Psychiatric medications have been established as an efficacious treatment for pediatric anxiety and depression, with approximately 60% of youth responding to pharmacotherapy alone and over 75% responding to multimodal intervention (March et al., 2004, Walkup et al., 2008). However, recent research has indicated that medication adherence for these conditions is suboptimal, with over 50% of children discontinuing treatment before the period recommended for full therapeutic benefit (Murray et al., 2004;Richardson et al., 2004). This is highly troubling given that these conditions are relatively common and highly debilitating psychiatric conditions, which are associated with substantial functional impairment, reduced quality of life, and suicidality (Langley et al, 2004, Puig-Antich et al., 1993;US Surgeon General, 1999). Moreover, poor adherence may have a widespread effect on treatment effectiveness for these conditions, as an estimated 2.6% of American children receive antidepressant medication in a given year (Olfson &Marcus, 2009). Unfortunately, relatively few empirical data exist about variables that may relate to medication adherence in pediatric anxiety and depression. With this in mind, the goal of the proposed investigation is to examine potential mechanisms of such adherence, with a particular focus on the therapeutic alliance (Shirk &Karver, 2003). Indeed, children and parents who do not feel a bond with the clinician, agree with the clinician on tasks to be performed in treatment, or have unrealistic goals for outcome may be less likely to continue pharmacotherapy in the face of side effects and inconvenience. Adolescent psychiatric outpatients (N=150) as well as their parents and clinicians will be evaluated through self-reports and tracking of pharmacy records to evaluate the role of therapeutic alliance and other behavioral mechanisms of medication adherence. Additionally, this fellowship will provide training to the applicant to prepare him to become an independent, externally funded investigator through a series of personalized activities (including additional coursework, didactic activities, and direct mentoring and consultation). Potential implications of this research are multifaceted. First, future research would need to be focused on developing evidence-based interventions to improve alliance (e.g., communications skills training for the working alliance;Meystre et al., 2012). Second, training curricula of medical personnel (e.g., psychiatry residents) would be indicated to include instruction in developing a therapeutic alliance. Third, identifying these mechanisms could assist in creating an idiographic approach to patient care, where specific interventions to improve medication adherence are employed only for patients who may need them. Thus, the proposed research has wide-ranging implications for future research and the training of medical personnel.

Public Health Relevance

Despite the widespread and disabling nature of pediatric anxiety and depression, little is known regarding reasons for the suboptimal adherence to medications observed in these conditions. In investigating mechanisms underlying medication adherence for these youth (with a particular focus on the patient-provider interaction through the therapeutic alliance), the proposed investigation has wide-ranging implications for future research and the training of future medical personnel.

National Institute of Health (NIH)
National Institute of Mental Health (NIMH)
Predoctoral Individual National Research Service Award (F31)
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Special Emphasis Panel (ZRG1)
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Hill, Lauren D
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University of South Florida
Schools of Arts and Sciences
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De Nadai, Alessandro S; Karver, Marc S; Murphy, Tanya K et al. (2017) Common Factors in Pediatric Psychiatry: A Review of Essential and Adjunctive Mechanisms of Treatment Outcome. J Child Adolesc Psychopharmacol 27:10-18
Skarphedinsson, Gudmundur; De Nadai, Alessandro S; Storch, Eric A et al. (2017) Defining cognitive-behavior therapy response and remission in pediatric OCD: a signal detection analysis of the Children's Yale-Brown Obsessive Compulsive Scale. Eur Child Adolesc Psychiatry 26:47-55
Nadeau, Joshua M; De Nadai, Alessandro S; Viar-Paxton, Megan et al. (2017) Further Psychometric Evaluation of the Child Disgust Scale. Child Psychiatry Hum Dev 48:32-39
Smith, Joseph L; De Nadai, Alessandro S; Storch, Eric A et al. (2016) Correlates of Length of Stay and Boarding in Florida Emergency Departments for Patients With Psychiatric Diagnoses. Psychiatr Serv 67:1169-1174
Storch, Eric A; De Nadai, Alessandro S; Conceição do Rosário, Maria et al. (2015) Defining clinical severity in adults with obsessive-compulsive disorder. Compr Psychiatry 63:30-5
Houghton, David C; Capriotti, Matthew R; De Nadai, Alessandro S et al. (2015) Defining treatment response in trichotillomania: a signal detection analysis. J Anxiety Disord 36:44-51
Storch, Eric A; Lewin, Adam B; Collier, Amanda B et al. (2015) A randomized controlled trial of cognitive-behavioral therapy versus treatment as usual for adolescents with autism spectrum disorders and comorbid anxiety. Depress Anxiety 32:174-81
Johnco, Carly; Salloum, Alison; De Nadai, Alessandro S et al. (2015) Incidence, clinical correlates and treatment effect of rage in anxious children. Psychiatry Res 229:63-9
Johnco, Carly J; De Nadai, Alessandro S; Lewin, Adam B et al. (2015) Defining treatment response and symptom remission for anxiety disorders in pediatric autism spectrum disorders using the Pediatric Anxiety Rating Scale. J Autism Dev Disord 45:3232-42
De Nadai, Alessandro; Nagpal, Prianka S; Piacentini, John et al. (2015) Contemporary models of pediatric obsessive-compulsive disorder: An evaluation with a large clinical sample. Psychiatry Res 229:620-2

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