2021 Research Annual Report

Behavioral Medicine and Clinical Psychology | Research Highlights

Lori E. Crosby, PsyD

Crosby a professor in the Division of Behavioral Medicine and Clinical Psychology at Cincinnati Children’s Hospital Medical Center and the director of the CCTST Community Engagement Core, received one of five Diversity, Equity, and Inclusion (DEI) grants from the American Psychological Association Society of Pediatric Psychology this past fiscal year. The focus of the grant is to implement the Diversity Champions program which seeks to increase the competency of pediatric psychologists in applying anti-racism practices in research, clinical, training, and administrative settings. Crosby and colleagues also received an institutional COVID-19 grant to examine changes in attitudes and beliefs about COVID-19, adherence to behavioral strategies (e.g., physical distancing, masking) and the impact on mental and physical health for populations most affected by COVID-19, such as people with chronic medical conditions, Black / African-American, Latinx, and people of color. The team used data from this project to develop innovative targeted messaging interventions (e.g., videos featuring prominent community leaders) for the Black and Latinx communities. In addition, Crosby chaired the Foundation for Sickle Cell Disease’s (SCD) Inaugural Behavioral Science Symposium in 2021 bringing together researchers, clinicians, and stakeholders from across the globe to learn about the current state of behavioral health research in SCD and future directions (e.g., relationship between social determinants and health outcomes in SCD).

Understanding the Impact of COVID-19 in Adolescents with ADHD

When the United States largely shut down in March 2020, the hypothesesis made around the COVID-19 pandemic and the consequences created were likely to be particularly magnified and salient in youth with pre-existing mental health and neurodevelopmental risk, such as ADHD. With CCRF RIP funding, Becker, an associate professor in the division, led a multi-site effort with colleagues at Virginia Commonwealth University (Dr. Joshua Langberg), Virginia Tech (Dr. Rosanna Breaux), Children’s National (Dr. Melissa Dvorsky), and Deakin University (Dr. Emma Sciberras) to study COVID-19’s impact for adolescent adjustment. Using multiple time points of data collected both before and during COVID-19, Becker and his colleagues published a series of studies providing some of the first insights into the impact of the pandemic for adolescents, and the differential impact for adolescents with ADHD. These studies show that, compared to adolescents without ADHD, adolescents with ADHD had more remote learning difficulties (Journal of Adolescent Health), increased problems with academic focus and motivation (School Psychology), worsened mental health functioning (Journal of Child Psychology and Psychiatry), insufficient sleep (SLEEP), fewer adaptive coping behaviors (Research on Child and Adolescent Psychopathology), decreased grade point average from the 2019-2020 to the 2020-2021 school years (Journal of Attention Disorders), and more COVID-19 vaccine hesitancy (under review). Together, these findings underscore the importance of attending to the educational and mental health impacts of the COVID-19 pandemic for youth with neurodevelopmental disorders as the pandemic prolongs with anticipated impact on functioning across crucial developmental domains.

Interdisciplinary Headache Center Celebrates 25th Anniversary with Continued National/International Leadership and Innovative NIH-funded Projects

Headache disorders are quite common in children and adolescents, with migraine affecting over 10% of youth. Migraine is the second most disabling disease worldwide, with a pattern of notable impact beginning in adolescence and sustaining into a person’s 50s. With over six million U.S. children and adolescents experiencing this painful neurological disease each year, the Headache Center at Cincinnati Children’s sees over 2,000 new patients per year. The Center is a collaboration between the Divisions of Neurology and Behavioral Medicine and Clinical Psychology. Powers started the Center with Ton DeGrauw, MD, then the director of the Division of Neurology, in 1996. Hershey joined as co-director with Powers in 1997. Over the past 25 years, the Headache Center has grown to add additional neurologists, psychologists, nurse practitioners, nurses, clinical research professionals, neuroscientists, and quantitative psychologists and biostatisticians. Since 2003, the group continuously receives funding from the NIH. The Journal of the American Medical Association (JAMA) and the New England Journal of Medicine (NEJM) published seminal trials designed and conducted by the Center. These studies, as well as others, informed the latest practice guidelines for both acute and preventive treatment of migraine in youth. Currently, the group is conducting three R01 projects, a multi-site U01 study, and is a primary location for training for a T32 postdoctoral award. In addition, we partner with industry to be a high enrolling site for a number of current protocols of new potential therapeutics (including both drugs and devices). Our current strategic research plan focuses on three key areas: 1. Mechanistic neuroscience studies using brain imaging and pain sensory testing to determine unique (as well as overlapping) reasons for why cognitive behavioral therapy, placebo pill, and medications improve outcomes for youth with migraine; 2. Adaptive intervention designs and eHealth applications to demonstrate real world effectiveness of non-pharmacological therapies based upon cognitive behavioral principles and mind and body pain management techniques and improve access to these useful interventions; and 3. Partnering in innovative efforts to develop new treatments and rigorously test whether they are safe and efficacious for youth with headache disorders.

Our highly integrated team is so proud of our first 25 years of care, teaching, research, and advocacy. We are even more excited about what the next 25 years will bring in terms of changing the life trajectories of children, adolescents, and young adults who come to us to understand their headache disorders, learn how to significantly decease headache days and related disability, and then use those skills to keep their headaches under good control throughout their adult years.

Collaborative Research Generates a Deeper Understanding of Pediatric Chronic Pain

Chronic pain remains tremendously challenging to treat due to a lack of understanding about the mechanisms that support this highly disabling experience. Researchers within the Division of Behavioral Medicine and Clinical Psychology and the Pediatric Pain Research Center serves as a hub for multiple collaborations across the institution examining different forms of chronic pain and its treatment. Breaking down silos in the investigation of these complex conditions is critically important for developing insights into the common mechanisms supporting chronic pain and its treatment. To these ends, brain imaging (Robert C. Coghill, PhD) is combing with quantitative sensory testing (Christopher D. King, PhD) to examine the mechanisms by which migraine (Scott W. Powers, PhD, ABPP, FAHS, and Andrew D. Hershey, MD, PhD, FAHS, from the Division of Neurology), juvenile fibromyalgia (Susmita Kashikar-Zuck, PhD, and Tracy Ting, MD, MSc, RhMSUS, from the Division of Rheumatology), musculoskeletal pain and complex regional pain syndrome (Sara Williams, PhD, Anne Lynch-Jordan, PhD, and Kenneth Goldschneider, MD, FAAP, from the Division of Anesthesiology), and functional abdominal pain (Neha Santucci, MD, MBBS, from the Division of Gastroenterology, Hepatology and Nutrition) are instantiating into an experience of pain. Emerging commonalities between these conditions center on how functionally connected the amygdala is with brain regions important in pain and pain modulation and how the body’s own ability to inhibit pain relates to the trajectory of recovery. The first wave of publications of these studies is just appearing in print. The design of multiple currently funded grants and new grant applications are leveraging these publications for studies prospectively to integrate findings from these distinct chronic pain conditions.

Improving Academic Executive Functioning in Middle Schoolers with Autism

Adolescents with autism who attend the majority of their school day in the general education classroom with their peers (i.e., fully included) struggle academically. In middle school, they perform on average two to three years behind their typically developing peers. In addition to autism symptoms, a major contributor to their academic challenges is their often poor executive functioning skills. The majority of school-aged youth with autism have deficits in organization, planning, prioritizing, and materials management, and thus, it may not be surprising that their academic performance suffers. Leanne Tamm, PhD, and Amie Duncan, PhD, developed an intervention, Achieving Independence and Mastery in School (AIMS) to specifically help middle school youth with autism improve their academic executive functioning skills. With funding from the National Institutes of Health (R21), they developed a version of AIMS to offer in the clinical setting to middle schoolers with ASD along with their parents. In four separate trials, they showed that parents and adolescents liked AIMS, found it helpful, and that adolescents’ academic executive functioning improved by both parent and teacher report. Importantly, adolescents maintained these gains over time. Encouraged by these promising findings, Tamm and Duncan sought and received funding from the Institute of Education Sciences (Goal II) to develop a school-based version of AIMS that school personnel could deliver during the school day. School personnel express excitement excited to learn AIMS as both teachers and parents report impaired academic executive functioning in ASD with limited resources to address these issues in the classroom setting. Currently six different schools are collaborating with the research team to test the school-based version of AIMS. Tamm and Duncan are also seeking NIH funding to mount a larger efficacy trial investigating the efficacy of the clinic based version of AIMS. Together these interventions will fill a critical gap in the literature for fully included youth with ASD who often receive fewer services as they transition to higher grades. The public health impact of improving academic functioning in ASD is significant. An estimated lifetime cost for an individual with ASD is $1.4 million, with special education as the largest cost.

Integrated Behavioral Health

The Division of Behavioral Medicine and Clinical Psychology formed the Integrated Behavioral Health Workgroup to guide clinical and research initiatives on integrating behavioral health into pediatric primary care. The objectives of integrated behavioral health are to improve access to psychological services and supports through prevention and treatment. Psychologists embedded in the primary care clinics at Cincinnati Children's see children during well-child visits to provide guidance and interventions promoting behavioral health and well-being and treatment for children in need of more intensive services. During this past year, we completed a grant from the Ohio Department of Medicaid to refine and study this innovative approach. Through their Medicaid Technical Assistance and Policy Program, we partnered with the Ohio Colleges of Medicine Government Resource Center to conduct the project. We focused on practice readiness, procedures for integrating into clinic flow, screening and assessment, theory and strategies for working with families, collaboration with multidisciplinary providers, and teaching and training. Findings indicate that integrated behavioral health associates with greater reach and engagement of underserved populations, improved adherence to well-child schedules, improvements in child emotional and behavioral health, and decreased use of emergency department visits. The creation of a change package assists other primary care sites in adopting our approach.

Using Dogs to Promote Therapeutic Engagement During Inpatient Rehabilitation Following Acquired Brain Injury: Understanding Mechanisms and Moderators of Treatment Response

Acquired brain injury (ABI) is the leading cause of acquired disability in children, and results in physical, cognitive, academic, and psychosocial impacts. Many patients with ABI require intensive inpatient rehabilitation. Maximizing the utility and benefit of acute inpatient rehabilitation is critical to set the foundation for long-term recovery. Unfortunately, these patients often demonstrate cognitive, behavioral, and emotional sequelae, such as executive dysfunction and emotional / behavioral dysregulation hindering their engagement in rehabilitation therapies. Use of animal assisted therapies (AATs) in a variety of clinical populations and settings to improve well-being and quality of life offer an innovative means for successful therapeutic engagement. With funding from the Ohio Department of Emergency Medical Services and an R21 funded by National Institute of Child Health and Human Development (NICHD), Megan Narad, PhD, along with her collaborators Shari Wade, PhD, and Brad Kurowski, MD, MS, in the Division of Rehabilitation Medicine and external consultants from Miami University and The Ohio State University, developed and implemented an AAT intervention for children with ABI in treatment in the inpatient rehabilitation unit at Cincinnati Children's. This intervention incorporated dogs from Cincinnati Children's volunteer dog program into inpatient physical and occupational therapy sessions for patients enrolled in the study. Overall, we learned that it is feasible to integrate AAT into clinical care provided on the inpatient unit, and AAT was very well received by patients, families, and therapists. Further, preliminary data suggested that patients were more engaged in the therapy sessions that included a volunteer dog. Although promising, our initial studies were unable to examine mechanisms of action for this improvement or moderators of treatment response. To address these gaps, Narad and her research team recently received an R01 award from NICHD. The study will use state-of-the-art technology to examine: 1) The effect of AAT on patient engagement in inpatient rehabilitation therapies, 2) Potential mechanisms of action for AAT-associated improvement in patient engagement (i.e., patient mood, physiological distress, pain), and 3) Factors that moderate the effect of AAT on patient engagement in therapy sessions (i.e., anthropomorphism, rapport with animal, and demographic/injury factors).

This project will provide important insights into why pediatric inpatients with ABI benefit from AAT and who is most likely to benefit. We hope to translate our findings to ultimately improve functional outcomes following pediatric brain injury.