Enrico Mezzacappa

Self‐Regulation and Its Relations to Adaptive Functioning in Low Income Youths

Most studies of self-regulation involving children have linked it to specific outcomes within a single domain of adaptive functioning. The authors examined the association of self-regulation with a range of indices of adaptive functioning among 155 youth ages 8-18 years from families with very low income. Controlling for other explanatory variables, self-regulation was strongly associated with various outcome measures in the areas of mental health, behavior, academic achievement, and social competence. The authors also contrasted youths relatively high and low in self-regulation (the top and bottom quartiles). Youths with good self-regulation had much better indices of adaptive functioning across measures of social competence, academic achievement, grades, problem behaviors, and depression and anxiety than their counterparts with more diminished self-regulatory capacities. In addition, youths with better self-regulation skills stated more adaptive responses both in terms of how they coped with past stressful live events and how they would deal with hypothetical stressors. This study indicates that self-regulation is robustly associated with a range of important indices of adaptive functioning across many domains. Findings are discussed in light of their implications for theory and intervention for children of diverse economic backgrounds.

Executive and Motivational Control of Performance Task Behavior, and Autonomic Heart‐rate Regulation in Children: Physiologic Validation of Two‐factor Solution Inhibitory Control

Forty-two (42) children (mean age 10.6 years) from mainstream public (N = 22) and therapeutic schools (N = 20) completed performance tasks assessing executive and motivational influences on motor responses. In a separate protocol, children underwent physiologic challenges of paced breathing and supine to standing postural change, while heart rate was continuously monitored. Executive control was associated with vagal modulation of respiratory driven, high-frequency heart-rate variability (t = 2.20, p < .03), whereas motivational control was associated with sympathetic modulation of posturally driven, low-frequency heart-rate variability (t = -2.22, p < .03). These findings supported a two-factor solution of inhibitory control derived in a previous study.

Child Abuse and Performance Task Assessments of Executive Functions in Boys

We examined executive functions using performance tasks in 126 boys aged 6 to 16 years. who attended public schools and therapeutic schools for children with emotional and behavioral problems. Children were further grouped based on the presence or absence of substantiated abuse histories. Based on their abuse histories and schools of origin, children were classified as Therapeutic, Abused (TA, N = 25). Therapeutic, Nonabused (TN, N = 52), and Public School (PS, N = 48). Controlling IQ and medication status, we compared children in the three groups on teacher ratings of behavior, on experimenter observations of behavior during testing, and on performance tasks challenging the capacities to inhibit an act in progress, and to passively avoid responses associated with adverse consequences. We examined mean group differences in symptoms, behaviors, and task performance, as well as differential age-dependent changes in these dimensions. Independent of abuse history, therapeutic school children demonstrated comparable levels of internalizing and externalizing symptoms, and comparable levels of redirections to task during testing-sessions, that were significantly higher than those of the public school children. Both groups of therapeutic school children also showed comparable overall performance on the capacities to inhibit an act in progress, and to passively avoid responses associated with adverse consequences that were poorer than the performance of children from the public school. Children with histories of substantiated abuse showed diminished improvement with increasing age in the capacity to passively avoid responses associated with adverse consequences when compared not only to the public school children, but also to the children from the therapeutic schools without histories of abuse. Our findings complement reports of behavioral observations of abused children, and reports associating child abuse with altered cognitive development in other areas of competence. They suggest that child abuse may negatively influence the expected developmental progression of competence in certain executive functions. This in turn could have implications for the nature and the persistence of certain forms of psychopathology associated with abuse and poor self-control. Given the cross-sectional nature of our data, however, longitudinal developmental studies of the relations between child abuse and executive functions are needed to elucidate the influence of abuse on the growth and development of such organizing principles of behavioral self-regulation.

Tricyclic antidepressants and cardiac autonomic control in children and adolescents.

OBJECTIVE To elucidate the effects of tricyclic antidepressants on sympathetic and vagal modulation of heart rate variability. METHOD Seventy-five children and adolescents (mean age 10.5 years, SD 2.0) from therapeutic and regular schools underwent challenges of paced breathing and orthostatic postural change, while heart rate was continuously recorded. Teachers completed dimensional ratings of behavior to quantity anxiety and conduct disorder. Spectral analysis of heart rate variability was utilized to decompose the postural (sympathetic) and respiratory (vagal) contributions to beat-to-beat variations in heart rate. RESULTS Under conditions in which cardiac vagal effects were expected to predominate, subjects medicated with tricyclic antidepressants (n = 13) showed significantly reduced vagal modulation of heart rate variability (F[5,69] = 5.23, p < .003), higher heart rates (F[5,69] = 5.54, p < .002), and higher relative sympathovagal balance (F[5,69] = 5.51, p < .002) than nonmedicated (n = 42) and medicated comparison groups (n = 20), even after controlling for the effects of age and psychopathology. CONCLUSIONS The relative loss of cardiac vagal control in young subjects medicated with tricyclic antidepressants, considered in the context of factors known to be associated with the development of tachyarrhythmias, presents as yet another risk, especially when coupled with factors such as maturational effects and psychopathology.

Retrospective study of hepatic enzyme elevations in children treated with olanzapine, divalproex, and their combination

OBJECTIVE To evaluate hepatic enzyme elevations during treatment with olanzapine, divalproex, and their combination. METHOD Fifty-two children, aged 4 to 18 years, with hepatic enzyme levels measured during treatment with olanzapine (n = 17), divalproex (n = 23), or their combination (n = 12), were identified in the computerized records at a pediatric medical center. Clinical characteristics as well as serial alanine aminotransferase, aspartate aminotransferase, and lactate dehydrogenase levels were collected. RESULTS Mean and peak hepatic enzyme levels were significantly higher for the combined treatment group compared to the olanzapine or divalproex groups. All 12 patients who received combined treatment had at least one peak enzyme elevation during the treatment. For 42% of these patients, at least one enzyme level remained elevated during the time for which values were available (mean 8 +/- 6 months). For those treated with divalproex either alone or in combination, the findings were not explained by variations in divalproex plasma levels. Two patients receiving combined treatment had the combination treatment discontinued because of medical complications (pancreatitis in one and steatohepatitis in the other). CONCLUSIONS Combined treatment with olanzapine and divalproex was associated with more elevations of hepatic enzymes than treatment with either agent alone. The long-term significance of this is unknown but warrants study.

Relations of age to cognitive and motivational elements of impulse control in boys with and without externalizing behavior problems.

In a cross-sectional study of 83 unmedicated boys, 6 to 16 years of age (M = 10.6, SD = 2.1), attending public (N = 48) and therapeutic schools for behaviorally disturbed children (N = 35), we examined relations of externalizing psychopathology to age-dependent change in performance on cognitive and motivational dimensions of impulse control assessed by laboratory tasks. When we controlled for internalizing symptoms and IQ or school achievement, all children showed improving competence with increasing age on both dimensions over the age range of the sample. Children with externalizing problems performed more poorly on both dimensions at all ages than children without such problems. Comparing age-dependent competence for the two groups, a model of convergent maturation in cognitive aspects of impulse control, and a model depicting a stable deficit in motivational aspects of impulse control in those children with externalizing behavior problems, relative to those without such problems, emerged. Studies of individual growth in impulse control, together with correlates of growth, are needed to validate these observations.

Prenatal cigarette exposure and infant learning stimulation as predictors of cognitive control in childhood.

Prenatal exposures to neurotoxins and postnatal parenting practices have been shown to independently predict variations in the cognitive development and emotional-behavioral well-being of infants and children. We examined the independent contributions of prenatal cigarette exposure and infant learning stimulation, as well as their inter-relationships in predicting variations in the proficiency of executive attention, a core element of cognitive control and self-regulation. Participants were an ethnic-racially, socio-economically diverse sample of 249 children followed from birth in the Project on Human Development in Chicago Neighborhoods. We obtained histories of prenatal exposure to alcohol, cigarettes, and other drugs, and we assessed socio-economic status and learning stimulation during a home visit when the participants were infants. In childhood we utilized the Attention Networks Test to assess the proficiency of executive attention during two home visits, one year apart. Accounting for age, SES, prenatal alcohol exposure, and baseline performance, we found that prenatal cigarette exposure impaired the speed of executive attention. Infant learning stimulation mitigated these effects, and predicted better accuracy of executive attention as well, suggestive of both protective and health promoting effects. Effect sizes for these relations, whether examined independently or by their inter-relationships, were comparable to if not greater in magnitude than the effects of age on speed and accuracy, highlighting the importance of these very early experiences in shaping the proficiency of self-regulation. Since executive attention is central to cognitive control and self-regulation, previously described relations between prenatal cigarette exposure, parenting practices, and some forms of childhood psychopathology may be contingent on how early learning stimulation contributes to the proficiency of executive attention through direct and indirect effects. Furthermore, considering the prolonged developmental trajectory of executive attention, interventions to support provision of learning stimulation may mitigate poor outcomes for some at-risk children by promoting development of more proficient executive attention.

A competency-based model for research training during psychiatry residency.

The Institute of Medicine recently identified a critical shortage of psychiatrist-researchers and highlighted the need for competency-based curricula that promote research training during psychiatry residency as a way to address that shortage. In this article we review extant approaches to research training during psychiatry residency. We then identify five core elements necessary for promoting research training: (1) mentoring, (2) education, (3) experience, (4) time, and (5) support. We describe six interrelated domains of core research competencies that can be mastered gradually over the course of residency training: (1) research literacy, (2) content mastery of specific research topics, (3) principles of research design and methods, (4) principles of biostatistics, (5) presentation and writing skills, including grant writing, and (6) principles of responsible conduct of research. Finally, we propose a broadly applicable, developmental, competency-based framework for applying these core elements to research training during psychiatry residency.

Recruitment and Training of Child and Adolescent Psychiatry Residents from Pediatrics

This article describes a 21-year experience of recruiting and training child and adolescent psychiatry residents with pediatric backgrounds. Three grounds of physicians are compared: those with previous training in general psychiatry alone, those with previous training in both general psychiatry and pediatrics, and those with previous training in pediatrics alone. Residents with pediatric backgrounds compared favorably with those with general psychiatry training. Those with only pediatric training were not only able to successfully complete the residency, but also the majority entered the field of child psychiatry. The findings support accepting residents directly from pediatrics as a viable pathway into child psychiatry.

Promoting Scholarship During Child and Adolescent Psychiatry Residency

BackgroundIn 2003, the Institute of Medicine (IOM) drew attention to the critical national shortage of psychiatrist-researchers and the need for competency-based curricula to promote research training during psychiatry residency as one way to address this shortage at the institutional level. Here, the authors report on the adaptation, implementation, and results attained with a broadly applicable, developmental, competency-based framework for promoting scholarship during child and adolescent psychiatry residency.MethodsThe authors instituted structural program changes, protecting time for all residents to engage in scholarly pursuits and a mentorship program to support residents in their scholarly interests. The authors assessed five graduating classes before and five classes after these changes were implemented, examining whether these changes sustained scholarship for residents with previous experience during general psychiatry residency and whether they promoted emergence of new scholarship among residents without such experience.ResultsThe authors observed a tenfold increase in the number of residents engaged in rigorously-defined scholarly pursuits after the program changes, which helped sustain the scholarship of more residents with previous experience and promoted the emergence of more new scholarship among residents without previous experience.ConclusionThe authors conclude that it is possible to sustain and promote scholarship during child psychiatry residency despite the relatively short duration of the program and the many requirements for graduation and certification. The changes implemented were universal in scope and required no special funding mechanisms, making this approach potentially exportable to other training programs.