Lauren Franz

Stigma and treatment delay in first‐episode psychosis: a grounded theory study

Aim: A longer duration of untreated psychosis (DUP) is associated with greater morbidity in the early course of schizophrenia. This formative, hypothesis‐generating study explored the effects of stigma, as perceived by family members, on DUP.

Defining, operationalizing and measuring the duration of untreated psychosis: advances, limitations and future directions

Objective: Substantial converging evidence from schizophrenia researchers indicates that the duration of untreated psychosis (DUP) represents a modifiable predictor of outcome during the early course of schizophrenia. As DUP is increasingly assessed in research settings, focused attention should be given to the complexities of measurement of this critical construct. In this review, three aspects of measurement are addressed: (i) definition of DUP, (ii) operational criteria for the construct, and (iii) methods used for measurement. Recent advances, current limitations and future directions are discussed.

The period of untreated psychosis before treatment initiation: a qualitative study of family members' perspectives.

AIM This study used a qualitative research methodology to explore common themes pertaining to the period of untreated psychosis before treatment initiation in hospitalized, urban, African American, first-episode psychosis patients. METHODS Twelve family members of 10 patients were interviewed at length to gather detailed narrative accounts of factors related to untreated psychosis and treatment delay. Using qualitative analysis, verbatim transcripts were reviewed by 2 researchers to identify prominent themes useful for generating future research hypotheses. RESULTS Four themes emerged as informative of the period of untreated psychosis before treatment initiation: (1) misattribution of symptoms or problem behaviors (eg, depression, drug use, and adolescent rebellion), (2) positive symptoms causing unusual or dangerous behaviors that served as a catalyst for initiating treatment, (3) views about personal autonomy of an adult or nearly adult patient, and (4) system-level factors (eg, unaffordability of health care and inefficiency on the part of health care providers). CONCLUSIONS Family members encountered numerous barriers when seeking treatment, including their own misattributions, the nature of the patients symptoms, financial issues, and system-level delays. The themes uncovered in this formative analysis merit further exploration with additional qualitative and quantitative research.

Preschool Anxiety Disorders in Pediatric Primary Care: Prevalence and Comorbidity

OBJECTIVE We sought to establish prevalence rates and detail patterns of comorbidity for generalized anxiety disorder, separation anxiety disorder, and social phobia in preschool-aged children. METHOD The Duke Preschool Anxiety Study, a screen-stratified, cross-sectional study, drew from pediatric primary care and oversampled for children at risk for anxiety. A total of 917 parents of preschool children (aged 2-5 years) completed the Preschool Age Psychiatric Assessment. RESULTS Generalized anxiety disorder, separation anxiety disorder, and social phobia are common in preschool-aged children attending pediatric primary care. Three-fourths of preschoolers with an anxiety disorder only had a single anxiety disorder. Generalized anxiety disorder displayed the greatest degree of comorbidity: with separation anxiety disorder (odds ratio [OR] = 4.1, 95% CI = 2.0-8.5), social phobia (OR = 6.4, 95% CI = 3.1-13.4), disruptive behavior disorders (OR = 5.1, 95% CI = 1.6-15.8), and depression (OR = 3.7, 95% CI = 1.1-12.4). CONCLUSIONS The weakness of association between generalized anxiety disorder and depression stands in contrast to substantial associations between these 2 disorders reported in older individuals. Attenuated associations in preschool-aged children could translate into clinical opportunities for targeted early interventions, aimed at modifying the developmental trajectory of anxiety disorders.

Psychological and Psychosocial Impairment in Preschoolers With Selective Eating

OBJECTIVE: We examined the clinical significance of moderate and severe selective eating (SE). Two levels of SE were examined in relation to concurrent psychiatric symptoms and as a risk factor for the emergence of later psychiatric symptoms. Findings are intended to guide health care providers to recognize when SE is a problem worthy of intervention. METHODS: A population cohort sample of 917 children aged 24 to 71 months and designated caregivers were recruited via primary care practices at a major medical center in the Southeast as part of an epidemiologic study of preschool anxiety. Caregivers were administered structured diagnostic interviews (the Preschool Age Psychiatric Assessment) regarding the child’s eating and related self-regulatory capacities, psychiatric symptoms, functioning, and home environment variables. A subset of 188 dyads were assessed a second time ∼24.7 months from the initial assessment. RESULTS: Both moderate and severe levels of SE were associated with psychopathological symptoms (anxiety, depression, attention-deficit/hyperactivity disorder) both concurrently and prospectively. However, the severity of psychopathological symptoms worsened as SE became more severe. Impairment in family functioning was reported at both levels of SE, as was sensory sensitivity in domains outside of food and the experience of food aversion. CONCLUSIONS: Findings suggest that health care providers should intervene at even moderate levels of SE. SE associated with impairment in function should now be diagnosed as avoidant/restrictive food intake disorder, an eating disorder that encapsulates maladaptive food restriction, which is new to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

Effect of an early perinatal depression intervention on long-term child development outcomes: follow-up of the Thinking Healthy Programme randomised controlled trial

BACKGROUND Perinatal depression has been linked with deleterious child development outcomes, yet maternal depression interventions have not been shown to have lasting effects on child development, and evidence is not available from countries of low or middle income. In the Thinking Healthy Programme cluster-randomised controlled trial, a perinatal depression intervention was assessed in Pakistan in 2006-07. The intervention significantly reduced depression levels 12 months post partum compared with a control. We aimed to assess the effect of this same intervention on the cognitive, socioemotional, and physical development of children at around age 7 years. METHODS Mother-child dyads who participated in the Thinking Healthy Programme cluster-randomised controlled trial were interviewed when the index child was about 7 years old. A reference group of 300 mothers who did not have prenatal depression and, therefore, did not receive the original intervention, was enrolled with their children at the same time. The primary cognitive outcome was the score on the Wechsler Preschool and Primary Scale of Intelligence (WPPSI-IV); primary socioemotional outcomes included scores on the Strengths and Difficulties Questionnaire (SDQ) and the Spence Childrens Anxiety Scale (SCAS); and primary physical outcomes were height-for-age, weight-for-age, and body-mass index (BMI)-for-age Z scores. Generalised linear modelling with random effects to account for clustering was the main method of analysis. Analyses were by intention to treat. The Thinking Healthy Programme cluster-randomised trial was registered at ISRCTN.com, number ISRCTN65316374. FINDINGS Of 705 participating mother-child dyads interviewed at the end of the Thinking Healthy Programme randomised controlled trial, 584 (83%) dyads were enrolled. 289 mothers had received the intervention and 295 had received a control consisting of enhanced usual care. The mean age of the children was 7·6 years (SD 0·1). Overall, cognitive, socioemotional, or physical development outcomes did not differ between children in the intervention or control groups whose mothers had prenatal depression. When compared with the reference group of children whose mothers did not have prenatal depression, the Thinking Healthy Programme trial children had worse socioemotional outcomes; mean scores were significantly higher on the SDQ for total difficulty (11·34 vs 10·35; mean difference 0·78, 95% CI 0·09-1·47; p=0·03) and on the SCAS for anxiety (21·33 vs 17·57; mean difference 2·93, 1·15-4·71; p=0·0013). Cognitive and physical outcomes did not differ. INTERPRETATION Our findings show that cognitive, socioemotional, and physical developmental outcomes of children at age 7 years whose mother had prenatal depression did not differ between those who received the Thinking Healthy Programme intervention and those who received the control. Further investigation is needed to understand what types of complex interventions or approaches are needed for long-term gains in maternal and child wellbeing. Prolonged, detailed, and frequent follow-up is warranted for all interventions. FUNDING Grand Challenges Canada (Government of Canada), Saving Brains programme.

Autologous Cord Blood Infusions Are Safe and Feasible in Young Children with Autism Spectrum Disorder: Results of a Single-Center Phase I Open-Label Trial

Despite advances in early diagnosis and behavioral therapies, more effective treatments for children with autism spectrum disorder (ASD) are needed. We hypothesized that umbilical cord blood‐derived cell therapies may have potential in alleviating ASD symptoms by modulating inflammatory processes in the brain. Accordingly, we conducted a phase I, open‐label trial to assess the safety and feasibility of a single intravenous infusion of autologous umbilical cord blood, as well as sensitivity to change in several ASD assessment tools, to determine suitable endpoints for future trials. Twenty‐five children, median age 4.6 years (range 2.26–5.97), with a confirmed diagnosis of ASD and a qualified banked autologous umbilical cord blood unit, were enrolled. Children were evaluated with a battery of behavioral and functional tests immediately prior to cord blood infusion (baseline) and 6 and 12 months later. Assessment of adverse events across the 12‐month period indicated that the treatment was safe and well tolerated. Significant improvements in childrens behavior were observed on parent‐report measures of social communication skills and autism symptoms, clinician ratings of overall autism symptom severity and degree of improvement, standardized measures of expressive vocabulary, and objective eye‐tracking measures of childrens attention to social stimuli, indicating that these measures may be useful endpoints in future studies. Behavioral improvements were observed during the first 6 months after infusion and were greater in children with higher baseline nonverbal intelligence quotients. These data will serve as the basis for future studies to determine the efficacy of umbilical cord blood infusions in children with ASD. Stem Cells Translational Medicine 2017;6:1332–1339

Social Functioning in Urban, Predominantly African American, Socially Disadvantaged Patients with First-Episode Nonaffective Psychosis

BACKGROUND Social functioning impairments develop and accumulate even prior to initial treatment-seeking for first-episode psychosis. This study, the first to examine social functioning in low-income, urban, predominantly African American first-episode patients: (1) assesses the internal consistency of Social Functioning Scale (SFS) subscales in this relatively unique sample; (2) identifies demographic and clinical variables that may be predictive of poor social functioning in this particular population; and (3) assesses changes in SFS scores in a subsample re-assessed six months after initial hospitalization. METHODS 109 participants (age, 23.1+/-4.7years; 76.1% male; 89.9% African American) hospitalized for a first episode of nonaffective psychosis in an urban, public-sector setting were administered the SFS along with other clinical research instruments. 34 (31.2%) returned for a follow-up clinical research assessment six months after baseline assessment. Associations between the variables of interest were analyzed utilizing independent samples Students t-tests and Pearson correlations. RESULTS Associations were observed between social functioning domains and negative symptoms (r=-.21--.32, p<.05), depressive symptoms (r=-.20--.23, p<.05), and general psychopathology symptoms (r=-.23--.24, p<.05). No significant differences were found in SFS subscale scores between baseline and six-month follow-up. CONCLUSIONS Deficits in social functioning are meaningfully related to several domains of symptoms, and such deficits may be relatively stable in the early course of psychotic disorders. Such findings may inform development of psychosocial interventions targeting social functioning in first-episode patients.

Autism spectrum disorder in sub‐saharan africa: A comprehensive scoping review

Autism spectrum disorder (ASD) is recognized as a global public health concern, yet almost everything we know about ASD comes from high‐income countries. Here we performed a scoping review of all research on ASD ever published in sub‐Saharan Africa (SSA) in order to identify ASD knowledge gaps in this part of the world. Fifty‐three publications met inclusion criteria. Themes included the phenotype, genetics and risk factors for ASD in SSA, screening and diagnosis, professional knowledge, interventions for ASD, parental perceptions, and social‐cognitive neuroscience. No epidemiological, early intervention, school‐based or adult studies were identified. For each identified theme, we aimed to summarize results and make recommendations to fill the knowledge gaps. The quality of study methodologies was generally not high. Few studies used standardized diagnostic instruments, and intervention studies were typically small‐scale. Overall, findings suggest a substantial need for large‐scale clinical, training, and research programmes to improve the lives of people who live with ASD in SSA. However, SSA also has the potential to make unique and globally‐significant contributions to the etiology and treatments of ASD through implementation, interventional, and comparative genomic science. Autism Res 2017, 10: 723–749.

Identification of provider characteristics influencing prescription of analgesics: a systematic literature review.

Pain is a comorbid and aggravating symptom that in many conditions can be perceived differently and should therefore be managed accordingly. Numerous factors, both social and cultural, are thought to influence the analgesic prescription. However, elucidation of such areas is limited. We therefore conducted a systematic literature review to test the hypothesis that variations in provider characteristics predict the prescription of pain medication.