David R. Topor

Parent Involvement and Student Academic Performance: A Multiple Mediational Analysis

Parent involvement in a childs education is consistently found to be positively associated with a childs academic performance. However, there has been little investigation of the mechanisms that explain this association. The present study examines two potential mechanisms of this association: the childs perception of cognitive competence and the quality of the student–teacher relationship. This study used a sample of 158 seven-year-old participants, their mothers, and their teachers. Results indicated a statistically significant association between parent involvement and a childs academic performance, over and above the impact of the childs intelligence. A multiple mediation model indicated that the childs perception of cognitive competence fully mediated the relation between parent involvement and the childs performance on a standardized achievement test. The quality of the student–teacher relationship fully mediated the relation between parent involvement and teacher ratings of the childs classroom academic performance. Limitations, future research directions, and implications for public policy initiatives are discussed.

Borderline personality disorder in transition age youth with bipolar disorder

To determine the longitudinal impact of borderline personality disorder (BPD) on the course and outcome of bipolar disorder (BP) in a pediatric BP sample.

Irritability and elation in a large bipolar youth sample: relative symptom severity and clinical outcomes over 4 years.

OBJECTIVE To assess whether relative severity of irritability symptoms versus elation symptoms in mania is stable and predicts subsequent illness course in youth with DSM-IV bipolar I or II disorder or operationally defined bipolar disorder not otherwise specified. METHOD Investigators used the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children to assess the most severe lifetime manic episode in bipolar youth aged 7-17 years who were recruited from 2000 to 2006 as part of the Course and Outcomes of Bipolar Youth prospective cohort study (N = 361), conducted at university-affiliated mental health clinics. Subjects with at least 4 years of follow-up (N = 309) were categorized as irritable-only (n = 30), elated-only (n = 42), or both irritable and elated (n = 237) at baseline. Stability of this categorization over follow-up was the primary outcome. The course of mood symptoms and episodes, risk of suicide attempt, and functioning over follow-up were also compared between baseline groups. RESULTS Most subjects experienced both irritability and elation during follow-up, and agreement between baseline and follow-up group assignment did not exceed that expected by chance (κ = 0.03; 95% CI, -0.06 to 0.12). Elated-only subjects were most likely to report the absence of both irritability and elation symptoms at every follow-up assessment (35.7%, versus 26.7% of irritable-only subjects and 16.9% of those with both irritability and elation; P = .01). Baseline groups experienced mania or hypomania for a similar proportion of the follow-up period, but irritable-only subjects experienced depression for a greater proportion of the follow-up period than did subjects who were both irritable and elated (53.9% versus 39.7%, respectively; P = .01). The groups did not otherwise differ by course of mood episode duration, polarity, bipolar diagnostic type, suicide attempt risk, or functional impairment. CONCLUSIONS Most bipolar youth eventually experienced both irritability and elation irrespective of history. Irritable-only youth were at similar risk for mania but at greater risk for depression compared with elated-only youth and youth who had both irritability and elation symptoms.

The influence of comorbid disorders on the episodicity of bipolar disorder in youth.

Bipolar disorder (BP) frequently co‐occurs with other psychiatric disorders. We examine whether course of anxiety disorders (ANX), attention deficit hyperactivity disorder (ADHD), disruptive behavior disorders (DBD), and substance use disorders (SUD) influence likelihood of recovery and recurrence of depression and mania in BP youth.

Use of Mental Health Services in Transition Age Youth with Bipolar Disorder

Objectives. There is concern that treatment of serious mental illness in the United States declines precipitously following legal emancipation at age 18 years and transition from specialty youth clinical settings. We examined age transition effects on treatment utilization in a sample of youth with bipolar disorder. Methods. Youth with bipolar disorder (N=413) 7–18 years of age were assessed approximately twice per year (mean interval 8.2 months) for at least 4 years. Annual use of any individual, group, and family therapy, psychopharmacology visits, and hospitalization at each year of age, and monthly use from ages 17 through 19 years, were examined. The effect of age transition to 18 years on monthly visit probability was tested in the subsample with observed transitions (n=204). Putative sociodemographic moderators and the influence of clinical course were assessed. Results. Visit probabilities for the most common modalities—psychopharmacology, individual psychotherapy, and home-based care— generally fell from childhood to young adulthood. For example, the annual probability of at least one psychopharmacology visit was 97% at age 8, 75% at age 17, 60% at age 19, and 46% by age 22. Treatment probabilities fell in transitionage youth from age 17 through 19, but a specific transition effect at age 18 was not found. Declines did not vary based on sociodemographic characteristics and were not explained by changing severity of the bipolar illness or functioning. Conclusions. Mental health treatment declined with age in this sample of youth with bipolar disorder, but reductions were not concentrated during or after the transition to age 18 years. Declines were unrelated to symptom severity or impairment. (Journal of Psychiatric Practice 2013;19:464–476)

Problematic video game use scale: initial psychometric properties with psychiatrically hospitalized adolescents.

OBJECTIVE Excessive video game use among youth has been a growing concern in the United States and elsewhere. The aims of this study are to establish validity of a video game measure in a large adolescent inpatient sample, identify clinical factors underlying problem video game use, and identify associations with measures of psychopathology. METHOD Three hundred eighty participants admitted to an adolescent inpatient psychiatric unit between November 2007 and March 2009 were administered a battery of self-report measures, including a questionnaire developed for this study that assessed reinforcers and consequences of past-year video game use (ie, Problematic Video Game Use Scale). Factor analysis was used to identify the underlying structure of behaviors associated with problem video game use. RESULTS A factor analysis of the Problematic Video Game Use Scale indicated 2 primary factors. One was associated with engaging in problem behaviors that impaired the adolescents functioning as a result of playing video games and one reflected the reinforcing effects of playing video games. Both factors were associated with measures of psychopathology, although associations were generally stronger for impairment in functioning than for reinforcing effects. Both factors were significantly correlated with self-reported daily video game use (P < .001). CONCLUSIONS Two underlying factors emerged to account for problem video game playing: impairment in functioning and reinforcing effects. Initial evidence of the content validity of the video game measure was established. Findings highlight the importance of assessing video game use among an adolescent population, the factors associated with video game use, and associations with symptoms of psychopathology. Limitations include a common reporter for multiple measures and cross-sectional data that do not allow for causal links to be made.

Creating Opportunities for Organizational Leadership (COOL): Creating a Culture and Curriculum that Fosters Psychiatric Leadership Development and Quality Improvement

The authors describe the Harvard South Shore Psychiatry Residency Training Program curriculum “Creating Opportunities for Organizational Leadership,” an innovative, multitiered, resident-driven, outcome-focused set of experiences designed to develop residents’ leadership skills in personal leadership, organizational leadership, negotiation, strategic thinking, and systems redesign.

Advancing LGBT Health Care Policies and Clinical Care Within a Large Academic Health Care System: A Case Study

ABSTRACT Culturally competent health care is especially important among sexual and gender minority patients because poor cultural competence contributes to health disparities. There is a need to understand how to improve health care quality and delivery for lesbian, gay, bisexual, and transgender (LGBT) veterans in particular, because they have unique physical and mental health needs as both LGBT individuals and veterans. The following article is a case study that focuses on the policy and clinical care practices related to LGBT clinical competency, professional training, and ethical provision of care for veteran patients in the VA Boston Healthcare System. We apply Betancourt et al.’s (2003) cultural competence framework to outline the steps that VA Boston Healthcare System took to increase cultural competency at the organizational, structural, and clinical level. By sharing our experiences, we aim to provide a model and steps for other health care systems and programs, including other VA health care systems, large academic health care systems, community health care systems, and mental health care systems, interested in developing LGBT health initiatives.

Interprofessional Health Care Education at Academic Medical Centers: Using a SWOT Analysis to Develop and Implement Programming

Introduction Health care is increasingly being provided by interprofessional teams. Academic medical centers (AMCs) need to offer educational experiences for trainees to work on these teams. Few resources exist to guide educational leaders in developing and implementing these experiences to meet the unique needs of their AMC. A commonly used planning tool is the strengths, weaknesses, opportunities, and threats (SWOT) analysis, which can help organizations identify issues and develop strategies that overcome barriers to program implementation. Methods This workshop focuses on teaching participants to use a SWOT analysis to develop interprofessional learning activities. The workshop contains both a didactic component and an experiential component. The workshop was offered as a 60-minute webinar and a 120-minute in-person presentation. The additional hour during the in-person presentation was used for experiential learning activities. Eighty-four educators from a number of health professions attended the webinar, and approximately 50 medical educators attended the in-person presentation. Results Participants reported satisfaction with the workshop and found its content met stated learning objectives. Participants believed they gained both the knowledge to develop a strategic plan to implement interprofessional educational programming and the ability to apply this knowledge at their AMC. Participants reported that their confidence in using strategic planning increased due to workshop participation. Discussion This workshop represents a first step in helping educational leaders learn and use strategies to develop and implement interprofessional educational programming unique to their AMC. This programming is important for training future health care providers to work on interprofessional health care teams.

Using Video Recordings of Psychotherapy Sessions in Supervision: Strategies to Reduce Learner Anxiety

Developing knowledge and skills in psychotherapy practice is an important component of competency-based psychiatry training in the USA [1]. The Psychiatry Milestones require learners demonstrate competency in using psychotherapy with patients [1]. Assessing this competency requires a mechanism to observe the learner’s skills and abilities in using psychotherapy. One method of assessment is by observing video recordings of psychotherapy sessions. Review of video recordings allows supervisors to directly observe the learner’s psychotherapy sessions [2] and learner knowledge, skills, and abilities in conducting psychotherapy [3, 4]. As a result, supervisors are able to be more objective when assessing the learner’s skills, than what can be achieved through reading psychotherapy notes or through discussion in supervision [3, 4]. For example, by watching a video recording of a session, the supervisor is able to objectively observe the learner’s verbal and nonverbal behaviors. Using video recordings to identify these behaviors provides supervisors with data about the encounter and the learner’s ability to conduct psychotherapy [4]. For the learner, there are well-documented benefits of using video recordings. These benefits include increased self-observation, self-reflection, and self-awareness [5, 6]. With video recording, learners are more objective in assessing their technique and identifying areas for improvement [3, 5]. Learners can also better assess treatment outcomes and identify improvement in patient functioning as a result of therapy [5]. Despite identified benefits of using video recordings as part of psychotherapy supervision, actual use of video recordings is negatively impacted by a number of barriers, including learner anxiety regarding recording sessions and showing the recordings in supervision [5]. High learner anxiety is related to a decreased willingness to disclose aspects of the therapy session in supervision and to increased withholding of information from supervisors [7]. This anxiety may stem from the learner’s “unwillingness” to display insecurity to a supervisor and the learner’s “need” to portray professional competence at conducting therapy. This unwillingness may be due to the achievement orientation and competitive nature of an academic training program that may not allow for sufficient discussion of difficulties and vulnerabilities [8]. Other potential contributors to anxiety are fear of receiving a negative reaction from a supervisor, worry about a supervisor negatively evaluating a learner’s clinical skills, shame, and embarrassment [7]. These concerns may be especially pertinent when a supervisor will likely serve as a reference for applications for additional training and/or employment. A learner’s own personal and clinical issues with insecurity, self-doubt, and avoidance of feedback may also contribute [2, 7]. For these reasons, learners may delay, or avoid, using video recordings as part of supervision. Instead, learners may attribute the delay to a number of external factors, such as a patient’s reluctance to being video recorded, technical difficulties, forgetting the equipment, or other reasons. This paper identifies strategies to reduce learner anxiety, increase use of video recordings in psychotherapy supervision, and ultimately improve the quality of psychotherapy supervision and training (Table 1). * David R. Topor David.Topor@va.gov