Helen Egger, MD - US grants

The purpose of this Mentored Patient-Oriented Research Career Development Award (K23) is to enable the candidate, a child psychiatrist, to became an independent research investigating the development pathways and causes of anxiety disorders in preschool children. The research goal is to place preschoolers' anxiety symptoms and disorders within the framework of developmental epidemiology by focusing on two questions: 1. What are the age-specific presentations of anxiety disorders in children ages 2 to 5 years old? (Nosology) 2. What are the relative contributions of genes and environment and their interaction in the early development of anxiety disorders? (etiology). This application details a program of training in infant/young child psychiatry, in behavioral and statistical genetics with an introduction to molecular genetics and genomics, and advanced training in pediatric anxiety disorders. The candidate is based in the Center for Developmental Epidemiology, Duke University Medical Center. Sponsors are child psychiatrists Adrian Angold MRCPsych (developmental psychopathology and measure development), Robert Emde MD, and Charles Zeanah MH (infant/young child psychiatry and assessment of young children), and John March MD (anxiety disorders). Lindon Eaves PhD, a leading behavioral geneticist, will provide mentoring in this area. The research plan includes: 1. A detailed review of current instrumentation for assessing preschool anxiety. 2. A pilot study of 60 children aged 36-72 months, using a multi-informant assessment protocol. DSM-IV and DC:0-3 diagnoses and symptoms will be assessed using the Preschool Age Psychiatric Assessment (PAPA), a structured parent interview developed by the candidate. 3. Analysis of data on 15,500 2-5 year-old twin pairs to examine the contributions of genes and shared and non-shared environmental factors to young children's anxiety symptoms. 4. Submission of an R01 application for a longitudinal, genetically-informed study of the development of anxiety disorders in preschool children. This work will make important contributions to the development of prevention and treatment interventions for young children and will contribute to our understanding of the etiology of childhood psychopathology.

[unreadable] DESCRIPTION (provided by applicant): Pediatric anxiety disorders, from preschool through adolescence, are prevalent, impairing, and associated with increased risk for depression and anxiety disorders in adulthood. We propose a longitudinal, cohort study of children diagnosed with three common anxiety disorders: social phobia (SoPh), separation anxiety disorder (SAD), and/or generalized anxiety disorder (GAD) as preschoolers (ages 2-5). We will employ functional magnetic resonance imaging (fMRI), and eye tracking to characterize the development and to identify the neural basis of deficits in emotion processing and social perception in young children diagnosed with these early onset anxiety disorders. We will recruit 180 subjects (120 with SAD, GAD and/or SoPh; 60 with no psychiatric disorder as preschoolers) one year after they participate in a current NIMH funded, cross-sectional study of preschool anxiety disorders in a representative sample of children recruited from pediatric primary care. The children will be followed annually across five years of data collection. Our aims are: (1) Identification of dysfunctions of the neural circuitry involved in emotion processing in children with preschool SAD, SoPh, and GAD (2) Examination of the mechanisms underlying the persistence and development of functional abnormalities in the neural circuitry involved in emotion processing in children with preschool SoPh, GAD, and SAD. PUBLIC HEALTH RELEVANCE: This proposed study has the potential to make substantial contributions to our understanding of the nature and development of the brain: behavior relationship in children with early onset anxiety disorders. It would also be the first longitudinal study of a representative sample of typically developing children using imaging and eye tracking approaches. This work will contribute to our understanding of early childhood mental health disorders and lead toward the development of reliable treatments and preventive interventions for young children with impairing anxiety. [unreadable] [unreadable] [unreadable]

DESCRIPTION (provided by applicant): This application, Feelings and Body Investigators (FBI): Interoceptive Exposure for Child Abdominal Pain is in response to PA-11-177, Translational Research for the Development of Novel Interventions for Mental Disorders (R21/R33). We propose development and pilot-testing of an acceptance- based behavioral treatment for young children (5-8 years old) with functional abdominal pain (FAP; R21, n=26, R33, n=100). FAP is one of the most frequent somatic syndromes in young children, causes significant impairment, and is predictive of psychiatric and pain disorders later in childhood and in adulthood. No treatments exist for very young children with FAP. Research supports that FAP is influenced by: (1) early pain on the neurodevelopment of the gut-brain axis and (2) maladaptive interactions with the social environment that inadvertently increase somatic fear. These vulnerabilities provide targets for early intervention. OBJECTIVE: To develop and pilot an intervention for FAP based on fundamental neuroscience research on the aberrant neurodevelopment of the gut-brain axis and subsequent modification by the social environment. Our treatment 1) links intervention strategies to unique patterns of neural circuit maturation associated with early visceral pain on the gut-brain axis, 2) adapts acceptance-based behavioral strategies used to address psychopathology in older children to younger children, and 3) incorporates caregivers as role models and facilitators based on attachment research. METHODS: Our ten session intervention trains children to be Feeling and Body Investigators. Half of the sessions will be done in clinic and half at home via web-camera to facilitate generalization. During the treatment child/caregiver dyads will 1) gather body clues (Learn), 2) investigate (Experience: perform interoceptive mystery missions to explore a body sensation), 3) organize body clues (Contextualize: recall other contexts that evoke similar sensations), and 4) go on increasingly daring missions (Challenge: decrease avoidance and safety behaviors). In the R21 phase we will develop and refine the FBI intervention in 26 child- caregiver dyads. In the R33 phase we will randomize 100 children with FAP to FBI or an active control (parent education with standard medical care) to conduct a pilot-test of the feasibility, acceptability, an clinical significance of FBI compared with an active control treatment. We will use epidemiological methods to screen all eligible children attending primary care practices so that our sample will be representative of young children with FAP, not simply a convenience sample. If we are successful, young children with FAP who complete our FBI early intervention will learn to experience changes in the viscera as fun and fascinating, rather than scary, and will develop new capacities for pain management, adaptive functioning, and emotion regulation. The success of our early intervention for FAP in young children will also have broad implications for the treatment and prevention of mental illness and chronic abdominal pain.

Project Summary/Abstract Mental health and developmental disorders begin early in life, are prevalent, impairing, and predict mental health and health challenges in later childhood and in adulthood. One in nine preschoolers has an impairing mental health disorder, yet less than 15% receive any treatment. In immigrant communities, the disparity between mental health needs and care is greater because of cultural and language barriers, limited mental health literacy, and decreased use of health IT solutions, like Electronic Health Record (EHR) patient portals. Chinese American immigrant families are a fast-growing immigrant group with unmet early childhood mental health needs. We propose to design, build, and implement OurChild, an integrated mHealth/EHR solution to increase access to early childhood mental health knowledge and mental health services and resources for Chinese American children ages 2-6 years old and their parents in Sunset Park, Brooklyn. Our proposal unites our longstanding partnership with the Chinese American community in Sunset Park and the safety-net clinics serving it with our team's 1) clinical and scientific expertise in health disparities, participatory research and early childhood mental health and 2) the digital health/health IT expertise of the WonderLab, a digital incubator in the NYU Langone Department of Child and Adolescent Psychiatry. Our goal is to reduce health disparities by explicitly designing a digital solution that facilitates connection and bidirectional exchange of information across the cultural, contextual, language, and setting differences that are key barriers to early childhood mental health knowledge and access to care for this immigrant population. Our first aim is to iteratively design, build, and test OurChild. To do this we will 1) collaborate with our family, clinical, and community stakeholders to conduct an early childhood mental health context/needs analysis and participatory design and discovery activities; 2) use these insights to adapt and user-test iterative prototypes; 3) evaluate the usability and acceptability of a beta version of OurChild in a mixed-methods pilot with 20 Chinese American parents and their 2- to 6-year-old children who receive care at the Sunset Park 7th Avenue Family Health Center; and 4) optimize the design, features, and performance to create OurChild 1.0.Our second aim it to evaluate the Reach, Effectiveness, Adoption, and Implementation of OurChild 1.0 with a 6- month longitudinal implementation cohort study with 200 parent/child dyads. We will use a mixed-methods approach using metadata collected with the OurChild app, parent-reported data from the app, EHR data, and post-implementation focus groups with providers to determine whether use of Our Child increases referrals of young children for a mental health consultation or evaluation (Primary Aim). Our secondary aims will examine whether use of OurChild 1) increases parent self-efficacy; 2) parent?provider engagement; and 3) linkage with community early childhood resources. Both OurChild and our digital methodology will be designed to be scaled to other Chinese populations and efficiently adapted for other health disparity populations.