral symptoms. There are no available biological treatments to ameliorate the core ASD symptoms, in part due to the tremendous heterogeneity of genetic risk factors for ASD. There is a critical need to better understand the common and distinct neurological impacts of ASD risk genes to focus investigations for new therapeutics. To investigate ASD risk-associated regulatory networks with high temporal and spatial resolution, we have undertaken studies to globally map regulatory targets of ASD risk-associated chromatin modifiers at an early stage of human neurodevelopment, and in specific cell types and brain regions during mouse embryonic cortical development. Methods: Using genome editing, we have incorporated epitope tags into ASD risk genes with chromatin modifier functions in human neural stem cells (hNSCs). To facilitate uniform ChIP-seq methods, we have placed a 3XFLAG epitope into the last coding exon of CHD8, CHD2 and other ASD risk genes. A fluorescent marker was placed downstream of the gene that enables its use as a molecular marker of ASD risk gene expression level. To characterize global targets of the ASD risk gene CHD8 in the developing mouse brain, we have generated a mouse line with a cre-activated epitope tag to allow purification of ASD risk protein complexes via bioChIP-seq from specific cell types using cre driver lines. Results: Genome editing in hNSCs integrates epitope tags into the endogenous loci of selected ASD risk genes consistently and robustly. ChIP-seq performed with antibodies directed to the epitope tag in tagged cells replicates ChIP-seq performed with native antibodies, and identifies additional targets. Genome editing in mouse embryos generated an epitope-tagged Chd8 line, and we are engaged in on-going efforts to characterize the Chd8 binding sites in specific cell-types using bioChIP-seq and to generate additional mouse lines with epitope tagged ASD risk genes. Conclusions: Correlation of ASD risk gene target maps with each other and in specific cell types will identify genes and regulatory elements enriched for ASD risk.

ANI, GS, ASD Supported by the AACAP Pilot Research Award for Junior Faculty and Child and Adolescent Psychiatry Fellows, which is supported by the Campaign for America's Kids, the Alan B. Slifka Foundation via the Riva Ariella Ritvo endowment, the Simons Foundation, and the Charles Hood Foundation http://dx.doi.org/10.1016/j.jaac.2017.09.291

5.9 EVALUATING THE RELATIONSHIP BETWEEN THE VINELAND ADAPTIVE BEHAVIOR SCALE AND THE ASSESSMENT OF BASIC LANGUAGE AND LEARNING SKILLS-MODIFIED Mang-tak A. Kwok, BS, Ohio State University, andy.kwok@ utoledo.edu; L. Eugene Arnold, MD, Ohio State University, L. [email protected]; Justin Barterian, PhD, Ohio State University, [email protected]; Xueliang Pan, PhD, Ohio State University, [email protected]; Lawrence Scahill, MSN, PhD, Marcus Autism Center,

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[email protected]; Michael Aman, PhD, Ohio State University, [email protected]; Christopher McDougle, MD, Massachusetts General Hospital, CMCDOUGLE@mgh. harvard.edu Objectives: The clinician-administered Vineland Adaptive Behavior Scale is the gold-standard measure for assessing adaptive functioning, especially in children with autism and developmental disabilities. Because of its broad assessment, the Vineland is better suited for characterizing overall development rather than domain-specific change over time. Therefore, a parent-rated, domain-specific instrument is necessary. This study reports the convergent validity of the Daily Living Skills domain of the Vineland with the Assessment of Basic Language and Learning Skills-Modified (ABLLS-M), so practitioners can use the latter to concisely measure change in adaptive functioning and age equivalence. Methods: A total of 124 children between the ages of four and 14 years, with a DSM-IV diagnosis of pervasive developmental disorder (PDD) were enrolled in a 24-week, randomized clinical trial to compare risperidone alone to risperidone plus parent training. Parents completed the parent-rated Vineland and ABLLS-M assessments at baseline and at weeks 16 and 24 (N ¼ 95). Spearman correlation analysis was run between the Vineland and ABLLS-M at different time points. Results: The Spearman correlation between the raw scores of the Vineland and ABLLS-M was strong at baseline (r ¼ 0.85, P < .001) and at week 24 (r ¼ 0.83, P < 0.001). Moderate associations (P < 0.001) are also found comparing the change of raw scores at baseline and at week 24 for both tests (r ¼ 0.42) and percent change in raw scores (r ¼ 0.46). Through their strong correlations, a polynomial equation (n ¼ 2, R2 ¼ 0.76) was found that best fits the relationship between the ABLLS-M raw score and age equivalence score established by the Vineland. Conclusions: The parent-rated ABLLS-M and the Daily Living Skills domain of the Vineland prove to have convergent validity through their correlations at baseline and at week 24, thus being able to measure similar patient characteristics. Moreover, the parent-rated ABLLS-M can be a more efficient and resourceful alternative than the lengthy clinician-administered Vineland, allowing clinicians to spend more quality time with patients. A method was also developed for calculating age equivalence from the ABLLS-M, so that practitioners can figure out age equivalence by solely administering the ABLLS-M.

ASD, RI, ADOL Supported by the AACAP Summer Medical Student Fellowship, which is supported by AACAP's Endowment Fund http://dx.doi.org/10.1016/j.jaac.2017.09.292

5.10 SURVEY OF CHILDREN WITH AUTISM IN A COMMUNITY IN NIGERIA Afis Akanni Agboola, MBChB, MPH, Neuropsychiatric Hospital Aro, [email protected]; Elizabeth Campbell, MBChB, Lagos University Teaching Hospital, [email protected]; Tunde Fadipe, MBChB, Lagos Unversity Teaching Hospital, [email protected]; Anna Lamikanra, Blazing Trails International Center, [email protected]; Oladipo Sowunmi, MBBS, Neuropsychiatric Hospital Aro, [email protected] Objectives: The goals of this presentation are to determine the prevalence of autism spectrum disorder (ASD) among children in a community in Nigeria and to describe characteristics of the study population. Methods: This presentation highlights a cross-sectional observational study of children referred for assessment by primary healthcare workers in the community. A two-stage study design involved initial administration of screening instruments of childhood autism spectrum test (CAST) or modified checklist for autism in toddlers (MCHAT), depending on the age of the patients and those who met the cutoff point qualified for the second stage, which involved a clinical interview. Results: A total of 392 children participated in the survey program, of which 222 (56.6%) met the criteria for the screening; 121 (30.9%) qualified for the second

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stage and were given DSM-5 diagnosis of ASD after the clinical interview. The prevalence of ASD in the community was 3.1 per 1,000. Majority of the children with ASD were male (n ¼ 74; 61.2%), and they were out of school (n ¼ 55; 45.5%). Some of the patients (n ¼ 47; 38.8%) had comorbid seizure disorder, and some of them (n ¼ 39; 32.2%) were first-born in birth rank. Conclusions: High rate of ASD in the community is a public health issue, and it should be a wake-up call for both health and education policymakers.

PUP, ASD, ND Supported by Guaranty Trust Bank Plc Nigeria http://dx.doi.org/10.1016/j.jaac.2017.09.293

5.11 HOW ACCURATE IS TEACHER REPORT OF AUTISM SYMPTOMS COMPARED TO PARENT REPORT? Susan D. Mayes, Penn State Health Milton S. Hershey Medical Center, [email protected]; Robin Lockridge, PhD, Brown University, robin_lockridge@ brown.edu; Raman Baweja, MD, MS, Penn State Health Milton S. Hershey Medical Center, rbaweja@pennstatehealth. psu.edu Objectives: In referred children with and without autism spectrum disorder (ASD), scores on the Checklist for Autism Spectrum Disorder (CASD) completed by a psychologist with a doctorate (following standardized administration procedures integrating parent and teacher report and clinical observations of the child) were compared with CASD scores completed independently by mothers and teachers. Methods: Children (n ¼ 168) with ASD and children with ADHD and no ASD (n ¼ 40) (ages 1–12 years) were evaluated by a psychologist with a doctorate, which included a parent interview, parent- and teacher-rating scales, observations of the child during testing, and a review of records. Children with ASD had a clinical diagnosis of ASD and a CASD score in the ASD range. The CASD consists of 30 ASD symptoms scored as present or absent. The cutoff ( 15 ¼ ASD) was determined in the normative study of 1,052 children with ASD evaluated in a psychiatry diagnostic clinic. In an independent standardization study, the CASD differentiated 632 children with and without ASD with 99.5 percent accuracy. Diagnostic agreement between the CASD and established ASD instruments is high. Children in the ADHD sample group had a clinical diagnosis of ADHD, a CASD score below 15, ADHD symptoms observed during testing, low scores on psychometric attention measures, and elevated parent and teacher ADHD ratings on the Pediatric Behavior Scale. Results: For children with ASD, many symptoms of ASD deemed present by the psychologist were not reported by mothers and teachers on the CASD. Mother–teacher correlations in the ASD sample group (r ¼ 0.15) and ADHD sample group (r ¼ 0.07) explained less than three percent of the variance, indicating little correspondence between mother and teacher report. Mother– psychologist correlations were 0.66 and 0.72 in the ASD and ADHD sample groups, respectively (vs. teacher-psychologists correlations of 0.18 and 0.42). Using the ASD cutoff of 15, mothers correctly identified 64 percent with ASD and teachers correctly identified 25 percent with ASD. Conclusions: Mother and teacher CASD scores should never be used alone to evaluate ASD, and teacher scores should be interpreted with great caution. Diagnostic instruments must be administered following standardized validated procedures. Nonstandardized use (e.g., having mothers or teachers independently complete the CASD) is invalid. Mothers and teachers both missed unacceptably high numbers of children with ASD (36 and 75%, respectively).

EPI, ASD http://dx.doi.org/10.1016/j.jaac.2017.09.294

5.12 PHYSIOLOGICAL BIOMARKERS FOR PREDICTION OF IMMINENT AGGRESSION IN MINIMALLY VERBAL CHILDREN WITH AUTISM SPECTRUM DISORDER Diana Cumpanasoiu, BS, Northeastern University, [email protected]; Carla Mazefsky, PhD,

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University of Pittsburgh, [email protected]; Amy Stedman, BS, Maine Behavioral Healthcare, astedman@ mainebehavioralhealthcare.org; Christine Peura, BS, Maine Medical Center Research Institute, [email protected]; Peng Tian, PhD, Northeastern University, [email protected]. edu; Yuan Guo, PhD, Northeastern University, guo.yu@husky. neu.edu; Stratis Ioannidis, PhD, Northeastern University, [email protected]; Deniz Erdogmus, PhD, Northeastern University, [email protected]; Matthew Siegel, MD, Maine Medical Research Institute and Tufts University School of Medicine, [email protected]; M.S. Goodwin, PhD, Northeastern University, m.goodwin@ neu.edu Objectives: We investigated the feasibility of using physiological biomarkers to predict the onset of aggression in minimally verbal (MV) youth with autism spectrum disorder (ASD). Methods: Nine MV youth with confirmed ASD wore a wristband-mounted E4 biosensor during repeated unstructured observation periods while they were hospitalized in a specialized child psychiatry unit. Physiological and three axis acceleration data were collected concurrent with coding of aggressive behavior. Physiological arousal was measured by: 1) heart rate and heart rate variability, both derived from blood volume pulse (BVP) and interbeat interval (IBI) via photoplethysmography at 64 Hz; and 2) electrodermal activity (EDA), which reflects autonomic innervation of sweat glands. Advanced signal processing and machine learning algorithms were then applied to predict aggression onset. The area under the curve (AUC) accuracy (based on true/false positive rates) was calculated to predict the onset of aggression in the next one minute from present time (t). The predictions were made through a ridge-regularized logistic regression using: 1) previous t ¼ 3 minutes of motor movement acceleration (ACC) signals; 2) time elapsed since last aggression event; 3) previous t ¼ 3 minutes of BVP, EDA, and IBI signals; and 4) all of the above signals combined. Results: All youth tolerated the sensor after desensitization, usable data were obtained in all cases, and there was an average of 9.67 (range ¼ 0-44) aggressive episodes per four-hour observation period. Time-synced coding of aggression and concurrent E4 signal data predicted the onset of aggression with AUC ranging from 0.69 to 0.78. Discriminative power increased by seven percent as each additional signal was added. Conclusions: Our pilot data indicate that it is feasible to obtain physiologic and motor movement data from wearable biosensors in MV youth with ASD and aggression. When all data streams were combined, three minutes of data predicted the occurrence of aggression in the following minute with an AUC of 0.79. This will likely improve after applying more advanced classification algorithms to a larger data set. Developing a biomarker-based predictive system for imminent aggression could open a new window for understanding and intervention in youth with MV-ASD and challenging behaviors.

AGG, ASD Supported by the Simons Foundation Grant SFARI #296318 and the Nancy Lurie Marks Family Foundation http://dx.doi.org/10.1016/j.jaac.2017.09.295

5.13 DESIGN AND EFFICACY OF A WEARABLE DEVICE FOR SOCIAL AFFECTIVE LEARNING IN CHILDREN WITH AUTISM Jena Daniels, BS, Stanford University, [email protected]; Jessey Schwartz, BA, Stanford Universtiy, [email protected]; Nick Haber, PhD, Stanford University, [email protected]; Catalin Voss, MS, Stanford University, [email protected]; Aaron Kline, Stanford University, [email protected]; Azar Fazel, MS, Stanford University, [email protected]; Peter Washington, MS, Stanford University, peter100@stanford. edu; Titas De, Stanford University, [email protected];


Carl Feinstein, MD, Stanford University School of Medicine, [email protected]; Terry Winograd, PhD, Stanford University, [email protected]; Dennis Wall, PhD, Stanford University, [email protected] Objectives: Applied behavioral analysis (ABA) is an effective form of therapy for children with autism spectrum disorder (ASD), but it faces criticism for being ungeneralizable, too time intensive, and too dependent on specialists to deliver treatment. Earlier age at onset of therapy is one of the strongest predictors of later success, but waitlists to begin therapies can be as long as 18 months. To combat complications associated with the clinical setting and expedite access to therapy, we have begun development of Autism Glass, a machinelearning-assisted software system that runs on Google Glass and an Android Smartphone; it is designed for use in the child’s natural environment during social interactions. This is an exploratory- and codesigned-based study to see how children with ASD respond to our device and examine preliminary data on its effectiveness. Methods: We sent our Autism Glass home with 14 families (mean age ¼ 9.57 years, SD ¼ 3.37; n ¼ 3 females) and assessed changes from intake to conclusion (after several months using Glass) through the following: 1) evaluations and parental observations, mainly by the Social Responsiveness Scale, Second Edition (SRS-2); 2) an “emotion guessing game” (EGG) to assess how well children correctly labeled emotions in person (of 40 questions); and 3) parent-qualitative reports. We used a repeated-measures one-way ANOVA to analyze changes in both SRS-2 and EGG scores. Participants were also asked to provide feedback on the mobile application (app) interface. Results: There was a significant decrease over time in SRS-2 total scores by an average of 7.14 points [F(1,13) ¼ 33.20, P 0.001, higher scores indicate higher ASD severity]. EGG scores also significantly increased by an average of 9.55 correct responses over time [F(1,10) ¼ 11.89, P 0.01]. Parents reported increases in eye contact and greater social acuity. In addition, participants shared innovative feedback, which led to user experience design changes on the mobile app. Conclusions: This study established Autism Glass as an accessible prototype for mobile therapy behavioral intervention. Additional research is necessary to further validate Autism Glass as a therapeutic tool, and an RCT is currently underway. This also supports the use of ubiquitous mobile technologies for therapeutic purposes for neuropsychiatric disorders as a whole.

ASD Supported by the Berry Fellowship, David and Lucile Packard Foundation Special Projects 2015-62349, a Beckman Technology Development Grant, a Coulter Translational Research Grant, the Dekeyser and Friends Foundation, the Mosbacher Family Fund for Autism Research, the Hartwell Foundation, and Google http://dx.doi.org/10.1016/j.jaac.2017.09.296

5.14 ATTENTION TO EYE IN STILL FACE STRONGLY RELATED TO SOCIALITY COMPARED TO OTHER SOCIAL INFORMATION IN CHILDREN WITH AUTISM SPECTRUM DISORDER Toru Fujioka, PhD, University of Fukui, [email protected]; Yoshifumi Mizuno, MD, United Graduate School of Child Development, Osaka University, Kanazawa University, Hamamatsu University School of Medicine, Chiba University, and University of Fukui, [email protected]; Shinichiro Takiguchi, MD, PhD, University of Fukui Hospital, [email protected]; Takashi X. Fujisawa, PhD, University of Fukui, [email protected]; Kenji J. Tsuchiya, MD, Hamamatsu University School of Medicine, [email protected]; Taiichi Katayama, PhD, United Graduate School of Child Development, Osaka University, Kanazawa University, Hamamatsu University School of Medicine, Chiba University,

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and University of Fukui, [email protected]; Akemi Tomoda, MD, PhD, University of Fukui, atomoda@ gmail.com; Michio Hiratani, MD, PhD, Hiratani Clinic for Developmental Disorders of Children, m-hiratani@hiratani-c. jp; Hirotaka Kosaka, MD, PhD, University of Fukui, hirotaka@ u-fukui.ac.jp Objectives: Abnormal attention to social information in children with autism spectrum disorder (ASD), which correlates with the degree of sociality, is reported with various types of stimuli as follows: movie clips of human faces; biological motion; people and geometric shapes simultaneously; and joint attention. However, no studies have reported what type of stimuli correlate more strongly with their features. This study aimed to clarify the relationships between sociality and attention to various types of stimuli together. Methods: We studied 12 children with ASD (8 boys and 4 girls, age 4.8 0.9 years) and 23 typically developed (TD) children (14 boys and 9 girls, age 4.5 0.9 years). For the group with ASD, we assessed their developmental status using the developmental or intellectual quotient; the scores of all children with ASD were over 80. For all of the participants, we used Vineland Adaptive Behavior Scales (VABS) and the Gazefinder, an all-in-one eye-tracking system. The Gazefinder consists of nine movie clips as follows: 1) still face; 2) blinking face; 3) mouth moving; 4) silent face (an actress with a still face); 5) talking face; 6) biological motion (upright and inverted dancing human); 7) people and geometrical patterns of the same size presented simultaneously; 8) geometrical patterns depicted in a small window on a movie of people; and 9) objects with or without pointing. The Gazefinder set the eye region in face stimuli, upright biological motion in biological motion, people region in people and geometry stimuli, and object with pointing in the movie of the objects with or without pointing as areas of interest (AoI); the percentage of fixation times was calculated for each AoI. We examined the percentage of fixation times to each AoI and sociality measured by the VABS. Results: In the group with ASD, sociality significantly correlated with the percentage of fixation times to the eye in still face with high effect size (r ¼ 0.61, P ¼ 0.03). No items were significant in the TD group. Conclusions: Compared with other types of stimuli, attention to the eye may be more strongly related to sociality in children with ASD.

PSC, ASD, R Supported by the Japan Society for the Promotion of Science Grant 15K08093 http://dx.doi.org/10.1016/j.jaac.2017.09.297

5.15 IRRITABILITY IN CHILDREN WITH AUTISM REFERRED FOR TREATMENT OF ANXIETY OR AGGRESSION Theresa R. Gladstone, BA, Yale University, theresa. [email protected]; Shivani A. Kaushal, BS, Yale University, [email protected]; Emilie .J. Bertschinger, BA, Yale University, [email protected]; Megan E. Tudor, PhD, University of California, Davis, megan.tudor@ yale.edu; Denis G. Sukhodolsky, PhD, Yale University, denis. [email protected] Objectives: There has been a lack of investigation into irritability in children with autism spectrum disorder (ASD) who have comorbid anxiety or disruptive behavior disorders (DBD). Thus, we tested the levels of irritability measured by the parent- and child-rated Affective Reactivity Index (ARI) in children with ASD and co-occurring anxiety or DBD. We also examined the correlations of irritability with ratings of anxiety and noncompliance. Methods: The sample group included 38 children (8 girls and 30 boys; ages 8–16 years; mean ¼ 12.25 years, SD ¼ 2.10) with ASD (assigned based on Autism Diagnostic Observation Schedule and Autism Diagnostic Interview-Revised), who were seeking treatment for anxiety or disruptive behavior as part of a research study in a university setting. A total of 17 children met criteria for ODD, and 21 children met criteria for an anxiety disorder (assigned based on Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) or Anxiety Disorders Interview Schedule). Parents and children completed the ARI to measure irritability; in addition, parents

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completed the Multidimensional Anxiety Scale for Children (MASC-2), Home Situations Questionnaire (HSQ), and the Disruptive Behaviors Rating Scale (DBRS). Results: Parent- and child-self report versions of the ARI had high internal consistency with Cronbach’s alpha coefficients of 0.89 and 0.82 for the parent and child versions, respectively. Compared with children with ASD plus anxiety disorder, children with ASD plus DBD had significantly higher scores on both parent (t ¼ 6.27, P < 0.001) and child (t ¼ 2.01, P < 0.5) ratings of irritability. Parent-rated irritability was significantly correlated with HSQ noncompliance scores (r ¼ 0.81, P < 0.001) but not with the total anxiety scores on the MASC-2 (r ¼ 0.01; P ¼ 0.95). Child report of irritability was significantly correlated with parent ratings of irritability (P ¼ 0.39, P < 0.05) but not with parent ratings of noncompliance and anxiety. Conclusions: Parent and child report of irritability were significantly higher in children with ASD plus DBD relative to children with ASD plus anxiety disorder. Parent ratings (but not child self-report) of irritability were also significantly correlated with noncompliance. Assessing irritability could guide treatment for either group; however, it might be particularly important for children with co-occurring aggressive behavior.

AD, ASD, IMD Supported by Eunice Kennedy Shriver National Institute of Child Health and Human Development Grant 5R01HD083881-02 and NIMH Grant 4R01MH10151404 http://dx.doi.org/10.1016/j.jaac.2017.09.298

5.16 AMO-01 IN THE SHANK3 KNOCKOUT TRANSGENIC MOUSE MODEL OF PHELAN MCDERMID SYNDROME Michael F. Snape, PhD, AMO Pharma, [email protected]; Joseph P. Horrigan, MD, Duke University, jphorrigan5@gmail. com; Robert M.J. Deacon, PhD, GEN-DDI Ltd, robert. [email protected]; Michael J. Hurley, PhD, Imperial College London, [email protected]; Patricia Cogram, PhD, GEN-DDI Ltd, patricia.cogram@ gmail.com Objectives: Phelan McDermid Syndrome (PMS) is a rare neurodevelopmental disorder associated with a chromosomal deletion at 22q13.3 involving the SHANK3 gene. SHANK3 is a scaffold protein in dendrites essential for synapse formation. A key molecular aberration in PMS is overactivity of the Ras-ERK (extracellular signal-regulated kinase) enzymatic pathway that plays a critical role in synaptic plasticity and neuronal survival. Autism spectrum disorder (ASD) is a frequent, co-occurring condition in patients with PMS. Several high-quality SHANK3 knockout mouse models have been developed for preclinical assessment of potential therapeutic agents for both PMS and ASD. These models recapitulate the neurobehavioral abnormalities and neurological problems (e.g., seizures) common in patients with PMS and ASD. Methods: AMO-01, a brain-penetrant inhibitor of the Ras-ERK pathway (IC50 < 1 mM), was assessed in the C57BL/6/ knockout mouse model of PMS. A single intraperitoneal dose of 30 mg/kg AMO-01 or vehicle was administered to four groups (n ¼ 10 per group) of two-month old test animals (knockout mice + vehicle, knockout mice + AMO-01, wild-type littermates + vehicle, and wild-type littermates + AMO-01). Over the next five days, neurobehavioral assessments were administered, as well as observation of aberrant behaviors. In addition, the threshold for audiogenic seizures in the knockout mice was evaluated. Experimenters were blinded to genotype and drug treatment. Results: AMO-01 significantly improved all aberrant neurobehavioral features that were assessed, including increased anxiety in the light dark box test, elevated self-injurious grooming behaviors, diminished interaction time with novel mice, diminished marble-burying behavior, and impaired beam-walking speed. In addition, AMO-01 significantly attenuated the audiogenic seizure threshold and incidence in the knockout mice. Reversal of these aberrant features was complete after a single dose of AMO-01 and persisted for five days. AMO-01 administration was not associated with obvious issues with tolerability or safety in the test animals.

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Conclusions: There are no approved treatments and very few viable treatment options for individuals with PMS. AMO-01 rendered rapid, robust improvements in the aberrant features of the PMS knockout mice and, therefore, may be a viable candidate for clinical development as a potential treatment for PMS.

ANI, PPC, ND Supported by AMO Pharma Ltd http://dx.doi.org/10.1016/j.jaac.2017.09.299

5.17 ACCESS TO SERVICES, PRIORITIES, AND CHALLENGES IN CAREGIVERS OF PERSONS WITH AUTISM Matias Irarrazaval, MD, MPH, University of Chile, mirarraz@ mail.harvard.edu; Ricardo Garcıa, Universidad de ChileClınica Las Condes, [email protected]; Sofıa Riesle, Universidad de Chile, sofi[email protected]; Andrea Moyano, Universidad de Chile, [email protected]; Marcia Cabezas, Universidad de Chile, marcia_cabezas@ yahoo.com; Alexia Rattazzi, PANAACEA, alexiapanaacea@ gmail.com; Gabriela Garrido, Universidad de la Rep ublica, [email protected]; Cristiane Silvestre, Developmental Disorder Program, Mackenzie Presbyterian University, [email protected]; Daniel Valdez, FLACSO, [email protected]; Cecilia Montiel-Nava, La Universidad del Zulia, [email protected]; Sebasti an Cukier, PANAACEA, [email protected]; Analia Rosoli, OEI, Santo Domingo, Dominican Republic, [email protected] Objectives: Research on autism spectrum disorders (ASD) and health and education services are limited. This study is part of a larger study conducted in six Latin American countries (Argentina, Brazil, Chile, Uruguay, Panama, Dominican Republic) by the Red Espectro Autista Latinoamerica (REAL). The aim of this study was to understand the diagnostic, service, and lived experiences of families affected by ASD in Chile. Methods: A total of 292 caregivers were surveyed from 2015 to 2016 about characteristics of the child with ASD, service encounters, and caregiver perceptions. Results: The average age at first concern was 29 months (SD ¼ 23.7), and at diagnosis, average age was 61 months (SD ¼ 43.6). Child neurologists were the most common professional who made the diagnosis. Almost all caregivers (83.8%) reported that their children with ASD had received some service in the past. The most frequently reported service was speech and language therapy (62.2%) and medication (52.9%), which increases in the most severe cases to 81 and 76.2 percent, respectively. Nevertheless, most of the subjects with severe symptoms received less than one hour per week of services, and only 42 percent of them have had a child psychiatrist evaluation. Finally, caregivers endorsed challenges in access to care and perceived stigma. Conclusions: This study found that, in Chile, there is a late diagnosis of ASD and low access to specialized clinical services, even in the more severe cases. Supporting a child with ASD was associated with difficulty or delays in accessing services, as well as high levels of frustration in getting the services.

ASD, ND http://dx.doi.org/10.1016/j.jaac.2017.09.300

5.18 A PROSPECTIVE OPEN-LABEL TRIAL OF EXTENDED-RELEASE LIQUID METHYLPHENIDATE FOR THE TREATMENT OF ATTENTION DEFICIT/HYPERACTIVITY DISORDER (ADHD) IN ADULTS WITH HIGH-FUNCTIONING AUTISM SPECTRUM DISORDER: AN INTERIM ANALYSIS Gagan Joshi, MD, Massachusetts General Hospital, joshi. [email protected]; Barbora Hoskova, BA,


Massachusetts General Hospital, [email protected]. edu; Maura Fitzgerald, MPH, Massachusetts General Hospital, mfi[email protected]; Tolga Atilla Ceranoglu, MD, Massachusetts General Hospital, [email protected]; Amy Yule, MD, Massachusetts General Hospital, [email protected]; Ronna S. Fried, EdD, Massachusetts General Hospital, [email protected]; Maribel Galdo, LICSW, Massachusetts General Hospital, [email protected]; Abigail H. Belser, BA, Massachusetts General Hospital, [email protected]; Haley Tornberg, Massachusetts General Hospital, [email protected]; Joseph Biederman, MD, Massachusetts General Hospital, jbiederman@mgh. harvard.edu Objectives: Treating ADHD comorbid with autism spectrum disorder (ASD) could improve morbidity and impairment in individuals with autism; however, lower tolerability to psychotropic medications, used to treat ADHD, has been noted in individuals with ASD. The purpose of this interim analysis of the ongoing six-week trial was to assess the tolerability and efficacy of extendedrelease liquid methylphenidate hydrochloride (brand name Quillivant) for the treatment of ADHD in adults with high-functioning ASD. Methods: Data from 11 adults (ages 19–28 years), with high-functioning ASD comorbid with significantly severe ADHD, were collected during a six-week clinical trial. During the initial three-week dose-optimization phase, medication was titrated up to the targeted daily dosage. Week 3 and onward, subjects were maintained on maximum achieved dose, with a one-time option to decrease to the next lowest available dose per clinician judgment. Efficacy was assessed using clinician-rated measures [Adult ADHD Investigator Symptom Report Scale (AISRS) and Clinical Global Impression (CGI) Scale] and a self-rated measure [Adult ADHD Self-Report Scale (ASRS)]. The primary outcome criteria for response were 30 percent reduction in the AISRS total score and CGI-ADHD-Improvement score of 2. Tolerability was assessed through safety measures, including vital signs and treatment-emergent adverse events. Results: Results show significant improvement in AISRS scores, with a significant mean reduction of 21.4 8 from baseline (35 3.47) to endpoint (11.8 5.88). Overall, 82 percent of subjects met the primary outcome criteria for response. Likewise, significant improvement was noted in the self-rated measure of ADHD severity (baseline: 43 6.7; endpoint: 33 10; mean reduction: 9 11). The medication was well tolerated in subjects. Adverse events were experienced by nine of 11 subjects (82%). Reported adverse events were transient and mild to moderate. Most frequently noted adverse events (>10%) were headaches (45%), insomnia (27%), decreased appetite (27%), and anxiety (18%). One subject was terminated because of treatment limiting adverse events (headaches, palpitations, jaw pain, and insomnia). Conclusions: Our findings suggest that extended-release methylphenidate formulation is very effective and well tolerated in the treatment of ADHD symptoms comorbid with high-functioning ASD.

PPC, ADHD, ASD Supported by Pfizer Inc. http://dx.doi.org/10.1016/j.jaac.2017.09.301

5.19 CALLOUS-UNEMOTIONAL TRAITS AND AGGRESSIVE BEHAVIOR IN CHILDREN WITH AUTISM SPECTRUM DISORDER Shivani A. Kaushal, BS, Yale University, shivani.kaushal@yale. edu; Theresa R. Gladstone, BA, Yale University, theresa. [email protected]; Emilie J. Bertschinger, BA, Yale University, [email protected]; Megan E. Tudor, PhD, University of California, Davis, megan.tudor@ yale.edu; Denis G. Sukhodolsky, PhD, Yale University, denis. [email protected] Objectives: Individuals with autism spectrum disorder (ASD) often present with behavioral difficulties such as anger, aggression and noncompliance. We

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tested whether callous-unemotional (CU) traits, characterized by socioemotional deficits in processing guilt and empathy, are associated with the core social skills deficits and aggression demonstrated in children with ASD. Methods: Parents of children with ASD (N ¼ 37) completed measures of CU traits (Inventory of Callous Unemotional Traits; ICU), aggressive behaviors (Child Behavior Checklist; CBCL), and autism symptom severity (Social Responsiveness Scale; SRS-2). Children with ASD (n ¼ 20) were referred to treatment for disruptive behavior (age: M ¼ 12.74 years; SD ¼ 2.08). Control participants with ASD presented with non-significant levels of aggression (n ¼ 17; age: M ¼ 12.8 years, SD ¼ 2.23). Results: Children with ASD and aggression demonstrated higher ICU Scores (M ¼ 30.54, SD ¼ 10.03) compared to children with ASD without aggression (M ¼ 23.00, SD ¼ 11.88; t(44) ¼ 7.54, p ¼ 0.027). In the ASD with aggression group, CBCL aggressive behavior subscale scores were positively correlated with the restricted repetitive behavior (RRB) subscale of the SRS-2 (p ¼ 0.004; r(20) ¼ 0.62), but not other SRS-2 subscales. However, in the same group, ICU total scores were positively correlated with other SRS-2 subscales: social awareness (p ¼ 0.00), r(20) ¼ 0.74; social cognition (p ¼ 0.042), r(20) ¼ 0.46; social communication (p ¼ 0.036), r(20) ¼ 0.47; but not associated with RRB scores. Conclusions: These results indicate that CU traits are more pronounced in children with ASD and aggression than in children with ASD without aggression. Levels of aggressive behavior were associated with RRBs but not with social functioning, while levels of CU traits were associated with social functioning impairment. Larger studies are needed to dissociate the sociocognitive deficits core to ASD from those associated with co-occurring CU traits. The differing levels of CU traits based on aggression level suggest that CU traits may be of import in developing behavioral assessments and treatments modified for youth with ASD.

PSP, ASD, DBD Supported by NIMH Grant R01MH101514 http://dx.doi.org/10.1016/j.jaac.2017.09.302

5.20 ALTERATION OF HUB ORGANIZATION IN THE WHITE MATTER STRUCTURAL NETWORK IN TODDLERS WITH AUTISM SPECTRUM DISORDER: A TWO-YEAR FOLLOW-UP STUDY Xiaoyan Ke, Nanjing Brain Hospital affiliated to Nanjing Medical University, [email protected]; Lu Qian, Nanjing Brain Hospital affiliated to Nanjing Medical University, [email protected] Objectives: The goals of this session are 1) to investigate longitudinal changes in hub regions two years after diagnosis in the whole-brain white matter (WM) structural network among toddlers (ages 2–3 years) with autism spectrum disorder (ASD) or developmental delay (DD); and 2) to further demonstrate the relationship between changes in the nodal efficiency of hubs and changes in clinical symptoms in the ASD group. Methods: A total of 37 toddlers with ASD and 27 age-, gender-, and developmental quotient-matched toddlers with DD at baseline were included, and two-year follow-up evaluations corresponding to the standards of DSM-IVText Revision were conducted. T1 and diffusion tensor image (DTI) data were collected with a 3.0T MRI apparatus at baseline and at the two-year follow-up. DTI tractography was used to construct whole-brain WM networks, followed by graph theoretical analysis to determine architectural changes of hubs in the cerebral anatomical network. Further assessments of clinical symptoms using the Childhood Autism Rating Scale and the Autism Diagnostic Interview– Revised at baseline and at the two-year follow-up were conducted to show the relationship between hub property changes and changes in clinical symptoms in the ASD group. Results: Our results showed that after two years, 17 hub regions were identified in subjects with ASD, including 13 hub regions that had not changed from baseline and four hub regions that were newly identified and associated with the limbic cortex. In the DD group, hub regions were completely the same after two years. Finally, we showed that alterations in the properties of some special hubs involving the right middle frontal gyrus, right insula, left median cingulate gyri, and bilateral precuneus were significantly correlated

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with alterations in behaviors in patients with ASD; this correlation was not evident in control subjects with DD. Conclusions: At ages 2–5 years, children with ASD showed distributions of network hub regions that were relatively stable with minor differences. Abnormal developmental patterns in the right middle frontal gyrus, right insula, left median cingulate gyri, and bilateral precuneus in ASD may contribute to abnormalities in the social and nonsocial characteristics of this disorder.

IMAGS, ASD Supported by National Natural Science Foundation of China Grant 87101111, National Social Science Foundation of China Grant 14ZDB161, and Jiangsu Provincial Key Research and Development Program Grant BE2016616 http://dx.doi.org/10.1016/j.jaac.2017.09.303

5.21 RESTING-STATE BRAIN ACTIVITY CORRELATES WITH PROCESSING SPEED IN CHINESE CHILDREN WITH AUTISM SPECTRUM DISORDER (ASD) Gaizhi Li, MD, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, [email protected]; Yasong Du, MD, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, yasongdu@163. com; Wenqing Jiang, MD, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, [email protected] Objectives: This study aimed to explore the association of properties of spontaneous brain activity and PSI (processing speed index) of boys with autism spectrum disorder (ASD). Methods: Thirty-three drug-naïve boys (aged 6–16 years) diagnosed with DSM-5-classified ASD participated in this study. All of the boys were only diagnosed with ASD. The participants were divided into two groups using the full-scale IQ of Wechsler Intelligence Scale for Children, Fourth Edition (WISC-IV), Chinese version [high functioning ASD (n ¼ 16, mean age 11.81 2.61 years), low functioning ASD (n ¼ 17, mean age 9.23 3.40 years)]. Dorsolateral prefrontal cortex (DLPFC) was chosen as the seed region, which is an important part of the parieto-frontal integration theory. The spontaneous brain activity of DLPFC used measures such as the regional homogeneity (ReHo); amplitude of brain activity used measures known as amplitude of low-frequency fluctuation (ALFF). The preprocessing steps of resting-state data include the following: 1) converting dicom files to NIfTI images; 2) removing the first 10 (more or less) time points; 3) slice timing; 4) head motion correction; and 5) normalization. For the ALFF score, smooth and detrend was done. For the ReHo score, detrend and filter was done. The possible relationships of ReHo/ALFF with processing speed index (PSI) using WISC-IV, Chinese version, were explored in two groups [higher-functioning children (HFASD) and lower-functioning children with ASD (LFASD)]. Results: Within the HFASD group, the PSI score was significantly correlated with the value of the ALFF score for the right DLPFC (r ¼ 0.568, P ¼ 0.017). However, the correlation was not observed for the LFASD group. The association of ReHo value and PSI score was not found for both of the two groups. Conclusions: The ALFF score of DLPFC was positively correlated with PSI scores in the HFASD group. The brain activity of DLPFC in boys with ASD was different from boys with HFASD.

IMAGS, ASD, SAC http://dx.doi.org/10.1016/j.jaac.2017.09.304

5.22 A COMPARISON OF THEORY OF MIND CAPACITY AND PERFORMANCE IN CHILDREN WITH AUTISM SPECTRUM DISORDER AND TYPICAL DEVELOPMENT Hsing-Jung Li, MS, Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, [email protected]; Ching-

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Hong Tsai, PhD, Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, [email protected]; Kuan-Lin Chen, PhD, College of Medicine, National Cheng Kung University, [email protected] Objectives: Assessments of theory of mind (ToM) can be divided into two constructs, capacity and performance, which represent ToM function in the laboratory and in daily contexts, respectively. However, few studies have simultaneously examined ToM capacity and performance in children with autism spectrum disorder (ASD) and typically developing (TD) children. This study sought to identify differences between children with ASD and TD children in terms of ToM capacity and performance to fully capture the ToM of children with ASD. Methods: A total of 62 children (aged 3–7 years), comprising 31 children with ASD and 31 TD children matched for verbal comprehension, participated in this study. The Theory of Mind Task Battery and the Theory of Mind Inventory2–Chinese version were administered to assess the children’s ToM capacity and performance, respectively. Two-way analysis of variance was used to identify any significant differences in ToM capacity and performance between the two groups. Results: The results indicated significant differences in both ToM capacity (P ¼ 0.021) and performance (P < 0.0001). Additionally, most of the children with ASD were in the stage of basic mental development, whereas most of the TD children were in the stage of advanced mental development. Conclusions: This result suggests that children with ASD are one stage behind TD children in both ToM capacity and performance, although their verbal comprehension was at the same level of TD children. The results highlight the importance to assess ToM capacity and performance in children with ASD.

PSC, ASD, DEV http://dx.doi.org/10.1016/j.jaac.2017.09.305

5.23 THE EFFECT OF CHRONIC GLYCOGEN SYNTHASE KINASE 3B INHIBITION ON THE BEHAVIOR AND NEUROANATOMY OF THE FMR1 KNOCK-OUT AND CHD8 HETEROZYGOUS MOUSE MODELS OF AUTISM Zsuzsa Lindenmaier, BS, Hospital for Sick Children, zsuzsa. [email protected]; Tiffany Chien, Hospital for Sick Children, [email protected]; Kaitlyn Easson, 25 Orde Street, [email protected]; Jacob Ellegood, PhD, Hospital for Sick Children, [email protected]; Evdokia Anagnostou, MD, Holland Bloorview Kids Rehabilitation Hospital, [email protected]; Jason Lerch, PhD, Hospital for Sick Children, jason.lerch@ sickkids.ca Objectives: Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by social communication deficits and repetitive behaviors. Knockout of the FMR1 gene, the gene responsible for the most common autism-related disorder, leads to upregulation of glycogen synthases kinase b (GSK3b). Therefore, treatment with a GSK3b inhibitor is predicted to ameliorate autism-related symptoms. To determine what might contribute to response susceptibility, we treated two different mouse models of autism spectrum disorder with Tideglusib, a GSK3b inhibitor, the FMR1 knockout model and the CHD8 heterozygous model. Methods: We investigated the effect of long-term administration of Tideglusib on the behavior and neuroanatomy of the FMR1 and the CHD8 mouse models. Tideglusib was administered five days each week for four weeks, starting at five weeks of age. During the last week of treatment, five behavioral tests of memory, anxiety, hyperactivity, and sociability were administered. The mice underwent three in vivo longitudinal MRI scans before, during, and after treatment, as well as a final ex vivo scan, to assess the effect of treatment on neuroanatomy. Results: No significant effect of treatment was found on any of the behavioral measures for either strain, but a trend toward increased


sociability (P < 0.0853) was found in the FMR1 mouse model, despite no significant genotype differences. Unexpectedly, treatment had no significant effect on anxiety, in either direction, despite significant differences in the FMR1 (decreased anxiety) and CHD8 (increased) mice. Neuroanatomical data show a significant (false discovery rate < 0.05) effect of treatment across both strains in regions of the cortex, regions that are important to memory such as the ectorhinal cortex and the hypothalamus. Conclusions: Long-term treatment with Tideglusib, a GSK3b inhibitor, had a significant effect on the neuroanatomy of both FMR1 and CHD8 mouse models but only affected the behavior of the FMR1 mouse model. Therefore, it is possible that patients with Fragile X Syndrome will benefit from Tideglusib treatment, whereas patients with CHD8 haploinsufficiency may not. Future directions involve looking at the response of multiple other strains of autism spectrum disorder-related mouse models to Tideglusib, yielding the ability to establish a translational paradigm for predicting responders from nonresponders.

ANI, ASD, TREAT Supported by Brain Canada http://dx.doi.org/10.1016/j.jaac.2017.09.306

5.24 ASSOCIATIONS BETWEEN BEHAVIORAL COMORBIDITIES IN YOUNG CHILDREN WITH AUTISM SPECTRUM DISORDER AND PARENTING STRESS Jill Lorenzi, PhD, Duke Center for Autism and Brain Development, [email protected]; Hannah S. Durham, BA, Duke Center for Autism and Brain Development, hannah. [email protected]; Rimsha Afzal, BA, BS, Duke Center for Autism and Brain Development, [email protected]; Michelle Green, BS, Duke Center for Autism and Brain Development, [email protected]; Geraldine Dawson, PhD, Duke Center for Autism and Brain Development, [email protected] Objectives: In addition to social communication deficits and repetitive behaviors, children with autism spectrum disorder (ASD) often present with comorbid behaviors (e.g., hyperactivity, irritability). Severity of comorbid behaviors has been shown to predict parenting stress (Parenting Stress Index; PSI). However, PSI total score includes questions about children’s hyperactivity/mood, and thus does not assess the independent contribution of comorbid conditions to parenting stress. This study examined the association between severity of ASD symptoms and comorbid behaviors on aspects of parenting stress that solely reflect parent characteristics (e.g., depression, health). Methods: Participants (N ¼ 25) ranged in age from 2.27-5.98 years (M ¼ 4.47); nonverbal IQ M ¼ 64.3 ( 24.6). ASD diagnosis included assessment via Autism Diagnostic Observation Schedule, Second Edition (ADOS-2) and Autism Diagnostic Interview-Revised (ADI-R). Pervasive Developmental Disorder Behavior Inventory (PDDBI autism composite) measured severity of ASD symptoms. Comorbid behaviors were measured with Aberrant Behavior Checklist-Community (ABC-C; irritability, lethargy, stereotypy, hyperactivity, inappropriate speech) and Behavioral Assessment System for Children, Second Edition (BASC-2; hyperactivity, aggression, externalizing problems, anxiety). Parenting Stress Index, Fourth Edition (PSI-4) parent domain measured stress related to parent factors (e.g., competence, isolation, depression, partner relationship). Backward elimination regression examined associations between ASD/comorbid behaviors and parenting stress. Results: Significant positive correlations emerged between stress related to parent characteristics (PSI-4 parent domain) and ABC-C irritability (r ¼ 0.63, p < 0.01) and hyperactivity (r ¼ 0.43, p ¼ 0.04). Three scales approached significance: BASC-2 hyperactivity (r ¼ 0.36, p ¼ 0.08) and externalizing problems (r ¼ 0.36, p ¼ 0.09), and PDDBI autism composite (r ¼ 0.36, p ¼ 0.08). Regression analysis with these scales retained only ABC-C irritability (R2 ¼ .40, F (1, 22) ¼ 14.72, p < 0.01).

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Conclusions: Irritability and hyperactivity correlated strongly with parenting stress related to parent characteristics (e.g., health, partner relationship). Child irritability explained 40 percent of variance in stress related to parent characteristics. Greater emphasis should be placed on child irritability and hyperactivity as significant factors in parental stress, with implications for early intervention and clinical care.

ASD, CM, STRESS Supported by the Marcus Foundation and PerkinElmer, Inc. http://dx.doi.org/10.1016/j.jaac.2017.09.307

5.25 RETROSPECTIVE CHART REVIEW OF YOUTH WITH AUTISM SPECTRUM DISORDER PRESENTING TO THE EMERGENCY DEPARTMENT Sarah Lytle, MD, University Hospitals Cleveland Medical Center, [email protected]; Grace Pinto-Britton, MD, University Hospitals Cleveland Medical Center, Grace. [email protected]; Andrew Hunt, MD, University Hospitals Cleveland Medical Center, andrew.hunt@ uhhospitals.org; Hongyan Liu, PhD, Case Western Reserve University, [email protected]; Marcie Hall-Mennes, MD, University Hospitals Cleveland Medical Center, mary-hall. [email protected]; Awais Aftab, MD, University Hospitals Cleveland Medical Center, muhammed@ uhhospitals.org; Martha Sajatovic, MD, University Hospitals Cleveland Medical Center, [email protected] Objectives: Youth with autism spectrum disorder (ASD) may present to the emergency department (ED) as a result of behavioral issues. ED evaluation, management, and disposition of youth with ASD can be complicated by a variety of factors. To better understand these complexities, we conducted a retrospective chart review of youth with ASD who presented to the ED. Methods: This single center, three-year retrospective chart review assessed youth with ASD (ages 4–17 years) who presented to the ED with behavioral problems. We evaluated demographics, events leading up to the ED visit, comorbid diagnoses, physical injuries, health resource utilization, use of restraints, and disposition. Results: The sample group comprised 55 patients, with a total of 152 visits in a three-year period. The majority were male, African American (n ¼ 25, 45.5%) or Caucasian (n ¼ 27, 49.1%), and on Medicaid insurance. Mean age was 13.5 SD 2.85 years. The most common comorbid diagnoses were ADHD (n ¼ 30, 54.5%), bipolar/mood disorders (n ¼ 18, 32.7%), and anxiety (n ¼ 16, 29.1%). Illustrating distress burden, patients presented to the ED in handcuffs in at least six percent (n ¼ 9) of visits. Patients (74.5%; n ¼ 41) presented to the ED with a recent history of aggression, agitation, or property destruction during at least one visit. Once in the ED, 39.9 percent (n ¼ 17) demonstrated these externalizing behaviors. A total of 13 patients (23.6%) received psychotropic medications in the ED, and eight (4.5%) were placed in physical restraints. A slight majority (n ¼ 75, 55.5%) of ED visits concluded with the patient being discharged to home, whereas 25.2 percent (n ¼ 34) and 14.1 percent (n ¼ 19) were admitted to a psychiatric hospital or medical floor, respectively. It is noteworthy that 60 percent (n ¼ 9) of medical admissions occurred because of lack of availability of inpatient psychiatry beds. Conclusions: This three-year retrospective chart review demonstrates that ED visits by youth with ASD occur in the context of high distress burden to youth and their families, can result in medical restraint interventions, and often leads to a psychiatric or medical admission and that lack of psychiatric bed availability may result in medical floor admission. Care approaches that include proactive interventions for externalizing behaviors, help to prevent ED visits, and optimize disposition after an ED visit are needed to advance care for youth with ASD.

ADOL, ASD, CON http://dx.doi.org/10.1016/j.jaac.2017.09.308

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5.27 EVIDENCE FOR AN INFANT CONSTRUCT OF SOCIAL MOTIVATION AND PREDICTIVE VALIDITY FOR AUTISM SPECTRUM DISORDER Natasha Marrus, MD, PhD, Washington University in St. Louis, [email protected]; Kelly N. Botteron, MD, Washington University in St. Louis School of Medicine, [email protected]; Lucille Dai-He, Washington University in St. Louis, [email protected]; Joshua Jackson, PhD, Washington University in St. Louis, [email protected]; Lori Markson, PhD, Washington University in St. Louis, [email protected]; Annette M. Estes, PhD, University of Washington Autism Center, [email protected]; Stephen Dager, MD, University of Washington, [email protected]; Heather Hazlett, PhD, University of North Carolina at Chapel Hill, [email protected]; Robert Schultz, PhD, Children’s Hospital of Pennsylvania, [email protected]. edu; Joseph Piven, MD, University of North Carolina at Chapel Hill, [email protected]; John N. Constantino, MD, Washington University in St. Louis School of Medicine, [email protected] Objectives: According to the social motivation hypothesis, individual differences in social motivation are present in infancy and may predict the emergence of autism spectrum disorder (ASD). We investigated the evidence for a social motivation construct in a large sample group of existing infant data with the following aims: 1) to derive a preliminary index of social motivation in infants and toddlers; and 2) to investigate psychometric properties of this index. Methods: Behavioral data were analyzed from the Autism Center of Excellence Infant Brain Imaging Study, a prospective, longitudinal study of more than 500 infants at high and low familial risk for ASD. Items were selected from multiple assessments based on face validity for social motivation, which was operationalized as the disposition to preferentially orient to social stimuli, seek social interactions, and exert effort to maintain social engagement. Item scores were uniformly weighted and summed to generate a “social motivation score” at ages six, 12, and 24 months. A clinical best estimate procedure (including the Autism Diagnostic Observation Schedule) was used to diagnose ASD at 24 months. Results: Summed items demonstrated a continuous, unimodal score distribution at ages 6, 12, and 24 months. Items showed good internal consistency (6 months: a ¼ 0.587; 12 months: a ¼ 0.714; 24 months: a ¼ 0.869), and significant cross-age correlations (ages 6–12 months: r ¼ 0.400, P < 0.001; ages 12–24 months: r ¼ 0.279, P ¼ 0.010), suggesting some trait-like stability. Scores at all three ages significantly correlated with ASD severity on the Autism Diagnostic Interview-Revised at age 24 months (age 6 months: r ¼ 0.174, P ¼ 0.012; age 12 months: r ¼ 0.259, P < 0.001; age 24 months: r ¼ 0.675, P < 0.001). Lower social motivation scores were observed by age 6 months for infants later diagnosed with ASD [age 6 months: t(328) ¼ 3.66, P < 0.001; age 12 months: t(365) ¼ 2.75, P ¼ 0.006; age 24 months: t(117) ¼ 5.05, P < 0.001]. Conclusions: These findings provide initial evidence for a measurable social motivation construct in infancy, which shows predictive validity for ASD by age six months. ASD-related score differences suggest that further characterization of social motivation in infancy could promote earlier identification of children with ASD who would benefit from intervention.

ASD, INF, DEV Supported by NMH Grant 1 K08 MH112891-01, Eunice Kennedy Shriver National Institute of Child Health and Human Development Grant HD055741, Autism Speaks Grant 6020, and Simons Foundation Grant 140209 http://dx.doi.org/10.1016/j.jaac.2017.09.310

5.28 BREASTFEEDING STATUS IS NOT ASSOCIATED WITH RISK FOR AUTISM SPECTRUM DISORDER: A SYSTEMATIC REVIEW AND META-ANALYSIS Sherief Gozy, MD, Mansoura University, Sherief_ghozy@ yahoo.com; Sadiq Naveed, MD, KVC Hospitals, snaveed@

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kvc.org; Ahmed Waqas, MD, KVC Hospitals, [email protected]; Tran T.H. Quynh, Viet Nam National University of Ho Chi Minh City, tranquynh.su@gmail. com; Ahmed K.H. Sayed, Minia University, A.Kamal@s-mu. edu.eg; Dang T.B. Hop, Ho Chi Minh City Medicine and Pharmacy University, [email protected]; Ibrahim A.M. Elsherbini, Alexandria University School of Medicine, [email protected]; Nguyen T. Huy, Ton Duc Thang University, [email protected] Objectives: A large number of studies have cited genetic, epigenetic, and perinatal factors as the cause of autism spectrum disorder (ASD). The present systematic review and meta-analysis explore the qualitative and quantitative nature of the association of pattern of continuous and exclusive breast feeding with the risk of development of ASD among offspring. Methods: In September 2015, 10 electronic databases were searched for peer-reviewed articles, theses, and dissertations for relevant articles. The study protocol detailing the methodology has been registered in PROSPERO with ID CRD42016043128. We used the following search terms: “breastfeeding,” “breast feeding,” “breastfed,” “breast milk,” “breastmilk,” “lactation,” or “human milk” and “autism,” “autistic,” “Asperger’s syndrome,” “Asperger,” “Child Development Disorders, Pervasive”[Mesh] or “disorders” and “pervasive” or “childhood disintegrative disorder,” with no limits on language or dates. Three reviewers independently screened titles and abstracts to select potential full-text articles and extracted data related to study design, participant characteristics, and effect sizes. All data were analyzed using comprehensive meta-analysis software, version 2.1. Separate meta-analyses were conducted for checking association of exclusive and continuous breastfeeding with the risk of ASD. All effect sizes were reported as OR with 95 percent confidence interval (95% CI). Results: There were seven studies (N ¼ 17,532) that had reported an association between pattern of exclusive breastfeeding and the risk of ASD among offspring. According to our analysis using fixed-effects model, exclusive breastfeeding lowers risk of ASD, but this effect is insignificant [pooled OR ¼ 0.952 (95% CI ¼ 0.826–1.096), P ¼ 0.169]. There were eight studies (N ¼ 40,965) that had reported an association between pattern of continuous breastfeeding and the risk of ASD among offspring. According to our analysis using random-effects model, continuous breastfeeding lowers risk of ASD, but this effect is insignificant (pooled OR ¼ 0.856, 95% CI ¼ 0.638–1.148, P ¼ 0.299). Conclusions: There is no significant association between patterns of breastfeeding and the risk of ASD among offspring.

ASD, EC, OTH http://dx.doi.org/10.1016/j.jaac.2017.09.311

5.29 INTEGRATING DEEP LEARNING WITH BEHAVIOR IMAGING TO ACCELERATE INDUSTRY LEARNING OF AUTISM CORE DEFICITS Ron Oberleitner, MBA, Behavior Imaging, ron.oberleitner@ behaviorimaging.com; Joel Schwartz, PhD, Biomedical Data Analytics, [email protected] Objectives: Autism spectrum disorder (ASD) is a behavior-defined disorder requiring professional diagnostic evaluation. Because ASD does not have clear biomarkers, a diagnosis must be based on clinical observation and developmental history. This can result in significant variability. However, new approaches using artificial intelligence (AI) and an associated computational method known as Deep Learning are now being developed to improve the consensus of behaviors observed that are associated with ASD. This presentation provides an overview of the project, its design, its logic, methods and procedures, and the outcomes of a preliminary study integrating Deep Learning into an established dataset of NODA. Methods: A DL computational method called a “DL Classifier” is being introduced to help analyze information collected by a new evidencesupported telehealth assessment called NODATM (Naturalistic


Diagnostic Assessment). NODA results in clinician-annotated videos reviewed by trained autism diagnosticians who identify and mark select atypical (autism-related) and typical behaviors in children at specific moments on video samples parents share from their home. The DL Classifier analyzes the behavioral information around the diagnostician’s mark into recognized patterns that can then be automatically “flagged” to a diagnostician to suggest identified examples of autism behavior. The more a clinician (or an industry of clinicians) trains the system, the better the DL Classifier gets in automatically recognizing clinically identified atypical behaviors. A total of 240 videos generated from a prior clinical study for n ¼ 51 research subjects, manually tagged by expert autism diagnosticians over 6,300 times with either atypical or typical tags, were used to test the first prototype Classifier that was developed to analyze the dataset. Results: The NODA DL classifier demonstrated an w80 percent correlation when only still images from the videos were analyzed. Subsequently, analyzing the video’s auditory and video data improved the classifier accuracy to 86 percent. Conclusions: From these results, use of the NODA dataset and Deep Learning methods shows promise for the establishment of a computerized method to automatically flag where atypical behaviors associated with autism are found on a videoclip.

ASD, TVM Supported by NIMH Grant R44MH099035 http://dx.doi.org/10.1016/j.jaac.2017.09.312

5.30 PROSPECTIVE, OBSERVATIONAL COHORT STUDY OF JAKEâ, AN AUTISM KNOWLEDGE ENGINE: CORRELATION OF BEHAVIOR RATINGS WITH EYE TRACKING G. Pandina, PhD, Janssen Research & Development, LLC, [email protected]; N.V. Manyakov, PhD, Janssen Research & Development, LLC, [email protected]; A. Bangerter, MA, Janssen Research & Development, LLC, [email protected]; D. Lewin, PhD, Janssen Research & Development, LLC, [email protected]; S. Jagannatha, PhD, Janssen Research & Development, LLC, [email protected]; M. Boice, Janssen Research & Development, LLC, [email protected]; A. Skalkin, MS, Janssen Research & Development, LLC, [email protected]. com; Geraldine Dawson, PhD, Duke University, geraldine. [email protected]; M.S. Goodwin, PhD, Northeastern University, [email protected]; R. Hendren, DO, University of California, San Francisco, [email protected]; Bennett L. Leventhal, MD, University of California, San Francisco, [email protected]; F. Shic, PhD, University of Washington, [email protected]; S. Ness, MD, Janssen Research & Development, LLC, [email protected] Objectives: Correlations of behavior ratings with more objective biosensor data were examined with a view to identifying potential eye-tracking biomarkers for change in autism spectrum disorder (ASD). Methods: Subjects (aged 6 years) were enrolled in an observational study [ASD, 144; typically developing (TD), 41). JAKE Sense and behavior rating scales were completed at baseline, midpoint (4 weeks), and endpoint (8 weeks) for the group with ASD and at baseline only for the TD group. Eye-tracking tasks included passive viewing of dynamic social videos containing actor(s) and including backgroundnonsocial distractors. In addition, a static visual exploration task (VET) was used. This study is registered at Clinicaltrials.gov (NCT02668991). Results: Across dynamic eye-tracking tasks, compared with the TD group, the group with ASD spent less time looking at faces (P ¼ 0.001) and less time looking at heads versus bodies (P < 0.001). Time attending to screen during social stimuli correlated with Autism Behavior Inventory (ABI)-Social Cognition (SC) (rs [69] ¼ 0.32, P ¼ 0.003), and time spent looking at eyes

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also correlated with ABI-SC (rs [69] ¼ 0.24, P ¼ 0.024). Changes in attention to heads from baseline to endpoint correlated with changes in ABI Core (rs [45] ¼ 0.33, P ¼ 0.01) in individuals who were under the age of 13 years. In older individuals, change in time spent looking at backgroundobjects correlated with change in ABI-Restricted Repetitive Behavior (RRB) (rs [46] ¼ 0.33, P ¼ 0.01). In the VET, there were significant differences between TD subjects and subjects with ASD in the total number of images explored, adjusted for total viewing time. The group with ASD explored fewer images (P < 0.001). There were significant differences between groups in the average fixation time on high autism interest (HAI) objects (P ¼ 0.036). Correlations between perseveration on HAI and ABI-RRB interests were observed across all time points (baseline, rs ¼ 0.18, P ¼ 0.026; at midpoint, rs ¼ 0.19, P ¼ 0.032; and endpoint, rs ¼ 0.18, P ¼ 0.038) in all groups and to a greater extent in the age group of 10 pounds (94%). Most parents (82%) would consider adding medication to combat weight gain if their child complained about weight gain or if their child gained > 10 pounds (87%). Conclusions: SGA drug-induced weight gain impairs medication adherence in young patients with bipolar disorder. A majority of youth with bipolar disorder would be willing to initiate pharmacological treatment to prevent SGA druginduced weight gain at the same time the SGA treatment is started; parents and clinicians would generally opt to wait until weight gain occurs and is perceived as a problem by the patient, parent and/or clinician. Open communication among patients, parents, and clinicians regarding strategies to mitigate potential side effects and promote medication adherence is needed.

APS, MAE, OBE Supported by Patient-Centered Outcomes Research Institute Award PCS1406-19276 http://dx.doi.org/10.1016/j.jaac.2017.09.322

5.40 PRELIMINARY POLYGENIC CLASSIFICATION APPROACH FOR ADOLESCENT BIPOLAR DISORDER Mikaela Dimick, BA, Sunnybrook Health Sciences Centre, [email protected]; Lisa Fiksenbaum, PhD, Sunnybrook Health Sciences Centre, lisa.fiksenbaum@ sunnybrook.ca; Natalie Freeman, BS, Centre for Addiction and Mental Health, [email protected]; James Kennedy, MD, Centre for Addiction and Mental Health, [email protected]; Benjamin I. Goldstein, MD, PhD, Sunnybrook Health Sciences Centre, benjamin. [email protected] Objectives: Bipolar disorder (BD) is a complex and heterogeneous illness that is among the most heritable in psychiatry. Genome-wide association studies and individual candidate gene studies have found several genetic

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polymorphisms associated with BD. Individually, these genes have limited effects, and few studies have examined the collective effects of multiple genes concurrently. We selected 35 genes that have previously been implicated with either BD or associated characteristics, from which to select the most robustly predictive group of genes. Methods: DNA was extracted from saliva and genotyped for 113 adolescents with BD (BD-I, n ¼ 29; BD-II, n ¼ 50; BD-NOS, n ¼ 34) and 146 healthy control subjects. Diagnosis was determined using the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS). The 35 candidate genes were entered into backwards and forwards stepwise AIC regression models, searching for the strongest predictors of BD. The 10-fold cross-validation prediction error was used to compare models along with area under the curve (AUC) of ROC. Results: The prediction errors were 22.96 and 23.23 percent, and the AUC of the ROCs were as follows: 73.27 percent (95% CI ¼ 67.27–79.27) and 75.69 percent (95% CI ¼ 69.94–81.44) for the forwards and backwards models, respectively. The following three genes were significant in both models: IL6 (rs1800795; x2Backward ¼ 7.05, pBackward ¼ 0.029; x2Forward ¼ 8.14, pForward ¼ 0.017); IL10 (rs1800896; x2Backward ¼ 12.77, pBackward ¼ 0.005; x2Forward ¼ 11.65, pForward ¼ 0.009); and SOD2 (rs4880; x2Backward ¼ 12.94, pBackward ¼ 0.004; x2Forward ¼ 12.24, pForward ¼ 0.0096). Additionally, the following genes were significant in the backwards model: DISC1 (rs821577); GPX3 (rs3792797); and PER2 (rs2304672). Conclusions: These preliminary findings implicate genes within inflammatory and oxidative stress pathways in adolescent BD, converging with prior evidence of imbalance in related proteins in adult BD. Future studies, including larger sample groups, genome-wide analysis, and imaging phenotypes, are warranted.

ADOL, GS, BD http://dx.doi.org/10.1016/j.jaac.2017.09.323

5.41 THE INPATIENT BURDEN OF PEDIATRIC BIPOLAR DISORDER IN THE UNITED STATES, ANALYSIS OF NATIONAL TRENDS Raghu Gandhi, University of Minnesota Medical Center, [email protected]; Aastik Joshi, Louisiana State University Health Sciences Center, [email protected]; Puneet Narang, Regions Hospital, puneet.d.narang@ healthpartners.com Objectives: Few studies have examined the national burden of inpatient admission of pediatric bipolar disorder. This study compares the burden over the years (from 1997 to 2012) across various patient and hospital characteristics. Methods: This study analyzed the nationally representative Kids’ Inpatient Database (KID) 2012 from the Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project (HCUP). The KID contains administrative data on pediatric discharges for patients 0 to 17 years of age. Inpatient sample includes all the pediatric patients in which bipolar disorder (ICD-9 codes: 296.0, 296.1, 296.4,296.5, 296.6, 296.7, 296.8-9) was the principal discharge diagnosis from 1997 to 2012. The statistical significance of the difference in the number of hospital discharges, length of stay, and hospital costs over the study period was determined. Results: Between 1997 and 2012, the number of hospitalizations for pediatric patients with a primary discharge diagnosis of bipolar disorder increased from 13,284 patients to 48,451, whereas the average length of hospital stay decreased from 9.83 days to 7.93 days. The rate of discharge per 100,000 people increased from 18.7 in 1997 to 65.7 in 2012. The mean charges per hospital discharge for bipolar disorder increased from $9,316 in 1997 to $17,229 to 2012. Conclusions: There is a significant increase in the inpatient burden of pediatric bipolar disorder in the United States over the years. This was not seen in other parts of the world, such as in the United Kingdom, where ICD-10 is used. This change in the diagnostic practice in the United States, associated with the increased use of atypical antipsychotic agents, was sufficiently concerning that the DSM-5 committee tightened the manic criteria and used data on

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severe mood dysregulation to create a new condition, disruptive mood dysregulation disorder. Our findings support previous studies.

BD, DDD, DIAG http://dx.doi.org/10.1016/j.jaac.2017.09.324

5.42 CONDUCTING A MULTI-SITE, COMMUNITYBASED, PRAGMATIC RESEARCH TRIAL: STUDY DESIGN, RECRUITMENT BARRIERS, AND INITIAL SAMPLE CHARACTERISTICS OF MOBILITY Claudine Higdon, MD, Northwell Health, chigdon@northwell. edu; Victor Fornari, MD, Northwell Health, vfornari@ northwell.edu; Eva Sheridan, MD, Zucker Hillside Hospital, [email protected]; Christina Klein, MPH, University of Cincinnati, [email protected]; Jeffrey Welge, PhD, University of Cincinnati, [email protected]; Thomas Blom, MS, University of Cincinnati, [email protected]; Jenna Nott, BS, University of Cincinnati, [email protected]. edu; Arielle Carmel, BS, Zucker Hillside Hospital, ACarmel@ northwell.edu; Luis Patino Duran, MD, University of Cincinnati, [email protected]; Michael T. Sorter, MD, Cincinnati Children’s Hospital Medical Center, Michael. [email protected]; Brian Perry Kurtz, MD, University of Cincinnati, [email protected]; Angie Day, Depression and Bipolar Support Alliance, [email protected]; Heather Turner, National Alliance on Mental Illness (NAMI) of Southwest Ohio, [email protected]; Avani Modi, PhD, Cincinnati Children’s Hospital Medical Center, [email protected]; Brittany Dyce, BS, University of Cincinnati, [email protected]; Norman Snead, BA, University of Cincinnati, [email protected]; Christoph U. Correll, MD, Northwell Health, [email protected]; Melissa P. DelBello, MD, MS, University of Cincinnati, delbelmp@ucmail. uc.edu Objectives: The goal of this presentation is to describe the MOBILITY study design, barriers to recruitment and retention, and initial sample characteristics. Methods: The MOBILITY team has recruited overweight/obese youth (ages 7–19 years) with current or past diagnosis of bipolar spectrum disorder who are continuing or starting treatment with second-generation antipsychotic (SGA) drugs. Patients were randomized in 1:1 ratio to either metformin (MET) + simple healthy lifestyle intervention (LIFE) or LIFE alone. The primary outcome measure is to assess overall and subgroup-specific impact of MET + LIFE versus LIFE alone on short- and long-term weight and metabolic health. The MOBILITY team analyzed differences in study design, collected qualitative data regarding barriers to recruitment and retention, and baseline sample characteristics. Results: Recruitment as of May 10, 2017, shows that 507 patients consented and 491 patients were randomized from 23 community mental health centers in the Greater New York and Cincinnati, Ohio regions. Recruitment barriers not unique to pragmatic clinical trials include high cancellation/noshow rates, lack of support staff, limited provider time, and referral outside of MOBILITY sites. Retention barriers include transitions in care from inpatient to outpatient or day hospital settings. The mean age of the initial sample group (n ¼ 438 for data capture) is 13.7 years, with 52 percent female, 63 percent Caucasian, 24 percent African American, and 12 percent Hispanic. Altogether, 34 percent of the sample group is overweight, and 66 percent of the sample group is obese, with a total mean BMI percentile of 95.5. Unspecified mood disorder or mood disorder not otherwise specified (45% of sample group) was the most common diagnosis, followed by bipolar I disorder (19%) and disruptive mood dysregulation disorder (19%). Other diagnoses include unspecified bipolar disorder (8%), bipolar II disorder (4%), and cyclothymic disorder (< 1%).

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Conclusions: MOBILITY highlights how conducting a multisite patientcentered pragmatic trial is much different from an explanatory trial with respect to study design, implementation, and barriers to recruitment and retention. The initial demographic data show a diverse clinical sample group and attest to the pragmatic nature of this trial. As comparative clinical effectiveness research becomes more prevalent in the field of child and adolescent psychiatry, understanding and adjusting for these differences will be paramount for its success.

APS, RCT, BD Supported by Patient-Centered Outcomes Research Institute Award PCS1406-19276 http://dx.doi.org/10.1016/j.jaac.2017.09.325

5.43 SLEEP LATENCY AND NOCTURNAL AWAKENINGS IN BIPOLAR OFFSPRING VERSUS CONTROLS Juan David Palacio, MD, Universidad de Antioquia, [email protected]; Rommel Andrade-Carrillo, MD, Universidad de Antioquia, [email protected]; Sujey G omez-Cano, MD, Universidad de Antioquia, [email protected]; Juan J. Erazo-Orozco, MD, Universidad de Antioquia, [email protected]; Claudia P. Quintero-Cadavid, MD, Universidad de Antioquia, [email protected]; Santiago Estrada-Jaramillo, MD, Universidad de Antioquia, [email protected]; Daniel C. Aguirre-Acevedo, MD, Universidad de Antioquia, daniel. [email protected]; Cristian Vargas-Upegui, MD, Universidad de Antioquia, [email protected]; Carlos A. Lopez-Jaramillo, MD, Universidad de Antioquia, [email protected] Objectives: The objective of this study was to compare the sleep-wake cycle profile between offspring of parent with bipolar disorder (BO) and offspring of parent controls (PCO). Methods: A descriptive, comparative cross-sectional study was carried out. Subjects were selected from a previous study comparing 127 BO versus 150 PCO. All parents and decedents were from the genetic isolate (“Paisa”). Parents with bipolar disorder (BD) must have a history of BD type I with a documented hospital intake. Control parents could have a history of any psychiatric disorder excluding BD or schizophrenia. The subjects’ ages ranged from six to 18 years, and all subjects were ascertained with the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL). The sleep profile was obtained with questionnaires applied to the participants: “Children Sleep Habits Questionnaire” and to their caregivers: “School Sleep Habits Survey.” The surveys were translated into Spanish with prior agreement of the authors. Subjects with DSM-5 diagnosed intellectual disability and autism spectrum disorders were excluded. A comparison of quantitative and qualitative variables was done using the Wilcoxon W or the Mann-Whitney U test. This research was approved by the local ethical review board (ERB). Results: A total of sixty subjects were evaluated: 32 belonged to the BO group and 28 to the PCO group. Clinical differences were found in sleep latency time (non-school days): PCO group with a mean of 21.39 minutes versus BO group with a mean of 13.09 minutes (p ¼ 0.074). Also, the frequency of nocturnal awakenings was higher in the BO group (50%) versus PCO group (5%). Compared to the PCO group, the BO group had higher frequency for bipolar spectrum symptoms (19%; p ¼ 0.016), psychotic symptoms associated with affective episodes (22%; p ¼ 0.020) and psychotic symptoms (31%; p ¼ 0.008), with a clinically and statistically significant difference. The BO group had also a higher frequency for social phobia (28%; p ¼ 0.093), MDD (25%; p ¼ 0.064), BD-NOS (13%; p ¼ 0.053) and BD (9%; p ¼ 0.096). This last finding has clinical significance but not statistical significance. Conclusions: A shorter sleep latency time and a greater number of nocturnal awakenings were found in the BO group compared to PCO group regardless of any associated psychopathology. Larger sample size studies are required in order to consider these sleep changes as possible endophenotypes for BD.


BD, RF, SLP Supported by Colciencias Code 111571149700 Convocatoria 711, RC 826 del 2015 http://dx.doi.org/10.1016/j.jaac.2017.09.326

5.44 PREVALENCE AND CORRELATES OF POLICE CONTACT AMONG CANADIAN ADOLESCENTS WITH BIPOLAR DISORDER Sandra Pietrantonio, MSC, Sunnybrook Health Sciences Centre, [email protected]; Lisa Fiksenbaum, PhD, Sunnybrook Health Sciences Centre, lisa.fi[email protected]; Vanessa Timmins, MSW, Sunnybrook Health Sciences Centre, vanessa.timmins@ sunnybrook.ca; Benjamin I. Goldstein, MD, PhD, Sunnybrook Health Sciences Centre, [email protected] Objectives: Adults with bipolar disorder (BD) have an increased risk for police contacts, including criminal activity. Little is known about adolescents with BD and police contacts. Therefore, we sought to examine the prevalence and correlates of police contact in a relatively large sample group of Canadian adolescents with BD. Methods: Participants comprised 168 adolescents (aged 13–19 years) with a diagnosis of BD-I, -II, or –NOS via the Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime (KSADS-PL). Information on clinical characteristics was obtained from the KSADS-PL. The Life Problems Inventory (LPI) questionnaire was used to provide a dimensional measure of impulsivity. Chi-square, t-tests, and binary logistic regression analyses were performed. Results: Sixty-one participants (36.3%) had lifetime contact with the police at an average of 1.77 1.16 separate times. Most common reasons for police contact were theft (40.9%), serious harm to themselves (36%), aggressive behavior (26.2%), mischief (19.4%), staying out late/running away (18%), being a witness or victim of an offense (14.8%), and drug possession or intoxication (13%). Youth with police contact, in comparison to youth without police contact, had higher impulsivity scores and were more likely to have a history of substance use disorder (SUD), ODD, and conduct disorder (CD), and family history of CD. They were also less likely to live with their natural parents. Multivariate analysis showed that a family history of ADHD and lifetime SUD and CD, in addition to having a psychiatric hospitalization, were the strongest independent predictors of police contact. Conclusions: History of police contact is extremely common among adolescents with BD and is associated with personal and family history of behavioral disorders and SUD. The different reasons for police contact suggest the potential importance of personalizing strategies for the prevention of police contact.

ADOL, BD, CD http://dx.doi.org/10.1016/j.jaac.2017.09.327

5.45 TWO GENERATIONS OF MORE ASSORTATIVE MATING IN THE US Robert M. Post, MD, Bipolar Collaborative Network, robert. [email protected] Objectives: There is more genetic vulnerability for a psychiatric disorder in the parents and grandparents of the United States compared with European patients with bipolar disorder, and this increases the risk of mental illness in the patient’s offspring. We now examine the additional role of assortative mating on this vulnerability. Methods: A history of mental illness (depression, bipolar disorder, suicide attempt, alcohol abuse, drug abuse, and “other” illnesses) was elicited for the parents, spouse, and the offspring of 968 patients with bipolar disorder (540 of whom had children) who gave informed consent for participation in a treatment outcome network. Assortative mating for a mood disorder in the spouse and parents of patients from the United States was compared in patients from the Netherlands and Germany and related to illnesses in the offspring.

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Results: There was more illness and assortative mating for a mood disorder in both the patient’s spouse (31 vs. 9%) and the patient’s parents (21 vs. 3%) from the United States compared with Europe. In the parents of the US patients, assortative mating for a mood disorder was associated with more depression, bipolar disorder, alcohol, and other illnesses in the patient’s offspring. Conclusions: This two-generation increase in assortative mating in the United States adds to the genetic vulnerability to mental illness in the offspring, further increasing the combined effects of greater amounts of psychosocial stress in the United States. The increases in childhood-onset illness driven by these factors deserve new efforts in research, clinical, and public health attempts to address and ameliorate this most unfortunate situation.

BD, DDD, GS http://dx.doi.org/10.1016/j.jaac.2017.09.328

5.46 PREVALENCE AND CLINICAL CORRELATES OF EATING DISORDERS AMONG CANADIAN ADOLESCENTS WITH BIPOLAR DISORDER Jessica L. Roane, MSW, Sunnybrook Health Sciences Centre, [email protected]; Lisa Fiksenbaum, PhD, Sunnybrook Health Sciences Centre, lisa.fiksenbaum@ sunnybrook.ca; Vanessa Timmins, MSW, Sunnybrook Health Sciences Centre, [email protected]; Benjamin I. Goldstein, MD, PhD, Sunnybrook Health Sciences Centre, [email protected] Objectives: We examined the prevalence and clinical correlates of eating disorders (EDs) among adolescents with bipolar disorder (BD), regarding which little is known. Methods: Participants comprised 168 adolescents (16.26 1.48 years, 62.5% female) with a diagnosis of BD-I, -II, or –not otherwise specified (NOS). EDs included anorexia nervosa (AN), bulimia nervosa (BN), and ED-NOS. Diagnoses were determined using the Kiddie Schedule for Affective Disorders and Schizophrenia–Present and Lifetime (KSADS-PL). The Life Problems Inventory (LPI) assessed impulsivity via self-report. The Children’s Affective Lability Scale (CALS) was used to measure parent and adolescent reports of total affective lability. Chi-square analyses, independent samples t-tests, and binary logistic regression analyses were used. Results: Twenty-nine percent of the participants had a comorbid ED (3% AN, 9.5% BN, and 17% ED-NOS). A comorbid ED was significantly associated with female sex, white race, BD-II subtype, greater current and most severe past depressive symptoms, impulsivity, and adolescent-reported affective lability and family history of anxiety disorders. The ED group had higher rates of selfinjurious behavior (SIB), suicidal ideation, suicide attempts, substance use disorders, ODD, and anxiety disorders. Adolescents with an ED were less likely to have received treatment with lithium. The significant predictors in multivariate analysis were most severe past depression severity, SIB, and impulsivity. Conclusions: EDs are highly prevalent among adolescents with BD and are consistently associated with increased burden of categorical, dimensional, and familial psychopathology. Treatment studies focused on this comorbidity may benefit from targeting depression, impulsivity, and distress tolerance. Prospective studies examining bidirectional effects of BD and EDs are warranted.

ADOL, BD, EA http://dx.doi.org/10.1016/j.jaac.2017.09.329

5.47 ATTENTIONAL MEASURES IN CHILDREN AND ADOLESCENTS WITH BIPOLAR DISORDER Cristiana Castanho A. Rocca, PhD, Institute of Psychiatry of University of S~ ao Paulo, [email protected]; Lee Fu-I, MD, PhD, University of Sao Paulo, [email protected] Objectives: This study aims to check the correlation between attention-deficit measured by a neuropsychological assessment and the Child Behavior Checklist (CBCL).

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Methods: The sample group was drawn from an early onset affective disorder program at the University of S~ao Paulo, Brazil. All patients met the DSM-IV criteria for bipolar disorder (BD) diagnosis through best-estimate consensus assessment through a face-to-face clinical interview, review of the clinical records, CBCL, and Diagnostic Interview for Children and Adolescents-IV (DICAIV). The exclusion criteria were as follows: 1) IQ < 70); 2) previous learning disability or school impairment failure; and 3) inability to complete all investigation procedures. The final sample group comprised 44 adolescents (32 boys and 12 girls), with a mean age of 13.3 years. The neuropsychological assessments were conducted through Wechsler Abbreviated Scale of Intelligence (WASI); Digit Span; Wechsler Intelligence Scale for Children (WISC-III); Finger Windows (Wide Range Assessment of Memory and Learning, Second Edition, WRAML–II); Trail Making A and B Executive Functioning Test; Stroop Test; and response inhibition skill and analyzed through Spearman rho correlation test. Results: There was a negative correlation between Digit backward (P ¼ 0.043), Finger Windows test (P ¼ 0.046), and the CBCL reports of attention problems. There was a positive correlation between errors in card 3 of the Stroop Color Test (P ¼ 0.024) and the CBCL reports of attention problems. Thought disturbance subscale of the CBCL showed negative correlations with Digit Span: total (P ¼ 0.047) and Digit backward (P ¼ 0.042). There was a positive correlation between errors in card 3 of Stroop Color Test (P ¼ 0.006), the CBCL of thought disturbance subscale. This measure can be considered one of the most accountable in the detection of inhibitory control. The Sluggish Cognitive Tempo subscale of the CBCL showed a negative correlation with the performance on Digit backward (P ¼ 0.039). There was a positive correlation between withdrawn/depressed symptoms and Stroop Color test [card 1 (P ¼ 0.047)]. There was no correlation between CBCL and Digit forward, Trail Making A and B Test, and Stroop Color Test, cards 2 and 3. Conclusions: The main measures of this study are mental control and inhibitory control. In this study, we established correlations between the CBCL intensive and results of mental control ability for attention tests. Therefore, it is possible that the neuropsychological evaluation associated to CBCL may be complementary in understanding the cognitive profile of the patients with BD.

BD, COG, NEPSYC Supported by S~ ao Paulo Research Foundation Grant 08/55402-8 http://dx.doi.org/10.1016/j.jaac.2017.09.330

5.48 FUNCTIONAL IMPAIRMENT AND SCHOOL FAILURE IN ADOLESCENTS WITH BIPOLAR DISORDER COMPARED TO HEALTHY CONTROLS: A CASE-CONTROL STUDY Soledad Romero, MD, Hospital Clinic of Barcelona CIBERSAM, [email protected]; Marisol Picado, PhD, Hospital Clinic of Barcelona, [email protected]; Sara Lera-Miguel, PhD, Hospital Clinic of Barcelona, slera@ clinic.cat; Elena Font, PsyD, Hospital Clinic of Barcelona, [email protected]; Roger Borras, MS, IDIBAPS, rborras@ clinic.cat; Alexandra Cosi, PhD, Fac. Ci encies de l’Educaci oi Psicologia, [email protected]; Pilar Santamarina, PhD, Hospital Clınic Barcelona, [email protected]; Josefina Castro-Fornieles, MD, PhD, Hospital Clinic of Barcelona, [email protected]; Iria Mendez, MD, Hospital Clinic of Barcelona, [email protected] Objectives: The goals of this presentation are to characterize bipolar disorder (BD) in adolescents using DSM-IV criteria and to compare sociodemographics, previous exposure to live events, suicidality, functioning, and school performance between euthymic adolescents with BD and healthy control (HC) adolescents. Methods: Cross-sectional, case-control study included 47 adolescents with euthymic BD (ages 12–18 years) matched by sex and age compared with 44 HC adolescents. Case and control subjects were assessed using the Kiddie Schedule for Affective Disorders and Schizophrenia–Present and Lifetime (KSADS-PL) and tested with a battery of tests measuring mood and psychotic

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symptoms, life events, and functioning. All analyses were performed with conditional logistic regression analysis. Results: Both groups were similar in age-groups (ages 16 1.9 years) and equally distributed by gender (53% females). A lower socioeconomic status (SES) was statistically and significantly associated with being in the group of subjects with BD (46.1 13.9 vs. 53.3 11.1; P ¼ 0.01). Subjects with BD were mostly from type I (91%), half of them had psychotic symptoms, and 75 percent reported at least one previous hospitalization. Depression was the index episode in most of the cases (70%). Ninety percent of adolescents with BD had a comorbid diagnosis; the most prevalent ones were anxiety disorder (62%), ADHD (30%), and ODD (28%). All subjects were under medication: primarily antipsychotic drugs (81%) followed by lithium (62%). None of the HC subjects and almost half of those with BD reported suicidal thoughts, and 32 percent had a previous suicidal attempt. Twenty-five percent of BD referred self-injury behavior. Having a BD was associated with a higher number of negative life events (14.3 10.8 vs. 7.9 7.1, P ¼ 0.02) and worse functioning based on Children’s Global Assessment Scale (CGAS) scores (59.9 12.1 vs. 85.4 4, P < 0.01). Good school performance was less associated with BD (45 vs. 96%, P < 0.001) compared with HC subjects. In the multivariate analysis, after controlling by SES differences, worse functioning based on CGAS scores [CI 0.65 (0.46, 0.93); P < 0.01] and worse performance at school [CI 0.03 (0.01, 0.67); P < 0.01] remained significantly more associated with BD compared with HC subjects. Conclusions: Cases of BD were mostly from BD-I subtype, came from inpatient unit, and had a severe form of the disease in terms of number of hospitalizations, doses of medication, psychotic symptoms, suicidal behaviors, and comorbidity. BD had a significant impact in functioning and school performance compared with HC subjects. Specific interventions to improve these areas should be considered.

ADOL, IMP, BD Supported by Instituto de Salud Carlos III Grant FIS: PI11/01224 http://dx.doi.org/10.1016/j.jaac.2017.09.331

5.49 CLINICAL CORRELATES OF AFFECTIVE LABILITY AMONG CANADIAN ADOLESCENTS WITH BIPOLAR DISORDER Ariel Silver, MSC, Sunnybrook Health Sciences Centre, ariel. [email protected]; Lisa Fiksenbaum, PhD, Sunnybrook Health Sciences Centre, lisa.fi[email protected]; Vanessa Timmins, MSW, Sunnybrook Health Sciences Centre, [email protected]; Rachel Mitchell, MD, Sunnybrook Health Sciences Centre, rach.mitchell@mail. utoronto.ca; Neal Westreich, MD, Sunnybrook Health Sciences Centre, [email protected]; Benjamin I. Goldstein, MD, PhD, Sunnybrook Health Sciences Centre, [email protected] Objectives: Affective lability that comprises sudden, disproportionate mood changes is a feature of many psychiatric disorders, including bipolar disorder (BD). Adolescents whose parents have BD have shown higher affective lability than mentally healthy control subjects. We examined the correlates of affective lability among Canadian adolescents with BD and the effect of current mood state on these relationships. Methods: Subjects consisted of 168 adolescents with a diagnosis of BD-I, BDII, or BD–NOS via the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children—Present and Lifetime (KSADS-PL). The Children’s Affective Lability Scale (CALS) was used to measure parent and child reports of total affective lability and two subscales [angry/depressed (AD) and disinhibited/impersistent (DI)]. The Children’s Global Assessment Scale (CGAS) was used to rate adolescent’s current and highest past levels of functioning. The Life Problems Inventory (LPI) assessed borderline personality traits, including impulsivity, via self-report. Chi-square tests, t-tests, and ANOVAs were used. Results: Adolescents with higher self-reported AD and DI scores had a higher lifetime prevalence of suicidal ideation, self-injurious behavior, and suicide attempts, as well as higher impulsivity scores. They also had lower-current and


lower-highest past CGAS scores. Adolescents with higher self-reported AD scores also had earlier age of onset of BD symptoms, higher lifetime prevalence of assault, and lower lifetime prevalence of psychosis. Symptomatic adolescents reported higher scores on both subscales and total CALS than euthymic adolescents. CALS total and subscale scores were higher among euthymic adolescents with BD-II and BD-NOS vs. BD-I. Parent-reported CALS scores were higher for euthymic adolescents with BD-II vs. BD-I. There was no effect of family history of BD. Conclusions: Affective lability is associated with multiple negative outcomes and may comprise a valuable treatment target. The effect of symptomatic status in this study brings into question the concept of affective lability as a trait; further longitudinal studies should examine affective lability in BD adolescents in relation to mood symptoms over time.

ADOL, BD http://dx.doi.org/10.1016/j.jaac.2017.09.332

5.50 SYMPTOM IMPROVEMENT ASSOCIATED WITH LURASIDONE TREATMENT OF CHILDREN AND ADOLESCENTS WITH BIPOLAR I DEPRESSION: RESULTS OF A SHORT-TERM PLACEBO-CONTROLLED TRIAL Manpreet K. Singh, MD, Stanford University School of Medicine, [email protected]; Robert Goldman, PhD, Sunovion Pharmaceuticals Inc, Robert.Goldman@sunovion. com; Michael Tocco, PhD, Sunovion Pharmaceuticals Inc, [email protected]; Andrei A. Pikalov, MD, Sunovion Pharmaceuticals Inc, [email protected]; Ling Deng, PhD, Sunovion Pharmaceuticals Inc, Ling.Deng@ sunovion.com; Josephine Cucchiaro, PhD, Sunovion Pharmaceuticals Inc, [email protected]; Antony Loebel, MD, Sunovion Pharmaceuticals Inc, Antony. [email protected] Objectives: The goal of this presentation is to evaluate change in specific depressive symptoms in children and adolescents presenting with bipolar depression who received short-term treatment with lurasidone. Methods: Data in this secondary analysis were derived from a study of patients ages 10–17 years (N ¼ 343) with a DSM-5 diagnosis of bipolar I depression who were randomized to six weeks of double-blind treatment with lurasidone (20–80 mg per day) or placebo. The primary endpoint was change from baseline to week 6 on the Children’s Depression Rating Scale, Revised (CDRS-R) total score. Change from baseline to week 6 for each individual CDRS-R item was assessed with an ANCOVA using an LOCF approach. Cohen’s d effect sizes were also calculated at week 6. Results: At the primary week 6 endpoint, treatment with lurasidone was associated with statistically significant and clinically meaningful improvement versus placebo in the CDRS-R total score (21.0 vs. 15.3; P < 0.0001; effect size [d] ¼ 0.45). A total of 13 CDRS-R items (76%) were significantly improved on lurasidone as follows: 1) impaired school work (P ¼ 0.023; d ¼ 0.25); 2) difficulty having fun (P ¼ 0.004; d ¼ 0.31); 3) social withdrawal (P < 0.0001; d ¼ 0.43); 4) sleep disturbance (P ¼ 0.0001; d ¼ 0.43); 5) appetite disturbance (P < 0.05; d ¼ 0.22); 6) irritability (P ¼ 0.026; d ¼ 0.24); 7) excessive guilt (P ¼ 0.0032; d ¼ 0.32); 8) low self-esteem (P ¼ 0.012; d ¼ 0.27); 9) depressed feelings (P ¼ 0.0068; d ¼ 0.29); 10) excessive weeping (P ¼ 0.014; d ¼ 0.27); 11) depressed facial affect (P ¼ 0.0009; d ¼ 0.36); 12) listless speech (P < 0.0001; d ¼ 0.43); and 13) hypoactivity (P ¼ 0.012; d ¼ 0.27). Four CDRS-R items were not significant: excessive fatigue (d ¼ 0.12); physical complaints (d ¼ 0.11); morbid ideation (d ¼ 0.10); and suicidal ideation (d ¼ 0.20). Mean severity scores at baseline were low for three of the four nonsignificant CDRS-R items: morbid ideation (1.8); suicidal ideation (1.4); and physical complaints (2.5). In contrast, mean severity scores at baseline were 4 on seven of the 13 significantly improved CDRS-R items: school work, difficulty having fun, social withdrawal, irritability, low self-esteem, depressed feelings, and excessive fatigue. Conclusions: In this placebo-controlled study of children and adolescents with bipolar depression, six weeks of treatment with lurasidone was effective in treating a wide range of depressive symptoms assessed by the CDRS-R.

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APS, BD, DDD Supported by Sunovion Pharmaceuticals Inc. http://dx.doi.org/10.1016/j.jaac.2017.09.333

5.51 EXAMINING THE CLINICAL PROFILE OF ADOLESCENTS WITH BIPOLAR DISORDER WHO HAVE ATTEMPTED SUICIDE Vanessa Timmins, MSW, Sunnybrook Health Sciences Centre, [email protected]; Lisa Fiksenbaum, PhD, Sunnybrook Health Sciences Centre, lisa.fiksenbaum@ sunnybrook.ca; Mark Sinyor, MD, Sunnybrook Health Sciences Centre, [email protected]; Ayal Schaffer, MD, Sunnybrook Health Sciences Centre, ayal. [email protected]; Neal Westreich, MD, Sunnybrook Health Sciences Centre, [email protected]; Benjamin I. Goldstein, MD, PhD, Sunnybrook Health Sciences Centre, [email protected] Objectives: The suicide rate among people with bipolar disorder (BD) is 10fold greater than the general population, and early onset of illness is associated with an increased risk for suicide attempts (SA) in adults. Up to one third of youth with BD have a history of SA, which is associated with higher rates of comorbid disorders, self-injurious behavior (SIB), psychiatric hospitalization, and a family history of suicide attempts. This study sought to expand on previous research on this important topic. Methods: Subjects were 168 adolescents (ages ¼ 16.25 1.56 years, 72.5% female), with a diagnosis of BD-I, -II, or -NOS via the Kiddie Schedule for Affective Disorders and Schizophrenia– Present and Lifetime version (KSADS-PL). Suicide attempt was characterized as any incident where the adolescent engaged in an SIB, with intent to die. Information on comorbid diagnoses and clinical characteristics was obtained from the KSADS-PL. The Children’s Global Assessment Scale (CGAS) was used to rate the adolescent’s functioning. Chi-square and ttests were followed by logistic regression using backward elimination. Results: The lifetime prevalence of SA was 24 percent. The three most common methods of SA were self-poisoning (68%), hanging (10%), and drowning (6%). Attempters compared with nonattempters had higher BMI, rates of SIB, psychiatric hospitalization, impulsivity, and more severe cases of depression and CGAS scores, and lower socioeconomic status. Attempters were also more likely to have PTSD, any anxiety disorder, substance use disorder, lifetime use of antidepressants or stimulants, and a family history of depression, anxiety, or suicide attempt. Lifetime psychiatric hospitalization, comorbid PTSD, family history of depression or anxiety, lifetime stimulant use, and SIB remained significant predictors in multivariate analyses. Conclusions: In our sample group, 25 percent of adolescents with BD have attempted suicide, and attempters demonstrated elevated dimensional, categorical, and familial psychopathology. Although constrained by crosssectional methodology, our findings highlight a number of potential treatment targets, including family psychopathology and elevated BMI that are not routinely targeted in usual care. Strategies for balancing the salutary effects of psychotropic medications with the risk of purposeful overdose using these medications are also warranted.

ADOL, BD, S Supported by philanthropic donations http://dx.doi.org/10.1016/j.jaac.2017.09.334

5.52 ANTERIOR CINGULATE CONNECTIVITY DURING REWARD PROCESSING MEDIATES THE RELATIONSHIP BETWEEN TRAUMA EXPOSURE AND DEPRESSIVE AND ANXIETY STATES IN YOUNG ADULTS Kristen Eckstrand, MD, PhD, Western Psychiatric Institute and Clinic, University of Pittsburgh, [email protected]; Lindsay C. Hanford, PhD, University of Pittsburgh Medical Center, [email protected]; Henry W. Chase, PhD,

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University of Pittsburgh, [email protected]; Erika E. Forbes, PhD, University of Pittsburgh, [email protected]; Mary L. Phillips, MD, University of Pittsburgh, phillipsml@ upmc.edu Objectives: Exposure to trauma during childhood has been associated with the development of depression and anxiety. While prior research has focused on emotional distress following trauma and the relation to threat processing, little research has focused on its relation to reward capacity. In this study, we examined the impact of trauma exposure on neural activity during reward processing and emotional states in young adults. Methods: One hundred eleven young adults (78 female, 33 male; aged 21.71.9 years) completed self-report measures of trauma and emotional states, and underwent fMRI during a standardized monetary reward task. Trauma-associated neural activation and psychophysiological interaction were analyzed during reward prediction error (RPE) using linear regression models in Statistical Parametric Mapping (SPM12) with a cluster extent threshold of pcorr < 0.05. Neurally mediated associations between trauma and emotional states were also examined. Age, sex, race, IQ, and pre-existing psychological distress were included as covariates. Results: Trauma exposure was associated with greater anterior cingulate cortex (ACC) activation during RPE, and decreased ACC connectivity with the right insula, middle frontal, inferior parietal, and temporoparietal regions. ACC connectivity with middle frontal and inferior parietal regions mediated the relationship between greater trauma exposure and heightened negative affective, while ACC connectivity with insula and temporoparietal regions mediated the relationship between greater trauma exposure and decreased negative affect (pcorr < 0.05). Conclusions: The combined pattern of greater ACC activation and reduced ACC connectivity following trauma exposure may reflect a pattern of aberrant regulatory mechanisms in the context of unexpected reward, where greater trauma results in abnormal recruitment of a prefrontal cortical region implicated in suppressive-style emotion regulation (ACC), together with a disconnection with other PFC regions implicated in self- and higher-order appraisal processes. Further, the association between decreased traumaassociated ACC connectivity with insular and temporoparietal regions and improved negative affective states may represent resilience mechanism to preserve reward processing.

AD, STRESS, DDD Supported by NIH Grant R01MH100041 http://dx.doi.org/10.1016/j.jaac.2017.09.335

5.53 FEASIBILITY AND ACCEPTABILITY OF A TRANSITION GROUP FOR EMERGING YOUNG ADULTS Jesica D. King, PhD, Children’s Health, Children’s Medical Center, [email protected]; Kristin L. Wolfe, MRC, University of Texas Southwestern Medical Center, kristin. [email protected]; Jacquelyn Matney, MRC, Children’s Health, Children’s Medical Center, jacquelyn. [email protected]; Remy Nadelman, LCSW, Children’s Health, Children’s Medical Center, remy.nadelman@ childrens.com; Julia Cartwright, BA, University of Texas Southwestern Medical Center, julia.cartwright@ utsouthwestern.edu; Brooke Castillo, MA, Children’s Health System of Texas, [email protected]; Matthew Tullis, Children’s Health, Children’s Medical Center, [email protected]; Betsy D. Kennard, PsyD, University of Texas Southwestern Medical Center, beth.kennard@ utsouthwestern.edu; Graham J. Emslie, MD, University of Texas Southwestern Medical Center, graham.emslie@ UTsouthwestern.edu Objectives: The goal of this presentation is to examine the feasibility and acceptability of a transition group in an outpatient psychiatric clinic at

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Children’s Health System of Texas that targets the challenges of transitioning out of the home in youth with depression and suicidality. Methods: Data were collected on youth who were enrolled in a pilot group of high school seniors with mood disorders who are preparing to transition out of the home. The program included six weeks of group sessions focused on topics relevant to independent living (e.g., finding mental health care providers, managing academics/work, managing relationships, applying for a job, etc.). To assess progress, youth and their parents completed a young adult transition measure that assessed four domains (i.e., daily life, health, academics, and relationships) with items ranging from 1 (completely dependent) to 6 (completely independent) at entry and exit of the program. Both youth and parents were administered the Client Satisfaction Questionnaire (CSQ-8) upon program exit to assess satisfaction with services received. Results: A total of 10 youth were enrolled in the pilot group, nine of whom completed the program. Youth were predominantly Caucasian (80%) and female (80%), with an average age of 17.4 0.52 years. Both youth and parents rated a high level of satisfaction with the program [youth M ¼ 26.86 2.03 and parent M ¼ 28.57 3.10 (max score ¼ 32)]. A paired samples t test was conducted to evaluate changes in independence. Youth perceived an increase in health knowledge upon completion of the program [entry M ¼ 2.00 . 82 vs. exit M ¼ 2.86 1.07, t(8) ¼ 3.29), P < 0.05]. In addition, they reported increased independence in the other domains (daily life, academics, relationships), although not statistically significant. Parents reported a significant increase in youth’s ability to manage relationships [entry M ¼ 2.33 1.21 vs. exit M ¼ 3.25 1.17), t(8) ¼ 3.38, P < 0.05]. Conclusions: Ninety percent of youth completed the program, indicating good feasibility and acceptability. In addition, youth reported increased perceived independence in health knowledge, and parents reported that their youth improved functioning in managing relationships. Curriculum and future directions will be presented.

PRE, COLST, DDD Supported by The Children’s Trust and the Women’s Auxiliary to Children’s Medical Center http://dx.doi.org/10.1016/j.jaac.2017.09.336

5.55 EFFECTS OF CHILDHOOD ADHD ON DRIVING OUTCOMES: LESSONS FROM THE MULTIMODAL TREATMENT OF ADHD STUDY (MTA) Arunima Roy, MBBS, PhD, University Hospital of Wuerzburg, [email protected]; Jeffrey Epstein, PhD, Cincinnati Children’s Hospital Medical Center, [email protected]; Annie Garner, PhD, Saint Louis University, [email protected]; Lily Hechtman, MD, McGill University, lily.hechtman@mcgill. ca; Betsy Hoza, PhD, University of Vermont, betsy.hoza@uvm. edu; L. Eugene Arnold, MD, Ohio State University, L.Arnold@ osumc.edu; Brooke S.G. Molina, PhD, University of Pittsburgh, [email protected] Objectives: The goal of this session is to assess a range of driving outcomes in the Multimodal Treatment Study of ADHD (MTA) sample group. We hypothesize higher levels of accidents and driving infractions in the following: 1) individuals with ADHD compared with no ADHD; and 2) persistent ADHD compared with desistent ADHD. Methods: Participants with (n ¼ 579) and without (n ¼ 258) childhood ADHD from the MTA (a 14-month randomized treatment study with observational follow-ups for 16 years, covering ages 9–25 years and with driving assessments from age 15 years onward) were assessed for car crashes and police involvement in driving infractions between licensure and age 25 years. Group differences in number of crashes and police involvement were assessed, accounting for driving experience. Results: Participants with childhood ADHD report higher numbers of accidents and police involvement in infractions of speeding, driving without a seat belt, using a cell phone while driving, and not yielding right-of-way than matched control subjects. No differences were found for persistent vs. desistent ADHD. Participants with childhood ADHD also have higher car crashes per month of


driving experience. Only individuals with persistent ADHD, but not desistent ADHD, had a higher rate of car crashes than control subjects. Conclusions: Childhood ADHD is associated with a high risk for poor driving behaviors, when accounting for driving experience, and is independent of ADHD symptom persistence. However, involvement in car accidents is associated with persistence of ADHD into adulthood.

ADOL, ADHD, LONG Supported by NIMH and National Institute on Drug Abuse Grants U01 MH50461, N01MH12009, HHSN271200800005-C, DA-8-5550, U01 MH50477, N01MH12012, HHSN271200800009-C, DA-8-5554, U01MH50440, N01MH12011, HHSN271200800006-C, DA-8-5551, U01 MH50467, N01 MH12007, HHSN271200800007-C, DA-8-5552, U01 MH50453, N01MH 12004, HHSN271200800004-C, DA-8-5549, U01 MH50467, N01 MH 12010, HHSN271200800008-C, DA-8-5553, DA 039881, N01MH12008, HHSN271200800003-C, and DA-8-5548 http://dx.doi.org/10.1016/j.jaac.2017.09.338

5.56 INFLUENCE OF AGE AT EXPOSURE AND SEX ON THE RELATIONSHIP BETWEEN PHTHALATE EXPOSURE AND INTELLIGENCE: EVIDENCE FROM A PROSPECTIVE BIRTH COHORT STUDY Jung Lee, MD, Seoul National University College of Medicine, [email protected]; Johanna Kim, MD, PhD, Seoul National University Bundang Hospital, iambabyvox@ hanmail.net; Yun-Chul Hong, MD, PhD, Seoul National University Medical Research Center, [email protected]; Choong Ho Shin, MD, PhD, Seoul National University College of Medicine, [email protected]; Young Ah Lee, MD, PhD, Seoul National University College of Medicine, nina337@ hanmail.net; Youn-Hee Lim, PhD, Seoul National University Medical Research Center, [email protected]; BungNyun Kim, MD, PhD, Seoul National University College of Medicine, [email protected] Objectives: To identify vulnerable ages at exposure and sex differences in susceptibility to phthalate, we investigated the associations between prenatal and postnatal urinary phthalate metabolite levels and intelligence in a sample group of a prospective population-based birth cohort study. Methods: The study included 93 children (41 girls) from an ongoing cohort named “Environment and Development of Children,” which aimed to observe the development of the offspring of pregnant women who were enrolled between 2008 and 2011. Phthalate metabolites were examined repeatedly in urine samples collected from mothers at pregnancy and children at ages two, four, and six years. We analyzed urine concentrations of mono-(2-ethyl-5hydroxyhexyl) phthalate and mono-(2-ethyl-5-oxohexyl) phthalate as markers of di(2-ethylhexyl) phthalate (DEHP) exposure, and mono-n-butyl phthalate as a marker of di-n-butyl-phthalate exposure (DBP). The children underwent Korean Educational Development Institute-Wechsler Intelligence Scale for Children (KEDI-WISC) at age six years. Multivariable linear regression models were used to investigate the relationship between phthalate metabolites at each age and intelligence at age six years. All multivariable models were controlled for demographic covariates, including sex, birth weight, prematurity, paternal education, maternal education, and maternal IQ. Results: DEHP exposure at ages two and six years were negatively associated with IQ scores. After adjusting the covariates, IQ scores were negatively associated with DEHP exposure at age two years (b ¼ 16.8, 95% CI 29.4,4.3) but not with the exposure at age six years. A significant inverse relationship between DEHP exposure at age two years and IQ score remained after controlling for DEHP exposure at age 6 years (b ¼ 16.6; 95% CI 29.3,3.9). Because there was substantial statistical interaction between DEHP exposure at age two years and sex, we performed sex-stratified analyses. DEHP exposure at age two years showed significant association with IQ score in boys (b ¼ 24.9; 95% CI 42.3,7.4) but not in girls in the multivariable model adjusted for the demographic covariates and DEHP exposure at age six years. Prenatal DEHP exposure and pre- and postnatal DBP exposure had no effects on IQ scores.

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Conclusions: These results suggest that DEHP exposure at age two years plays a more significant role in children’s intelligence than exposure after age four years and that boys are more vulnerable to phthalate exposure than girls.

LONG, COG, NEURODEV Supported by the Environmental Health Center, funded by the Korean Ministry of Environment and the Ministry of Food and Safety Grant 15162MFDS046 http://dx.doi.org/10.1016/j.jaac.2017.09.339

5.57 MATERNAL DEPRESSION TRAJECTORIES IN ADOLESCENT MOTHERS LIVING IN A POOR URBAN AREA AND THEIR ASSOCIATION WITH PARENTAL STRESS, INFANT BEHAVIORAL PROBLEMS, AND PSYCHOLOGICAL VIOLENCE Daniel Fatori, PhD, University of Sao Paulo Medical School, [email protected]; Guilherme V. Polanczyk, MD, PhD, Universidade de S~ ao Paulo, [email protected]; Euripedes Miguel, MD, PhD, University of Sao Paulo Medical School, [email protected]; Alicia Matijasevich, MD, PhD, University of Sao Paulo Medical School, alicia.matijasevich@ usp.br Objectives: The goals of this study are to identify maternal depression trajectories (MDT) during the antenatal and postnatal period and to evaluate whether distinct MDTs predict parental stress, home environment characteristics, and infants’ behavior and developmental problems. Methods: We conducted a pilot randomized controlled clinical trial to test the feasibility of a nurse home visitation program for poor pregnant youth. The intervention consisted of home visits focused on health/social care, environmental health, life course goals, and parenting skills. Pregnant youth (N ¼ 80) were included in the study. Participants were randomized to intervention (n ¼ 40) and control group (usual care, n ¼ 40). Maternal depression was assessed during gestation (16th and 30th weeks) and after child birth (infant age of 3, 6, and 12 months) using the Beck Depression Inventory. Outcomes were measured at 12 months of infant age and consisted of the following instruments: Parental Stress Index, Home Observation for Measurement of the Environment, Ages and Stages Questionnaire, and Parent-Child Conflict Tactics Scale. A group-based trajectory modelling approach was used to determine latent MDTs. To identify associations between MDTs and outcomes we conducted ANOVAs with pairwise comparisons. Intervention/control group status was inserted as a covariate in all models. Results: We identified four MDTs across five time points: 1) low stable (n ¼ 42); 2) moderate antenatal and low postnatal (n ¼ 21); 3) moderate chronic (n ¼ 13); and 4) high antenatal and decreasing postnatal (n ¼ 4). MDTs were associated with parental stress (p ¼ 0.004), infant behavior problems (p ¼ 0.019), and infant psychological violence (p ¼ 0.013). Mean scores increased significantly from the low stable group to the high antenatal and decreasing postnatal group. Infant development and the home environment were not associated with MDTs. Conclusions: Our study showed that MDTs have different manifestations and are associated with parental stress, infant behavior problems, and infant psychological violence. Given the potential long-term effects of maternal depression, early identification, appropriate treatment and follow-up of depressed adolescents must be a key priority for primary health care services.

LONG, STRESS, DEV Supported by Saving Brains, Bill & Melinda Gates Foundation, and Companhia Brasileira de Metalurgia e Mineraç ~ao. http://dx.doi.org/10.1016/j.jaac.2017.09.340

5.58 SEROTONIN NOREPINEPHRINE REUPTAKE INHIBITORS (SNRI), SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRI), BREASTFEEDING, AND CONCERNS FOR INFANT SAFETY Tapan Parikh, MD, MPH, Cooper University Hospital, [email protected]; Dharmendra Goyal, MD, Augusta

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University, [email protected]; Ramkrishna Makani, MD, MPH, Cooper University Hospital, [email protected]; Consuelo C. Cagande, MD, Cooper University Hospital, cagande-consuelo@ cooperhealth.edu Objectives: Antidepressants secreted into mothers’ breastmilk may have potential side effects in infants. Mental health of mother is crucial for maternal infant bonding, and mothers may need medications. Clinicians may not have the information on potential effects of medications on infants readily available. This abstract describes literature review of SSRIs and serotonin norepinephrine reuptake inhibitors (SNRIs). These are commonly used for MDD, postpartum depression, OCD, and anxiety. Methods: A thorough literature search using the PubMed and TOXNET was conducted. From 196 informative articles on various SSRIs and SNRIs published until May 2017, after excluding irrelevant articles, the search was narrowed to 98 articles. Results: It is known that there are very little to no side effects to infants if the relative infant dose (RID) is 5 percent, Hardy-Weinberg Equilibrium P < 5 104, or minor allele frequency 100 marijuana use episodes in lifetime) and binge drinkers, respectively. In smokers, unique associations were seen between alcohol severity and depression (R2 adjusted ¼ 0.44, P < 0.001); marijuana severity, impulsivity, and reward sensitivity (R2 adjusted ¼ 0.372, P < 0.001); and nicotine dependence and anxiety (R2 adjusted ¼ 0.058, P < 0.05) after controlling for sociodemographics. Conclusions: Among smokers, common and unique associations exist between alcohol, marijuana, and tobacco use and neural and self-report measures of reward processing, impulsivity, and affect. These findings carry significant clinical implications for treatment of substance use disorders in adolescents.

IMAGS, CM, SUD Supported by the AACAP Pilot Research Award for Junior Faculty and Child and Adolescent Psychiatry Fellows, supported by Lilly USA, LLC, the AACAP Physician Scientist Program in Substance Abuse, supported by NIDA, and NIH Grant P50DA009241 http://dx.doi.org/10.1016/j.jaac.2017.09.391

6.47 ENCOMPASS: INTEGRATED TREATMENT FOR CO-OCCURRING SUBSTANCE AND PSYCHIATRIC DISORDERS Jesse D. Hinckley, MD, PhD, University of Colorado School of Medicine, [email protected]; Bryan McNair, MS, Colorado School of Public Health - University of Colorado Denver, [email protected]; Paula Riggs, MD, University of Colorado Denver School of Medicine, paula. [email protected] Objectives: The goal of this study was to evaluate the impact of “Encompass” on reducing substance use and symptoms of comorbid psychiatric conditions in community (COM) and school-based (SB) clinics. Methods: Encompass is an integrated treatment program for adolescents with substance use disorder (SUD) that combines 17 individual manualstandardized motivational enhancement therapy/CBT sessions with contingency management and pharmacotherapy for comorbid psychiatric disorders. ADHD, MDD, and generalized anxiety disorder (GAD) symptoms were established at baseline and evaluated monthly using standardized clinical measures. Encompass was implemented in three community clinics and adapted to three school-based clinics (9 sessions). Mean change in substance use was measured using a linear model. Negative urine drug screen proportions were modeled via logistic regression. Results: Youth treated in COM (n ¼ 322, mean age ¼ 16.7 years) were, on average, a year older than youth referred to SB (n ¼ 51; mean age ¼ 15.4 years), were predominantly male in both settings, and reported similar frequency of baseline 28-day non-tobacco substance use (10.7 days vs

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14.8 days, respectively). COM patients had twice the mean number of SUD diagnoses (mean ¼ 2.14) compared to referred students (mean ¼ 0.90). Cannabis and alcohol use disorders were most common. The mean number of co-occurring psychiatric disorders was similar in both settings (COM ¼ 1.97, SB ¼ 1.45), with ADHD, MDD, and GAD most common. SB youth showed a greater reduction in the change in 28-day substance use (mean ¼ -13 days; Cohen’s d ¼ 1.22) compared to COM patients (-3.2 days; Cohen’s d ¼ 0.28). A greater proportion of COM youth achieved abstinence (58.9%) and at least one month of sustained abstinence (38.7%) by the end of treatment compared to those who received a briefer eightweek version (42.3% and 23.5%, respectively). Overall 50 percent of COM patients with MDD, 76 percent of patients with GAD, and 64 percent of patients with ADHD achieved remission of these disorders by the end of treatment. Conclusions: To our knowledge Encompass is among the first evidencebased interventions that fully integrates the treatment of SUD and common co-occurring psychiatric disorders in adolescents. Encompass can be feasibly implemented in community- and school-based settings and produces significant reductions in substance use and in symptoms of co-occurring MDD, GAD, and ADHD.

ADOL, EBP, SUD Supported by NIDA Grants U10 DA013720, R01 DA013176, R01 DA022284, and U10 DA01372 http://dx.doi.org/10.1016/j.jaac.2017.09.392

6.48 ADOLESCENT EXERCISE AND PHYSICAL RECREATION INFLUENCES THE DEVELOPMENT OF CANNABIS USE DISORDER (CUD) Michelle S. Horner, DO, Johns Hopkins University, [email protected]; Maureen Reynolds, PhD, University of Pittsburgh, [email protected]; Michael Vanyukov, PhD, University of Pittsburgh, [email protected]; Levent Kirisci, PhD, University of Pittsburgh, [email protected]; Ralph Tarter, PhD, University of Pittsburgh, [email protected] Objectives: Regular exercise and physical recreation (EPR) by youths is associated with lower rates of cannabis use. However, it is unclear whether this relationship holds for the development of cannabis use disorder (CUD). We examined prospectively the association of parental substance use disorder (SUD) history, offspring EPR and substance use frequency during adolescence, and offspring CUD outcome in adulthood. Methods: Under the aegis of the Center for Education and Drug Abuse Research (CEDAR), boys (N ¼ 467) and girls (N ¼ 186) were prospectively tracked on risk measures for SUD. Past 30-day EPR participation and substance use frequency were measured at ages 12–14, 16, 19, and 22 years using the Drug Use Screening Inventory (DUSI). Structured interview was used to determine parental SUD history at baseline and offspring CUD at age 22 years. Multivariate latent growth curve modeling, with a distal outcome of CUD at age 22 years, was used to show the association between offspring EPR, substance use, CUD, and parental SUD. Results: For sons, the number of parents with SUD predicted negative rate of change in EPR participation between ages 12 and 22 years (P ¼ 0.001), which correlated with rate of change in substance use frequency that, in turn, predicted CUD. Furthermore, rate of increasing substance use frequency mediated the relationship between the rate of EPR decline and development of CUD. For daughters, the number of parents with SUD predicted EPR level at ages 12–14 years (P < 0.001), which correlated with rate of EPR decline between ages 12 and 22 years (P < 0.001). Rate of EPR decline correlated with rate of substance use increase from 12–22 years of age (b ¼ 0.248, P ¼ 0.001), which predicted CUD ( b ¼ 1.067, p < 0.001). Rate of increase in substance use frequency mediated the relationship between rate of EPR decline and CUD ( b ¼ 0.26, P ¼ 0.03). Rate of decreasing EPR was associated with rate of increase in substance use frequency (b ¼ 0.507, P < 0.001), which covaried with risk for CUD ( b ¼ 0.926, P < 0.001). In addition, rate of substance use frequency increase from 12 to 22 years of age mediated the association between number of parents with SUD and CUD (b ¼ 0.08, P ¼ 0.02).


Conclusions: Declining EPR participation throughout adolescence is associated with risk for CUD at age 22 years via increase in substance use frequency. Given the rising rates of sedentary lifestyles and cannabis use, clinical implications are discussed.

ADOL, SUD Supported by National Institute on Drug Abuse Grant P50 DA005605 http://dx.doi.org/10.1016/j.jaac.2017.09.393

6.49 SHIFTING AND DISENGAGEMENT ATTENTION SOCIAL PARADIGM IN CHILDREN WITH AUTISM AND CONTROL GROUP Tania Vargas-Rizo, MD, Hospital Psiquiatrico Infantil Dr. Juan N. Navarro, [email protected]; Montserrat Avila-Acosta, The World Bank, [email protected]; Gema TorresSuarez, MD, Hospital Psiquiatrico Infantil Dr. Juan N Navraro, [email protected]; Yassel Flores-Rodriguez, MD, Hospital Psiquiatrico Infantil Dr. Juan N. Navarro, avellanafr@ hotmail.com; Jorge Chavez-Dozal, MD, Hospital Psiquiatrico Infantil Dr. Juan N. Navarro, [email protected]; Jose Juan Escoto Lopez, MD, Hospital Psiquiatrico Infantil Dr. Juan N. Navarro, [email protected]; Fernanda RojasMiranda, Hospital Psiquiatrico Infantil Dr. Juan N. Navarro, [email protected]; Alejandra Hernandez Duarte, Hospital Psiquiatrico Infantil Dr. Juan N. Navarro, farina_duarte@ hotmaill.com; Lilia Albores-Gallo, MD, DrPH, Hospital Psiquiatrico Infantil Dr. Juan N. Navarro, lilialbores@ gmail.com Objectives: The goal of this presentation is to compare shifting attention and disengagement attention using a social quantitative paradigm between children with autism spectrum disorders (ASD) and neurotypical preschool-aged children. Methods: A social joint attention paradigm was conducted by exposing children in both groups to five-second event exposure of bubbles, with a battery-operated gun and five-second pause events. Disengagement occurs if the child turns his gaze toward the examiner during the bubbles event, and shifting attention occurs if this happens during the pause event. A binary variable was created based on the number of seconds it took for the child to turn his gaze toward the examiner during the bubbles event (disengagement attention) and during the pause event (shifting attention). A value of zero was assigned if the child did not turn his gaze during either event, and a value of one was coded if the child turned to the examiner in five seconds or less. This was done for each of the five exposures to bubbles and pause events. Subsequently, the five binary variables were added, denoting the total number of times each child actually turned to the examiner. To explore the difference in means between children with ASD and neurotypical children, a t-test for unequal variances was performed. Results: Participants were 39 children with an age range between 2.2 and 5.9 years (mean ¼ 4.3 years). For the disengagement attention task, the mean value for children with ASD (N ¼ 19) was 0.10 (SD ¼ 0.31), and the mean value for the neurotypical group (N ¼ 20) was 1.2 (SD ¼ 1.1, P ¼ 0.0003). For the shifting attention task, the mean value for children with ASD was 0.31 (SD ¼ 0.47), and the mean value for the neurotypical group was 4.1 (SD ¼ 1.37, P ¼ 0.0000). Conclusions: Our results show that there is strong evidence suggesting that children with ASD show significantly less disengagement and shifting attention than neurotypical children. Shifting attention and disengagement attention can be easily measured.

PSC, ASD, COG http://dx.doi.org/10.1016/j.jaac.2017.09.026

6.50 SELECTIVE SEROTONIN REUPTAKE INHIBITORS AND LONGITUDINAL GROWTH IN CHILDREN AND ADOLESCENTS Chadi A. Calarge, MD, Baylor College of Medicine, chadi. [email protected]; James Mills, MA, University of Iowa,

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[email protected]; Babette Zemel, PhD, University of Pennsylvania, [email protected] Objectives: Little is known about the potential of SSRIs to impact longitudinal growth. We examined change in height as a function of SSRI use in a group of risperidone-treated children and adolescents. Methods: Medically healthy risperidone-treated boys (ages 7–17 years) were enrolled in one of several studies. They underwent a clinical evaluation, and their anthropometric measurements were recorded. Their medical records were reviewed to extract all anthropometric data and medication information. Sex- and age-specific Z-scores were generated using published normative data. Given the growth spurt, three age-groups were defined as follows: 1) 7–11 years; 2) 11–13.5 years; and 3) more than 13.5 years. Mixed regression analysis examined predictors of longitudinal change in height Zscore. Results: A total of 272 boys (baseline age 7.9 1.2 years; follow-up 4.7 2.5 years) contributed data to this analysis. After adjusting for follow-up time, the use of psychostimulants, and the use of antipsychotic drugs, the interaction effect of time x age-group x SSRI use was significant (P ¼ 0.05), whereby extended SSRI use in boys ages 11 years and older was associated with significant decrease in height Z-score. Furthermore, after accounting for the baseline value, duration of SSRI treatment was inversely related to height Z-score (Pearson’s r ¼ 0.30, P 500,000 single nucleotide polymorphisms. Statistical analyses were conducted using the PLINK and R programs. Results: The most significant findings showed associations between the IQ and variants in a disintegrin and metalloprotease (ADAM12) (P ¼ 4 105), a gene previously associated with ASD. Likewise, associations were detected between an ASD-reported gene (SLC25A24) and intellectual disability (P ¼ 7 105 ). No significant associations were detected with language-onset delay. Conclusions: Our study confirmed the genetic contribution to ASD, confirming several previous findings and identifying novel genetic variants potentially associated with ASD symptomatology. Furthermore, several associations were detected between genes associated with mental disorders and ASD symptomatology, suggesting a common genetic origin.

GS, ASD, ID Supported by Instituto de Salud Carlos III and Fundaci o M utua de Terrassa http://dx.doi.org/10.1016/j.jaac.2017.09.403

6.59 AN EVALUATION OF THE PUBLICATION RATE OF AACAP ANNUAL MEETING PRESENTATIONS FROM 2012-2013 Alexander M. Hoelscher, BA, Oklahoma State University, [email protected]; Jake X. Checketts, BS, Oklahoma State University, [email protected]; Matthew Vassar, PhD, Oklahoma State University, matt. [email protected] Objectives: In 2015, a study found that publication rates for the National Congress of Child and Adolescent Psychiatry (NCCAP) was 25.2 percent, and the time to publication was 30.72 months. The rate of publication at this conference was much lower than conferences in other specialties that were similarly evaluated. A lack of publication of study results can lower the quality of evidence available, and can introduce practice gaps into practice parameters and clinical practice guidelines. Our study investigated the rate of publication of presentations at the 2012-2013 AACAP Annual Meetings. Furthermore, we evaluated time to publication in the most common publishing journals, and sent emails to survey authors on the most common reasons for studies not reaching publication. Methods: We reviewed the official programs from AACAP Annual Meetings from 2012-2013. The official programs list all research presented at each meeting, and these presentations were extracted from the programs for analysis. We used Google Scholar and PubMed to determine whether the presentations were published. Two investigators used a combination of the first author’s name and keywords from abstract titles to identify potential matches. The presentations within the official programs were then compared to the published studies to ensure a correct match and relevant data were extracted. Emails for the corresponding authors were searched using similar methods to determine the most common reasons for studies not reaching publications, and we are still awaiting responses from this analysis. Results: There were 658 presentations between the two AACAP Annual Meetings, and of these, 313 (46%) were published. Of the 313 published studies, 37 (11.8%) were published in Journal of Child and Adolescent Psychopharmacology, and 24 (7.7%) were published in JAACAP. The mean time to publication was 20.1 months.

Conclusions: The publication rate of abstracts presented at AACAP Annual Meetings is much higher than those of the NCCAP. Furthermore, projects presented at the AACAP Annual Meeting are published at a quicker rate. Email inquiries are currently in progress to determine reasons for nonpublication.

QA, R, OTH http://dx.doi.org/10.1016/j.jaac.2017.09.404

6.60 ACCEPTABILITY AND RESULTS OF WEB-BASED BEHAVIORAL HEALTH ASSESSMENT PLATFORM IMPLEMENTED WITHIN A PRIMARY CARE PEDIATRIC INTEGRATED CARE CLINIC Jessica Kay Jeffrey, MD, MBA, MPH, University of California, Los Angeles, [email protected]; Maegan Sinclair, MPH, University of California, Los Angeles, [email protected]; Hilary Aralis, PhD, University of California, Los Angeles, [email protected]; Rachel Linonis, MA, University of California, Los Angeles, [email protected]; Wendy Barrera, MPH, University of California, Los Angeles, [email protected]; Alan Semaan, University of California, Los Angeles, [email protected]; Mark Grossman, MD, University of California, Los Angeles, [email protected]; Patricia Lester, MD, University of California, Los Angeles Semel Institute of Neuroscience and Human Behavior, [email protected] Objectives: The goal of this session is to describe the acceptability and results of the behavioral health checkup (BHC), a web-based behavioral health assessment platform implemented within a primary care pediatric-integrated care clinic. Methods: Behavioral Health Associates (BHA), a primary care pediatric-integrated clinical care setting within UCLA Health System implemented the BHC in March 2014. The BHC is a web-based behavioral health assessment and clinician-decision making tool that collects self-report data from patients and caregiver-report data for youth (age 17 years) and provides real-time guidance and a patient registry for clinical monitoring. All BHC assessments are launched through Epic and are completed by the patient/caregiver on a tablet in the waiting room of the clinic before a behavioral health intake appointment and again at three-month increments. One administrative staff member and six pediatric behavioral health clinicians (two child psychiatrists and four master’s level therapists) were surveyed about the BHC. Results: From March 1, 2014, to May 1, 2017, 736 children (average age 12.6 years) and 831 caregivers completed baseline assessments on intake, and 207 children and 204 caregivers completed at least one follow-up assessment. Using the Mood and Feelings Questionnaire cutoff of 8 for depression, the number of children with depressive symptoms decreased from 47 to 34 percent from baseline to first follow-up (n ¼ 146, P < 0.001). Using the Strengths and Difficulties Questionnaires cutoff of 12 for total difficulties, the number of children with total difficulties decreased from 49 to 42 percent from baseline to first follow-up (n ¼ 207, P < 0.001). Using the Screen for Child Anxiety-Related Disorders cutoff of 25, the number of children with anxiety symptoms increased from 34 to 44 percent from baseline to first follow-up (n ¼ 207, P < 0.001). The administrative staff member reported being comfortable with introducing the BHC. Eighty-three percent of clinicians rated the BHC results as “very useful,” and 17 percent rated them as “somewhat useful” in providing care (n ¼ 6). Conclusions: The BHC results have assisted with monitoring and guiding care within a primary care pediatric-integrated behavioral health setting. Administrative staff and behavioral health clinicians indicated having a positive experience with the platform. Web-based technology platforms are well suited to aid in achieving the goals of enhancing patient care.

RI, COMP http://dx.doi.org/10.1016/j.jaac.2017.09.405


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6.61 CARE OF TRANSITIONAL AGE YOUTH AT FIRST PRESENTATION TO THE EMERGENCY DEPARTMENT WITH PSYCHOTIC DISORDER Nicole Kozloff, MD, MS, St. Michael’s Hospital, n.kozloff@ mail.utoronto.ca; Binu Jacob, MS, PhD, Centre for Addiction and Mental Health, [email protected]; Aristotle Voineskos, MD, PhD, Centre for Addiction and Mental Health, [email protected]; Paul Kurdyak, MD, PhD, Centre for Addiction and Mental Health, [email protected] Objectives: Emergency departments (EDs) are often the first point of care for transitional-age youth with psychosis. We sought to examine care and aftercare after the first ED visit for psychotic disorder. Methods: We retrospectively examined a population-based cohort of youth (aged 16–24 years) in Ontario, Canada, with a first ED presentation for psychotic disorder between 2010 and 2013. We used t-tests, Chisquared tests, and ANOVA to compare those who were admitted with those who were discharged. Among discharged patients, we examined the 30-day and 1-year rates of psychiatrist visits, primary care visits for mental health, ED revisits, and psychiatric admissions. We generated KaplanMeier curves for time to outpatient psychiatric care and used Cox proportional hazard regression models to examine predictors of care within 30 days and one year. Results: Of 2,875 youth with first ED presentations for psychosis, 812 (28.2%) were discharged to the community. Among those discharged, 325 (40.0%) received no outpatient mental health care within 30 days; factors associated with receipt of psychiatric aftercare included the following factors: neighborhood income [income quintile 5 vs. 1, hazards ratio (HR) ¼ 1.48 (95% CI 1.05–2.09)]; rural residence [HR ¼ 0.46 (95% CI 0.31–0.70)]; and mental health care in the 60 days before presentation [outpatient psychiatrist visit: HR ¼ 1.89 (95% CI 1.50–2.37); psychiatric admission: HR ¼ 0.71 (95% CI 0.52–0.98)]. By one year after the incident ED visit, 105 (12.9%) still had not received any outpatient mental health care, 416 (51.2%) had returned to the ED, and 334 (41.1%) had a psychiatric admission. Conclusions: Many transitional-age youth do not receive timely mental health follow-up evaluations after their first ED visit for psychotic disorder. These findings may be used to improve service access for this vulnerable population.

SZ, OTH Supported by the Medical Psychiatry Alliance, the University of Toronto, the Centre for Addiction and Mental Health, the Hospital for Sick Children, Trillium Health Partners, the Ontario MOHLTC, and an anonymous donor http://dx.doi.org/10.1016/j.jaac.2017.09.260

6.62 SUBSTANCE USE AND EATING DISORDERS IN CHILDREN AND ADOLESCENTS: HOW SUBSTANCE USERS DIFFER FROM NON-SUBSTANCE USERS IN AN EATING DISORDERS TREATMENT CLINIC Ryan H. Kirkpatrick, Kingston Health Sciences Centre, 12rhkl@ queensu.ca; Ashleigh Vance, BS, Kingston Health Sciences Centre, [email protected]; Brittany Marshall, Kingston Health Sciences Centre, [email protected]; Patricia Marchand, MSW, Kingston Health Sciences Centre, [email protected]; Marina Kanellos-Sutton, RN, Kingston Health Sciences Centre, [email protected]; Sarosh Khalid-Khan, MD, Kingston Health Sciences Centre, [email protected] Objectives: The relationship between eating disorders (EDs) and substance use has only been described briefly in literature using mainly nonclinical adult populations. Therefore, this study aims to examine the prevalence and characteristics of substance use among patients of the ED outpatient program (EDO) in the Division of Child and Adolescent Mental Health (CAMH) at Hotel Dieu Hospital in Kingston, Ontario, Canada.

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Methods: A retrospective analysis of medical charts from patients referred to the EDO between 2011 and 2017 (n ¼ 113) was conducted to determine patients’ medical status, social history, treatment course, and treatment outcome (i.e., time in treatment, medical status, weight status, reason for leaving the EDO program, etc.). Beck Youth and ED Inventory Scores were compared to determine differences in self-reported mental health, well-being, ED risk factors, and psychological profiles between substance and nonsubstance users through a combination of descriptive statistics and parametric and nonparametric testing. Results: More than 44 percent of the patients referred to the EDO reported regularly using substances, and 30.6 percent of substance users received a DSM-5 diagnosis involving purging behaviors (anorexia nervosa (AN)-binge/ purge type and bulimia nervosa) compared with only 3.2 percent of nonsubstance users. Substance users were older (U ¼ 757.0, P < 0.001), reported higher levels of self-harm (53.2% in substance users vs. 35.0% in nonsubstance users), relationship impairments [t(66) ¼ 2.202, P ¼ 0.031], emotional eating [t(66) ¼ 2.31, P ¼ 0.024], and maturity fears [t(66) ¼ 2.557, P ¼ 0.013]. Substance users were also more likely to require weight maintenance (61.2%), whereas nonsubstance users were more likely to require weight gain (54.1%). More often than not, substance users dropped out of (40.8%) or declined starting (10.2%) the EDO program and were less likely to meet their weight goal if they did participate in the EDO program (88.6% of substance users vs. 97.4% of nonsubstance users met their weight goal). Conclusions: Child and adolescent substance users present distinctly from nonsubstance users in the EDO and therefore could benefit from innovative, multidisciplinary programming within the EDO program and Division of CAMH that encourages their participation in the program and helps prevent these challenging patients from dropping out of the program.

ADOL, SUD, EA Supported by a Queen's University Department of Psychiatry Internal Grant http://dx.doi.org/10.1016/j.jaac.2017.09.407

6.63 THE ASSOCIATION BETWEEN LENGTH AND NUMBER OF DEPLOYMENTS ON THE EMOTIONAL HEALTH AND BEHAVIOR OF CHILDREN AND ADOLESCENTS IN MILITARY FAMILIES Donna L. Londino, MD, Medical College of Georgia at Augusta University, [email protected]; Patrick Molitor, MD, Dwight D. Eisenhower Army Medical Center, [email protected]; Claire Slocumb, MD, Medical College of Georgia at Augusta University, [email protected]; Kaitlin Burchett, BS, Medical College of Georgia at Augusta University, [email protected] Objectives: Since Operation Desert Storm, military deployments have increased in length and number. Early studies were conflicting, but recent studies suggest that deployment may have negative effects on the functioning of the family, specifically the children, of the deployed soldier. This study sought to investigate the correlation between length and number of deployments and psychosocial functioning. Methods: Families participating completed a packet consisting of four documents, including a demographic form, the Pediatric Symptoms Checklist (PSC), the Weiss Functional Impairment Rating Scale (WFIRS), and the Response to Stress Questionnaire. The data were compiled and analyzed to determine any significant clinical associations between variables. Results: Several significant associations (n ¼ 30) were found. A greater number of deployments positively correlated with higher scores on the WFIRS (r ¼ 0.43; P < 0.01) and the PSC (r ¼ 0.33; P < 0.05). In particular, a greater number of deployments positively correlated with poorer functioning in the school domain on both the WFIRS (r ¼ 0.37; P < 0.05) and the PSC (r ¼ 0.38; P < 0.05). Length of deployment also positively correlated with poorer functioning in the school domain of the PSC (r ¼ 0.36; P < 0.05). Of particular interest was the finding of a significant interaction between sex and length of deployment. Males of parents with more extended deployments had scores suggesting greater dysfunction in the Life Skills domains of the WFIRS (P < 0.05).

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Conclusions: Results support other literature suggesting that deployment has a negative effect on psychosocial outcomes of children in military families. In this study, limited by low subject number and subsequent power, number of deployments was significantly correlated with higher scores on two measures assessing a child’s functioning in multiple domains and in general. These results can serve as pilot data to support the need for further studies on the effect of deployment on the functioning of children and teenagers residing in the home of a deployed parent. In particular, further studies should focus on the effect of deployments on school functioning. If continued research confirms these clinical correlations, findings may be useful in shaping the policy on military deployment.

RF, SP, STRESS http://dx.doi.org/10.1016/j.jaac.2017.09.408

6.64 FAMILY RESPONSE STYLE IN A COHORT OF MILITARY FAMILIES AND ITS ASSOCIATION WITH PSYCHOSOCIAL FUNCTIONING Donna L. Londino, MD, Medical College of Georgia at Augusta University, [email protected]; Patrick Molitor, MD, Dwight D. Eisenhower Army Medical Center, [email protected]; Shameem Momin, Medical College of Georgia at Augusta University, smomin@ augusta.edu; Christopher F. Drescher, PhD, Medical College of Georgia at Augusta University, [email protected] Objectives: Stress and response to stress are important determinants of functioning within the family and among its members. This study sought to assess response styles in military families and to evaluate any significant correlations between response styles and child and adolescent psychosocial functioning as assessed through parent reports. Methods: Participating families completed packets consisting of a demographic form, the Pediatric Symptoms Checklist (PSC), the Weiss Functional Impairment Rating Scale (WFIRS), and the Response to Stress Questionnaire. Data were analyzed to note any clinically significant correlations between variables. Results: Thirty packets of data were obtained. Both primary (r ¼ 0.45; P < 0.01) and secondary (r ¼ 0.44; P < 0.01) controlled response styles were negatively correlated with scores on the PSC medical domain (fewer somatic complaints). Involuntary response styles either through involuntary engagement (r ¼ 0.46; P < 0.01) or involuntary disengagement (r ¼ 0.44; P ¼ 0.01) were positively associated with scores, suggesting poorer functioning (more somatic complaints). Primary (r ¼ -0.33; P < 0.05) and secondary (r ¼ -0.51; P < 0.01) controlled response styles were negatively correlated with scores on the life skills domain of the WFIRS, whereas involuntary engagement (r ¼ 0.49; P < 0.01) and involuntary disengagement (r ¼ 0.37; P < 0.03) positively correlated with scores suggestive of more dysfunction in this domain. Controlled coping responses, both primary and secondary (r ¼ -0.46; P < 0.01) negatively correlated with scores on the self-concept domain of the WFIRS (lower scores suggestive of better self-concept), whereas involuntary response styles of engagement (r ¼ 0.42; P < 0.02) and disengagement (r ¼ 0.50; P < 0.01) were positively correlated with poorer scores in this same domain. Conclusions: In several domains of functioning assessed in this study, involuntary response styles were associated with scores indicative of poorer functioning than in those families who endorsed the use of more controlled coping responses. If further research reveals similar findings, efforts can be made to teach families and family members more adaptive coping through more controlled response styles with an anticipation that implementation of this instruction would lead to more improved overall functioning.

FAM, RF, COPI http://dx.doi.org/10.1016/j.jaac.2017.09.409

6.65 ASSOCIATION OF THE KYNURENINE PATHWAY, ANHEDONIA, AND INFLAMMATORY MARKERS IN PEDIATRIC INFLAMMATORY BOWEL DISEASE Manivel Rengasamy, MD, University of Pittsburgh, [email protected]; Meredith Spada, MD, University of


Pittsburgh, [email protected]; Eva M. Szigethy, MD, PhD, University of Pittsburgh, [email protected]; Frank Lotrich, MD, PhD, University of Pittsburgh, lotrichfe@ upmc.edu Objectives: To our knowledge, the interaction between tryptophan, tryptophan metabolites (e.g., kynurenine), and inflammatory markers [e.g., C-reactive protein (CRP) and interleukin-6 (IL-6)] in the context of adolescent depressive symptoms has not been well described in the literature. On an exploratory basis, we sought to assess levels of these plasma metabolites in adolescent participants with inflammatory bowel disease (IBD), in whom unique gut-brain axis changes may contribute to psychiatric symptoms, such as anhedonia. Methods: We conducted a cross-sectional naturalistic assessment of plasma metabolites, depression severity, and anhedonia in pediatric participants with IBD as part of a post-hoc analysis from a larger study. Participants who were recruited from major metropolitan hospitals with gastroenterologist-diagnosed IBD comprised 27 children ages 9–17 years. Plasma kynurenine, tryptophan, CRP, and IL-6 levels were measured. We also obtained parent- and child-reported Childhood Depression Inventory (CDI) rating scores and composite anhedonia scores based on CDI subscales for anhedonia. Results: We found that plasma kynurenine/tryptophan ratio was positively correlated with IL-6 (r ¼ 0.679, P < 0.01). Anhedonia scores positively correlated with both CRP (r ¼ 0.623, P < 0.05) and kynurenine (r ¼ 0.679, P < 0.01). We did not find any correlation between plasma kynurenine, tryptophan, IL-6, and other depression severity scores. Conclusions: In this preliminary study, we found evidence that elevated inflammatory markers and tryptophan metabolites were associated with anhedonia symptoms but not with depression severity in adolescent participants. We suspect that the active inflammatory process of IBD (as evidenced by elevations of inflammatory markers such as IL-6) may lead to activation of the kynurenine pathway and, subsequently, contribute to neurobiological alterations associated with anhedonia. Thus, in adolescent patients with IBD, elevations in inflammation and kynurenine pathway activity may explain biomechanistic pathways that place these patients at greater risk of developing depressive symptomatology, particularly anhedonia.

NEURO, NI Supported by NIMH Grant R01 MH077770 and NIH Director’s Innovator Award Grant 1DP2OD001210 http://dx.doi.org/10.1016/j.jaac.2017.09.410

6.66 DIGITAL COGNITIVE-BEHAVIORAL THERAPY IN THE TREATMENT OF ADOLESCENT DEPRESSION: A RANDOMIZED CONTROLLED TRIAL Naira W. Topooco, MSC, Link€ oping University, naira. [email protected]; Gerhard Andersson, Karolinska Institute, [email protected] Objectives: Globally, depression is the primary cause of disability-adjusted life years among adolescents. Psychotherapeutic treatment capacities are recommended but are insufficient. Young individuals are under-represented in standard care settings for reasons of stigma and limited mental healthcare literacy. Digital interventions have the potential to increase availability of treatment and to reduce individual barriers. In this randomized controlled trial, we evaluated digital treatment based on CBT against a brief active control condition. Methods: Seventy adolescents (aged 15–19 years) presenting with depressive symptoms were randomly assigned to receive CBT (n ¼ 35) or active control condition (n ¼ 35). The CBT program was delivered over eight weeks and composed of text-based material and chat sessions with a psychologist. The primary outcome was self-reported depression symptoms at posttreatment, as measured with the self-reported Beck Depression Inventory (BDI-II). Assessments were made at baseline and posttreatment and are planned at 6 months and 2 years (trial currently running). Results: Preliminary results showed significant reductions in depressive symptoms after treatment, with an obtained large between-group effect [d ¼ 0.99; CI 0.48–1.51; F(1,63) ¼ 29.93, P < 0.001]. Participants indicated satisfaction with the CBT program on self-reported questionnaires and in written feedback.

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Conclusions: Digital psychological treatment for adolescents with depressive symptoms can be effective. The findings regarding participants’ experiences indicate that synchronous support in digital treatment is in line with the preferences of young patients.

ADOL, DDD Supported by the Swedish Riksbank Grant P16-0883:1 and Her Majesty Queen Silvia’s Jubilee Fund, Sweden http://dx.doi.org/10.1016/j.jaac.2017.09.411

6.67 COGNITIVE-BEHAVIORAL THERAPY (CBT) FOR CHILDREN WITH ANXIETY DISORDER: DO THE THERAPISTS’ ADHERENCE AND COMPETENCE MATTER? Stine Harstad, MA, Lovisenberg Hospital, stineharstad@ outlook.com; Scott N. Compton, PhD, Duke University School of Medicine, [email protected]; Marianne A. Villabo, PhD, Akershus University Hospital, [email protected] Objectives: This study aimed at exploring whether the therapists’ adherence and competence related to a cognitive behavioral treatment protocol (i.e., Coping Cat) was associated with treatment outcome. Methods: Participants were 129 children (aged 7–13 years) diagnosed with an anxiety disorder by independent evaluators (IEs) using the Anxiety Disorders

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Interview Schedule IV–Children and Parent Schedule (ADIS-V). All participants were referred for treatment to community mental health clinics. Primary treatment outcome was loss of principal anxiety disorder. Secondary outcomes were change in anxiety symptoms and global functioning assessed by the Multidimensional Anxiety Scale for Children (MASC) and Children’s Global Assessment Scale (CGAS). Treatment outcome was assessed posttreatment and at two-year follow-up. Therapist adherence and competence were rated on the Cognitive Therapy Adherence and Competence Scale (CTACS). Results: The preliminary results suggested that there were no significant associations between therapist adherence and competence and loss of primary anxiety disorder posttreatment or at follow-up. The association between adherence and loss of primary anxiety disorder was b ¼ 0.09, P ¼ 0.68 after treatment and b ¼ 0.01, P ¼ 0.96 at follow-up. The association between competence and loss of primary anxiety disorder was b ¼ 0.02, P ¼ 0.92 after treatment and b ¼ 0.17, P ¼ 0.59 at follow-up; there were no significant associations between therapist adherence and competence after treatment and at follow-up and child-reported anxiety symptoms, mother-reported anxiety symptoms, or CGAS (all P values were nonsignificant). Conclusions: The results indicate limited associations between therapists’ adherence and competence and treatment outcome. These preliminary findings from the study will be discussed, along with their implications for clinical practice.

AD, OTH http://dx.doi.org/10.1016/j.jaac.2017.09.412

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1.0 — 1.1 1 Co-Occurring Psychiatric Disorders in Children With Autism Spectrum Disorder 2 Hidden Risk Factors for Adolescent Substance Use Disorders: Caffeine Use, Sleep Disturbances, and Their Interplay 3 Medical Traumatic Stress: Risk, Resilience, and Response 4 As Needed Medications (PRNs): Do We Know What to Do When All Else Fails? 5 Research Symposium: Social Neuroscience and Child and Adolescent Psychiatry Research Priorities at the National Institute of Mental Health 6 Childhood Adversity and Psychiatric Disorders: Advances in Neurobiological Research 7 The Story of Risk and Resilience in Youth With Bipolar Disorder, High-Risk Youth, and Low-Risk Youth: Converging Evidence From Electroencephalogram, Neuroanatomy, Gene-Environment Interaction, and Brain Activation 8 Biological Underpinnings of the Development of Psychotic and Bipolar Disorders: What Do We Learn From High-Risk Studies? 9 Scientific Update on Borderline Personality Disorder in Adolescents: Assessment, Comorbidites, and Treatments 10 Behavioral, Biological, and Epigenetic Consequences of Early Life Adversity in Children, Adolescents, and Monkeys 11 Results From the Child/Adolescent Anxiety Multimodal Extended LongTerm Study (CAMELS) 12 When Depression Strikes in Pediatric Bipolar Disorder: From Recognition to Treatment 13 Advancing Sex- and Gender-Based Research to Understand Mechanisms and Developmental Trajectories of Depression: New Findings and Implications for Research and Treatment 14 Found in Translation: Clinical Relevance of Imaging Findings in Pediatric Bipolar Disorder 15 New Approaches to the Study of Irritability 16 The What, Where, and When of Childhood Psychopathology: First Steps Towards Identifying the Etiological Factors That Shape Brain Development 17 Developmental Perspectives on Aggression and Disruptive Behaviors and Implications for Treatment 18 Molecular and Genetic Mechanisms in Autism: From Bench to Bedside 19 Not Fake News: Gun Violence is a Serious Public Health Problem 20 Simon Wile Symposium: Super-Powered Child Psychiatry Access Programs! Adding Value From System-Wide Integration, Early Childhood Interventions, and Quality Improvement Initiatives 21 Adult Follow-Up of the Multimodal Treatment Study of Attention-Deficit/ Hyperactivity Disorder (MTA): Participants’ Substance Use and Growth Trajectories 22 Animal Models Advancing the Field of Child and Adolescent Psychiatry 23 Clinical Management of Pediatric Acute-Onset Neuropsychiatric Syndrome: Part I - Psychiatric and Behavioral Interventions, Part II - Treatment and Prevention of Infections and Part III- Use of Immunomodulatory Therapies 24 From Prodrome to Psychosis: Prevention and Evidence-Based Treatment 25 Subclinical Mood Symptoms: Working Toward a Better Understanding of Phenomenology and Treatment 26 Public Health Interventions in Schools for Child and Adolescent Psychiatrists 27 Using the Newest Antidepressants: A Conversation for Child and Adolescent Psychiatrists

SYMPOSIUM 1 CO-OCCURRING PSYCHIATRIC DISORDERS IN CHILDREN WITH AUTISM SPECTRUM DISORDER Connor M. Kerns, PhD, Drexel University, cmk352@drexel. edu; Antonio Hardan, MD, Stanford University, hardanay@ stanford.edu Objectives: The goal of this session is to present a series of studies on psychiatric comorbidity in autism spectrum disorder (ASD) highlighting five different disorders [anxiety, depression, ADHD, ODD, and schizophrenia (SZ)] using diverse methods of inquiry.


Methods: Study 1 describes 1) the presentation of anxiety in 176 children with ASD in a multisite trial; and 2) the psychometric properties of an adapted anxiety interview (n ¼ 56). Study 2 evaluates risk factors for depression in ASD by comparing 1) the trajectory of depressive symptoms between ages 6 and 24 years in ASD vs. other developmental delays; and 2) rumination and pupilindexed affect modulation in depressed young adults with and without ASD. Study 3 evaluates the factor structure and convergent validity of parent (n ¼ 386) and teacher (n ¼ 203)-rated ADHD assessment tools in youth with ASD. Using the Collaborative and Proactive Solutions Framework, Study 4 examines whether skill deficits predict ODD behaviors in 182 youth with ASD. Study 5 uses an item-encoding task and neuroimaging to examine the nature and neural substrates of episodic memory deficits and schizotypal symptoms in 17 youth with ASD and 19 typically developing (TD) control subjects. Results: In study 1, results support the validity and reliability of an adapted anxiety interview and suggest both traditional and ambiguous presentations of anxiety in youth with ASD who seek anxiety treatment. In study 2, results suggest a similar trajectory of depression symptoms over time for youth with ASD and developmental disability but with some variation in depression severity, rumination, and pupillary response compared with depressed and nondepressed TD control subjects. In study 3, in the sample group of youth with ASD, the results suggest convergence between ADHD assessment tools, including a psychiatric interview, but variations in scale factor structure. In study 4, deficits in emotion regulation and executive function explained 40 percent of the variance in ODD behavior in youth with ASD, with emotion regulation deficits emerging as the most powerful predictor. In study 5, results provide evidence of episodic memory deficits and related neural patterns in ASD that are distinct from those previously reported in SZ. Conclusions: Findings support claims that youth with ASD are at particular risk for psychiatric comorbidity and suggest both similarities and differences in the presentation and underpinnings of these conditions in youth with and without ASD.

EBP, ASD, CM http://dx.doi.org/10.1016/j.jaac.2017.07.576

1.1 ASSESSING TRADITIONAL AND AMBIGUOUS ANXIETY SYMPTOMS IN YOUTH WITH AUTISM SPECTRUM DISORDER Connor M. Kerns, PhD, Drexel University, [email protected] Objectives: We aim to describe the following: 1) challenges associated with differentiating autism spectrum disorder (ASD) and anxiety symptoms; 2) the presentation of anxiety disorders in treatment seeking youth with ASD; and 3) the psychometric properties of an adapted diagnostic interview for assessing anxiety in ASD—the Anxiety Disorders Interview Schedule/Autism Spectrum Addendum (ADIS/ASA). Methods: Youth with ASD (ages 8–13 years, IQ > 60) completed a comprehensive evaluation, including measures of IQ; autism [Autism Diagnostic Observation Schedule-2, Social Responsiveness Scale (SRS2)]; anxiety (ADIS/ ASA); and behavior (Child Behavior Checklist) to assess eligibility for a multisite trial of two anxiety treatments. The ADIS/ASA provides a standardized approach to differentiating anxiety and ASD symptoms and assesses impairment (Clinician Severity Rating 0–8) associated with both traditional anxiety disorders and ambiguous symptoms, such as fears related to change; unusual stimuli (e.g., beards, toilets); special interests; and social unpredictability. ADIS/ASA interviews were recorded, and in a random subsample group (N ¼ 59), subjects were observed independently and scored for inter-rater reliability. Results: The ADIS/ASA provided reliable measurement of traditional (ICC ¼ 0.85–0.98; K ¼ 0.67–0.91) and ambiguous anxiety (ICC ¼ 0.87–0.95; K ¼ 0.77– 0.90). Convergent (CBCL Anxiety, r ¼ 0.30, P < 0.05) and discriminant validity (CBCL Attention, r ¼ 0.02, not significant) were supported for traditional anxiety disorders and partially supported for ambiguous symptoms (CBCL Anxiety, r ¼ 0.11, not significant; Attention, r ¼ 0.09, not significant). In the full sample group, generalized anxiety was common (67%) followed by social phobia (43%), specific phobia (34%), separation anxiety (24%), and OCD (12%). Youth also presented with ambiguous symptoms (39%), including fears related to change (20%), unusual stimuli (11%), special interests (2%), and social unpredictability (6%). IQ and age were not associated with traditional or ambiguous symptoms. ASD symptoms (SRS2) were significantly associated with ambiguous (r ¼ 0.20, P ¼ 0.01) but not traditional anxiety (r ¼ 0.13, not significant). Conclusions: Findings suggest that comorbid and more ambiguous anxiety can be reliably differentiated and measured in youth with ASD. In addition to

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more traditional anxiety disorders, ambiguous anxiety seems common in treatment-seeking youth with ASD and may be closely related to ASD deficits.

AD, ASD, CM Supported by Autism Science Foundation, Eunice Kennedy Shriver National Institute of Child Health and Human Development Grants K23 HD087472 and R01 HD0800098 http://dx.doi.org/10.1016/j.jaac.2017.07.577

1.2 MODELING DEPRESSIVE PROFILE IN AUTISM SPECTRUM DISORDER: TRAJECTORIES OVER 15 YEARS AND AFFECTIVE RESPONSE WITHIN EIGHT SECONDS Katherine Gotham, PhD, Vanderbilt University Medical Center, [email protected] Objectives: In this study, we aim to do the following: 1) model trajectories of depressive symptoms in a longitudinal autism spectrum disorder (ASD) sample group, highlighting relations between growth patterns and participant characteristics and outcomes; and 2) comment on two potential pathways to depression in ASD by comparing rumination and pupil-indexed affect modulation in young adults with ASD and typically developing (TD) depressed and never-depressed control subjects. Methods: In study 1, participants [N ¼ 165: n ¼ 109 with ASD; n ¼ 56 with no ASD but developmentally delayed (DD)] were followed between 6 and 24 years of age. Parent-rated Child and Adult Behavior Checklists (CBCL; ABCL) were collected every 3 to 6 months from age 9 years and modeled with mixedeffects Poisson models of co-varying diagnosis, gender, age, and verbal IQ (VIQ). In study 2, young adults aged 18 to 35 years with VIQ >80 were recruited from three cohorts (N ¼ 53: n ¼ 21 with ASD; n ¼ 13 TD-depressed; n ¼ 19 TD-never-depressed). Participants completed Ruminative Response Scale (RRS) and Beck Depression Inventory, 2nd Edition (BDI-II) self-reports and a passive-viewing pupil task in which emotionally expressive faces were displayed for 400 ms and then masked through eight seconds. Results: In study 1, controlling for VIQ, depressive symptoms were greater in participants with ASD than those who were DD and were associated with poorer emotional regulation in school age and with lower life satisfaction and greater social difficulties in early adulthood. Whereas symptom levels in females increased at a faster rate throughout adolescence, males with ASD had elevated levels of depressive symptoms in school age that were maintained into young adulthood. In study 2, when viewing sad faces, individuals with ASD who had higher depression scores approximated TD-depressed participants’ faster, larger, and sustained pupil response to dysphoric stimuli. Rumination and depression scores contributed jointly to sustained pupil response in ASD. Conclusions: Findings support previous claims that individuals with ASD are at particular risk for mood problems and suggest that men and women with ASD have unique depressive symptom trajectories. Across ASD and TD samples, elevated depressive symptoms seem to be associated with greater immediate-and-sustained pupil response to dysphoric stimuli. Findings have implications for social-emotional processing research in autism and for treatment of comorbid depression.

ASD, CM, DDD Supported by NIMH Grant R01 MH103500 http://dx.doi.org/10.1016/j.jaac.2017.07.578

1.3 EVALUATING ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER DIAGNOSTIC TOOLS IN YOUTH WITH AUTISM SPECTRUM DISORDER Benjamin Yerys, PhD, Children’s Hospital of Philadelphia, [email protected] Objectives: It is only with the release of the fifth edition of our diagnostic manual (DSM-5) that an individual may carry a diagnosis of both autism spectrum disorder (ASD) and ADHD. Many in the field of ASD have been applying ADHD diagnostic tools to sample groups with ASD without

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considering whether these tools would be valid in an ASD population. We examined the validity of ADHD diagnostic tools in youth with ASD. Methods: We collected parent (n ¼ 386) and teacher ratings (n ¼ 203) on the ADHD Rating Scale, 4th Edition (ADHD-RS-IV) for youth ages 7–17 years with ASD, as well as parent ratings on executive function (Behavior Rating Inventory of Executive Function; n ¼ 365). For 22 children in our sample group, we also assessed convergent validity by conducting a well-validated psychiatric interview [Kiddie-Schedule for Affective Disorders and Schizophrenia— Present and Lifetime Version (K-SADS-PL)]. Results: The ADHD-RS-IV showed similar prevalence of ADHD in ASD compared with other large-scale studies using the DSM-based diagnostic tools. The ADHD-RS-IV demonstrated similar relationships with age and parent-reported executive function as is seen in those with ADHD. Furthermore, our exploratory subsample group with a psychiatric interview shows generally good convergence with the ADHD-RS-IV. Whereas the overall factor structure of the scale generally coheres to the expected two-factor solution (inattention and hyperactivity/impulsivity), the ADHD-RS-IV fails to meet goodness-of-fit criteria for factorial validity. Conclusions: The present study takes a critical step toward improving the measurement of ADHD symptoms in ASD. We demonstrate that ADHD screeners that closely adhere to DSM descriptions of symptoms will yield expected relationships; however, the failure to achieve factorial validity means that the scale does not adequately separate the constructs of inattention and hyperactivity/impulsivity. This work has implications for the study of ADHD in ASD, and for best practices in the clinic.

ADHD, ASD, CM http://dx.doi.org/10.1016/j.jaac.2017.07.579

1.4 CHALLENGING OUR PERSPECTIVES OF OPPOSITIONAL BEHAVIORS IN CHILDREN WITH AUTISM SPECTRUM DISORDER Brenna B. Maddox, PhD, University of Pennsylvania, [email protected] Objectives: Many school-age children with autism spectrum disorder (ASD) display challenging behaviors. Nearly 30 percent of a population-derived sample group of youth with ASD met diagnostic criteria for ODD, exceeding the average prevalence estimate of 3.3 percent in the general population. However, the label of ODD implies that the problem resides solely within the child, failing to consider the interaction between a child’s skills and environmental demands that exceed a child’s capacity to respond adaptively. The Collaborative and Proactive Solutions (CPS) framework proposes that challenging behaviors result from an incompatibility between environmental demands and a child’s “lagging skills” (primarily executive function, emotion regulation, language, and social skills). It is not known whether these lagging skills relate to ODD behaviors in youth with ASD. Methods: Parents of 182 cognitively unimpaired youth with ASD (ages 6–15 years) completed measures of their children’s challenging behaviors, executive function, language, emotion regulation, and social skills. We tested whether the CPS-lagging skills predicted challenging behaviors using multiple linear regression. We hypothesized that lagging skills would explain significant variance in challenging behaviors, given that these skills are known to be impaired in youth with ASD. Results: The CPS framework explained significant variance (40%) in participants’ challenging behaviors. The Depression (emotion regulation), Inhibit (executive function), and Sameness (executive function) scales emerged as significant predictors. Conclusions: Our data support the CPS framework of lagging skills associated with challenging behaviors in school-age, cognitively unimpaired youth with ASD. The high rate of ODD in youth with ASD may result from the high prevalence of lagging skills in this population. Considering the relationship between lagging skills, environmental demands, and challenging behaviors raises questions about how to best treat challenging behaviors in this group (e.g., applied behavior analysis or parent training vs. a cognitive-behavioral approach that explicitly teaches emotion regulation and executive function skills).

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SYMPOSIUM 2 HIDDEN RISK FACTORS FOR ADOLESCENT SUBSTANCE USE DISORDERS: CAFFEINE USE, SLEEP DISTURBANCES, AND THEIR INTERPLAY Naimah Weinberg, MD, National Institute on Drug Abuse and National Institutes of Health, [email protected]; Karen Sirocco, PhD, National Institute on Drug Abuse, [email protected] Objectives: This symposium will present emerging research findings on the potential roles of sleep disturbances and caffeine use during adolescence in substance use and abuse trajectories to assist practitioners in recognizing these factors in their evaluations and treatment of at risk adolescents and to foster cross-fertilization between sleep and caffeine researchers to consider the interplay of these factors in adolescent substance abuse. Methods: Presentations will review available cross-sectional and longitudinal data to shed light on the relationships among sleep disturbances, caffeine use, and substance use trajectories in adolescence. The first presentation draws on data from the National Consortium on Adolescent Neurodevelopment and Alcohol (NCANDA) study relating circadian preference for later sleep–wake timing and other sleep characteristics to concurrent or subsequent substance involvement. The second presentation will cover cross-sectional and longitudinal data from two separate studies on sleep and substance use in adolescence and incorporate measures of caffeine use where available. The third presentation analyzes data from the Camden Youth Development Study on cross-sectional relationships between caffeine consumption, sleep, and alcohol use, and longitudinal relationships between earlier caffeine use patterns and later sleep and alcohol use. The fourth presentation will analyze data relating sleep habits, depression, caffeine and alcohol use in late college-bound adolescents. Results: Four presentations on these studies will be made, and a panel discussion moderated by the chairs will discuss how to further integrate considerations of sleep disturbances and caffeine into research studies on trajectories of substance abuse and comorbid conditions in adolescence and their clinical implications. Conclusions: Both sleep disturbances and caffeine use seem to contribute to adolescent substance abuse and comorbid conditions, and further explication of their interplay will assist clinicians in their evaluations of high-risk adolescents and spur further needed research.

NIDA, SLP, SUD

University, [email protected]; Fiona C. Baker, PhD, SRI International, fi[email protected]; Ian M. Colrain, PhD, SRI International, [email protected]; Duncan B. Clark, MD, PhD, University of Pittsburgh School of Medicine, clarkdb@ upmc.edu Objectives: Growing cross-sectional evidence indicates that a circadian preference for eveningness (e.g., later sleep-wake timing) is linked to greater substance involvement among adolescents and young adults. Longitudinal studies are required to test whether eveningness is a risk factor for subsequent substance use. A better understanding of the longitudinal associations between eveningness and substance use is particularly needed during adolescence, which is marked by parallel peaks in eveningness and risk for the onset of substance use disorders (SUDs). Methods: The present study examined whether circadian preference and other sleep characteristics were associated with concurrent or subsequent substance involvement among 729 participants (368 females; age 12–21 years) in the National Consortium on Adolescent Neurodevelopment and Alcohol [NCANDA] study. Associations between the sleep variables and three categorical substance variables [at-risk alcohol use, alcohol bingeing, and past year marijuana use (y/n)] were examined using ordinal and logistic regression with baseline age, sex, race, ethnicity, and socioeconomic status as covariates. Results: At baseline, greater eveningness was cross-sectionally associated with greater at-risk alcohol use, greater bingeing, and past-year use of marijuana. Later weekday and weekend bedtimes, but not weekday or weekend sleep duration, showed similar cross-sectional associations across the three substance outcomes at baseline. Greater baseline eveningness was also prospectively associated with greater bingeing and past-year use of marijuana at the one-year follow-up after covarying for baseline bingeing and marijuana use. Later baseline weekday and weekend bedtimes and shorter baseline weekday sleep duration were similarly prospectively associated with greater bingeing and past-year use of marijuana at the one-year follow-up after covarying for baseline values. Conclusions: These findings buttress burgeoning evidence that circadian preference and sleep timing are under-recognized risk factors for adolescent involvement in alcohol and marijuana. Adding available sleep interventions to current approaches to adolescent SUD prevention and treatment may enhance their effectiveness.

ADOL, SLP, SUD Supported by the National Institute on Alcohol Abuse and Alcoholism, NIDA, NIMH, and the National Institute of Child Health and Human Development Grants AA021695, AA021692, AA021697, AA021696, AA021681, AA021690, AA021691, and K01DA032557 http://dx.doi.org/10.1016/j.jaac.2017.07.584


2.1 CIRCADIAN PREFERENCE AND SLEEP TIMING PREDICT RISK FOR SUBSTANCE USE IN ADOLESCENCE: INITIAL FINDINGS FROM THE NCANDA STUDY Brant P. Hasler, PhD, University of Pittsburgh School of Medicine, [email protected]; Peter L. Franzen, PhD, University of Pittsburgh School of Medicine, franpl@upmc. edu; Massimiliano de Zambotti, PhD, SRI International, [email protected]; Devin Prouty, PhD, SRI International, [email protected]; Sandra A. Brown, PhD, University of California, San Diego, [email protected]; Susan F. Tapert, PhD, University of California, San Diego, [email protected]; Adolf Pfefferbaum, SRI International, [email protected]; Kilian Pohl, PhD, SRI International, [email protected]; Edith V. Sullivan, PhD, Stanford University School of Medicine, [email protected]; Michael D. De Bellis, MD, Duke University Hospital, michael.debellis@ duke.edu; Bonnie J. Nagel, PhD, Oregon Health and Science


2.2 SLEEP DIFFICULTIES AND THE DEVELOPMENT OF SUBSTANCE-RELATED PROBLEMS Maria M. Wong, PhD, Idaho State University, wongmari@isu. edu; Timothy A. Roehrs, PhD, Henry Ford Health System, [email protected]; Leon I. Puttler, PhD, University of Michigan, [email protected]; Kirk J. Brower, MD, University of Michigan, [email protected]; Deirdre A. Conroy, PhD, University of Michigan, [email protected]. edu; Robert A. Zucker, PhD, University of Michigan, zuckerra@ med.umich.edu Objectives: We examine the relationship between sleep difficulties/sleep duration/sleepiness and substance use. We also discuss how caffeine use may mediate or moderate this relationship. Findings from two studies are presented. The first study focuses on the cross-sectional relationship between sleep difficulties/sleepiness and common behavioral problems in childhood. The second study assesses the longitudinal relationship between sleep difficulties, rhythmicity and overtiredness and the development of substancerelated problems. The role of caffeine use on the relationship between sleep and substance use is explored using data from the second study.

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Methods: Study one presents cross-sectional data from an ongoing longitudinal study on sleep and substance use (N ¼ 105; 53% girls; mean age ¼ 10.21 years; SD ¼ 1.41). Study two presents longitudinal data from another ongoing study on the development of substance use disorders. The data involve the first eight waves of the study. Participants were assessed every three years beginning when they were at ages 3 to 5 years. Data presented here spanned a developmental period of 23 years (ages 3–26 years; N ¼ 386; 24% girls; mean age at T1 ¼ 4.85; SD ¼ 1.47). Results: In study one, parental ratings of children’s sleepiness and sleeping difficulties were associated with externalizing problems, including impulsivity and aggression, and internalizing problems, such as withdrawal and anxiety. Past research shows that these behavioral problems are risk factors for substance use. In study two, parental ratings of childhood sleep difficulties (i.e., rhythmicity, trouble sleeping, and overtiredness) predicted trajectories of behavioral control in adolescence, which in turn predicted binge drinking and illicit drug use in young adulthood. Effects of caffeine in mediating/moderating the relationship between sleep difficulties and binge drinking/drug use are also reported. Conclusions: Sleep difficulties/sleep duration/sleepiness increased the risk for the development of substance use disorders among adolescents and young adults. Implications for prevention and treatment of adolescent substance use will be discussed. Additionally, results from caffeine consumption from the second study are used to discuss the possible joint effects of sleep and caffeine use on substance use.

ADOL, ALC, SLP Supported by the National Institute on Alcohol Abuse and Alcoholism Grants R01AA020364, R01AA00304, and R01AA07065. http://dx.doi.org/10.1016/j.jaac.2017.07.585

2.3 ASSOCIATIONS AMONG CAFFEINE USE, SLEEP, AND ALCOHOL USE AMONG EARLY ADOLESCENTS Naomi Marmorstein, PhD, Rutgers University, Camden, [email protected] Objectives: Previous research has demonstrated links between caffeine consumption and risk for alcohol use and between sleep problems and alcohol use. This study examined associations between caffeine consumption and sleep among early adolescents and explored how caffeine and sleep may interact in the concurrent prediction of alcohol use. Methods: Participants were from the longitudinal Camden Youth Development Study (n ¼ 127; 50 percent male; 32 percent African American, 71 percent Latino; 81 percent qualifying for free lunches). Sleep was assessed using the Pittsburgh Sleep Quality Index and the Child and Adolescent Sleep Habits questionnaire. Frequency of energy drink, coffee, soda, and alcohol consumption were assessed using a five-point scale (“not at all” to “most days”). Regression analyses, adjusting for age, gender, and race/ethnicity, were used to examine associations between sleep variables and consumption of each caffeinated beverage. Most analyses were cross-sectional at the final assessment (mean age 13.2 years, SD ¼ 0.8) because that is when sleep data were available; we also examined whether caffeine consumption at the initial assessment 16 months earlier (mean age 11.9 years, SD ¼ 0.8) predicted sleep at the final assessment. Finally, we explored interactions between sleep and caffeine use in the concurrent prediction of alcohol use (at the final assessment). Results: Concurrently, frequency of energy drink consumption was associated with daytime sleepiness and tiredness, later bedtimes, and shorter sleep duration. Longitudinally, energy drink use at the initial assessment predicted these same sleep variables 16 months later. Likewise, coffee consumption at the initial assessment predicted these same sleep variables 16 months later, although cross-sectional associations with coffee were not significant. Youth with initial insomnia who also used energy drinks were particularly likely to use alcohol (interaction effect); the same pattern was found for coffee but did not reach significance (P < 0.07). Soda consumption was not associated with sleep or alcohol use. Conclusions: Energy drink and coffee consumption during the transition to adolescence may be risk markers for later sleep issues in early adolescence. Early adolescents who consume energy drinks or coffee and also experience insomnia are particularly likely to use alcohol.

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ADOL, ALC, SLP Supported by NIDA Grant DA022456 http://dx.doi.org/10.1016/j.jaac.2017.07.586

2.4 ASSOCIATIONS OF CAFFEINE, SLEEP, AND BEHAVIORAL ISSUES INCLUDING ALCOHOL USE IN ADOLESCENTS Mary A. Carskadon, PhD, Bradley Hospital and Brown University Alpert Medical School, mary_carskadon@ brown.edu Objectives: Self-report data from college-bound high school seniors are used to describe the association of caffeine to sleep patterns in adolescents. In conjunction with biobehavioral developmental changes in sleep during adolescence, caffeine use may contribute to insufficient sleep. Methods: High-school seniors (N ¼ 1,451) who accepted admission to Brown University in 2010–2014 (mean age ¼ 18.4 0.3 years; 648 males) completed a four-page survey that included demographic information, the Sleep Habits Survey, the Pittsburgh Sleep Quality Index, the Center for Epidemiologic Studies-Depression Scale, and the Young Adult Alcohol Consequences Questionnaire, along with single-item questions on the frequency of caffeine and alcohol use. Results: Data from this project have shown interesting patterns of association among sleep variables and depressed mood, in which latent class analysis identified sleep phenotypes that differed in mood. A person-centered approach will be taken to identify whether sleep phenotypes can distinguish high and low caffeine users and subsequently whether alcohol use and alcohol consequences are associated with these phenotypes. Conclusions: Adolescent development is associated with major changes in sleep biology; circadian timing is delayed, and sleep “pressure” takes longer to accumulate across the waking day. Ample evidence from adults points to ways that caffeine impacts these biological processes. Whether they emerge in adolescents is not known. Data relating caffeine use to sleep in adolescents have been associational and not causal, thus much work is needed. We hypothesize that caffeine use contributes to sleep disruption through circadian and sleep homeostasis mechanisms and that insufficient sleep leads to many troubling outcomes, including excessive sleepiness and associated behavioral and learning difficulties, mood disorders, risk-taking behavior, and substance use and abuse.

ADOL, COLST, SLP Supported by NIMH Grant R01MH079179 http://dx.doi.org/10.1016/j.jaac.2017.07.587

SYMPOSIUM 3 MEDICAL TRAUMATIC STRESS: RISK, RESILIENCE, AND RESPONSE Maalobeeka Gangopadhyay, MD, NewYork-Presbyterian/ Columbia University Medical Center, mg3569@cumc. columbia.edu; Jake Crookall, MD, Hospital for Sick Children, [email protected]; Maryland Pao, MD, National Institute of Mental Health and the National Institutes of Health, [email protected] Objectives: Child and adolescent psychiatrists increasingly appreciate the prevalence and effects of medical traumatic stress on parents and children who are hospitalized and experience illness. With this increasing awareness, it becomes necessary for providers to have reliable measures of evaluating these symptoms, an understanding of the risk factors for developing psychopathology, and strategies for implementing interventions in integrated models of care. Methods: Dr. Crookall will review the literature about behavioral manifestations of distress in infants and young children and discuss a quality

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improvement project and clinical tool to systematize detecting distress. Dr. Gerwin will describe the results of a focus group exploring parental emotional responses to their babies undergoing therapeutic hypothermia in the neonatal intensive care unit (NICU). Dr. Samsel will present the results of a retrospective review of a cohort of 393 patients who had undergone solid organ transplantation and the factors associated with medical traumatic stress disorder development. Dr. Ihle will discuss the literature on posttraumatic growth and the development of a multidisciplinary approach to support coping and emotional well-being in hospitalized patients. Results: It is important for child and adolescent psychiatrists to have a systematic way to evaluate distress in infants and young children in medical environments so treatment interventions can be personalized. Equally as important is the experience of the parent in medical settings, such as the NICU, where child and adolescent psychiatrists can address anxiety, PTSD, and helplessness to empower parents. Attendees will recognize the significance of traumatic stress disorders contributing to lengths of stay and adherence difficulties and will appreciate the different traumatic stress variables between thoracic and abdominal organ transplants. They will be more informed of multidisciplinary approaches to promote resilience and growth after medical trauma and recognize stress as a salutogenic experience. Conclusions: With the prevalence of adverse childhood events, it is important that trauma screening and mental health services are integrated into medical care. Medical traumatic stress disorder can occur in both parents and children, and early identification of at-risk populations and behavioral phenomena can lead to earlier intervention and improved health outcomes.

PYI, PTSD, INF Sponsored by AACAP's Physically Ill Child Committee http://dx.doi.org/10.1016/j.jaac.2017.07.589

3.1 MEDICAL STRESS IN INFANTS AND YOUNG CHILDREN: PILOT OF A CLINICAL ASSESSMENT TOOL Jake Crookall, MD, Hospital for Sick Children, jake.crookall@ sickkids.ca Objectives: This presentation will describe the behavioral responses noted in children from birth to age 6 years during exposures to medical stressors. A description of a quality improvement project aimed to increase sensitivity of frontline staff to infant and young children’s displays of stress responses will be reviewed. Methods: A review of literature regarding behavioral displays of distress in infants and young children, particularly in medical environments, will be presented. An overview of the quality improvement project completed by this author will be provided, including the clinical tool developed to support frontline staff in observing stress responses in children from birth to age 6 years. Results: In medical settings, we frequently expose children to sources of stress, including painful or restrictive procedures, foreign environments, and interactions with strangers, often at times when their usual caregivers are less able to support them through these stressors. Infants and very young children demonstrate abnormal behavioral signs of distress and increased, dampened, or uncharacteristic displays in response to stressors. Depression and posttraumatic stress symptoms have been demonstrated to be reduced through implementing psychosocial interventions while patients are admitted to hospital. Validated observational instruments exist to assess stress responses in newborns (Newborn Behavioral Assessment Scale) and school-aged children (Children’s Emotional Manifestation Scale); this author presents a potential means of assessing stress responses for children between these age ranges. Conclusions: Medical stress in infants and young children can lead to significant adverse medical and psychiatric outcomes. The ability to detect abnormal stress responses in clinical populations may be a means of identifying cases for further biopsychosocial interventions to help mitigate these effects.

CON, EC, STRESS http://dx.doi.org/10.1016/j.jaac.2017.07.590


3.2 UNDERSTANDING THE PARENT EXPERIENCE OF NEWBORN THERAPEUTIC HYPOTHERMIA Roslyn Gerwin, DO, Maine Medical Center, rgerwin@ mmc.org Objectives: A great deal of research has examined the experiences of parents in the general neonatal intensive care unit (NICU) population, with a paucity of studies focusing on the setting of babies undergoing therapeutic hypothermia. Further characterization is needed to guide supportive interventions specific for this population. This study provides increased awareness of the emotional experiences of parents with newborns who have undergone therapeutic hypothermia, with specific focus on the development of trauma and approaches to ameliorate negative experiences. Methods: Family members of 15 infants who underwent therapeutic hypothermia at Maine Medical Center participated in one of five focus groups. Focus groups consisted of a group interview moderated by a psychiatry resident or child psychiatry fellow and a social worker. Audio transcripts of the interviews were coded and quantified using MaxQDA. Clinical case examples will also be included. Results: Based on the focus group responses, emotional experiences could be grouped into commonly cited subthemes, including separation, trauma, loss of normalcy, and disruption in initial bonding. Neonatal hypothermia involves the catastrophic birth of an often previously healthy term pregnancy. Parents remembered witnessing their infant being resuscitated and then shivering from the morphine part of the protocol. There was a loss of normalcy from the birth they expected, the inability to breastfeed or hold the infant, and the disruption of initial bonding. Some parents even reported symptoms of PTSD after leaving the NICU from the intense anxiety and feeling of helplessness. Effective healing experiences included consistent communication, parental education, incorporating families early in daily care, and supporting the role of being a parent. Access to other families with shared experiences lessened the isolation they felt. Conclusions: Parents with infants who have undergone therapeutic hypothermia have unique emotional experiences in the NICU. Future directions for care include developing a policy for holding during hypothermia, which does exist at other institutions, and better quantifying rates of PTSD within these families. We are also establishing a more formal role for child psychiatry involvement, both inpatient and outpatient, which is presently not in place at our institution.

INF, PYI, PTSD http://dx.doi.org/10.1016/j.jaac.2017.07.591

3.3 PSYCHIATRIC CARE AND PSYCHOTROPIC UTILIZATION IN A SOLID ORGAN TRANSPLANT POPULATION WITH MEDICAL AND NONMEDICAL TRAUMATIC STRESS DISORDERS Chase B. Samsel, MD, Boston Children’s Hospital/DanaFarber Cancer Institute, [email protected] Objectives: The current study examines the characteristics of patients who have undergone solid organ transplant (SOT), with traumatic stress disorders across organ groups, and who were seen by a psychiatry consultation service over a six-year period at a tertiary pediatric hospital. Pertinent associations and treatment variables could help providers focus on care and quality improvement when working with SOT patients and their treatment teams. SOT patients with trauma disorders were predicted to involve greater psychiatric care and psychotropic usage. Methods: Institutional review board-approved chart reviews were performed for all SOT consultations between 2008 and 2014. Data included the following: demographic information, medical history, reason for consultation, DSM-5 psychiatric diagnoses, treatment, and disposition, as well as hospital variables, such as length of stay and number of psychiatry encounters. Results: Consultations were analyzed for 393 unique patients between the ages of 3 and 29 years. More than 6.5 percent of SOT patients suffered from traumatic stress disorder. More than one third (38.3%) of consultations

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involved patients who were prescribed psychotropic medication. Patients with traumatic stress disorders were nine times more likely to have or have used psychotropics in their lifetime (P ¼ 0.001). Patients with thoracic transplants (e.g., heart and lung) were more likely to develop medical traumatic stress disorders than patients with abdominal transplants (e.g., liver and kidney) (P < 0.01). SOT patients with medical and nonmedical traumatic stress disorders used more psychiatric consultation than their nontraumatized peers (P < 0.001). Patients with traumatic stress disorders had higher hospital lengths of stay and more difficulties with adherence (P < 0.01). Conclusions: Pediatric and young adult SOT patients with traumatic stress warrant more intensive psychiatric and medical support. Medical traumatic stress may be predictable in certain SOT patients. This identified population would benefit from increasing psychoeducation of patients and teams, along with more tailored interventions for prevention and treatment. The differences between medical and nonmedical traumatic stress deserve further study.

PTSD, PTA, RF http://dx.doi.org/10.1016/j.jaac.2017.07.592

3.4 POSTTRAUMATIC GROWTH IN HOSPITALIZED CHILDREN AND ADOLESCENTS Eva C. Ihle, MD, PhD, University of California, San Francisco Benioff Children’s Hospital, [email protected] Objectives: This presentation will describe the phenomenon of posttraumatic growth through a review of the literature on complex developmental trauma and salutogenesis. A description of a multidisciplinary approach to support posttraumatic growth (PTG) will also be presented. Methods: A review of the literature on adverse childhood events, complex developmental trauma, medical trauma in children, positive psychology, and PTG will be presented. This seminar will then describe a multidisciplinary, collaborative approach [developed at University of California, San Francisco Benioff Children’s Hospital (UCSF BCH)] to enhance well-being and support PTG. Results: There is much attention being paid to the role that complex developmental trauma and adverse childhood events (ACEs) play in determining the overall well-being of children and adolescents. One ACE that is particularly relevant to consultation-liaison (C/L) pediatric psychiatrists is the threat to bodily integrity; serious medical illness (and its treatment) is one such threat. ACEs have been associated with the maladaptive consequences of the stress response. However, it is important to highlight the auspicious role of stress in addition to its adaptive role (supporting survival). One positive aspect of stress is PTG where individuals gain strength and insight from crises. When medical trauma can be reframed as a stressor that promotes PTG, ACE is transformed from something pathogenic to an experience that is salutogenic. At UCSF BCH, a number of specialists play complementary roles in the effort to support salutogenesis. Our multidisciplinary, collaborative approach involves child and adolescent C/L psychiatrists, pediatric palliative care physicians, psychologists, and child life specialists in the effort to promote coping and enhance the emotional well-being of hospitalized patients. Conclusions: Medical trauma can be considered an ACE that challenges the resilience of both patients and their families. Interventions informed by the field of positive psychology can enhance resilience by supporting salutogenesis. Diverse disciplines can work collaboratively to support well-being and enhance PTG.

STRESS, PYI, PRE http://dx.doi.org/10.1016/j.jaac.2017.07.593

SYMPOSIUM 4 AS NEEDED MEDICATIONS (PRNS): DO WE KNOW WHAT TO DO WHEN ALL ELSE FAILS? Gabrielle A. Carlson, MD, SUNY at Stony Brook, Gabrielle. [email protected]; Christopher Bellonci, MD, Tufts Medical Center, [email protected] Objectives: Prolonged tantrums/outbursts with verbal and physical aggression pose a danger to the child and others and are a challenge to manage.

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Although all forms of physical seclusion and/or chemical restraint are eschewed as sometimes dangerous and generally ethically unjustified, interventions are not equivalent. The child’s age, developmental status, diagnosis, and concomitant medication are critical. Staff training, staffing levels, milieu, physical location, and treatment goals are important. It is noteworthy that there is no guidance in child and adolescent psychiatry for what to do when efforts to avoid severe agitation are unsuccessful. There are no randomized trials in children or outcome studies to advise us whether time out, seclusion, or medications/PRNs used to reduce restrictive measures provide any short- or long-term benefit for children, their parents, and/or their schools. Treatment data on reducing “irritability” and aggression over a period of six to eight weeks exist, but there are no data on their short- or long-term effectiveness in emergency and inpatient settings. The goal of this symposium is to examine PRN interventions for acutely agitated children in emergency and inpatient settings. Methods: There will be four presentations and a discussion. Results: The first presentation will use data from around the country regarding the substantial differences in prescribing practices in emergency department settings. The second study will examine retrospective data on PRN use in crisis/restraint events over a five-year period (2011–2016) in a busy city emergency department. The third study examines both seclusion and PRN use in three cohorts of psychiatrically hospitalized children (ages 5–12 years) from 2003 to 2015 and describes prescribing trends and relative effectiveness of these interventions. The final presentation summarizes the pharmacokinetics of the medications we use with the goal of helping the audience understand what we can realistically expect from the drugs we use. Conclusions: Management of severely agitated children who at least acutely require intervention for their safety and that of those around them requires a good deal more systematic research than has occurred to date. Our hope is that this symposium will begin to examine some of the issues that will move the field to further scrutiny of this problem.

IMD, AGG, PPC http://dx.doi.org/10.1016/j.jaac.2017.07.595

4.1 PRN MEDICATION UTILIZATION OVER FIVE YEARS IN A SPECIALIZED CHILD PSYCHIATRIC EMERGENCY PROGRAM Ruth Gerson, MD, Bellevue Hospital/NYU School of Medicine, [email protected] Objectives: Youths increasingly present to emergency departments (EDs) with agitated behavior or aggression attributed to psychosis, anxiety, mania, or intoxication or related to underlying behavioral disorder. They can be dangerous to themselves, staff, and other patients in the ED and may require restraint. Although reduction of restraint and injury is a priority of every ED, there are little published data on the use and effectiveness of PRN medications to treat or prevent acute agitation. Further work is needed to understand PRN usage and identify efficacy of different PRN medications to guide clinical practice. Methods: This report describes the use of PRN medications during restraint events in a specialized child psychiatric emergency program between the program’s opening in 2011 until December 2016. During this period, 8,800 youth (ages 2–17 years) were seen, and 185 experienced restraint. Chart review examined patient demographics, diagnosis, medication utilization, and efficacy. Results: The youth who experienced restraint ranged in age from six to 17 years. Diagnoses included internalizing, externalizing, and developmental disorders, as well as substance intoxication. The medications used predominantly included most commonly diphenhydramine, chlorpromazine, haloperidol, lorazepam, and risperidone, among others, at a range of doses. Documented efficacy of medication varied significantly as we will report. Conclusions: There are currently no published consensus guidelines for the psychopharmacological management of agitation and little published literature comparing effectiveness of different PRN medications or comparing those medications to placebo. A review of PRN prescribing practices in a specialized child psychiatric emergency program, where all patients are

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treated by child and adolescent psychiatrists, illustrates the range of medication usage and the varying degree of efficacy of these medications. Further research is needed into the effectiveness of PRN medications, as is professional guidance for choice of medication and dose.

IMD, MAE, PTA http://dx.doi.org/10.1016/j.jaac.2017.07.596

Conclusions: An appreciation of the extant literature about the pharmacokinetics of these drugs might provide meaningful insights into clinical strategies when these medications are prescribed to acutely agitated youths. Clinicians can incorporate information from these scientific data into evidence-based intervention strategies for this vulnerable population.

AGG, APS, ICP http://dx.doi.org/10.1016/j.jaac.2017.07.598

4.2 PRN MEDICATION USE FOR AGITATION IN THE EMERGENCY DEPARTMENT: REGIONAL DIFFERENCES ACROSS THE UNITED STATES

4.4 PRNS IN HOSPITALIZED CHILDREN FROM 2003-2015

Megan Mroczkowski, MD, Columbia University Medical Center, [email protected]

Gabrielle A. Carlson, MD, SUNY at Stony Brook, Gabrielle. [email protected]

Objectives: More than 30 million children present to emergency departments (ED) in the United States annually. It is estimated that 16–20 percent of US children meet at least partial criteria for a psychiatric disorder; furthermore, 3– 4 percent of all ED presentations are for psychiatric or behavioral chief complaints. A common psychiatric chief complaint is agitation or aggression; furthermore, patients frequently become agitated in the ED. There are no published AACAP Practice Parameters for the psychopharmacologic management of agitation. Further work is needed to characterize PRN (as needed) medication practices for pediatricians and child psychiatrists nationwide. Methods: Work is underway in the Emergency Child Psychiatry Committee to create consensus guidelines written by psychiatrists for the management of agitation in the pediatric ED. This preliminary work has illuminated regional differences in the choice of PRN medications for agitated pediatric patients in the ED. Expanding upon this project, a voluntary written survey for pediatricians and child psychiatrists nationwide was distributed to further characterize PRN medication practices. Results: Based on initial survey responses, there was a vast array of prescribing differences in PRN medications across the country. In the Northeast region of the United States, a sample group was given diphenhydramine, lorazepam, and chlorpromazine or haloperidol to treat mild, moderate, and severe agitation, respectively. In the Pacific Northwest, the sample group was not prescribed diphenhydramine to treat agitation, given the potential for a paradoxical effect. In the Mountain states, atypical antipsychotic drugs were prescribed to the sample group before typical antipsychotic drugs. Most child psychiatrists do not use ziprasidone for agitation because of the risk of QT prolongation. Conclusions: Because there currently are no published AACAP Practice Parameters for the psychopharmacological management of agitation, there is a vast array of prescribing differences in PRN medications across the country. This section illuminates these regional differences in prescribing practices. It invites future research into both effectiveness of medications for this indication and measuring the use of the various interventions.

Objectives: Acutely agitated children account for 50 to 75 percent of children’s psychiatric inpatient unit admissions. Treating these children is clearly a goal. Increasingly, regulatory agencies require this be done without using physical or chemical restraint. Neither long-term outcomes nor randomized trials are available to advise with regard to the best interventions when deescalation and comfort measures fail. This presentation examines changes in the frequency and treatment of outbursts using more than three cohorts of psychiatrically hospitalized children from 2003 to 2015. Methods: PRNs (intramuscular, oral, and seclusion), their frequency, type of medication used, and time between PRNs were examined in three cohorts of inpatients aged five to 12 years (mean age 9.3 years, total N ¼ 345), with n ¼ 215 (62 percent) admitted for outbursts. Approximately 45 percent of children did not require PRNs in spite of their outpatient history of outbursts. We summarize the two most recent cohorts from 2009–2010 (cohort 2) and 2014–2015 (cohort 3) (n ¼ 132). Results: Rates of outbursts per day increased in recent years (from 0.04 to 0.12); 78 percent occurred within the first week of hospitalization. For the first intervention, cohort 2 used more intramuscular and oral diphenhydramine (41.6 vs 4.7 %). Cohort 3 used a neuroleptic drug, usually oral risperidone (95.3 vs. 58.3 %) (P < 0.000). Getting a second PRN (70 % of those getting a first PRN) and additional PRNs, the time to second or third PRN did not differ by cohort or type of intervention (mean 4.4 + 6.9 days). A number of admission medications were similar between cohorts (1.8 + 1.25), but compared with cohort 2, cohort 3 was discharged on significantly more medications (2.0 vs. 2.6), represented mostly by a great increase in the use of a agonists (5.7 vs. 44.3 %, P < 0.000). There was a trend toward higher antidepressant (45.3 vs. 61.5 %) and ADHD medication use (73.6 vs. 86.1 %). The rates of neuroleptic drug (57.6 %) and mood stabilizer use (14.4 %) were similar. Conclusions: The completed study will include previously published data. Although not yet formally compared with cohorts 2 and 3, we tentatively conclude that by themselves, oral PRNs are ineffective at changing the course of severe outbursts. Further data are needed to determine whether this is a dose, timing, or pharmacologic limitation. Double-blind, placebo-controlled treatment studies of agitated children are sorely needed.

ADOL, AGG, PPC http://dx.doi.org/10.1016/j.jaac.2017.07.597

4.3 PHARMACOKINETICS OF PRN MEDICATION IN AGITATED YOUTHS Robert L. Findling, MD, MBA, Kennedy Krieger Institute and Johns Hopkins University, [email protected] Objectives: The purpose of this presentation is to provide a review of what is known about the biodisposition of medications that appear to be commonly used in acutely agitated children and teenagers. Another goal of this presentation is to consider the potential clinical relevance of what is known about the pharmacokinetic parameter estimates of these drugs. Methods: Several literature searches were performed. In addition, books, book chapters, and presentations from relevant scientific meetings were examined. Results: The biodisposition of some of the medications that are used on a PRN basis has been described in the pediatric population. Conversely, there is relatively little known about the pharmacokinetics of several agents that are administered to acutely agitated children. For these reasons, extrapolation from adult data is needed to consider the biodisposition of some agents that are used in these vulnerable patients.


AGG, ALC, ATA http://dx.doi.org/10.1016/j.jaac.2017.07.599

SYMPOSIUM 5 RESEARCH SYMPOSIUM: SOCIAL NEUROSCIENCE AND CHILD AND ADOLESCENT PSYCHIATRY RESEARCH PRIORITIES AT THE NATIONAL INSTITUTE OF MENTAL HEALTH Manpreet K. Singh, MD, Stanford University School of Medicine, [email protected] Objectives: The goals of the 2017 research symposium are to highlight funding priorities of the NIMH relevant to the field of child and adolescent psychiatry and to present groundbreaking basic/translational research in the field of social neuroscience.

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Methods: The symposium will highlight two speakers from the NIMH; the first is Dr. David Leopold, an accomplished basic neuroscientist who studies social behavior in macaque monkeys, and the second is Dr. Shelli Avenevoli, the deputy director of NIMH. Results: Dr. Leopold will present current cutting-edge translational research aimed to elucidate the fundamental underpinnings of human behavior as it relates to social neuroscience, and Dr. Avenevoli will present on the current funding priorities of the NIMH. Conclusions: This year’s research symposium promises to stimulate the audience with thought-provoking science and discussions on future research directions.

R, NIMH, NEURODEV Sponsored by AACAP's Research Committee and Supported by the Research Initiative http://dx.doi.org/10.1016/j.jaac.2017.07.601

5.1 COMBINING ELECTROPHYSIOLOGY AND FUNCTIONAL MAGNETIC RESONANCE IMAGING TO STUDY SOCIAL VISUAL COGNITION David Leopold, PhD, National Institute of Mental Health, [email protected] Objectives: The goals of this work were as follows: 1) to test whether neurons in macaque temporal cortex face patches respond to facial identity in a manner that reflects human face perception; and 2) to test whether high-level visual selectivity measured in flashed-stimulus paradigms provides a foundation for understanding brain activity during naturalistic viewing conditions. Methods: We used fMRI to localize face patches in macaques and subsequently implanted chronic electrodes into the anterior fundus and anterior medial face patches. These electrodes allowed us to isolate and track the activity of individual neurons longitudinally for weeks at a time. In the first experiment, we examined neural tuning using flashed images of faces that were morphed to vary in their identity. We tracked neural tuning across multiple sessions, including those in which the animal was trained to recognize low identity faces. In the second experiment, we combined single unit recordings with fMRI to create a novel since-cell “readout” based on wholebrain correlational maps. Results: Findings from the first experiment indicate that the brain encodes facial identity in the context of “caricaturization,” where neurons respond based on the deviation of a given face from an internally stored average or norm, consistent with a large number of psychophysical findings in humans. The second experiment yielded the surprising result that, during natural viewing, face-selective neurons within 1 mm3 (80 percent. Results: A greater proportion of the ADHD group were weekly marijuana users (32.8% ADHD, 21.3% LNCG; P ¼ 0.002) and smoked tobacco daily (35.9% ADHD, 17.5% LNCG; P < 0.0001) by early adulthood. No group differences emerged for alcohol use, nonmarijuana illicit drug use, or prescription drug (i.e., stimulant) misuse. Substance use escalated into adolescence and declined slightly after age 21 years in both groups. The ADHD group had greater increases in heavy drinking (P ¼ 0.009) and illicit drug use (P ¼ 0.034) through age 21 years, which were no longer significant by age 25 years. In contrast, both groups had similar rates of increases in marijuana and tobacco use through age 21 years but higher rates in the ADHD group by age 25 years (P ¼ 0.074 marijuana, P < 0.0001 tobacco). Substance use escalation rate did not differ between groups for developmentally atypical early users. Conclusions: Children with ADHD are at increased risk for marijuana and tobacco use into young adulthood. Prescribed and illicit stimulant misuse did not differ and was low (2 times per week) and reasons for use and nonuse from the MQI. The ADHD subgroups were compared for stimulant medication treatment and persistence of ADHD symptoms. Results: ADHD group and LNCG showed similar trajectories of SU over time, but subgroups with Persistent SU compared with Non-persistent SU showed the following: 1) steeper, nonlinear increases in quantitative measures of SU, with high adult use of marijuana (w375 uses per year), alcohol (w125 uses per year), and other drugs (w40 uses per year); and 2) higher rates of self-perception of frequent substance use in adulthood (also without significant ADHD-LNCG differences) and positive reasons for use (increased stability and quality of life). Within the ADHD group, the subgroups with Persistent SU and Non-persistent SU did not differ on measures of medication treatment (percentage with different patterns of extended use and average cumulative dose) or on measures of persistence of ADHD symptoms (percentage meeting criteria for diagnosis in adulthood or average rating of symptom severity). Conclusions: In the strategically selected Qualitative Interview Study sample group, subjects from ADHD group and LNCG, selected with Persistent SU and Non-persistent SU, showed differences in quantitative (SUQ) and qualitative (MQI) measures of SU across types of substances (with highest use for marijuana). In the ADHD group, neither extended treatment with stimulant medication nor the persistence of ADHD symptoms was related to SU.

ADHD, LONG, SUD Supported by NIMH and NIDA Grants U01 MH50461, N01MH12009, HHSN271200800005-C, DA-8-5550, U01 MH50477, N01MH12012, HHSN271200800009-C, DA-8-5554, U01MH50440,N01MH1201, HHSN271200800006-C, DA-8-5551, U01 MH50467, N01 MH12007, HHSN271200800007-C, DA-8-5552, U01 MH50453, N01MH 12004, HHSN271200800004-C, DA-8-5549, U01 MH50467, N01 MH 12010, DA039881, HHSN271200800008-C, DA-8-5553, N01MH12008, HHSN271200800003-C, and DA-8-5548 http://dx.doi.org/10.1016/j.jaac.2017.07.701

21.4 TURNING POINTS IN THE LIVES OF YOUTH OF WITH/WITHOUT ATTENTIONDEFICIT/HYPERACTIVITY DISORDER: ARE THEY LINKED TO CHANGES IN SUBSTANCE USE? Peter S. Jensen, MD, University of Arkansas for Medical Science and The REACH Institute, PeterJensen@ TheReachInstitute.org; Kumi Yuki, MD, kumiyuki1026@gmail.

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com; Desiree W. Murray, PhD, University of North Carolina at Chapel Hill, [email protected]; John T. Mitchell, PhD, Duke University Hospital, [email protected]; Thomas S. Weisner, PhD, University of California, Los Angeles, [email protected]; Stephen P. Hinshaw, PhD, University of California, Berkeley and University of California, San Francisco, [email protected]; Brooke S.G. Molina, PhD, University of Pittsburgh, [email protected]; James M. Swanson, PhD, University of California, Irvine Child Development Center, [email protected]; L. Eugene Arnold, MD, Ohio State University, [email protected]; Lily Hechtman, MD, McGill University, lily.hechtman@ mcgill.ca Objectives: In this presentation, we examine the behavior beliefs, social supports, and turning points in individuals with/without ADHD related to their substance use/abuse (SU/A) decisions. Methods: The coded interviews from 60 participants with/without ADHD were compared for their SU/A decisions and precipitants to these decisions among abstainers, persisters, and desisters. Results: Subjects with ADHD reported fewer social advantages to avoid SU/A than subjects with no ADHD. Desisters and persisters reported more social advantages of using drugs than abstainers. Persisters reported both more negative and positive psychological/physiological effects of SU/A. Subjects with ADHD reported fewer positive role models in their lives. Patients with no ADHD reported more positive turning points than subjects with ADHD, regardless of SU/A status. Conclusions: Individuals with ADHD face challenges in making healthy decisions about SU/A because of the lack of positive role models. Reinforcing accurate behavioral beliefs may be important to change behaviors in individuals with SU/A or to prevent SU/A initiation in individuals with ADHD.

ADHD, LONG, SUD Supported by NIMH and NIDA Grants U01 MH50461, N01MH12009, HHSN271200800005-C and DA-8-5550, U01 MH50477, N01MH12012, HHSN271200800009-C, DA-8-5554, U01MH50440, N01MH1201, HHSN271200800006-C, DA-8-5551, U01 MH50467, N01 MH12007, HHSN271200800007-C, DA-8-5552, U01 MH50453, N01MH 12004, HHSN271200800004-C, DA-8-5549, U01 MH50467, N01 MH 12010, DA039881, HHSN271200800008-C, DA-8-5553, N01MH12008, HHSN271200800003-C, and DA-8-5548 http://dx.doi.org/10.1016/j.jaac.2017.07.702

SYMPOSIUM 22 ANIMAL MODELS ADVANCING THE FIELD OF CHILD AND ADOLESCENT PSYCHIATRY Sunil Q. Mehta, MD, PhD, Mayo Clinic, [email protected]; Paul E.A. Glaser, MD, PhD, Washington University in St. Louis School of Medicine, [email protected]; Hanna Stevens, MD, PhD, University of Iowa, hanna-stevens@ uiowa.edu Objectives: Animal models continue to contribute to a new understanding and potentially new treatments for child and adolescent psychiatric disorders. This forum provides a way to bring translatable scientific findings from highly respected scientific investigators to clinicians and clinician–scientists. Methods: Model systems from Drosophila to primates will be presented. A variety of approaches will be used that shed light on several important questions as follows: 1) How do neural systems identified in animals inform the development of treatments?; 2) How do known risk factors for childhood psychiatric disorders affect brain development and functioning?; 3) Do factors that influence a wide variety of psychopathology in children such as stress or sleep leave epigenetic or other biomarkers that can be used to predict treatment response or disease course?; and 4) What types of animal model

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data are required or helpful in justifying a particular form of treatment or pharmaceutical agent for human clinical trials, and are there ways to improve the predictive validity of animal models? Results: This symposium will briefly review the scope of animal research and recent contributions to child psychiatry. It will then specifically address the following: 1) epigenetic changes in primates caused by early life stress; 2) neurodevelopmental consequences of sleep-cycle disruption in Drosophila; 3) use of rodent models to identify more effective psychostimulants; 4) biomarkers for resilience in mouse models of stress; and 5) an industry perspective on how animal models are used to identify promising treatments to move into clinical trials. Conclusions: The ultimate goal of all of these areas of investigation is to more deeply understand the underpinnings of psychiatric disorders to improve outcomes in children and adolescents by developing better diagnosis, prevention, and treatment.

ANI, ADHD, SLP http://dx.doi.org/10.1016/j.jaac.2017.07.704

22.1 INTRODUCTION Hanna Stevens, MD, PhD, University of Iowa, [email protected] Objectives: Current work in animal models with relevance in child psychiatry has benefited from both past animal model systems and from recent advances in the technology used to manipulate and assess brain structure and function. The objective in this introduction session is to present the current work on fruit flies, macaques, and mice and its relevance in child psychiatry. Methods: In this introduction, we will discuss the different concepts of valid animal models, major advances in child psychiatry made possible by the use of animal models, and future trends in the collaboration of basic neuroscientists with child psychiatry. Results: Animal models are conceptualized for different kinds of validity— face validity, etiological validity, construct validity, and predictive validity. Our understanding of the neuroscience of child psychiatry has evolved from the use of animal models to understand how the brain works, the key components of its functioning, and how molecules and cells are related to behavior. Significant advances in our understanding of childhood mental health that have involved the use of animal model systems include the following: critical periods of development disrupted by mental illness, epigenetic modification as a result of adversity during early development, and the use of novel pharmacological agents in the treatment of autism spectrum disorder. Conclusions: By focusing on well-grounded etiological validity or risk factors for psychiatric disorders, animal models have been used to identify potential targets for treatment and prevention. Future efforts with similarly valid models will benefit from new technology that can examine a wide range of cellular, physiological, and behavioral measures.

ANI, R, RF http://dx.doi.org/10.1016/j.jaac.2017.07.705

22.2 GENOME-WIDE EPIGENETIC CONSEQUENCES OF DIFFERENT EARLY SOCIAL EXPERIENCES IN RHESUS MONKEYS: A PROSPECTIVE LONGITUDINAL EXPERIMENT Stephen J. Suomi, PhD, National Institute of Child Health and Human Development, National Institutes of Health, suomis@ lce.nichd.nih.gov Objectives: Research over previous decades has demonstrated that different early social experiences, in early infancy to preadolescence in similar differentially-reared rhesus monkeys (e.g., being reared by one’s mother vs. in a nursery with access to peers), can have profound and long-lasting consequences for behavioral, emotional, cognitive, and biological development in rhesus monkeys. More recent research has shown that such differential early social experiences can also have epigenetic consequences, both short-term (e.g., genome-wide patterns of expression in leukocytes) and some that can be detected in adulthood (e.g., genome-wide patterns of methylation in both

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lymphocytes and prefrontal cortex). The present study was designed to track patterns of genome-wide methylation longitudinally. Methods: Laboratory-born rhesus monkeys (N ¼ 48; 24 males and 24 females) were raised from birth through their first 6–7 months of life either by their biological mothers (MR) or hand-reared in a neonatal nursery for their first month of life and then given extensive access to same-aged peers (SPR). At age 7–8 months, all monkeys were weaned from their initial rearing environments and moved into large, mixed social groups where they remained together for the duration of the study. Blood samples were obtained from each monkey at four time points: between 14 and 30 days of age (early infancy), at age 6 to 7 months (preweaning), at age 9 to 10 months (postweaning), and again at 2 years of age (preadolescence). CD3+ T cells were isolated, DNA was prepared, and the state of DNA methylation in all known promoters of the rhesus monkey genome was determined. Results: There were dramatic changes in methylation patterns in both MR and SPR monkeys from infancy to six months in both males and females, affecting wide swaths of the genome, but the patterns differed as a function of rearing history. Many of the sex differences were largely reversed before weaning, and these differences continued after weaning, albeit with some attenuation, but increased again by two years of age, albeit with different overall trajectories in MR and SPR monkeys. Conclusions: This study demonstrated that genome-wide patterns of methylation in lymphocytes are highly dynamic throughout prepubertal development and vary as a function of both sex and early social rearing history.

ANI, EC, R http://dx.doi.org/10.1016/j.jaac.2017.07.706

22.3 INVESTIGATING THE ROLE OF EARLY LIFE SLEEP IN BRAIN DEVELOPMENT USING DROSOPHILA Leela Chakravarti, Perelman School of Medicine at the University of Pennsylvania, [email protected] Objectives: Increased sleep during early life is thought to play an integral role in brain maturation. Disordered sleep during this time portends later neurocognitive deficits, and childhood sleep disturbances are highly prevalent across many psychiatric and developmental disorders. Childhood sleep abnormalities may be an early manifestation of future neuropathology. Thus, correcting sleep abnormalities may represent a new avenue for therapeutic intervention. However, the molecular and genetic relationship between disturbed sleep and neurodevelopmental disease remains poorly defined. Sleep is a highly conserved behavior that has been studied in diverse species, nearly all of which also exhibit increased sleep amount in early life, known as “sleep ontogeny.” This study aims to discern neuronal circuitry controlling early life sleep and understand the neurobiological consequences of early life sleep loss using Drosophila melanogaster. Methods: Work in the genetically accessible fruit fly, D. melanogaster, has provided insight into the genetic and molecular basis of sleep. Recent studies in flies have begun to unravel the neurobiological underpinnings of sleep ontogeny. Using the tools for genetic manipulation in Drosophila, we mapped circuitry controlling sleep ontogeny and investigated how disruption of this signaling affects brain structural maturation and related social behavior. Results: Our work demonstrates that developmentally regulated signaling through specific dopaminergic circuitry controls ontogenetic sleep change. Additionally, inappropriate disruption of sleep in early life through manipulation of this circuit results in aberrant development of a specific brain structure in association with a long-lasting behavioral deficit. Conclusions: Our results suggest that regions of the brain undergoing rapid synapse elaboration in early life are especially sensitive to sleep loss during this developmental window. Given the robust conservation of sleep biology at the behavioral and genetic level, it is likely that a similar logic governs the relationship between sleep ontogeny and brain maturation in humans. Ongoing efforts aim to identify genes that specifically control ontogenetic sleep changes, with the hope of providing new insights into the regulation and function of early life sleep.

ANI, R, SLP http://dx.doi.org/10.1016/j.jaac.2017.07.707


22.4 CHRONIC PSYCHOSOCIAL STRESS REDUCES MYELINATION IN THE MEDIAL PREFRONTAL CORTEX AND INDUCES A COMPLEX CENTRAL IMMUNE RESPONSE IN SUSCEPTIBLE BUT NOT RESILIENT MICE Miles Herkenham, PhD, National Institute of Mental Health, [email protected] Objectives: Long-term exposure of a subordinate mouse to an aggressor mouse in a social conflict living condition for two weeks induces anxiety, depression, and antisocial behavior in the defeated mouse. The chronic defeat reduces hippocampal neurogenesis rates and myelin levels in the medial prefrontal cortex, two stress-responsive brain areas that control affective behavior and emotional circuits. In addition, chronic social defeat (CSD) engages the immune system, both centrally and peripherally. Microglia in the brain are major targets and effectors of these immune signals, and their activation serves to address threats to cellular homeostasis during stress. Methods: We performed a microarray analysis of microglia isolated from CSD-stressed or home-caged (HC) mice to gain insights into the roles they play in altering brain function. The CSD group was divided into two subgroups: one that succumbed to the defeat procedure by showing mood changes, stress susceptible (CSD-s), and one that resisted the effects of defeat and did not show anxiety and mood changes, stress resilient (CSD-r). Results: Microarray results showed that the gene expression profiles of the CSD-s group showed numerous changes relative to the other groups that could be categorized into distinct functional pathways. CSD-s microglial mRNAs were relatively elevated for genes involved in the extracellular matrix, oxidative stress, phagocytosis, inflammation, and leukocyte extravasation. Many of the pathways suggested that the blood-brain barrier was compromised. Histological tests confirmed elevations in matrix metalloproteinases 8 and 9 (MMP-8 and MMP-9), phagocytic activity, reactive oxygen species (ROS), and blood leakage into the brain. It is possible that the activated microglial profile reflects events that underlie the observed demyelination in the medial prefrontal cortex. Several pharmacological manipulations (MMP inhibition or ROS inhibition) blocked the CNS changes and the affective deficits in CSD mice. Conclusions: These findings illustrate that stress susceptibility is associated with a host of CNS alterations that involve microglial activation and structural changes seen in stress-responsive bran areas. Future work needs to address the basis for stress resilience versus susceptibility and the triggers for a central immune-related response.

ANI, DDD, R http://dx.doi.org/10.1016/j.jaac.2017.07.708

22.5 ANIMAL MODELS AND AMPHETAMINE ISOMERS IN ATTENTION-DEFICIT/ HYPERACTIVITY DRUG DEVELOPMENT Paul E. A. Glaser, MD, PhD, Washington University in St. Louis School of Medicine, [email protected] Objectives: Psychostimulants with different isomers of amphetamine, such as Adderall and d-amphetamine, are known to be safe and effective treatments for ADHD. Clinical studies have demonstrated that l-amphetamine is not an inactive isomer. Adderall contains approximately 25 percent l-amphetamine; Evekeoâ contains approximately 50 percent l-amphetamine. Clinical studies and animal models have suggested that there may be a role for different isomer combinations of amphetamine based on the patient’s diagnosis and genetic makeup. Methods: A 2-mm microdialysis probe was inserted into a F344 rat striatum and prefrontal cortex for perfusion with artificial cerebrospinal fluid (aCSF)/ aCSF + drug and sample collection at 20-minute intervals, whereas dopamine (DA), norephinephrine (NE), and metabolites were determined by high-pressure liquid chromatography/electrochemical detection (HPLC-EC). After a one-hour baseline period, different d- and l-amphetamine ratios were tested

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at clinically relevant concentrations. Only one drug concentration was tested per animal. Results: DA overflow for 0.01 (36.2 nM DA) and 0.1 mM (36.9 nM DA) damphetamine were not significantly different; however, 0.01 (26.4 nM DA) and 0.1 (50.8 nM DA) mM Adderall were significantly different (P < 0.05), indicating a difference in dose response for d-amphetamine vs. Adderall. d-, lAmphetamine (50/50) showed differences in NE overflow in the prefrontal cortex. Conclusions: An animal model demonstrates different neurochemical responses to different amphetamine isomers in areas of the brain implicated in ADHD. Implications for further clinical trials and correlation with other animal models of ADHD will be discussed.

ANI, ADHD, STIM http://dx.doi.org/10.1016/j.jaac.2017.07.709

22.6 MOVING FROM ANIMAL MODELS TO APPROVED NEW TREATMENTS FOR CHILD PSYCHIATRY PATIENTS Albert John Allen, MD, PhD, Eli Lilly and Company, Allenaj@ Lilly.com Objectives: The identification of animal models for psychiatric conditions affecting children is a necessary but not sufficient requirement for industry to develop new treatments for child psychiatry patients. This talk will describe some of the challenges from an industry perspective. Methods: Industry data and 17 years of personal experience will be reviewed to identify and describe challenges. Results: Target identification and validation are the initial and essential but not sufficient steps in the process of rational drug development. Industry concerns regarding potential targets include scientific questions such as the degree of validation (including reproducibility) and the correlation between animal findings and human disease, but other diverse factors are also important. These include intellectual property considerations, other potential preclinical models, the size of the patient population affected, the degree of unmet medical need, the potential benefit/risk balance, patient and advocate concerns and support, alignment with the company’s therapeutic areas of focus, the size of the company, and so on. Conclusions: Child psychiatrists developing animal models of psychiatric conditions affecting children can help their efforts to develop new treatments by gaining a greater understanding of the drug development process and industry concerns.

ANI, PPC, R http://dx.doi.org/10.1016/j.jaac.2017.07.710

SYMPOSIUM 23 CLINICAL MANAGEMENT OF PEDIATRIC ACUTE-ONSET NEUROPSYCHIATRIC SYNDROME: PART I - PSYCHIATRIC AND BEHAVIORAL INTERVENTIONS, PART II TREATMENT AND PREVENTION OF INFECTIONS, AND PART III - USE OF IMMUNOMODULATORY THERAPIES Kyle Allen Williams, MD, Massachusetts General Hospital, [email protected]; Tanya K. Murphy, MD, University of South Florida, [email protected] Objectives: This symposium presents recently published consensus guidelines as follows: Clinical Management of PANS: part I—Psychiatric and Behavioral Interventions; part II—Treatment and Prevention of Infections; and part 3—Use of Immunomodulatory Therapies, with discussion of the levels of evidence necessary for clinicians and families to make ethical and effective clinical decisions. PANS, defined by consensus-derived criteria, is characterized by the sudden and severe onset of cardinal symptoms, such as obsessive

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compulsive disorder and/or severe food restriction, with at least two of the following symptoms also having a sudden and severe onset: anxiety, sensory amplification, motor abnormalities, behavioral regression, deterioration in school performance, mood disorder, urinary symptoms, and sleep disturbances. Evidence supports understanding PANS as an inflammatory brain disorder. Presentations of PANS vary in symptom constellation, age of onset, trigger, severity, family history, immunocompetency context, etc., and in clinical courses. Evidence supporting treatments for PANS is growing, but it is insufficient to support definitive treatment prescription. Extant PANS specialty clinics and experienced clinicians lack capacity to manage patients with PANS, so others will be called upon for help. These guidelines aim to inform the community, attempting span the gaps in knowledge and treatment capacity, to assist those caring for patients with PANS until knowledge advances. Methods: Clinicians and basic scientists, including child psychiatrists, immunologists, rheumatologists, neurologists, infectious disease experts, general pediatricians, primary care practitioners, and research scientists, with expertise in PANS-related areas developed the guidelines steered by current literature and pooled clinical experience. Results: Consensus guidelines (Clinical Management of PANS: part I—Psychiatric and Behavioral Interventions; part II—Treatment and Prevention of Infections; and part III—Use of Immunomodulatory Therapies) have been developed and published in a peer-reviewed journal. Conclusions: When inadequate empirical evidence exists to direct clinical decision making, expert consensus guidelines can help until further research.

TICS, OCD, EA http://dx.doi.org/10.1016/j.jaac.2017.07.712

23.1 CLINICAL MANAGEMENT OF PEDIATRIC ACUTE-ONSET NEUROPSYCHIATRIC SYNDROME: BEHAVIORAL AND PSYCHIATRIC INTERVENTIONS Margo Thienemann, MD, Stanford University, mthiene@ stanford.edu Objectives: More patients with PANS are identified than current specialists and specialty clinics can serve, so other healthcare providers must learn to treat them. Because of the fluctuating course of PANS and its inflammatory nature, treatment of PANS symptoms differs in some ways from treatment of idiopathic behavioral and emotional symptoms encountered in child psychiatry. This presentation reviews expert consensus guidelines for the psychiatric and behavioral clinical management of patients with PANS, aiming to better equip other treating clinicians. Methods: Clinicians and clinical and basic science researchers, with expertise in PANS and PANS-related topics, reviewed current literature and pooled clinical experience. They published a three-part consensus guideline describing clinical management of psychiatric and behavioral, infectious disease, and immunomodulatory clinical management of PANS areas. This presentation focuses on psychiatric and behavioral interventions. Results: The presenter will review the PANS symptom picture and challenges encountered when treating patients with PANS and discuss the importance of interacting with their families, healthcare providers, and the healthcare and educational systems. Practical recommendations for environmental, psychotherapeutic, psychopharmacological, and educational interventions will be discussed in the context of extant evidence. In general, treatment of particular PANS symptoms mirrors that of idiopathic symptoms, with some modification in light of PANS’ inflammatory basis and fluctuating course. Conclusions: The fluctuating nature of the psychiatric and behavioral symptoms of PANS and the essential work in tandem with concomitant medical interventions complicate the assessment of impact of each intervention. Patients with PANS differ in their triggers, immunocompetency, and illness course, among other factors, leading to differing clinical courses. Many patients with PANS/PANDAS will recover, and psychiatric and behavioral treatments can be discontinued. Less fortunate patients who have ongoing symptoms will require ongoing environmental, psychotherapeutic, and psychopharmacological intervention. Future research is necessary to better understand mechanisms driving PANS and effective treatments.

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IMD, OCD, PPC http://dx.doi.org/10.1016/j.jaac.2017.07.713

23.2 CLINICAL MANAGEMENT OF PEDIATRIC ACUTE-ONSET NEUROPSYCHIATRIC SYNDROME: TREATMENT AND PREVENTION OF INFECTIONS Michael Cooperstock, MD, University of Missouri, [email protected] Objectives: Although the trigger of each initial onset or flare of pediatric acuteonset neuropsychiatric syndrome (PANS) is not known, infections frequently precede PANS flares and successful treatment of infection often resolves a flare or improves the clinical course of PANS. This presentation reviews expert consensus guidelines for the clinical management of infection in patients with PANS. Methods: Clinicians and clinical and basic science researchers with expertise in PANS and PANS-related topics reviewed current literature and pooled clinical experience. They published consensus guidelines describing clinical management of psychiatric, behavioral, infectious disease, and immunomodulatory clinical management of PANS areas. This presentation focuses on infectious disease interventions for patients with PANS. Results: Much attention and research have focused on group A streptococcal (GAS) infection-triggered subset of PANS called pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). In addition to GAS, other infections have been observed to incite PANS episodes, including Mycoplasma pneumoniae, influenza, and other common viruses. Infections commonly affect the upper respiratory tract (rhinitis, sinusitis, and pharyngitis), but GAS dermatitis (perianal and perivaginal) may also trigger flares. Organism-specific and other nonspecific immune activation may contribute to PANS symptom development. A guideline for assessment of infection is presented. Consensus recommendations include screening of close contacts for infection, an initial course of antistreptococcal treatment for all newly diagnosed PANS cases, and close monitoring for infection between flares in the patient and close contacts. Indications for chronic secondary antimicrobial prophylaxis or tonsillectomy are discussed. Standard immunizations and attention to vitamin D are encouraged. Conclusions: Because any infection may induce a symptom flare, close observation with appropriate therapy for any infection in a patient with PANS and close contacts is warranted. A guideline for assessment of infection at initial onset or exacerbation of neuropsychiatric symptoms is provided. Future research is needed to identify pathogenic GAS strains, improve diagnostic tools, examine GAS antimicrobial prophylaxis and tonsillectomy, and clarify mechanisms of immune activation.

MDM, OCD, PYI http://dx.doi.org/10.1016/j.jaac.2017.07.714

23.3 CLINICAL MANAGEMENT OF PEDIATRIC ACUTE-ONSET NEUROPSYCHIATRIC SYNDROME: USE OF IMMUNOMODULATORY THERAPIES Jennifer Frankovich, MD, Stanford University, jfranco@ stanford.edu Objectives: Treatment of PANS requires the treatment of infection, psychiatric and behavioral management, and often times, immunomodulatory intervention. This presentation focuses on the tailored use of immunomodulatory strategies as part of a multidisciplinary approach to PANS treatment. Methods: Clinicians and clinical and basic science researchers with expertise in PANS and PANS-related topics reviewed current literature and pooled clinical experience, as well as other childhood autoinflammatory disorders. This presentation focuses on the resulting consensus guideline describing immunomodulatory interventions for PANS. Results: Neuroinflammation seems to play a role in the pathogenesis PANS. Because presentations of PANS and clinical trajectories vary, symptom


severity and course of the disease guide treatment choices for each individual. A PANS at onset or a new PANS flare may respond or resolve with infection treatment alone and, if necessary, with directed psychotherapy and first-line anti-inflammatory treatment (nonsteroidal anti-inflammatories, brief courses of corticosteroids after infection risk is assessed). In new onset/flares with higher symptom severity, along with infection control and psychiatric interventions, higher intensity immune therapy is indicated. The cases of PANS that follow a relapsing-remitting course require amelioration of the current episode and prevention of future recurrences, often with immunologic intervention. Patients with PANS presenting with severe symptoms and a chronic-static course require consideration of more intensive immunomodulatory approaches. Before initiating immunotherapy, clinicians should ensure completion of the infectious disease and inflammatory brain disease workup, the level of evidence for and the risk/benefit ratio of considered treatment. Conclusions: Along with infection and psychiatric treatment, immunomodulatory treatment can improve the course of PANS. Choosing an immunomodulatory treatment course requires consideration of the disease severity and trajectory. Current experience suggests that, when indicated, patient prognosis improves in patients who receive immunotherapy and when treatment is given early. When patients fail first-line therapy, second-line therapy improves outcomes and reduces relapses.

MDM, NI, OCD http://dx.doi.org/10.1016/j.jaac.2017.07.715

SYMPOSIUM 24 FROM PRODROME TO PSYCHOSIS: PREVENTION AND EVIDENCE-BASED TREATMENT Liwei L. Hua, MD, PhD, Baltimore Catholic Charities, LLH228@ gmail.com; Gary M. Blau, PhD, Substance Abuse and Mental Health Services Administration, [email protected] Objectives: Symptoms of psychosis are impairing and frightening; these symptoms are concerning for current and future psychiatric disorders and increase the likelihood of future psychotic disorder. Conversion to psychosis is an important topic of research, with prevention of this transition being the focus, such as in North American Prodromal Longitudinal Study (NAPLS) and Early Detection and Intervention for the Prevention of Psychosis (EDIPPP). Other research studies, such as Recovery after Initial Schizophrenia Episode (RAISE), have focused on best-treatment practices, including coordinated specialty care (CSC) that addresses medications, family psychoeducation, therapy/resilience training, and education/employment services. This session intends to provide clinical pearls on screening for psychosis, especially in youth and adolescents, as well as inform the audience of the results from important national studies on psychosis, such as NAPLS, EDIPPP, and RAISE. The audience will also learn about broadening treatment findings statewide (OnTrackNY) and national coordination efforts for study of early onset psychosis. Methods: Findings from NAPLS, EDIPPP, and RAISE will be presented, focusing on screening, likelihood of conversion, and evidence-based treatments. Application of these results statewide will also be described, using OnTrackNY as a model. Results: Community education, screening for psychosis, and early intervention are important in improving outcomes for people presenting with symptoms of psychosis, as evidenced in EDIPPP. NAPLS, designed to study mechanisms of conversion to psychosis, recently put forth an individualized risk calculator to determine the likelihood of conversion to psychosis in clinically high-risk patients. RAISE shows the importance of CSC for patients with psychosis; manuals detailing evidence-based practices from this study are readily accessible. Conclusions: Psychoses are serious and impairing disorders, generally with poor prognoses. The longer the duration of untreated psychosis, from initial presentation of symptoms to the time of treatment, the poorer the outcomes. Increased efforts to identify patients with symptoms of psychosis, modify risk/

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prevent transition to psychosis, and engage in early intervention, as demonstrated by these programs, continue to be in great need.

PRE, PSY, TREAT Sponsored by AACAP's Adolescent Psychiatry Committee http://dx.doi.org/10.1016/j.jaac.2017.07.717

24.1 SYMPTOMATIC AND NEUROCOGNITIVE PREDICTORS OF PSYCHOSIS DURING THE CLINICAL HIGH-RISK (PRODROMAL) PHASE OF ILLNESS Jason Schiffman, PhD, University of Maryland, Baltimore County, [email protected]; Larry J. Seidman, PhD [deceased], Harvard Medical School at Beth Israel Deaconess Medical Center, [email protected] Objectives: The functional decline and development of attenuated positive psychotic symptoms prior to onset of psychosis is known as the clinical highrisk (CHR; “prodromal”) period. CHR symptoms in approximately 20–35 percent of individuals ages 12–35 years, who meet CHR criteria, convert to psychosis within two years. Identification of predictors and mechanisms of conversion to psychosis is a major public health concern and is necessary for the development of more effective, earlier interventions. Our goal was to identify neurocognitive dysfunctions and symptomatic features associated with the transition to psychosis. Methods: Two case-control studies were carried out by a consortium of eight university-based, outpatient programs studying the psychosis prodrome by the North American Prodrome Longitudinal Study (NAPLS). CHR individuals (n ¼ 291 in NAPLS-1, n ¼ 596 in NAPLS-2) were assessed at baseline and followed up for at least two years to determine outcome regarding transition to psychosis. All participants were assessed by the Structured Interview for Prodromal Symptoms and a neurocognitive test battery. Results: In NAPLS-1, 35 percent of CHR participants developed psychosis by 2.5 years. In NAPLS-2, conversion to psychosis was 16 percent in two years. In NAPLS-1, five of the following baseline features contributed uniquely to prediction of psychosis: genetic risk for schizophrenia with recent deterioration in functioning, higher levels of unusual thought content, suspicion/ paranoia, social impairment, and a history of substance abuse. Neurocognitive dysfunction, especially verbal memory impairment, was significantly associated with conversion to psychosis. In NAPLS-2, higher levels of unusual thought content and suspiciousness, greater decline in social functioning, lower verbal learning and memory, slower speed of processing, and younger age at baseline each significantly contributed to individual risk for psychosis. Conclusions: Growing evidence indicates that specific symptoms, neurocognitive features, and social decline can enhance individual prediction of psychosis during the CHR phase of illness. This has been replicated, suggesting that it may be useful in clinical settings for individualized prediction. Further work combining biological assays (e.g., MRI measures of cortical thickness) with clinical measures should be carried out to determine optimal predictors of psychosis.

PSY, RF, SZ Supported by NIMH Grant U01 MH081928 http://dx.doi.org/10.1016/j.jaac.2017.07.718

24.2 RANDOMIZED COMPARISON OF COMPREHENSIVE VERSUS USUAL COMMUNITY CARE FOR FIRST-EPISODE PSYCHOSIS: THE RAISE-ETP STUDY Delbert G. Robinson, MD, Feinstein Institute for Medical Research, [email protected] Objectives: The RAISE-ETP (Recovery After an Initial Schizophrenia Episode Early Treatment Program) study compared NAVIGATE, a comprehensive, multidisciplinary, team-based treatment approach for first-episode psychosis (FEP) to clinician-choice community care (CC). The primary outcome was quality of life; secondary outcomes included symptoms and work and school participation. Methods: Thirty-four community treatment clinics in 21 states were randomly assigned to provide either NAVIGATE or CC care. NAVIGATE treatment

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included four core interventions: 1) personalized medication management (assisted by COMPASS, a web-based decision support system developed for RAISE-ETP); 2) family psychoeducation; 3) resilience-focused individual therapy; and 4) supported employment and education. Diagnosis, duration of untreated psychosis (DUP), and clinical outcomes were assessed live and remotely by two-way video of centralized raters masked to treatment allocation. Participants (N ¼ 404; mean age 23 years, 13.6% 18 years or younger; 37.4% 20 years or younger), with schizophrenia spectrum disorders and lifetime treatment for antipsychosis (