|
Child Psychiatry
David Shaffer, F.R.C.P., Chief
of Psychiatric Research
In the mid 1990s, we set out to improve our ability to conduct psychotherapy and psychopharmacology research for children and teens with the common psychiatric disorders of childhood. We obtained NIMH grants to establish both a Research Unit for Pediatric Psychopharmacology (RUPP) and a Clinical Research Center. These grants provided us with the staff and structure to recruit children and adolescents into the treatment studies, to ensure that they received the best and safest care, and to see that we were well placed to provide advice and assistance to other centers. A new Chair in Pediatric Psychopharmacology was established, and precious foundation funds gave added support.
Over twenty research protocols were started, and the year 2000 saw some of the first products of this effort, led by Drs. Greenhill, Waslick, and Pine.
Honors
* Hector Bird received the Hulse Award from the New York Council of Child Psychiatry.
* Peter Jensen Received the 2000 AACAP Elaine Schlosser Lewis Award for the best paper on ADHD in the JAACAP.
* David Shaffer received the Ittelson Award from the APA.
* Clarice Kestenbaum received the Alexander Gralnick Award for Research in Schizophrenia from the Child Welfare League of America.
* Lisa Kotler received the Beatrix A. Hamburg Award for Best New Research Poster by a Child and Adolescent Psychiatry Resident from the AACAP.
* K-Awards were received by Miriam Ehrensaft and Ping Wu.
* NARSAD Young Investigator Award was received by Helen Smith.
* NARSAD Independent Investigator Award was received by Daniel Pine.
* NARSAD Independent Investigator Award was received by Laura Mufson.
Research
The MTA Study Ritalin and other related medications have been known to be effective treatments for ADHD for many years. However, previous research left many unanswered questions: For how long is the treatment effective? How does medication compare with psychosocial treatments? And are there some children who do especially well or less well on Ritalin-like medications? The New York State Psychiatric Institute has acted as one of the six performance sites of the Multimodal Treatment Study of ADHD (MTA), it developed many of the measures used in the study, and led many of the later analyses of the findings. The study demonstrated substantial superiority of the MTA medication-management strategy over intensive behavioral treatment or community care. There were only modest additional benefits from the combined treatment over medication alone. Dr. Greenhill has now been funded to follow-up the patients in the original study to examine whether their responses persisted and what the impact was on later delinquency, academic failure, involvement in substance use and dependence, and traffic accidents. The MTA medication strategy also showed persisting significant superiority over psychosocial treatment for oppositional-defiant symptoms ten months after the formal MTA treatments had stopped. The findings suggest that more cumulative time on medication, especially high-quality medication management beginning at younger ages, might result in greater benefits than starting medications later, after early development has been compromised.
RUPP Multisite Anxiety Disorders Treatment Study Anxiety disorders are the most common psychiatric illness in children, but most children with anxiety disorders do not receive treatment. Those who do are given a variety of psychotropic medications, often by primary care practitioners, but those drugs have not been studied for safety or efficacy in the school-age group with anxiety disorders. This trial was designed to address the underserved children with anxiety disorders, by studying a selective serotonin reuptake inhibitor (SSRI), fluvoxamine, to a parallel-design, multi-site, double-blind, eight-week trial. The New York State Psychiatric Institute was one of the performance sites, Nathan Kline Institute was the data-analytic site, and the protocol itself was written by a research psychiatrist at NYSPI. On the "Clinical Global Impressions Improvement" scale filled out by the study psychiatrist, 48 of the 63 children in the fluvoxamine group (76 percent) had a response to the treatment, as indicated by score of less than 4, as compared with 19 of 65 children in the placebo group (35 percent, P<0.001). The results showed that fluvoxamine is an effective treatment for children and adolescents with social phobia, separation anxiety disorder, or generalized anxiety disorder. The study design satisfies standard criteria of evidenced-based medicine for the generalizability of results. The treatment had a large effect (effect size 1.1) on symptoms.
The RUPP and IRC studies were conducted under optimal laboratory conditions with patients carefully selected for this purpose. The results have been published and will be used in the "real world" by clinicians on patients who might be older or younger, who come from very different home backgrounds, and who might have a variety of added conditions or problems that were not seen in the original studies. The doctors prescribing the medication may use the same doses as those in the study or may use smaller or larger doses or even mixtures of different medications. Because it is important to know whether the treatments will work as well under those circumstances as in our research clinics, we are now engaged in new research activities that will be carried out in the "field."
One of these studies, led by Laura Mufson, M.D., which commenced two years ago, is examining the effects of a certain type of psychotherapy given in the schools; yet another, led by Peter Jensen, M.D., will be a study of medications given to child and adolescent psychiatric inpatients.
In those settings, the so-called "antipsychotic" medications are used very frequently, despite the fact that there are almost no controlled trials of their safety and efficacy to guide the physicians who make use of them. It is essential that we find out how best to assist physicians in choosing the optimal dose of these medications and that we discourage inappropriate prescribing.
Staff from the Department of Child Psychiatry's Center for the Advancement of Children's Mental Health are partnering with staff from the New York State Office of Mental Health and the directors of children's psychiatric inpatient and day-treatment centers across the state to test specific methods for assisting physicians' decision-making related to their assessment, monitoring, and use of antipsychotic medications of youth with severe aggression. Ninety-three child psychiatrists across the state will be randomly assigned to one of three conditions: the traditional psychoeducational approach used in imparting information about practice guidelines (a conference, plus reading materials), versus two more-intensive physician-targeted interventions based on basic behavioral-science theories of cognition, motivation, and decision- making.
What it could lead to: In addition to yielding safer and potentially more-effective medication practices for children in state settings, the results are expected to lead to computerized applications to assist physician decision-making in the use of these medications. These applications will be developed based on the effects and possible benefits of the physician- targeted intervention. These computerized systems can be designed to give feedback to physicians as to their practice behaviors, and well as offer assistance in medication-prescribing decision-making.
Training Programs
The Child and Adolescent Psychiatry Training Program, under the leadership of Clarice J. Kestenbuam, M.D., director, and Ian A. Canino, M.D., deputy director, trains graduate psychiatrists wishing to pursue a career in administrative, clinical, academic, research, or hospital-based child psychiatry. There are approximately six positions available in the program annually. The residency is divided into separate rotations:
1. New York-Presbyterian Hospital, Jennifer Havens, M.D., Director of Clinical Services in Child and Adolescent Psychiatry;
2. Rockland Children's Psychiatric Center, Sadhana Sardana, M.D., Clinical Director;
3. Queens Children's Psychiatric Center, David M. Rube, M.D., Clinical Director.
The goals of the program are to offer training in the most important and useful methods of evaluation, diagnosis, and treatment. It ensures familiarity with a broad range of clinical problems, provide trainees with an introduction into research methods and strategies, and imparts a sense of competence in clinical teaching, consultation, and administration.
Bruce D. Waslick, M.D., is the assistant director of curriculum development and is responsible for the didactic program. A three-year course in general residency training in child psychiatry is under the direction of Owen W. Lewis, M.D., and medical student education in child psychiatry is under the direction of John K. Burton, M.D. In addition, a community-based rotation has been established to study culturally sensitive approaches for inner-city urban children.
Established in 1988, "CARING at Columbia," a not-for-profit organization, trains child and adolescent psychiatry residents to work with inner-city urban children exposed to violence and poverty through combined creative arts, social skills, and preventive programs.
Clinical Services
The Pediatric Psychiatry Service at the Children's Hospital at New York provided over twenty- five thousand mental health visits to children and families in the year 2000. Over twelve hundred children and adolescents were evaluated on the Diagnostic Intake Service and the Crisis Service, and over twelve hundred children, adolescents, and adult family members were treated in one of Pediatric Psychiatry's seven subspecialty programs. Considerable progress has been made in addressing operational problems on the service, resulting in significant revenue recovery and the implementation of administrative procedures to ensure fiscal viability in the future.
The year 2000 laid the foundation for much-needed expansion of service capacity in several different arenas:
1. The Behavioral Health Service line at New York Presbyterian Hospital dedicated new dollars to support the development of a new subspecialty clinic, the Consult/Liaison Clinic, which will provide outpatient services to patients cared for on the Pediatrics Diabetes and Pulmonary Service. In addition, service-line funding will support expansion of the Disruptive Behavior Disorders Clinic.
2. Collaboration between the Pediatric Psychiatry Service at the Children's Hospital, the Ambulatory Care Network Corporation, and the Turn 2 Foundation has led to development of a new program, Turn 2 Us, which will provide expanded mental health services and preventive and literacy service in one of our local elementary schools, P.S. 128.
3. Considerable progress
has been made towards the goal of getting New York State Office of Mental
Health approval for the out-stationing of child and adolescent mental
health clinicians in community-based primary-care clinics to provide assessment,
treatment, and co- management of primary-care patients.
|
||||||||||||||||||||||||||||||||||||||||
| [ HOME | RESEARCH & CLINICAL DIV. | CLINICAL DEPARTMENTS | EDUCATION IN PSYCHIATRY | SPECIAL ACTIVITIES & SPONSORED RESEARCH ] |