Prudence Fisher

Prudence W. Fisher – Personal Statement

The primary focus of my career has been on assessment and measurement (including nosology) and on methodology more generally as it relates to youth mental health. Indeed, it is because of my expertise in diagnostic assessment, and, in particular, my work and my association with the Diagnostic Interview Schedule for Children (DISC),that I have received the most recognition by the field at large. I am widely acknowledged as being a member of the the small community of ‘experts” in youth diagnostic assessment and measurement: collaborating on studies and consulting on measures and measurement issues, participating on several “expert panels” for government agencies, serving as a reviewer for many journals (especially around measurement/assessment studies), and co-authoring papers and chapters in psychiatry textbooks on youth psychiatric assessments. I’ve coauthored many of the most widely used instruments in the field – the Columbia Suicide Severity Rating Scale, (CSSRS), the Children’s Global Assessment Scale (CGAS), The Columbia Impairment Scale, and, most notably, the DISC, as well as other measures (most recently the Covid-19 Experiences (“COVEX”), included on the PhenX website, which is being updated as the pandemic has continued).  Because of my experience with assessment and encyclopedic knowledge of psychiatric diagnostic criteria, I was invited to participate as an advisor/consultant for five DSM-5 workgroups and committees and to consult with The WHO ICD-11 group  on text for “developmental presentations” that is included in the ICD-11 Diagnostic Guidelines in the chapter on mental disorders.. In the last several years NonVerbal Learning Disorder (defining it) has been a major area of attention. A second, now minor, focus continues to be youth suicide. Finally, a completely new focus has recently emerged: Equine assisted Therapy (EAT).

Assessment, Measurement, Nosology: My interest in assessment was sparked early on, soon after I joined the Child Psychiatry Division at Columbia/New York State Psychiatric Institute as a research assistant for David Shaffer, M.D., a renowned expert in these areas. An early project aimed at implementing standardized assessment measures into the busy outpatient child psychiatry clinic. I noticed that parents sometimes did not understand the questions/items or instructions as intended, even when read to them and that the clinical staff viewed the assessments as adding to their burden and of little use. Surely there was lots of room for improvement-- in the measures themselves and how best to implement them. I also had the opportunity to work on formulating and testing the CGAS, still widely used throughout the world for which I am still the primary contact (and developed a protocol for undertaking (and verifying) non-English translations, of which there are over 20).

My work on Dr. Shaffer’s and Dr. Madelyn Gould’s “psychological autopsy” study of adolescent suicide was a formative educational experience. Together, Dr. Shaffer, Dr. Paul Trautman (a child psychiatrist) and I put together the comprehensive symptom/diagnostic interview and selected/wrote other measures. I piloted the whole protocol with parents and youth and then continued as an interviewer. Based on early interviews, we revised some sections and completely changed the order of the measures to improve the “flow;” the importance of piloting and considering protocol flow are things I always stress when I consult on or become involved with a study. Each “case” was thoroughly discussed in team meetings (including how to think about symptoms) which was an invaluable for my learning how to think about clinical probes, consider alternative ways symptoms might present, and appreciate the importance of research clinician training and quality control procedures when using semi-structured clinical interviews. 

While I’ve maintained my interest in youth suicide – I am a grant reviewer for American Foundation for Suicide Prevention, a co-author on the CSSRS, on the Editorial Board for Archives of Suicide Research, regularly consult and collaborate with investigators who are examining suicide in their research,  and was recently an invited presenter at an NIMH conference on preteen suicide – my focus shifted to become more squarely placed on measurement and diagnostic assessment as I became fixated on the importance of careful measurement (in research the quality of your data is everything!).  My work on the Diagnostic Interview Schedule for Children (DISC) marks the beginning of this shift.  

DISC:  Unlike clinician administered diagnostic interviews, the DISC is fully structured, respondent-based (questions are read to the respondent exactly as written) specifically designed for use in large scale epidemiologic studies to assess youth mental health diagnoses. As documented on my CV, my work with the DISC has been extensive – writing questions, participating in psychometric studies, preparing manuals, training material and training, writing scoring algorithms, advising/consulting/ collaborating with users) resulting in numerous publications, including writing the ‘reference” article1 for the interview.  The DISC-P is for parents (or caretakers) to complete about youths’ symptoms and behaviors, while the DISC-Y, is administered directly to the youth, which necessitates that the language be kept simple. I’ve particularly enjoyed writing/editing questions/probes that are efficient but clear and figuring out how to put difficult concepts into simple language (usually by breaking them down into several simple questions). Moreover, I was good at it.  

Since 1985, the DISC has been housed at Columbia/NYSPI, and from 2010 onwards, under my sole direction. Development of the DISC (DISC-R, DISC-2, DISC-IV and now, DISC-5) has always been an iterative process involving input from expert advisors and psychometric testing. Versions and modules of the DISC-IV, keyed to DSM-IV, found wide use in the research settings (over 300 DHHS funded studies and many funded by other sources), as well as in juvenile justice and community settings and the field has been waiting for the new version, updated to correspond to DSM-5. With partial funding from the CDC, I recently completed preparing the DISC-5 (DSM-5), again with input from experts, and it is anticipated that the DISC-5 will find wide use as well. The DISC-5 assesses over 30 diagnoses, grouped into 26 “stand-alone” modules (with over ~3500 questions, per informant, a branching structure means many fewer are asked); typically a subset of the modules are used. TeleSage, Inc, is computerizing the DISC-5 through an SBIR from CDC, on which I am a consultant and oversee testing at a community clinic. I coauthored a paper on the performance of the DISC-5 Tic and ADHD modules that is undergoing CDC review before submission (a poster was presented at the AACAPmeeting). Currently I am collaborating on two international studies in which modules from the DISC-5 are being used, and over the years have collaborated on many other studies using the DISC. 

DSM-5:  As an advisor for the DSM-5, I observed and participated in discussions and heated debates about diagnostic criteria, potential changes and methodological issues in the extant and planned research.  Participation in discussions with “thought leaders” on diagnosis, assessment, disability, measures, was fascinating and exhausting. I prepared proposals for inclusion of NonSuicidal Self Injury and Suicide Behavior Disorder, (both approved as Conditions for Further Study), and participated in the discussions about and reviewed the final proposals for Disruptive Mood Dysregulation Disorder (DMDD) and changes to criteria for Intermittent Explosive Disorder (approved for the main book). In addition, I undertook analyses that informed DSM decisions regarding ADHD and youth depression and led one of the child field trials. These experiences gave me a sophisticated understanding of the diagnostic system that so many use, which has been useful for the course I teach at the Columbia School f Social Work and for my supervision of trainees in the CHONY evaluation service.

NonVerbal Learning Disability (NVLD):  My DSM-5 experience was largely responsible for my involvement with “the NVLD Project” (www.nvld.org), which has at a main goal to have NVLD included as a DSM diagnosis. After outlining what I perceived to be necessary steps to have a successful proposal-  a comprehensive research review, a consensus DSM style criterion set (which could obtain buy in from the field), some evidence for reliability, validity and clinical usefulness. I was asked to lead the project; At the time, I was unsure what NVLD even was and whether it was a discrete condition, but I was intrigued by the opportunity to find out. My first step was to see what the research revealed about how to define NVLD and what  support there was for it as a standalone diagnosis; my comprehensive review of the extant literature was the first paper on NVLD ever published in the major child psychiatry journal2. Applying a similar methodology to that used for DSM-5, I formed a “working group” of recognized “NVLD experts” to participate in arriving at a consensus definition for NVLD. and hosted two focused in-person consensus conferences attended by these experts and experts in neurodevelopmental and child psychiatric diagnoses; an editor for DSM; and others. (I also helped the NVLD Project identify and recruit renowned experts in child psychopathology for a scientific council/advisory board) In addition, I held several smaller meetings with the NVLD experts, scientific council members and with local experts in child diagnosis. To obtain data that could be useful for the proposal, including “stakeholder feedback” on a new name for the disorder, I wrote and launched two on-line surveys (one for adults diagnosed with NVLD and one for parents of children with NVLD).  Final consensus on a DSM style criterion set was reached in early 2022 and a proposal for the DSM committee, which summarized extant research support, including data from the surveys,  was submitted in May 2022. Current and future plans on this initiative include completing and writing up analyses from the survey data (including overseeing dissertation using data from survey), launching an on-line clinician reliability “vignette”  study (employ similar methodology to that used in ICD field trials (in progress), and developing a screening instrument for NVLD, using data from the earlier surveys and then testing its sensitivity and specificity.

Equine Assisted Therapy – the Man O’ War Project  (mowproject.org) The MOW Project came about in response to an inquiry from philanthropist (Earle I Mack) about whether retired racehorses could be used help veterans with mental health problems. Knowing nothing about Equine Assisted Therapy (EAT),but having a fondness for horses and being aware of the need for alternative treatment modalities that offer opportunities for individuals who either do not benefit from traditional modalities or avoid them, I was intrigued. Given EM’s initial concern for veterans, I asked Yuval Neria, Ph.D. the head of the Military Family Wellness Center in our department, to work with me and the MOW Project  was born. Our first step was to learn everything we could about EAT – visiting programs, conducting internet searches, evaluating the research literature (which was abysmal), reading popular press and books, attending the annual Equine Assisted Growth and Learning Association (EAGALA) conference, all of which revealed that there was no standard method or any existing well specified manual for how to deliver EAT for any mental health condition, although EAT was widely used. Based on what we learned and with EAT providers and faculty experienced with developing treatment manuals, we developed an 8 session, group EAT protocol for veterans with PTSD, piloted it with two groups of veterans,3 revised it based on the pilot, and then tested it in a large open trial 4 (introducing before/after MRI, later in the trial5) – treatment sessions were held at an equestrian center in Leonia, NJ. .We prepared a well-specified treatment manual6 -- the first of its kind in the EAT field for any mental health condition-- and received funding from the Bob Woodruff Foundation, in collaboration with PATH International,  to develop an initial training program (which we continue to work on) and we have trained other groups in the protocol. Recently we received funding that allows us to offer the Man O’ War Protocol as a treatment option offered by Dr. Neria’s military center. The MOW Project has received a great deal of media attention and a documentary on the program is being planned. With few exceptions (i.e., the Woodruff grant, a small contract with an Israeli collaboration) our work in the area of EAT has relied on funding from Foundations and gifts and we anticipate that we continue to be successful at raising funds. I have also received funding to  examine whether the MOW protocol might be adapted for use with anxious adolescents and am  currently recruiting participants for sessions that will take place at a facility in Brewster NY. As for the veterans studies, there  will be two pilot groups to identify where the protocol/manual should be adapted/revised before undertaking a  larger trial (for which I will seek funding).

Teaching and mentorship:  Since 2009, I have taught a course on child psychopathology (including the DSM diagnoses) at the Columbia School of Social work (typically twice per year) I am a “career mentor” to six junior faculty (social workers) in the Child and Adolescent Psychiatry area.  Each year, I invite one or more of them to present at the class I teach on child psychopathology at Columbia. School of Social Work and I am working with two recent graduates on papers they plan to publish that expand on the paper they wrote as their final assignments.  Since 2011, I have been faculty on the Whitaker Scholar Program in Developmental Neuropsychiatry, focusing on measurement and methodology, and for the past two years, have been a senior faculty advisor/consultant, focusing on a assessment and methodology, for Dr.Cristiane Duarte’s and Dr.Yuval Neria’s labs, in each instance attending weekly “paper group” meetings, where work in progress and manuscripts are reviewed.  I also regularly give “in-service” presentation talks on assessment to clinical staff at Columbia/NYSPI.  Until 2021, I was the course director for “research selective/scholarly activity’ for 2nd year child psychiatric residents. Finally, my research assistants and volunteers routinely apply and get accepted to graduate school in psychology and related field. 

REFERENCES:

1. Shaffer, D., Fisher, P., Lucas, C.P., Dulcan, M.K., & Schwab-Stone, M.E. (2000). NIMH Diagnostic Interview Schedule for Children, Version IV (NIMH DISC-IV): description, differences from previous versions, and reliability of some common diagnoses. Journal of the American Academy of Child and Adolescent Psychiatry, 39(1), 28–38. [DOI: 10.1097/00004583-200001000-00014; PMID: 10638065]
2. Fisher, P.W., Reyes-Portillo, J.A., Litwin, H.D. & Riddle M.. (2022)  Nonverbal Learning Disability:  A systematic review.  American Academy of Child and Adolescent Psychiatry, 61(2);  159-186  [PMID:  33892110,  DOI: 10.1016/j.jaac.2021.04.003. Epub 2021 Apr 20]
3. Arnon, S.*, Fisher, P.W.*, Pickover, A*., Lowell, A., Turner, J.B., Hamilton, J.F., Hamilton, A., Markowitz, J.C., & Neria, Y.  (2020)   Equine assisted therapy for PTSD:  Treatment development and pilot findings among military personnel.  Military Medicine, Feb 8. pii: usz444.  [DOI: 10.1093/milmed/usz444. [Epub ahead of print] PMID: 32034416] *First authors listed alphabetically
4. Fisher, P.W.*. Lazarov, A.*, Lowell, A., Arnon, S., Turner, J.B., Bergman, M. Ryba, M,. Such, S., Morahasy, C., Zhu, X., Suarez-Jimenez, B., Markowitz, J.C., & Neria, Y. (2021)  Equine-Assisted Therapy for Posttraumatic Stress Disorder:  An open trial. Journal of Clinical Psychiatry 82 (5): PMID:  34464523. *First authors listed alphabetically
5. Zhu, X., Suarez-Jimenez, B., Silcha-Mano, S., Lazarov, A., Arnon, S., Lowell, A., Bergman, M., Ryba, M., Hamilton, A.J., Hamilton, J.F., Turner, J.B., Markowitz, J.C., Fisher, P.W., & Neria, Y., (2021)   Neural changes following equine-assisted therapy of posttraumatic stress disorder:  A longitudinal multimodal imaging study.   Human Brain Mapping, 42(6) 1930-1939

[DOI: 10.1002/hbm.25360. Epub 2021 Feb 5. PMID: 33547694]

Fisher, P.W., Lowell, A., Markowitz, J.C., & Neria, YEquine Assisted Therapy for Posttraumatic Stress Disorder (ETA-PTSD) Treatment Manual.  New York, New York:  The Man O’War Project:   Department of Psychiatry, Columbia University Irving Medical Center/New York State Psychiatric Institute.  https://mowprouect.org,  © 2021 Research Foundation for Mental Hygiene, Inc.