< JCCAP FDF < 2019

Most of the information below is up to date, however, some sections are placeholders copied from the 2018 Forum page, which can be found here. Still to be updated- editor's corner description, keynote presenter descriptions (breakout leaders are updated), materials, and notes.

Day 2 is our science day! Leading figures in our field give addresses based on recent articles published in JCCAP. We hope you find inspiration from these addresses, and fuel for new research ideas. And we want you to put these ideas into action. So following each address, we encourage you to attend one of the breakout discussions. Led by experts in areas germane to the addresses, these breakout discussions are designed to help you find resources you need to pursue new research ideas, from funding agencies receptive to your work, to publicly available datasets to carry out pilot research.

Day 2 also includes our Editor's Corner, which is [DESCRIPTION HERE]

Block I: Future Directions Address 1: "Future Directions in Adversity and Mental Health" (9:10 am-10:10 am)

Dr. Kate McLaughlin, Ph.D.

Assistant Professor of Psychology at Harvard University, and the principle investigator of the Stress and Developmental Lab. With her joint Ph.D. in Clinical Psychology and Chronic Disease Epidemiology from Yale University she focuses her research on how environmental experience influences brain and behavioral development in children and adolescents.

Description

In Dr. Katie McLaughlin's Neurodevelopmental Mechanisms Linking Childhood Adversity with Psychopathology Across the Life-Course address, she discusses research on the links between adverse early experiences and mental health, with a particular emphasis on the developmental mechanisms linking childhood adversity to the onset of psychopathology.

Learning Objective

Highlight future directions for research on links between childhood adversity and youth mental health.

Address 1 Materials
Notes
Click "Expand" for notes
  • Childhood Adversity examples

    • Example 1

      • Father has a drinking problem

      • Explosive rage that is unpredictable

      • Hits children and their mother when angry

      • Growing up in an environment with an uncontrollable and unpredictable threat

    • Example 2

      • Single mother who is depressed

      • (graphic citation)[3] 

  • 12 Childhood Adversities: Parent death, Divorce, parent loss, parent psychopathology, parent substance abuse, parent criminality, family violence, poverty, emotional abuse, neglect sexual abuse, physical abuse

    • Almost half of children have experienced these

    • Relationship with the child’s mental health problems

    • As the number of adversities increases the risk for psychopathology increases (Five times more likely)

      •  (graphic citation)[4] 

        • Nearly one quarter of psychopathology that develops into adulthood  can be explained by exposure to adversity in childhood 

  • Neurodevelopmental Mechanisms

    • Physical abuse, neglect, domestic violence --> psychopathology

    • Sexual abuse, domestic violence, neglect, other violence, physical
    • Literature used to be separate from each other, problematic because these experiences don not come in isolation

      • On average children exposed to one form of adversity are more likely to experience at least 3 other forms of adversity

      • Recognition of this issue, has led to a shift called the cumulative risk approach (ACES)

    • ACES Approach-The number of adversities, equivalent to social and cognitive deprivations

      • Number of adversities predicts health outcomes

      • Number of adversities predicts neurodevelopmental mechanism

      • There is a problem with this approach- oversimplifies boundaries of environmental experiences

    • Assumes environment influences psychopathology the same way

      • (graphic citation)[5]
    • Four underlying mechanisms (differing approach from ACES)

    • Experiences of threat: harm or threat of harm

    • Experiences of deprivation: absence of input brain is expecting for normal development

    • Threat exposure

    • Harm or threat of harm (e.g., violence exposure, physical and sexual abuse)

  • Threat exposure influences neural systems involved in fear learning and salience processing including amygdala, hippocampus, and medial PFC [5]

  • Neurodevelopmental Mechanisms model figure of the current opinion in psychology [6]

  • Information processing biases [7] [8] 


2005

  • Children exposed to trauma exhibit info processes that facilitate the rapid identification of threat:

    • Hostile attribution biases

    • When presented with ambiguous situations/faces, more likely to perceive as threatening

      • Attention bias

      • Attention more captured by threat- related information in environment

  • Childhood Adversity changes the way that children process their environment and cues

    • Strong predictors of psychopathology

    • Eight kids exposed to violence have stronger emotional and neurobiological responses to threats

      • A Show children emotional pictures in scanner
 20
        • Look negative > look neutral

        • Look positive > look neutral

      • The same area of the brain like the Amygdala is activated regardless of negative or positive affect provoking picture because they are responding to salient stimuli

  • Trauma and Amygdala Reactivity

    • Children exposed to violence, have higher reactivity in the amygdala when exposed to negative images

    • Negative images more salient

    • Many labs have found this increased reactivity in the amygdala (Hein & Monk, 2016)

  • Trauma and Neural Response to Threat Cues 

    • (Jenness et al., under review)

    • Other differences emerge in brain when kids process threat related cues

    • Activation in regions involved in action preparation (preparing to flee)

    • Reductions in activity in PFC (including the DLPC AND dACC)

    • Regions recruited when children actively regulating emotional responses using something like cognitive appraisal

  • Boston Marathon Bombing

    • How do patterns of brain response to emotional cues have relevance to emergence of psychopathology?

    • Direct exposure limited to those in Boston, yet atmosphere in Boston was that of heightened threat (closed the entire city)

      • Research shows that exposure to media coverage of terrorist attacks can lead to the development of  PTSD symptoms in children

    • Can the patterns of brain response predict children’s PTSD?

      • Kids with greater amygdala response were more likely to develop symptoms of PTSD related to the Boston marathon bombing

      • Even after controlling for prior trauma

      • Associated with increased risk for anxiety and other psychopathology [5]
    • Four underlying mechanisms (differing approach from ACES)


  • General psychopathology (p) factor 

  • (graphic citation)
[9][10]
    • Two factors: internalizing and externalizing problems

    • P explains correlations across externalizing and internalizing dimensions

      • Transdiagnostic psychopathology risk

      • Reductions in PFC mediated Trauma and p factor relationship

  • Emotional Learning

    • Fear learning and extinction

      • (graphic citation)[11]
      • Kids presented with blue and yellow bells

        • One associated with aversive noise

        • How children learn to acquire fear 

  • Trauma and Fear Learning 

    • (graphic citation) [12]
    • Pattern is different for those who have experienced trauma

      • Kids do not discriminate between threat and safety

      • Exhibiting fear to broader set of stimuli than kids who have never experienced trauma

      • Neural correlates of fear learning (tried to replicate above study)

        • (DeCross et al, in prep)

    • Brain areas that respond to threat cues: ACC, aINS, Amygdala

      • Strong at first but slowly start to habituate after time
        • Respond to safety cue: hippocampus, VVS

        • Increase response over time

    • Similar data to above study

      • Amygdala, hippocampus over learning period

        • Kids without trauma at beginning of learning, discrimination between threat and safety cue, habituation

        • Trauma: worse discrimination between threat and safety, no habituation

          • Failure to discriminate between threat and safety overall

          • Less cross talk between hippocampus and amygdala in kids with trauma

      • Fear Learning and Psychopathology 

        • Poor discrimination over time is associated with increases in Depression, Anxiety, externalizing, PTSD

    • Information Processing
      • (graphic citation)[13] [14]
      • Patterns specific to threat

      • Attention biases to threat

    • Severe deprivation (Romanian orphanages) has the same pattern as threat exposure

      • No difference in emotional reactivity 

  • Fear Learning

    • Children who grow up with high deprivation resembles the pattern exhibited by the control subjects

    • * No effect of deprivation 

  • Deprivation

    • Language exposure by SES [15]
    • Kids growing up in high SES families have heard 30 million more words than children growing up in low income households 

    • The brain requires input from the environment to develop normally

      • (graphic citation) [16]
    • If expected inputs are absent, the connections that process that information are eliminated

      • Connections between neurons that are not being utilized are eliminated 

        • Deprivation in social and cognitive inputs may hijack the developmental process of synaptic pruning 

      • Grey Matter development
        • Certain degree of cortical thinning during childhood reflects pruning, increased efficiency of neural processes
 [17]
    • Sensory deprivation
      • Depriving the brain of visual stimulation leads to a reduction in the number of synapses developed 
[18]
      • Social and Cognitive Deprivation
        • (graphic citation) [19]

        • Increase in Dendrites vs. Decrease in Dendrites

        • Bucharest Early Intervention Project [20]
  • Institutionalization as Deprivation

    • Isolation 

      • Little interaction with peers or adults

      • No selective attachments

    • Lack of psychological investment by caregivers

      • High child/caregiver ratio

      • Rotating shifts

    • Low cognitive complexity

  • Cortical Grey Matter
    • (graphic citation) [21] [22]
    • Early deprived setting children v. typically developing

      • Less brain matter development

      • Thinner cortical gray matter (language processing, attention, working memory, DSPFC)

  • Institutionalization and ADHD

    • Institutionalized 5X as high at risk for ADHD than typically developing

    • Can explain ADHD with early deprivation

  • Socioeconomic Status (SES) 

    • More than 1 in 5 children in the U.S. lives in a family below the poverty line

    • Replicated findings among those in poverty in the US

    • Low income and parent education associated with deprivation

      • Lower access to complex lang

      • Access to food and shelter

        • Enriching experiences

  • SES and Cortical Thickness
    • (graphic citation) [23]
    • Lower SES is associated with lower cortical thickness
      • Similar patterns to those in Romanian orphanages

  • Executive Functioning
    • (graphic citation) [24]
    • Deprivation predict reductions in executive functioning

      • Those in poverty perform worse

      • Exposure to trauma has no effect

  • Frontoparietal Network

  • Translating Mechanisms into Intervention [25]
    • Proposed intervention strategies

      • ABMT

      • Relaxation, cognitive reappraisal

      • Behavioral Activation


Questions
 from Audience

  • Speak about differences in findings between your lab and another lab

    • Not too different

    • They found no differences in amygdala, more connectivity in orphanage children

    • We found more connectivity in those with trauma

  • Have you looked at children exposed to trauma and deprivation? Would this change interventions?

    • These experiences often co-occurring

    • Approach in these studies- measure all experiences of children and control for other experiences in the model like poverty

      • Must put both trauma and deprivation in the model

  • Do you have data on those who overcome adverse beginnings look like in comparison to those who do not? (resilience)

    • This is a great future direction- finding out buffers to psychopathology

      • Characteristics of child- age, sex

      • Highly sensitive to reward are less likely to develop depression after experiencing adversity

    • Can target with interventions such as behavioral activation

      • Not all kids exposed to adversity develop psychopathology



Block I Break Out Discussions for Future Directions Address 1 (10:15 am-11:00 am)

Description

Dr. Matthew Lerner and Dr. Jessica Fish will serve as Breakout Discussion Leaders following Dr. Kate McLaughlin’s Future Directions Address (“Future Directions in Evidence-Based Youth Psychotherapy in the Mental Health Ecosystem”)

Dr. Matthew Lerner, Ph.D.

Dr. Matthew Lerner is an Associate Professor of Psychology, Psychiatry, & Pediatrics in the Psychology Department at Stony Brook University, where he directs the Stony Brook Social Competence and Treatment Lab. His research focuses on understanding mechanisms of and developing interventions for social and emotional functioning (in particular peer relations) among children and adolescents with autism spectrum disorders and ADHD. Dr. Lerner has received over $11 million in funding for his work from the National Institute of Mental Health, Brain & Behavior Research Foundation, American Psychological Foundation, Simons Foundation, Alan Alda Fund for Communication, Arts Connection, and Pershing Charitable Trust.

Notes
Click "Expand" for notes

Transdiagnostic

  • Encompassing a wide range of people, ideas, and diagnoses

How access to nutrition impacts brain development

  • How do you operationalize these ideas (threat, etc.)?
    • There’s no real way to know what people have experienced early on or if what they’re reporting is 100% accurate
    • Open science helps by pre-registering what we think encompasses these variables and allows up to explore them and apply them to different demographics/variables
      • Multiple operations within each variable
  • All of these measures are imperfect and correlated
    • For example: you may measure the amount of books in a home, but they may go to the library every day

Prompt: McLaughlin begins with the idea that these different forms of adversity are not distinct, but yet there is a methodological necessity of reducing things down to common mechanisms and identify mechanisms that cut across. How do you think about that balance? The balance between the fact that any factors between people are going to covary with each other.

  • Q1: There’s a pull between the most valid design and the most generalizable/applicable design
    • She pushed for a population of all children under 18, while the dissertation committee pushed for early childhood
    • To know what they mechanisms are, you have to restrict things such as your sample to a smaller pool, but you also want to be able to apply your findings to what exists within the real world
  • Q2: Most kids have comorbidities - do you just group all of them together or should you administer different interventions on different schedules?
    • A1: No need to separate threat and intervention - the more of both, the worse it gets. The skills and interventions that you would use would be more based on the context.
    • A2: Be nice if clinicians/researchers could place participants/kids into specific groups before testing
    • A3: It’s be nice if you could divide up a person’s adversity/risk in order to best treat them
      • ACE scores
      • Do you then deliver an intervention that is proportionate to the threat that they face
      • When pressed about where knowing about mechanisms and all the research we have is leading, the NIMH will say that it does lead us to think about how all of this information informs our interventions
    • Q3: Interested in seeing how the number of phone apps have increased to help with panic disorders and therapy. Looking forward to seeing how more resources are available
      • Dissemination and accessibility of psychological science
  • Q4: Thinking about how we have such imperfect measures due to retrospective reports, self-report biases - how do we fix this?
    • The original idea of RDoC was to move towards comprehensive assessment batteries which, on the one hand, is great to have reliable and valid measures but we know that that’s unlikely and breeds a risk of turning science into contract work.
  • Q5: Going back to access to care, you see many children who have experienced trauma come into Children’s Hospital. Often times you get to have 10 sessions of treatment with a family, highlighting the importance of a modular approach (using the MATCH protocol). This type of model isn’t perfect but in terms of providing treatment for a part of the DC population who doesn’t receive mental health treatment, it’s interesting to think about.
    • It’s clear that on one hand access is an issue, but on the other hand, some are thinking about innovations and it’s neat to hear those two ideas starting to merge. How do we target, scale and disseminate?
  • Q6: Thinking about how in some instances the stress response of these children experiencing adversity are adaptive, does it make sense to intervene if they’re in harmful situations?
    • A1: What you said is important, but if it’s causing that much stress and ruining their lives, then something should be done. Having a heightened response to threat is important but if it’s detracting from life then it should be addressed
    • A2: It reminds her of the saying that the world is unsafe, and these children do live in an unsafe world so it’s not necessarily a maladaptive thought
    • A3: Important to look at increasing sensitivity to the appropriate situations to improve capability to adapt
  • Q7: How plastic are fear and adversity mechanisms?
    • In practicing and doing CBT you can see that you can reduce attribution biases, and it’s interesting to think about if this would breed changes in the brain
    • At what point is it still plastic and easy to change?
    • The brain is very plastic and any behavior is changing the brain. There may be periods in adolescence that may allow for interventions and restructuring
      • Adolescence presents a second opportunity for plasticity, therefore it’s not too late to engage plasticity
        • This could have interesting implications for adoption, since there’s a second chance for plasticity they could have a great opening to bring them into a safe environment
  • Q8: Are there interventions in the US for middle school students for general mental health development?
    • A1: There are models that can be implemented in schools, but they aren’t necessarily always done.

This includes things such as having teachers using reinforces in the classroom, building classroom support It’s built between three tiers which go from a broad group range to the individual level

    • A2: At an individual level we usually refer to a 504C plan or an IEP but a lot of different districts approach these issues in completely different ways
  • Q9: In cases where there are children who deal with adversity at home such as violent trauma, sometimes the law causes parents to tell the parents who are actually the perpetrators. The policy behind this needs to be worked on where the children can say “I need help” without getting in trouble for it
    • A1: Through school-based intervention research and primary care, whenever a child is experiencing or witnessing abuse that’s more than open hand on the bottom, we are mandated to report it to CPS. Often times the family is right there telling you this, and it’s a tricky line to walk saying “thank you for disclosing this, we understand that growing up you experienced this and are now doing it to your child, but we’re required by law to report this.” We try to keep the families involved in the phone call. Some understand, and some blow up in your face which brings up another issue where you may really want CPS to follow-up but they’re too swamped, so you know the child is going home to an unsafe environment. There needs to be improvements from all angles, but in primary care you see the importance of working through it with the family.
    • A2: Zero tolerance policies feed a cycle of sending students home on suspension and placing them in unsafe environments. Using in-school suspension could be a great place to intervene with the family.

Wrap-Up: Protective factors that moderate the relationship between risk and mechanism and mechanism to outcome -

  • A1: Studying resilience and mental health of abandoned children in China
    • Not every kid left behind develops
    • Hope for the future may be a big protective factor
    • Your belief system about adversity may also be a big factor (for example, “what doesn’t kill me makes me stronger”)
  • A2: How do we instill hope and optimism?
    • Just having one caring adult in their lives can help
Dr. Jessica Fish, Ph.D.

Dr. Jessica Fish is a human development and family science scholar whose research focuses on the health and well-being of sexual and gender minorities (i.e., lesbian/gay, bisexual, and transgender people) and their families. Broadly, Dr. Fish studies the sociocultural and interpersonal factors that shape the development and health of sexual and gender minority youth and adults. Her overarching goal is to identify modifiable factors that contribute to sexual and gender minority health disparities in order to inform developmentally-sensitive policies, programs, and prevention strategies that promote the health of sexual and gender minority people across the life course.

Notes
Click "Expand" for notes
  • Jessica Fish studies developmental vulnerabilities of LGBT youth

  • Prompt: How does Dr. McLaughlin’s work relate to or inform your own work?

    • How does it support your work or challenge it?

    • How does it inform new perspectives of your work?

      • Answers: How adversity happens on multiple levels, makes adversity definition flexible

      • How multiple adversities could impact outcomes

      • Controlling for income in studies, could be important to start including these variables

      • Clinician perspective of diagnosing individuals, eliminate biases of gender/race?

        • Importance of representation in labs and therapists: interviewer with similar demographics and lived experiences

        • Balancing real threats with adversity- not invalidating a trans individual’s experience (social anxiety v transphobia) 

          • Multiplicative effect of developmental factors and societal factors

      • Identifying mechanisms is not possible in real life

  • Prompt: the process in which she does her research- she has created a clean and clear model in a methodical way (good strategy for rigorous research)

  • Question: Does the strength of adversity perception depend on the environment? How does this impact treatment? (you cannot treat society)

  • The epigenetic impact of deprivation and trauma is permanent after the critical period

    • Importance of prevention

      • How do you do this when everyone’s experiences of adversity are different?

      • Examples of Head Start and Wick

      • How do you disrupt intergenerational effects?

  • Prompt: any other professional development questions?

    • Intimidating nature of creating a model- how do you go about doing this?

      • Advice: Pulling literature starting with names you know, using lucidchart.com, Xmind (mind-mapping software), interdisciplinary collaboration, using references from other papers, branching outside of clinical psychology (read diverse literature), understand why you believe your work is important- the application and impact of your work and what is your core ground truth you are going deep on but pull in other experts to add breadth to your work, find existing models and fill the gaps (ex. Minority stress model)

Block II Future Directions Address 2: "Future Directions in Mediators of Treatment" (11:00 am - 12:00 pm)

Dr. Philip Kendall, Ph.D.

Associate Professor of Sociology at Columbia University. His research broadly focuses on examining the health consequences of structural forms of stigma and on identifying biopsychosocial mechanisms linking stigma and health. Dr. Hatzenbuehler has published over 100 peer-reviewed articles and book chapters, and his research has been published in several leading journals, including American Psychologist, Psychological Bulletin, American Journal of Public Health, and JAMA Pediatrics. His work has been widely covered in the media, including interviews on NPR and MSNBC, and it has been cited in amicus curiae briefs for court cases on status-based discrimination.

Description

How do psychological therapies work? How can we enhance treatment to improve outcomes? Questions of mediation lie at the heart of these inquiries. In this address, Dr. Philip Kendall delineates some of the issues confronting tests of treatment mediation in youth mental health and suggests future directions in research on addressing these issues.

Learning Objective

Highlight future directions for research on mediators of the outcomes of youth mental health treatments.

Address 2 Materials
Notes
Click "Expand" for notes

Overview: one of the dilemmas in our field is the misuse of mediators and moderators, it’s up to the future psychologists to get it right

Have you heard this question: “a goal of the evaluation of psychological treatments has been to answer the question posed over 50 years (Kiesler, 1966; Paul, 1967) and often restated contemporary times: “What treatment provided by whom is the most effective for individuals with what specific problem?”

  • Don Kiesler was the first person to set out and study what type of treatment works for what type of person in what setting
  • While Don Kiesler was Rogarian, Gordon Paul was more behavioral
  • Kiesler was right: There is no one treatment that works most effectively for everyone, so we need to do something to figure out what treatment works for who and in what setting
    • For years, psychotherapy meant a traditional setting where you lay on a couch, and in some settings it still looks that way. If you try to use psychological treatment instead of psychotherapy, you’ll avoid the excess baggage.

With regard to treatment outcomes

  • A predictor of an individual's response to treatment is a variable that is associated with a defined treatment outcome, but has no interaction with treatment condition
    • For example, if treatment A works better for boys than girls, that’s a predictor not a moderator
    • These variables identify factors that are associated with treatment outcome and can be viewed as correlates and risk factors of the outcome
  • A moderator is a variable that informs us as to for whom and or under what circumstances a treatment works
    • Moderators are baseline factors that interact with treatment conditions to produce differential outcomes
    • Moderator variables must be assessed prior to randomization and must not be correlated with treatment conditions
    • Ex: If you take one treatment that involves CBT and the other does not, and then take into account individual CBT where the parents are in the session and the parents are not
      • The moderator of ASD: When it is low, the children do better in the individual treatment, and when it is high they do better in the family session
  • “Mediator” is often misused. It is a variable that tells you why there is a relationship between an independent variable and dependent variables.
    • Mediation models reveal that there is no direct relationship between an independent variable and the dependent variable. Rather, the relationship is established through the third party, mediator variable.
    • There are few mediation studies in adolescent and child psychology, and even in the case they exist the methodology may be flawed
      • When we study mediators we take one or two variables that might exist and run the analyses
      • If you find support it’s not a mediator, it’s a partial mediator
        • If you found one or two you can’t ignore the other 18 because you never evaluated them
      • Ex: Looking at changes in anxious self talk
        • How do you measure that? Kids won’t just tell you their thoughts. They created a questionnaire method that said everyone has things that pop into their heads, some kids have these things pop into their heads - how often do you have these things pop into your head?
          • Used emotional set-ups to see all the types of thoughts kids would write down
          • Then differentiated which children had depression and anxiety and how their thoughts differentiated
        • What they found when looking at mediators was that anxious-self talk was a mediator, but they didn’t have temporal precedence
      • Ex: Studied potential mediators of outcome with an adequate design but still didn’t have temporal precedence
        • Still, anxious self-talk was found as a mediator, but without full temporal precedence
      • Ex: When looking at loneliness, change in loneliness was found as a mediator but still: there was no temporal precedence
      • Ex: with temporal precedence: did not have a control group so while they could make the claim of a mediator, they had sources of poor internal validity [
    • CAMS: CBT (Coping Cat), medication (Zoloft) based treatment (Sertraline) vs. placebo
      • Attempted to look at coping and negative self-talk as a potential mediator
      • Found that an increase in coping was a mediator of improvement
    • Temporal precedence is important, but so it looking at multiple factors that may be mediating variables
      • One study found that physical symptoms mediate change but only in a medication based condition

A few caveats

  • There is a lot of exciting work going on in this area, so the analyses discussed today are just a sampling of new ideas
  • Not everything discussed examines mediation, but are important techniques nonetheless for those interested in research questions around mediation
  • Most of these analyses require high frequency data collection methods such as Ecological Momentary Assessment techniques (EMA)

Limitations of prior group-based approaches

  • Assumption that change over time is equivalent across participants
    • In practice, timing and pattern of change varies across individuals
      • Example from CAMS: After running analyses, they found that the medication affect was greatest during the initial period of taking the pills whereas the CBT affect was strongest during the period of exposure (which was later on)

A modern paradigm for examining change

  • Dynamical systems approaches examine change ideographically
    • Some terms:
      • Attractors: stable patterns of affect, behavior or cognition
      • Phase change
  • Why dynamical systems?
    • Therapy is designed to change stable and maladaptive
  • Examples:
    • Carper and colleagues are examining changes in affective variability over the course of (a) CBT and (b) client-centered therapy for youth anxiety using dynamical systems
      • The idea is to see if there’s changes in the EMA data that have to do with outcome
  • Another version of this approach looks at temporal relationships between mediators and outcomes
    • Here, you assess them at multiple times and look at the relationships over time
    • Marker, Comer, Abramova, & Kendall (2013): used BLDS approach to examine the relationship between therapeutic alliance and anxiety symptoms
      • Changes in mother-reported therapeutic alliance significantly predicted later changes in child anxiety symptoms
  • Sequential Multiple Assignment Randomized Trial (SMART) Designs

Where do we go from here?

  • Need for higher frequency data collection methods
  • Need for temporal precedence
  • Need to consider the use of person centered approaches
  • Dynamical systems approach is one paradigm that can be used to understand mechanisms
  • Lots of new analyses being developed for causal inference, so keep the journal alerts on!
  • We need to have a person-centered approach

Q&A Q1: With talking about week-to-week measurements, what about the processes that happen within seconds? So something about EMA may be working into the multi-scale analysis and look at seconds, minutes, etc.

  • A: It’s important to think about will they drop out if they have two much burden? So you have to balance that

Q2: I struggle with employing EMA in a way that doesn’t offer as much incentive. Are we making the data funky by the nature of having to make the data?

  • A: I like the idea of bursts. Instead of having too little collected at too little time points or too much, you do it in bursts. I think that’s a reasonable solution. We gave smart phones to kids, that didn’t help. Paying them did help, but that’s very expensive. Then you have the question of when does it go off, some schools don’t allow it, and then you may be getting them in non-representative environments.

Q3: The think I kept thinking about during this talk was thinking about the side about fidelity and implementation issues, so I keep thinking about all of this kind of contemporary measurement relies on conformity in the intervention, and I don’t know that we have the technology to knit together those two different lines of work? Ultimately, where does that leave us - how do you resolve those two lines?

  • A: Fidelity to a treatment is important, flexibility is also important. I like to think of flexibility within fidelity. Everyone gets rewards, but different kids do different things and they all get exposure and rewards. When i think of fidelity I think of what’s necessary, and if you don’t have what’s necessary you don’t have fidelity. Usually when you do an RCT you have fidelity. In CAMS there were multiple therapists that had to be fired because they weren’t doing CBT, but the data is still in the charts. Fidelity is necessary, but flexibility is also important - when I communicate with other professionals they really like the idea of fidelity, but unfortunately, some take it too far. In CBT for child anxiety, kids drop at exposure, so it’s a challenging issue. When we study mediation we should study it in a randomized CBT trial that has fidelity

Q4: I almost feel like I have this fussy need to remind folks that sometimes I almost here that the data entry approach to identify mediators, and I want to go back to the basics to emphasize that yes while that makes sense it can be more helpful if the intervention points are driven by theory rather than the idea that we need to do a pre measure and post measure at x,y and z points.

  • A: The notion that we have to have theoretically derived assessment points is a good idea.

Note: When we send EMAs to people and we want them to respond but at some point they fatigue, and then just ignore it completely - there is some work being done in software engineering to find at what point fatigue emerges. To be safe, less than 5 notifications within two days should be an initial baseline that we shouldn’t go beyond. Another approach used in engineering is that interventions that use in-person therapy and a digital approach, we can track what they’re doing on the phone and the phone can determine what the best times are to gather the data. Q: In the context of what you told us I wonder if you have suggestions on methods of data collection based on the age of the child (i.e., how can we have a higher response rate from children of younger ages)

  • A1: It’s important to look at SES to see if they even have phones - we gave them devices for awhile but that only helped in the beginning.
  • A2: One of the things we’ve learned is that when you have the initial reaction to give them the technology, one of the main issues that has come up is something as simple as the fact that they weren’t charging the devices. You also have to think about what types of devices they are (android, IOS, etc.). The intelligent approach of knowing when they’re on their phone and what they’re doing and forcefully trying to get them to respond by sending a text message (the little ones may not see it, but the adolescents may). But then at the third request when they ignore it, it can take over the phone and not let them enter any other app until they do it. There are varying levels of notifications that you can use as an approach. For little ones, the EMAs can be embedded in the video games that they play the most so that they show up when they play the game. Embedding the science within the context that they’re already using is something that people are exploring.
  • A3: A really important point is that we really can’t always ask the same types of questions using specific methodology. So when thinking about mediation, we have to be much more careful. This requires a reframe of how we think about intervention work.
  • A4: One more little thing that’s important to consider is security issues when it comes to these methods. Things like GPS location would never be passed through the IRB, but with security proof technology we may be able to dream better.

Block II Break Out Discussions for Future Directions Address 2 (12:05 pm - 12:50 pm)

Description

Dr. Armando Piña and Dr. Susan White will serve as Breakout Discussion Leaders following Dr. Philip Kendall’s Future Directions Address (Future Directions in Mediators of Treatment)

Dr. Armando Piña, Ph.D.

Dr. Armando Piña is an Associate Professor of Psychology at Arizona State University and Principal Scientist in The Courage Lab. He has authored or co-authored about four dozen peer-reviewed articles and book chapters and serves on editorial boards for the Journal of Consulting and Clinical Psychology, the Journal of Clinical Child and Adolescent Psychology, and the Journal of Psychopathology and Behavioral Assessment. His research been funded by the National Institute for Mental Health and the National Institute of Child Health and Human Development. Recently, he has been collaborating with school administrators and individuals who deliver social and emotional learning (SEL) curriculum to elementary school youth. Because of these collective experiences, his interests have shifted from working in the laboratory to working in the “real-world.” He is interested in child anxiety research and in the study of children's courage. This positive strength-based approach serves community organizations, like schools and providers working with children, adolescents, and caregivers.

Notes
Click "Expand" for notes
  • Sharing thoughts about the presentation
    • Younger people coming into the field feel a lot of pressure to be accurate in their understanding of the concepts from the address but that can be difficult- any advice?
      • Being at conferences and being exposed is a good step
      • All scientists regardless of experience are trying to figure stuff out and will be wrong a lot
      • The two paper looking at mediators were secondary analyses from RCTs, so they were very tentative about the extent that these things are mechanisms of change. You want to be right, but be very clear about the extent to which things are tentative
      • To do these robust studies, you have to have money, which is tough to get
        • Especially as a younger scientist, you will get lesser amounts
      • New science comes out all the time and you integrate that
    • How to get people to be more open about sharing data? How to get access to other people’s data?
      • NIMH now requires data sharing plan in grants. The data will be deidentified, have a codebook, and a plan to give it to outside people. It also discusses how long the PI has  to work independently before sharing
      • Data were collected by tax dollars, so they should be shared, but it is up to individuals to do the actual sharing
      • There are large repositories (like Michigan, where you can request access to datasets)
      • So, we are making progress in this area, but there are powerful security reasons that cause caution.
    • How to sustain adherence and engagement to EMA protocols?
      • It would be cool to get data from apps people already use.
      • Example- If someone plays Xbox, and you are able to embed content in the game
      • Essentially, partnerships with private companies to gather data. They already gather heaps of data without any IRB approval
        • For instance, microtransactions that, rather than money, ask for a question to be answered in exchange for in game benefits
        • Funding from a grant could be a means of accomplishing this
          • Intrinsic (being a  part of a community, saying how it would help other kids) vs. extrinsic rewards (level ups, gems, etc) built into games from a software engineering perspective
      • What could apps do with the information that we don’t know, especially if it’s now health information?
        • We don’t know what they do with the data they already get that is likely less sensitive
        • How do we balance getting this information from users without swaying them
        • We don’t want to influence behavior through our methodology
          • This really depends on the type of data we want to collect
        • For instance, with questionnaires, having answered the questions may have made the patient feel better by gaining a greater insight into their issue
        • Have to remember that there are already existing digital health technology. Many are only partially evidence based, but you could buy the data from them to test hypotheses about the evidence based aspects to compare it to any new approach.
        • Main concern is geographical information when it comes to IRB and security
      • Phones now collect screen time data- can we get it?
        • We could answer questions like social media’s relationship with mood
        • Could we get this from the company or participant
        • There are apps you can get that track what you do on your phone that allow you to download and examine data from enrolled participants.
          • Even things they think they deleted
          • For example, for kids at risk for suicide, parents have an app that shows what they’ve done on their phone for clinical purposes
    • Using many data points and establishing temporal precedence is hard to achieve if you don’t have a lot of funding, so you may want to use a public dataset.  How do you tell whether open access datasets are methodologically sound?
      • There are state and federal level registries that have data sets, but there are also commercial data sets that you can buy
        • Commercial data sets will be dirty
        • Ex: there was a study on the times and days of the week that were associated with mood dysregulation and analysing kid’s text messaged
          • This data was from a company but it did show the temporal data for date and time. So, it could be used to establish temporal value
          • Depends on question you want to ask
    • Privacy is leaving the world rapidly. It is dangerous to get info from businesses because they obtain it when the researcher did not have permission to collect it.
      • This is happening- mTurk, for instance. We don’t know who these people are or if they are who they say they are
        • mTurk is a place where people sign up to do studies for pay and researchers could post on it.
        • Money could be differentially valuable in different locales, resulting in an unbalanced sample of people who see the money as more valuable
    • This could give a plug into cross-collaboration, such as with computer science we’ve come up with some novel or alternative ways to get information that aren’t as complex as what we were typically using
    • Why don’t psychologists work with cookie-based advertising on the Internet that notices what's been typed
      • If someone displays a pattern of depressive searches, show them resources instead of ads
      • Can be done but have to pay per click
      • Some people have assessments built into Facebook- like questions about domestic violence
      • Is this ethical? Might have very nonthreatening first couple of questions and pull them in and get a consent and then ask more probing questions. Data is thrown out from the beginning questions if they do not consent
      • It also matters if it is from a research or clinical perspective (storing data or not, for example
    • Companies probably have psychological professionals looking at data they have. Does this come out in publications
      • No. They don’t care about peer review. It’s all business
      • They usually pay people in psychology that they recruit very well
    • For studies using devices to collect data from youth, is it common to have pushback with giving younger children devices to collect data?
      • Some parents limit time, forbid it, but others use technology as a babysitter, so it varies widely
      • In a usability study for an app for anxiety, two children came who were not allowed to use devices at home and this was a barrier
    • What about using EMA to get at idiographic change and clinically significant change?
      • The big piece is how you define clinically significant change. Can be returning patients to normative change of functioning. How many points does it take to say they change? Is it a change to them going to a birthday party and enjoying it, or not hitting their brother/sister? Can also be whether the patient has developed more prosocial behavior
      • Operational definition defines the assessment method
      • Caution statement- Sometimes all people tend to gravitate toward putting a paper assessment you’re doing into an app. That’s the same as a professor teaching a face-to-face class going to online materials. Think about it as if you aren’t starting from paper. This is a different animal and the materials needed are different.
        • Difference in implementation and the constructs. Implementation is the method you’re using such as relaxation training. The idea should stay the same behind it
      • What is an equivalent, alternative way to measure your construct.
      • If you want to study children, study what people are doing in classrooms  
    • How to provide more information so that participants aren’t confused during EMA? Usually, face to face, the person can ask, but digitally they have no resource person to ask
      • One study did factor analysis to see if EMA was measuring the same thing as the in person questions
      • Some things don’t have a questionnaire that isn’t easy to translate to EMA, so you have to come up with questions
      • It is up to you to create and test these things. “What are you waiting for?”
      • You have the training and access- so you do it.
      • Could use a recording to capture facial emotions rather than asking basic questions, which puts the burden on you to understand the patient.
      • Imotions is a software in this vein
        • A data analytic software where you upload videos and it codes them for you and integrates the data
    • Mediators and moderators in the context of risk factors? Was the talk just treatment specific for anxiety?
      • In treatment, there are many potential mediators interacting over the course of treatment and are confounded with the components of treatment. Are you teaching to the test and then measuring it? Should the mediator be separate from the treatment components?
      • For CBT for anxiety you do cognitive restructuring as an active ingredient. Is it a mediator? Well, you just trained to it, and it’s a facet of anxiety so it’s confounded with the dependent variable. Now, try and pull it all apart. But that’s correlational
      • So you have SMART trials where people are randomized over and over based on how they’re doing, but then there's’ individual level change. What if we take a SMART trial in an umbrella trial (Precision medicine trial) so that people are randomized then reassigned based on clinical presentations/profiles which have various levels and then are randomized over and over by progress  
Dr. Susan White, Ph.D.

Dr. Susan White is Professor and Doddridge Saxon Chair in Clinical Psychology at the University of Alabama. Her clinical and research interests include development and evaluation of psychosocial treatments that target transdiagnostic processes underlying psychopathology. She is associate editor for the Journal of Clinical Child and Adolescent Psychology and the Journal of Autism and Developmental Disorders, and she is the Editor in Chief of the ABCT Series on Implementation of Clinical Approaches. Her research has been funded by the National Institutes of Health and the Department of Defense. She received her PhD from Florida State University.

Notes
Click "Expand" for notes
  • Sharing thoughts about the presentation
    • Younger people coming into the field feel a lot of pressure to be accurate in their understanding of the concepts from the address but that can be difficult- any advice?
      • Being at conferences and being exposed is a good step
      • All scientists regardless of experience are trying to figure stuff out and will be wrong a lot
      • The two paper looking at mediators were secondary analyses from RCTs, so they were very tentative about the extent that these things are mechanisms of change. You want to be right, but be very clear about the extent to which things are tentative
      • To do these robust studies, you have to have money, which is tough to get
        • Especially as a younger scientist, you will get lesser amounts
      • New science comes out all the time and you integrate that
    • How to get people to be more open about sharing data? How to get access to other people’s data?
      • NIMH now requires data sharing plan in grants. The data will be deidentified, have a codebook, and a plan to give it to outside people. It also discusses how long the PI has to work independently before sharing
      • Data were collected by tax dollars, so they should be shared, but it is up to individuals to do the actual sharing
      • There are large repositories (like Michigan, where you can request access to datasets)
      • So, we are making progress in this area, but there are powerful security reasons that cause caution.
    • How to sustain adherence and engagement to EMA protocols?
      • It would be cool to get data from apps people already use.
      • Example- If someone plays Xbox, and you are able to embed content in the game
      • Essentially, partnerships with private companies to gather data. They already gather heaps of data without any IRB approval
        • For instance, microtransactions that, rather than money, ask for a question to be answered in exchange for in game benefits
        • Funding from a grant could be a means of accomplishing this
          • Intrinsic (being a part of a community, saying how it would help other kids) vs. extrinsic rewards (level ups, gems, etc) built into games from a software engineering perspective
      • What could apps do with the information that we don’t know, especially if it’s now health information?
        • We don’t know what they do with the data they already get that is likely less sensitive
        • How do we balance getting this information from users without swaying them
        • We don’t want to influence behavior through our methodology
          • This really depends on the type of data we want to collect
        • For instance, with questionnaires, having answered the questions may have made the patient feel better by gaining a greater insight into their issue
        • Have to remember that there are already existing digital health technology. Many are only partially evidence based, but you could buy the data from them to test hypotheses about the evidence based aspects to compare it to any new approach.
        • Main concern is geographical information when it comes to IRB and security
      • Phones now collect screen time data- can we get it?
        • We could answer questions like social media’s relationship with mood
        • Could we get this from the company or participant
        • There are apps you can get that track what you do on your phone that allow you to download and examine data from enrolled participants.
          • Even things they think they deleted
          • For example, for kids at risk for suicide, parents have an app that shows what they’ve done on their phone for clinical purposes
    • Using many data points and establishing temporal precedence is hard to achieve if you don’t have a lot of funding, so you may want to use a public dataset. How do you tell whether open access datasets are methodologically sound?
      • There are state and federal level registries that have data sets, but there are also commercial data sets that you can buy
        • Commercial data sets will be dirty
        • Ex: there was a study on the times and days of the week that were associated with mood dysregulation and analysing kid’s text messaged
          • This data was from a company but it did show the temporal data for date and time. So, it could be used to establish temporal value
          • Depends on question you want to ask
    • Privacy is leaving the world rapidly. It is dangerous to get info from businesses because they obtain it when the researcher did not have permission to collect it.
      • This is happening- mTurk, for instance. We don’t know who these people are or if they are who they say they are
        • mTurk is a place where people sign up to do studies for pay and researchers could post on it.
        • Money could be differentially valuable in different locales, resulting in an unbalanced sample of people who see the money as more valuable
    • This could give a plug into cross-collaboration, such as with computer science we’ve come up with some novel or alternative ways to get information that aren’t as complex as what we were typically using
    • Why don’t psychologists work with cookie-based advertising on the Internet that notices what's been typed
      • If someone displays a pattern of depressive searches, show them resources instead of ads
      • Can be done but have to pay per click
      • Some people have assessments built into Facebook- like questions about domestic violence
      • Is this ethical? Might have very nonthreatening first couple of questions and pull them in and get a consent and then ask more probing questions. Data is thrown out from the beginning questions if they do not consent
      • It also matters if it is from a research or clinical perspective (storing data or not, for example
    • Companies probably have psychological professionals looking at data they have. Does this come out in publications
      • No. They don’t care about peer review. It’s all business
      • They usually pay people in psychology that they recruit very well
    • For studies using devices to collect data from youth, is it common to have pushback with giving younger children devices to collect data?
      • Some parents limit time, forbid it, but others use technology as a babysitter, so it varies widely
      • In a usability study for an app for anxiety, two children came who were not allowed to use devices at home and this was a barrier
    • What about using EMA to get at idiographic change and clinically significant change?
      • The big piece is how you define clinically significant change. Can be returning patients to normative change of functioning. How many points does it take to say they change? Is it a change to them going to a birthday party and enjoying it, or not hitting their brother/sister? Can also be whether the patient has developed more prosocial behavior
      • Operational definition defines the assessment method
      • Caution statement- Sometimes all people tend to gravitate toward putting a paper assessment you’re doing into an app. That’s the same as a professor teaching a face-to-face class going to online materials. Think about it as if you aren’t starting from paper. This is a different animal and the materials needed are different.
        • Difference in implementation and the constructs. Implementation is the method you’re using such as relaxation training. The idea should stay the same behind it
      • What is an equivalent, alternative way to measure your construct.
      • If you want to study children, study what people are doing in classrooms
    • How to provide more information so that participants aren’t confused during EMA? Usually, face to face, the person can ask, but digitally they have no resource person to ask
      • One study did factor analysis to see if EMA was measuring the same thing as the in person questions
      • Some things don’t have a questionnaire that isn’t easy to translate to EMA, so you have to come up with questions
      • It is up to you to create and test these things. “What are you waiting for?”
      • You have the training and access- so you do it.
      • Could use a recording to capture facial emotions rather than asking basic questions, which puts the burden on you to understand the patient.
      • Imotions is a software in this vein
        • A data analytic software where you upload videos and it codes them for you and integrates the data
    • Mediators and moderators in the context of risk factors? Was the talk just treatment specific for anxiety?
      • In treatment, there are many potential mediators interacting over the course of treatment and are confounded with the components of treatment. Are you teaching to the test and then measuring it? Should the mediator be separate from the treatment components?
      • For CBT for anxiety you do cognitive restructuring as an active ingredient. Is it a mediator? Well, you just trained to it, and it’s a facet of anxiety so it’s confounded with the dependent variable. Now, try and pull it all apart. But that’s correlational
      • So you have SMART trials where people are randomized over and over based on how they’re doing, but then there's’ individual level change. What if we take a SMART trial in an umbrella trial (Precision medicine trial) so that people are randomized then reassigned based on clinical presentations/profiles which have various levels and then are randomized over and over by progress

Block III Future Directions Address 3: "Future Directions in Immunology and Mental Health" (2:00 pm - 3:00 pm)

Dr. Greg Miller, Ph.D.

Associate Professor of Family Medicine at the University of Colorado School of Medicine and Associate Professor of Pediatrics at National Jewish Health, where she directs the Pediatric Behavioral Sleep Clinic and Actigraphy Clinic. Her program of research examines sleep in children with chronic illnesses and their parents, the impact of deficient sleep on health outcomes in adolescents with asthma, and the development and validation of objective and subjective measures of pediatric sleep. She is board certified in Behavioral Sleep Medicine by the American Board of Sleep Medicine, and co-author of Pediatric Sleep Problems: A Clinician’s Guide to Behavioral Interventions.

Description

In this address, Dr. Gregory Miller provides an overview of the recently developed neuroimmune network hypothesis and highlights implications and future directions for theory and empirical research on early-life stress and its links with physical and emotional health problems.

Learning Objective

Highlight future directions for research on links between early-life stress, immunological and neural functioning, and youth physical and mental health.

Address 3 Materials
Notes
Click "Expand" for notes
  • This talk will look at early life stress (SES) and how that relates to physical health
    • There are widely reported differences in life expectancy that vary by SES across racial groups (Braveman et al. AJPH 2010)
      • This is true for all different kinds of negative outcomes (e.g., cancer) and for different measures of SES (income, education, etc.)
    • These differences start very early in life (Barveman et al. AJPH )
      • E.g., the impact of maternal education on infant / neonatal mortality
    • These effects continue through childhood
      • E.g., obesity and carotid atherosclerosis predicted by SES (percent federal poverty threshold) (Singh et al, 2010.; Lui et al., 2017)
    • This stretches across the lifecourse (Kittleson et al. Arch Intern Med 2006)
      • SES conditions in childhood impact long-term health
      • Kittleson et al. (2006): followed medical students graduating from JHU and the incidence of coronary heart disease
      • If the physician’s father had a manual or non-manual occupation when the doctor was a child predicts heart disease across life
      • All the subjects are high-SES themselves!
    • Yet the childhood conditions (even crudely measures) predict differential outcomes
      • Early experiences are not fully erased by later conditions
      • That doesn’t mean that interventions are ineffective, but the effects can persist
    • Next generation evidence (mostly from animal models)
      • Findings are consistent; kids with asthma (8 to 17 yo.) have different outcomes based on SES of kids’ parents when the parents were children themselves
      • SES status of mother at childhood is informative, independent of the child’s current SES
      • Measure: immunologic measures of immune response related to asthma (Chen et al., 2017)
      • Early life conditions relate to health across the life course
    • Takeway: there are many factors that don’t pattern with SES (e.g., genetics), but there are also many factors that do
      • The strongest effects (so far) are in the cardio/metabolic domain
      • E.g., lung diseases, asthma; not as strong in, e.g., cancer
  • Some common responses to this work
    • These are interesting associations, but it’s probably all about…
      • … genetics!
      • Bad genes run in families and lead to many kinds of bad social and health outcomes
      • What does the evidence say?
    • Studies in northern europe (e.g., adoption studies) show that both SES of biological parents and of the adoptive parents matter!
    • Thus, there’s a genetic signal and there’s an independent signal of SES
    • Furthermore, mouse, rat, and monkey models show convergent evidence for the causal effects of early experiences on long-term health outcomes
      • … limited access to healthcare!
      • Unequal access to high-quality care leads to these disparate outcomes
      • What does the evidence say?
    • Most of the problems that people face start before people go to the doctor
    • Furthermore, many of the problems do not have effective treatments (yet)
    • Thus, the biggest differences are in incidence in the first place, not necessarily about treatment
      • In places with universal access to healthcare (e.g., canada) we still see these disparities
      • … it’s lifestyle!
      • Low-income families behave badly
    • They smoke, eat badly, etc.
      • Response:
    • Yeah, there are differences in health behaviors, but we shouldn’t view lifestyle behaviors in a vacuum
    • There are differences in policy, structure, environment, etc. that back people into less healthy lifestyles
    • Furthermore, when we measure these things, health behaviors explain some of the variance but not all of it
  • So if it’s not genetics, healthcare and lifestyle, what is it?
    • We can use observational studies and animal models to identify:
      • Biological mechanisms
      • Protective and vulnerability factors
      • Use these to inform policy and practice
  • Part 1: Identifying mechanisms
    • The immune system is a key nexus of the interface between environment and health
      • Non-resolving inflammation as common pathway (Nathan & Ding, 2010)
      • SES patterns with NRI
      • Implicated in the pathophysiology of many different diseases
    • (Very) Simplified framework
      • There are immune cells (monocytes) that become macrophages and then immune cells
      • Hypothesis: kids in disadvantaged environments have a phenotype that involves having cells that are more reactive to threats over time
      • Threats include: bacteria, viruses, and also own body cells that are damaged by injury / trauma
      • The argument: early adversity primes these cells to respond to microbial / injury threats in a more aggressive fashion
      • Furthermore, besides being more primed to respond, the body is less able to shut down these responses
    • E.g., by being less able to produce / respond to cortisol (which helps reduce inflammation)
    • From disadvantage to inflammation (Miller et al., 2011)
      • How do we get from SES to inflammation?
      • Of course, it’s not just material hardship; there are many exposures in individual, family, and system level that covary with SES
      • The social and physical environments of low-SES kids are different than for more advantaged kids
      • SES captures many of these factors, despite the specific circumstances of each child being unique
    • However: these exposures shape the way that stress systems are organized and their brains develop
    • 2 over-arching pathways that connect SES with the pro-inflammatory phenotype (programming and accentuating effects)
      • Barker: embedding / programming
      • But also: early experiences shape the way that we engage in healthy behaviors
      • These pathways are equally important; they continue to change the immune system over the lifespan
      • Thus: behavior, emotion, and cognition continue to be important across the lifespan (it’s psychology!)
    • What is inflammation?
      • Monocytes can transform into dendritic cells
      • Dendritic cells encounter bacteria that have LPS molecules on them
      • When the dendritic cell / monocyte binds with the LPS molecule, it sends off a signalling cascade that ultimately converges on NF-kappa B (transcription factor)
      • This is the lynchpin for the inflammatory response
    • It moves into the cell’s nucleus, binds to DNA, and switches on the genes that control proteins that lead to inflammation
      • These are signalling molecules that tell the immune system to activate in certain areas: IL-6, IL-12, IL-3, IL-1, and TNF-alpha
      • In many studies, we take blood cells and add LPS
      • How much of these molecules do these cells make and how much NF-kappaB gets activated?
    • But what about cortisol?
      • It’s an anti-inflammatory hormone
      • Binds on a cell’s glucocorticoid receptor and tethers NF-kappa B
  • Early work: Is phenotype evident in young adults? (Miller et al., 2009)
    • Higher- and lower-SES families were matched based on current SES, but with differences in parents’ occupations
      • This was trying to isolate the effects of early SES (rather than later SES)
    • Testing different microbial threats:
      • Poly I:C via TLR3- mimics microbial stimulus
      • Flagellin via TLR5
    • For both stimuli, young adults with lower-SES parents showed greater activation of immune response
      • NB: this is probably adaptive in the moment!
      • However, there’s a tradeoff
      • Over the course of the lifespan: better in-the-moment response, but with increased risk of chronic inflammation, leading to a wide range of negative health outcomes
  • Transcriptional profiling of PBMC (Miller et al., 2009)
    • Even when cells were at rest (without stimulation by microbial threat)
      • Subjects with more disadvantaged families had more activation of the NF-kB pathway (cells are primed)
    • And they have less activity of genes that involve the glucocorticoid receptor
    • Redux: higher baseline activity with less ability to down-regulate inflammation (“more on gas, less on breaks”)
  • Recent work: tracing the development of the phenotype
    • Looking at 12 and 13 year olds (N=277; from Chicago; 8th graders), we see similar results on the NF-kB axis
      • This is present in monocytes, as well as in HSPCs (stem progenitor cells)
      • This is important because if there’s a “sticky” programming effect (cf. Barker), it’d have to be in the progenitor cells, because monocytes turn over very quickly
      • Interestingly, in kids the glucocorticoid effect is not present (as they are in adults)
      • However, this is consistent with developmental changes over time
    • When does this inflammatory process begin? In utero?
      • A key part of the placenta is the villas layer, where exchange between mother and fetus occurs
      • It turns out, in some pregnancies you can get pretty severe inflammation in this layer
      • Obstructs transfer of nutrients and oxygen
      • The fetal capillaries get infiltrated and destroyed by maternal immune cell inflammation
      • Early studies: are there differences by SES?
      • In a word, yes! The effects are linear, and fairly profound
      • Maternal income and placenta inflammation (Keenan-Devlin et al., 2017)
      • Note, these lesions are pretty minor, but the findings are consistent
    • Transcriptional profile of chorionic villi (Miller et al., 2017)
      • Lower-SES women: more immune activation -> less fetal tissue maturation, relative to higher-SES women
      • Note: we don’t have enough data yet to know whether these have any clinical implications
      • However, this does suggest that even in utero, there are differences across SES
  • Part 2: Protective and vulnerability factors
    • What other characteristics of kids influence these outcomes?
    • Protective factors for low-SES youth
      • Supportive parenting is consistently shown to be important
      • Especially, a nurturing, caregiving relationship with the mother
      • This almost completely mitigates negative health outcomes due to SES
    • We see this in larger cohort studies (MIDUS, N=1205)
      • Lower rates of metabolic syndrome at midlife
    • Can we leverage parenting to improve health?
      • Blood samples from a few hundred 19 year olds who had earlier been part of a drug-use / mental health intervention a 11 years old (SAAF Intervention; Miller et al., 2014)
      • The intervention was associated with reduced inflammation 8 years later!
      • Note: these findings are from rural African Americans around Athens, GA
      • Modal family: single-caregiver household with minimal higher education
      • At age 19, kids who got the intervention showed marked differences in inflammatory markers
    • How did this intervention have such an effect on inflammation?
      • The big operator seemed to be differences in parenting (which was the goal of the intervention)
      • To encourage nurturing parenting; reduce harsh parenting
      • Thus, there is evidence to suggest that changes in the parent/child relationship during adolescence seemed to help children cope with challenges (e.g., racism, limited opportunities, physical activity challenges, healthy diets)
      • These are the hypotheses; data to support these are forthcoming!
      • Bottom line: nurturing parenting can buffer the negative effects of SES
    • Can we leverage social relationships to improve pregnancy outcomes? (Miller et al., 2017)
      • Group-based prenatal care (Centering Pregnancy) changes gene expression patterns in the placenta and umbilical cord in favorable directions
      • We’ll know more in the future about how robust these findings really are (upcoming RCT)
    • Another protective factor for low-SES youth: self-control
      • There is evidence from many sources that low-SES kids with high levels of self-control seem to be protected from negative outcomes
      • The data, however, suggest that upward economic mobility and high levels of persistent and striving might have unforeseen negative health outcomes, particularly for low-income children of color (Miller et al., 2015)
      • AIM study (Adults In the Making): children 17 to 20 years old
    • Measured family SES and self-control
      • Regardless of the specific outcome, the main predictor of psychosocial outcomes is self-control, not SES
      • If you look at physical health (measured by DNA methylation of immune cells)
      • The relationship between self-control and this metric were not as favorable
      • There is a prominent interaction between SES and self-control when this is the outcome
      • Rural African Americans: higher self-control/persistence was related to faster biological aging
    • Cf. less disadvantaged children: the self-control was beneficial; cells aged more slowly
      • Thus, a true crossover interaction
    • What might all this mean? Hidden costs of mobility for Black Americans? (Braveman et al., 2010)
      • There is a major gap in longevity between black and white americans
      • But this gap is largest for people (black and white) with higher levels of education
      • The racial disparities in longevity and health are most extreme at the high level of the education scale
      • More education and more affluence (and potentially more striving) might lead to some sort of physical health cost
      • Does this generalize to other areas of the US?
    • Add Health data (N = 13,009) (Gaydosh, Schorpp, Chen, Miller, & Harris, 2018)
      • Depressive symptoms by childhood disadvantage and college degree
      • Going to college is good for your mental health overall
    • Sx with a college degree have lower depressive symptoms
      • Not so with physical health: (looking at metabolic syndrome)
      • For white Americans, going to college is better regardless of SES
      • This is not true for black or latino americans
    • For high-SES, there is an advantage
    • For low-SES, there is an associated health risk
    • Redux
      • Costs to striving
      • Costs to arriving
      • Academic and workplace environments can be hostile
    • Hostile climate leads to erosion of health outcomes

Block III Break Out Discussions for Future Directions Address 3 (3:05 pm-3:50 pm)


Description

Dr. Katherine Ehrlich and Dr. Deborah Drabick will serve as Breakout Discussion Leaders following Dr. Greg Miller’s Future Directions Address (“Future Directions in Sleep and Developmental Psychopathology”)

Dr. Katherine Ehrlich, Ph.D.

Dr. Katherine Ehrlich is an Assistant Professor at the University of Georgia where she holds a joint appointment in the Department of Psychology and the Center for Family Research. Dr. Ehrlich received her B.A. at Washington & Lee University, her Ph.D. in Psychology at the University of Maryland, and she completed a postdoctoral fellowship at Northwestern University. Dr. Ehrlich’s research, which lies at the intersection of developmental, clinical, and health psychology, focuses on how social experiences, such as early adversity, close relationships, and socioeconomic status are associated with physical health across the lifespan. In addition to utilizing a variety of methods to evaluate social and emotional functioning, her research incorporates a number of health assessments, including clinical health outcomes, measures of cellular function, and adaptive immunity. Dr. Ehrlich is a recipient of pre- and post-doctoral Ruth L. Kirschstein National Research Service Awards, a NARSAD Young Investigator Grant, an R03 from the National Institute of Child Health and Human Development, and was named a Rising Star by the Association for Psychological Science.

Materials
Notes
Click "Expand" for notes
  • How can I get involved in psychoneuroimmune (PNI) research?
    • It seems really complicated!
    • Long story short: you can do it!
      • Networking, training opportunities, career planning
  • Dr. Ehrlich’s background
    • PhD (2006 - 2012)at UMD - developmental psychology
    • Somewhere in 2009…
      • Caught the bug for PNI: interest in mental and physical health
      • However, given how far along she was, decided to do this as a postdoc
    • No biology background (that’s ok!)
  • Where to start?
    • Read some stuff!
      • There’s a big literature
  • Journals: psychosomatic medicine is the flagship
    • Networking! (conferences)
      • American Psychosomatic Society (Long Beach 2020)
      • PNIRS (Los Angeles 2020)
      • ISPNE (psychoneuroendocrinology)
      • Developmental Psychobiology (Chicago 2019; DC 2020)
      • Society of Behavioral Medicine (San Francisco 2020)
      • SRCD
    • Cold emails (with a purpose)
      • Something specific, with a question, is good
      • Nominate a person for a talk (e.g., a brown-bag)
    • Week-long workshops
      • Northwestern Summer Institute on Biological Approaches in the Social Sciences (might die because of lack of funding)
    • Salimetrics “Spit Camp”
      • Getting into measures you can measure via saliva
      • Information on technical details of how to gather these data
    • Mini collaborations
      • Think about getting your advisor involved
      • A lot of health psychology is interdisciplinary, so many people are open to potential collaborations
    • Postdoc training
      • A good time to make a pivot to something you didn’t get training in before
      • You might feel the urge to go straight for a faculty position…
  • Don’t do it!
  • Get the additional training and time to write papers
      • Consider an F-32 grant
  • Networking is important for this!
      • See also T-32 (training grant)
  • Apply to a university, instead of the NIH directly
  • Go to map on NIH website
      • Does NSF have postdoc grants?
  • They have pre-doc (GRFP), unsure if postdoc is available
  • Planning
    • Short term
      • Read read read read read read read
      • What will make your research more exciting to you?
      • Take note of researchers who keep showing up in your lit reviews
    • Medium-term
      • Can you start a study now, or will you need more training?
      • Find an excuse to meet with mentors or their grad students
      • Make connection with a potential advisor and discuss working together
      • Give yourself time to start writing a fellowship proposal
  • Might take multiple submissions
  • Give yourself a solid year
    • Long-term
      • Hard to determine a priori, but…
      • What are your 5 to 10 year career goals?
      • Work backwards to develop a roadmap
      • Flexibility is important
  • Two notes of caution
    • This advice is from Dr. Ehrlich’s experience
      • Caveat emptor
    • You might be told to “add biology” to your study
      • Proceed with caution; these measures are no more ‘real’ than other measures of psychological phenomena
  • Questions
    • How did you present yourself in job talks? (Dr. Ehrlich)
      • She combined her interests in developmental psychology and health
      • She had a gap year of being unsure of what to do
      • “Creative smoothing”
      • Don’t necessarily present papers in chronological order
    • The two body problem: what to do when you have a partner?
      • Fellowships
  • Bringing your own funding can provide flexibility
      • Have contingencies in place
      • Decide if you make both of your careers a focus or not
      • Try to be in a big city with multiple universities and med schools
Dr. Deborah Drabick, Ph.D.

Dr. Deborah Drabick is an Associate Professor of Psychology at Temple University. Her expertise is broadly in developmental psychopathology, and more specifically in youth externalizing problems. Her work includes such areas as risk and resilience, co-occurring psychological conditions, contextual influences, and intervention. Dr. Drabick has been funded by the National Institute of Mental Health, American Psychological Foundation, PA Department of Health, and Temple University. She currently serves as an Associate Editor for the Journal of Clinical Child & Adolescent Psychology.

Materials
Notes
Click "Expand" for notes

Neuroimmune network hypothesis

  • Early life stress/adversity amplifies bidirectional crosstalk between neural and immune systems
  • Contributes to psychological and physical conditions that have inflammatory underpinnings
  • Neuroimmune crosstalk perpetuates inflammation and neural alterations associated with early life adversity
  • Hostinar et al. Figure
    • Early life stress creates a dysregulated relation between neural and immune signaling with consequences for lifespan physical and emotional health

Background

  • Links between peripheral low-grade inflammation, early life stress, and various physical and psychological outcomes
  • Early adversity sensitizes (a) brain’s cortico-amygdala regions and (b) immune cells that propagate inflammation
    • Increases vigilance for sensitivity to threatening stimuli
    • Decreases sensitivity to awards
    • Exaggerated immune responses to infections
    • Dampens executive control (prefrontal) processes
  • Parenting styles can also interact with these individual differences

Theoretical and conceptual implications

  • Systems approach
    • Problems stem from perturbations in biological networks
    • Dysfunction can spread throughout brain into other systems
  • Cascade model
    • Low SES is mediated by a multitude of other factors
      • As a parent, it can bring depression which could lead to things such as a lack of warmth towards the child -> child isn’t ready for school, and so forth
      • Each factor accounts for a small part of the variance
  • Opportunities for resilience
  • Understanding normative vs. atypical development
    • Heterogeneity in outcomes
    • Multifinality- same risk factors lead to many outcomes
      • Want kids developing a sense of self, peer relations, and parent relations
      • The same set of risks don’t post the same set of issues for every child
    • Question- why is neuroinflammation shared between depression and autism? The data is only on people with ASD
      • If you have demographic data such as low SES, what would the question be/what would you do with that information?
        • Answer: trying to figure out mediators and moderators
      • Thinking about young children with autism where the mothers are expressing warmth but the children don’t receive the warmth, are the same processes happening there?
        • It could be that the parent is being warm, but if the kid has problems with reciprocity, then what?
          • SES could be a moderator
  • Explaining multi-morbidity
    • Shared underlying processes (e.g., low-grade inflammation)
    • One condition confers risk for another

Research issues

  • Assessment
  • Proxies or phenotypes for these processes
    • High threat responsively, low sensitivity to reward, diminished executive control
  • Question: how do operationalize SES - if we had one measure we can insert into a study or one or two questions, what would the gold standard be?
    • Answer (From Dr. Greg Miller): While this is a developing area, a bunch of our area is derived from inadequate measures - things like education, prestige and wealth are only moderately correlated, so you probably can’t (unless you have a large epidemiological study that can handle high levels of error) say which is the best. All the things we can look at really work in different ways. There’s no one measure. Early life stress has not been well conceptualized - it’s important to remember this field has just gotten on its feet. One way to approach this is saying “Im interested in early adversity and want to think about what adversity early on means down the line for diseases at an older age.” But, if you start with the disease, you look at things a bit differently. Both forms of research are valuable.
    • From Dr. Drabick- In our lab we used to report SES, but now we ask “do you have what you need for these different things in your life” such as food, clothes, etc., which has worked as a good measure. Some people are similar in circumstances but more stressed and think they don’t have what they need
    • One thing Dr. Miller recommends- wealth and savings because income is unstable. For some multigenerational households, income ends up being $150k to support 7 or so people which isn’t a lot to go around, but that ends up being coded as high income.
    • Question: wouldn't having a multigenerational household create a wider support system for the child to grow up in?
      • Dr. Greg Miller: it could be a buffer
    • Might also be endophenotypes externally that reflect something biological
  • Measures that tap into biomarkers and early stress
    • “Non-resolving inflammation” can be indexed by C-reactive protein (CRP) and interleukin-6 (IL6)
      • Is there a cut score? Could use info from primary care
        • What about cheek swab tests? Could this be a way for primary health care providers to contribute to research?
  • How do we operationalize “early life stress?”
    • Maltreatment, early SES
  • How to index constructs?
    • If something predicts ~1% of variance for an outcome, is that clinically significant enough to publish really?

Empirical approaches

  • Concurrently assess neural, immune, and behavioral processes prospectively and within different developmental periods
  • How can one do research without a large grant?
    • Cross-sectional approaches with multiple cohorts
    • Using proxies for constructs of interest
    • Cross disciplinary collaborations
    • Determining sensitive periods and places in developmental trajectories to focus
      • Not clear what happens to neurobehavioral process during normative transitions
  • Contextual influences on immune responses and physiological reactivity
  • Other ideas:
      • Utilizing collaborations with primary care doctors who already gather that information
        • Different settings to do the research where data is already coming in
      • Publicly available data sets
        • There may be some proxies you can use within these to test your hypotheses

Intervention implications

  • Multidisciplinary collaborations can facilitate the development of appropriate interventions to mitigate risk associated with chronic inflammation
  • Making assessment batteries to identify people and build data
    • Helpful to use NIH toolbox
    • Think about what the gold standard may be
  • Prenatal interventions for families likely to experience adversity
  • Family-based interventions
    • Start including physical outcomes in the battery - when examining the person’s functioning it’s important to go back to the developmental milestones
  • Interventions shown to reduce inflammation (e.g., exercise) need to be examined
    • Include physical processes as outcomes in intervention research
    • With depression, we think about the triad between cognitions, emotions and behaviors. When dealing with depression we try to deal with one corner of this triad to perhaps reduce anhedonia, and exercise aligns with this idea. We could look at exercise as a potential mediator because it may reduce inflammation
  • Dissemination of knowledge to caregivers, training agencies, social service agencies, schools, pediatricians, etc.
  • Use multi-setting, multi-pronged approach to facilitate implementation of this information in youth care
  • Thoughts about other things we can do
    • Prenatal care aspect: There's a wide range of ages that a pregnant mother can be - it may be interesting to intervene in a wide range of SES as well as ages
      • Suggestion: Also look at the amount of children the mother has had due to the differences between the first and second experiences
        • There is this physical connection but we typically think about stress and its effects on the body, so getting this information to pregnant mothers could be beneficial
        • One issue is that you don’t always get prevention funding
    • The catch with disseminating information, is that you never know if it has an effect/is being implemented
      • Think about different vehicles for dissemination and how to measure if it’s being implemented
      • Involve key stakeholders when creating your projects

Block IV Future Directions Address 4: "Future Directions in Parent-Child Separation" (4:00 pm - 5:00 pm)

Dr. Kathryn Humphreys, Ph.D.

Dr. Kathryn Humphreys is an Assistant Professor at Vanderbilt University in the Department of Psychology and Human Development and is the director of Stress and Early Adversity Laboratory (SEA). For more information about her and her work please visit her personal website here.

Description

In this address, Dr. Kate Humphreys reviews salient emerging themes in the scientific literature related to the study and treatment of parent-child separation.

Learning Objective

Highlight future directions for research on parent-child separation and links with youth mental health.

Address 4 Materials
Notes
Click "Expand" for notes

Outline

  • Background, education, and training
  • Urgent real world relevance
  • Process of writing the “Future Directions” paper
  • Themes and examples
  • What to do now about parent-child separations

Background, education, training

  • Clinical psychologist by training
  • Inspired after finding out the origins of disorders (better word? I think she quite literally said why people hurt people so idk lol 🤡) began at a very young age
    • Realized it begins with families and children
    • 75% of cases classified as neglect
  • Tracing how different experiences in early life may predict long term outcomes
  • Children raised in institutional care
    • Raised without individual attention or specific care
    • World wide there are roughly 130 million children who are orphans
    • Very few orphanage based care groups in the US

Children reared in institutions

  • Growth delays
  • Disturbances of attachment
  • Romania in the late 20th century
    • Tens of thousands of institutionalized young children -- mostly abandoned at birth
    • Invited to conduct study by Minister for Child Protection
    • Interest in developing policies for intervening with abandoned children
  • Bucharest Early Intervention Project (BEIP)
    • 136 Institutionalized Children (6-30 months)
      • Foster care (n = 68)
        • At the time, there was no state sponsored care
        • Recruited people to be foster care providers
          • A lot were adults who had adult aged children themselves
      • Care as usual (n = 68)
        • Kids who are already in institutional care and did not interfere
      • Never institutionalized group (n = 72)
        • Allowed for baseline comparison
      • Assessment at baseline, 30, 42, and 54 months
      • Follow ups at 8, 12, and 16 years (21 soon!)
    • There could be an effect where the children who seem like they are faring better are adopted more
    • At age 12
      • Analyzed the data with an intent-to-treat design
      • Signs of attachment disorders (Humphreys, 2017)
        • Reactive attachment disorder
        • Disinhibited social engagement disorder
      • Internalizing and Externalizing Disorders (Humphreys, 2017)
      • Callous-Unemotional traits (Humphreys, 2017)
        • Effect of Intervention:
          • Boys who were cared as usual were much more likely to present CUT’s
    • Character development
      • The parent-child relationship, especially the responsiveness between parent and child, is thought to be especially important for conscience development
        • Warmth, Responsive to Distress
        • Caregiver response indirectly affected the potential for developing CUT’s (Humphreys, 2015)
  • Parent-Child Separation and psychopathology
  • Internalizing (e.g., depression and anxiety)
  • Externalizing (e.g., oppositional, defiant and aggressive behaviors)
  • Attention-deficit/hyperactivity disorder
  • Attachment disorders (e.g., reactive attachment disorder and disinhibited social engagement disorder)
  • Posttraumatic stress disorder
    • If a child was separated from their parents as a result of a natural disaster the child was predisposed to developing symptoms of PTSD for up to 2 years following the separation

Urgent Real world relevance

  • “Government sanctioned child abuse” - Dr. Colleen Kraft
    • Came together for an Op-Ed column: “How to Turn Children Into Criminals”
      • The act of separating kids is likely to increase the potential of criminal traits and externalizing behaviors
  • Children have the best chance for success under the care of committed and nurturing caregivers (typically children’s biological parents)
  • Despite these known risks, policies were recently in place in the united states that separated children from their caregivers (e.g., as a consequence of a “zero tolerance” immigration policy; Office of the Attorney General, 2018)
  • Merely surviving is insufficient and setting aside the psychological needs of children (i.e., having a committed and nurturing caregiver) is likely to result in significant harm
    • Children in custody are not having their caregiver needs met
  • Separation at the border
    • Separation from your caregiver is incredibly traumatic if you have strong attachment
    • Not having your caregiver to help you regulate your distress forces children to take care of themselves
  • Complexities or nuance in response to issues related to parent-child separation
On the one hand On the other
Separation causes harm Pre-separation events are also often harmful
Children belong with their caregivers Except some caregivers are dangerous
Children need swift places into families Stable long-term “permanent” placements are better than short term placements
Brain plasticity may mean increased vulnerability to separation Plasticity also affords the opportunity for growth and recovery
Many children recover from injury Just because you can recover doesn’t mean the injury is acceptable
Group based care meets children’s survival needs Survival is insufficient

Themes and Examples

  • Complexities in parent child separation research
    • Varieties of parent-child separation (e.g., there’s separation at the border, but children may also not see their parents due to their career)
      • Thinking of them on a continuum vs. a yes or no basis
    • Causal inferences
    • Definitional and informant issues
  • Conceptual model
    • When thinking about a child's mental health functioning it’s important to consider:
      • Pre-separation experiences
      • Circumstances of separation
      • Post separation experiences
  • Parsing the types of stress
    • Modeling stress (stressors “hang together”)
    • Stress vs. attachment disruption (having stronger attachment leads to greater stress when separated)
    • Interactive models - being multiplicative in their impact
    • Careful consideration of covariates
    • Quasi-experiments
      • Every child welfare system is a different fiefdom - different states/counties have different systems for taking a child from their family or returning a child to their family
  • Everyday child welfare dilemmas
    • Parents struggling with substance use disorder should be given the opportunity to rehabilitate and meet the needs of their children
      • But how long should children wait in limbo wondering how and whether they will have a permanent caregiver
    • → The goal of family unity could result in prolonged suffering in children exposed to unpredictable environments and increased risk for maltreatment
  • Sensitive Periods
    • Uematsu et al. (2012)
    • Age related changes in the hippocampus
      • Rapid growth in the first 5 years of life
    • Stress measurement
      • Youth interviews on the Traumatic Events screening inventory
      • Assessed 31 potentially traumatic events for children
      • Objective panel rated events individually and identified consensus  
      • Humpreys et al (2018) found that there was no association between stress severity in later childhood and left hippocampal volume, but did find negative association in early childhood
  • Mechanisms
    • Gray and white matter volume
    • White matter tract development
    • Task Based and fMRI
  • Adolescence as a sensitive period
    • Adolescence may be a period of increased plasticity
    • Distributed foster care (n=52) into disrupted vs. stable foster care
      • Examined group differences at age 54 months on: IQ, total psychiatric symptoms, percent time in institutional care
        • No differences in groups
  • Children placed in institutional care have higher rates of psychopathology
    • Children who were stably places look the same in terms of psychopathology whereas children who were disrupted look almost as bad as those in institutional care as usual which points us to believe that early intervention isn’t enough
  • Cultural and Political Context
    • Who is separated
    • Where are children placed
    • What services are available
    • Urgency of reunion or permanency
  • Caregiver input exists on a continuum
    • Humphreys, King, & Gotlib (2018) HIMH
    • There is a continuum of severe separation to enriched environment as well as of healthy development
  • Emotional input (“nurturance”) vs. Cognitive input (“stimulation”)
    • Caregiving is multidimensional
      • How sensitively is it delivered?
        • If your child is sitting comfortably and you run up to them and say “I love you so much” and give them a big hug, that is definitely warm but not sensitive
    • Research (King, Humphreys & Gotlib, 2019)
      • Qualitative coding of maternal sensitivity during the SFP and Micro-analytic coding of maternal touch during the SFP
        • No correlation between maternal sensitivity and . ? .
        • Slightly negative but not significant correlation between (??)
      • Mothers reports of her own distress were associated with less maternal touch
    • Future direction:
      • Putting devices on mothers and babies to measure their distance over time
      • TotTags - wearable devices that measure distance and time
        • Relationship between physical proximity and stimulation (word count)
      • Idea is that close contact would mean more enriching experiences with the child
        • Ex: strange situations study

Take home messages

  • Children benefit from high-quality, stable, family care with a committed adult
  • Particularly early in life, infants and young children are entirely dependent on caregivers to provide them stimulation and nurturance and to protect them from harm
  • Although there are moral, political, and cultural reasons to be examining the effects of parent-child separations today, for decades _______
  • There are hundreds of thousands of (orphans worldwide?)
  • Scientists have a strong inclination to pursue work with the hopes that policymakers and government officials will use the products of our research to inform their decision making
  • The ability for our science to influence parent-child separation has not been established
  • The Romanina government passed a law in 2005 banning children younger than 24 months of age from being placed in institutions
    • This shows some proof that policy makers are listening to science when making their decisions
  • Include a list of individuals to follow and organizations (donations, information)

Q&A

  • Used to work with kids separated from their families because they were a risk to themselves or others. Were in the school and lived there, but had time with their parents - any thoughts?
    • Keeping kids in close contact with their caregivers is preferrable
    • Regular phone calls for older kids may have similar benefits
    • There’s a shift to wanting to treat children as if they’re not a part of a larger context but we need to treat children within their own context
  • Is there research within parent-child separation that looks at separations within juvenile justice
    • Stressors do not occur independently - the first priority is for children to be in a safe caregiving relationship
    • Sometimes, it is beneficial to be removed from their biological family or origin
      • It’s hard to speak definitively about letting a child stay in certain settings with their family of origin
    • A few years ago there was research on keeping children with offenders who were incarcerated for nonviolent offenses (such as drug charges), which found it was beneficial to keep the child with their caregiver
  • Sibling separation? Is there an age threshold where sibling separation can lead to psychological harm
    • There have been studies if children in the foster system should be reunited for the sake of being reunited with siblings, which found that it’s still better to keep them with their foster family that they’ve adjusted to          
  • Issue of culture. The culture that the families bring with them to the country they are seeking asylum in.

Block IV Break Out Discussions for Future Directions Address 4 (5:05 pm-5:50 pm)

Description

Dr. Deborah Drabick and Dr. Elizabeth Talbott will serve as Breakout Discussion Leaders following Dr. Kathryn Humphreys’s Future Directions Address (“Future Directions in Parent-Child Seperation”)

Dr. Deborah Drabick, Ph.D.

Dr. Deborah Drabick is an Associate Professor of Psychology at Temple University. Her expertise is broadly in developmental psychopathology, and more specifically in youth externalizing problems. Her work includes such areas as risk and resilience, co-occurring psychological conditions, contextual influences, and intervention. Dr. Drabick has been funded by the National Institute of Mental Health, American Psychological Foundation, PA Department of Health, and Temple University. She currently serves as an Associate Editor for the Journal of Clinical Child & Adolescent Psychology.

Discussion Materials
Notes
Click "Expand" for notes
  • Heterogeneity in aspects of separation
    • Necessity of separation for children's wellbeing (maltreatment vs. immigration)
      • When we see maltreatment, we might see intergenerational transmission.
      • When parent has poor regulation, we might teach them skills
      • If the problem is with substance use, the more important question is when to reunite the child and parent
    • Pre-separation environment (e.g, attachment, violence exposure)
    • Post-separation placement (e.g., high-quality family care vs. group-based care)
      • Is there a family network to go to?
    • Effects of developmental stage
      • When kids are 2-3 we see conscious developing
      • A spectrum of empathy- at the low end is callous-unemotional behavior
      • If a mother has CU traits, she can’t teach her children these foundational abilities
    • Foundational abilities (e.g., cognition, emotion regulation) in place to promote resilience?
      • If kid is small and being separated and not getting stimulation they might need, what are the building blocks that they need to be given?
      • It’s useful to have emotion regulation but everyone has a temperament
        • Ex: if you’re more labile then you use much more regulation than someone who’s calm
    • Factors contributing to risk
      • Goodness of fit helps protect from risk. The challenge is when there is a difference on both ends
    • APA Sent a letter to the President on policy
      • Example- someone experiencing trauma fleeing to the US with a child. The kid is attached, the mom is traumatized. These factors inform the nature of intervention
  • Parsing types of stress
    • Cascade models
      • One risk factor may lead to others (there’s a cumulative piece to it)
        • Contextual risk -> Family difficulties -> child difficulties
          • Ex: low SES ->neighborhood disadvantage -> Parent psychopathology -> problematic parenting ->cognitive or emotion regulation challenges -> poor school readiness.
    • Role of context
      • Distal to proximal risks
      • Child x context interactions- individual is going to interact with the context they’re in
        • If the kid is tantruming and the parent gives in- the kid is positively reinforced and the parent is negatively reinforced by the removal of the tantrum- everyone is shaping each other
        • Are we setting the necessary behavioral foundations?
        • Some parents might be more touchy but not talk to the child a lot or vice versa
          • Brings us to the idea of person-centered models in order to adapt treatments to the type of family
    • Potential mediators
    • Reciprocal and transactional processes
    • Person vs. variable centered modeling
      • Helps address complex circumstances
      • Different trajectories for different individual
      • LCA/LPA, GCM with covariates
  • Sensitive periods
    • Role of attachment
      • Think about attachment disorders with primary caregiver and kids can also have other adults that give love and support.
      • It is malleable- may have a bad attachment with a primary caregiver but there are still chances to learn emotion regulation and other skills
    • Developmental demands and expectations
      • Available resources to promote positive development? We know there’s neural plasticity and other supports in the environment will promote resilience
    • How to characterize “sensitive” periods
      • Role of neural processes
      • Cognitive and emotional functioning
    • Individual differences in response to context (e.g., diathesis-stress vs. differential susceptibility)
      • Diathesis-stress: you have a genetic predisposition for a disorder which is then brought out by environmental stressors
      • Differential susceptibility: in the presence of positive events you’re going to do better than those without the diathesis (in the place of stressors, you fare worse in the same sense of diathesis-stress)
        • Essentially states that with diathesis, you’re more reactive to the environment in all realms
    • Possibility of resilience
      • Adversity can promote problem-solving, increase autonomy and facilitate future adjustment when experienced during adolescence, though this developmental period presents other challenges in the context of separation
      • If you go through something tough as an adolescent you cope better as adults
  • Cultural and political contexts- challenges on the back end
    • Availability of resources
    • Types of alternate placement
    • Variations in cultural practices and acceptability of separations
    • Immigration policies
    • Broader messages and influences of social media
      • Many groups are active online with misinformation and hateful messages and it is easy for them to do
  • Assessment and intervention implications-
    • What aspects of the family lead to positive adaptation
    • What constructs need to be assessed?
      • Parent child behavioral synchrony- dysregulation may be transmitted to the children from parents
      • Parental consistency and warmth- both personality traits that benefit child
      • Self soothing abilities in children
      • Absence of conflict vs presence of strong alliance (low conflict versus just lots of warmth). Which is leading to the issue/lack of issue?
        • Do want chances to model conflict resolution and problem solving
    • How should these be indexed and data integrated to inform decision making?
      • Multiple levels of analysis.
        • Talk about warmth/consistency when young
        • In adolescence, may look at monitoring of child, but there are differences in how much kids will share as well as how much parents are asking
      • Proxies for underlying developmental processes
      • Problems with retrospective reporting and informant biases
    • How can these assessments inform interventions and preventative service
      • Do we put these into assessments?
      • Do we use the information that we’ve gained to match kids with the best resources, do we use it for assessment?
      • Of course, if it’s a safety issue, they need to be removed
  • Policy perspective
    • Stop removal of children from loving and capable caregivers
    • Provide support to families who have experienced separation
    • Address challenges with available resources
    • How can we gather the necessary data to understand the sequelae of separation
    • How can these data be disseminated better to inform policy and practice>
    • What support is useful?
      • For some kids, reunification is just it. But for many, there may then be a fear created of “Is this going to happen again?” - it depends on how traumatic the separation was
      • Qualitative research could be helpful as a start to determine from the people in distress what can be done that they can’t do for themselves and that it would be possible and helpful for us in psychology to be able to help
        • Also want to think in the long run after
        • People who have been suffering and escaping violence are more likely to develop PTSD
        • So treating the trauma now could result in a lower likelihood of future PTSD
      • This is not happening in isolation- even after reunification, there will still be a high degree of stressors
        • These things may be like not speaking English or needing a bed to sleep in
        • People with more basic needs are not going to be so concerned with mental health until they are able to feel like they are safe in general
      • Strengthening qualities of adversity-
        • People have said “Stop making it so easy for your kids”
        • Some degree of adversity can have benefits (much lower adversity on the continuum that parent-child separation, but still something)
        • The basis is that some highly privileged parents allow their children to have no worries
Dr. Elizabeth Talbott, Ph.D.

Dr. Elizabeth Talbott is Associate Professor of Special Education and legislative advocate for the Council for Exceptional Children-Division for Research. Talbott’s research addresses the mental health and academic needs of youth with disabilities, particularly urban youth. To meet the needs of these youth, Talbott and her colleagues study the characteristics and work of effective Individualized Education Program (IEP) teams.

Discussion Materials
Notes
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  • Dr. Talbot’s background
    • Council for Exceptional Children: Division of Research
      • Uses data
  • Advocacy: using evidence from science to influence public policy
  • Uptake or use of scientific evidence by policymakers and professionals in the field
  • Q1: What else can we do as citizens?
    • A1: We do know that there is a problem and it’s scientifically based. Need to convince experts that we are knowledgeable and we need to implement solutions
      • Parent separation story is easy because of how objectively bad it is
    • A2: One source of reluctance of going on the record is how it can be painted as a political battle; fear of harm to career
      • Kate: Easy for the science and my views to alight, but I did have to tone down. Struggle is in limiting bias to ensure the science shines through, afraid of coming across as biased even though the science backs you up
    • A3: So much xenophobia, people try to justify things they feel are rational but really aren’t. People gang up on both sides
    • A4: Fear of coming across as biased.
      • Talbot: Bias towards evidence
    • A5: Call policy-makers, use your knowledge and inform them, journals we rely on are behind pay walls (lay person or policy maker won’t read journal - make it easy to understand while still being informational)
    • A6: fear of people not caring about the research
      • Talbot: democracy is a powerful tool, we must use it by voting and calling representatives, grassroots side
    • A7: common argument of policy-maker- budget issues
      • Response: will cost so much more to provide health care down the line (this may make people care)
        • Importance of not demonizing people who only care about money, work with them and use all the evidence
        • Question: has this argument been in the media?
          • Talbot: cost runs into the public school system
          • Information is out there but it’s not reaching the proper audience
          • A lot of people don’t actually have access to this information, how do we get this information to the public?
          • Talbot: “Rise from Trauma Act”- bipartisan and bicameral act to teach teachers trauma-informed care
    • A8: Keep the topics going in the public eye (not just the “hot” topic) and continue to care
      • Actions to take: donate, call congress, vote, know the issues and have stories relevant to your district, be informed with reliable news sources, be committed for the long haul
    • A9: Dr. Humphrey’s dream of being called to inform policy (playing the long game)
      • Talbot: It takes time, but it is becoming more prominent. The way to make a difference as a professional is to get involved in APA government relations or other organizations to help facilitate professional development, meet with representatives, and spin the information to present it in a way that’s most appropriate to the individual/group
        • Tldr: Make sure the information gets to our lawmakers
  • Q2: What are the perceived incentives for folks working in congress with Dr. Talbot’s organization?
    • Talbot: Try to figure out what they want - if it’s really not what the people want, vote them out/they’ll probably get voted out. Thank the ones who are fighting for you.
    • How research influences policy
      • Every Student Succeeds Act (2015) - includes evidence based interventions and trauma informed services in schools
      • Grassroots fight to save Medicaid funding (2017)
        • Physically fighting makes a difference.
        • Sometimes the only way to capture people’s attention is through stark exposure to the harms
  • Q3: As an advocate and a researcher, how do you deal with the burnout, the backlash, and the intense research
    • Talbot: Pacing yourself and sticking with it alongside your colleagues. Having support and maintaining hope throughout your career helps motivate change and prevent burnout
    • Kate: Shifting focus, rationalizing your involvement, and realizing that your work means something
  1. ↑ McLaughlin, Katie (2019)."Adversity and Mental Health (Mclaughlin)". Open Science Framework. doi:10.17605/osf.io/r3p76.
  2. ↑ McLaughlin, Katie A. (2016-05-03). "Future Directions in Childhood Adversity and Youth Psychopathology". Journal of Clinical Child & Adolescent Psychology 45 (3): 361–382. doi:10.1080/15374416.2015.1110823. ISSN 1537-4416. http://www.tandfonline.com/doi/full/10.1080/15374416.2015.1110823.
  3. ↑ McLaughlin, Katie A.; Greif Green, Jennifer; Gruber, Michael J.; Sampson, Nancy A.; Zaslavsky, Alan M.; Kessler, Ronald C. (2012-11-01). "Childhood Adversities and First Onset of Psychiatric Disorders in a National Sample of US Adolescents". Archives of General Psychiatry 69 (11): 1151. doi:10.1001/archgenpsychiatry.2011.2277. ISSN 0003-990X. http://archpsyc.jamanetwork.com/article.aspx?doi=10.1001/archgenpsychiatry.2011.2277.
  4. ↑ Green, Jennifer Greif; McLaughlin, Katie A.; Berglund, Patricia A.; Gruber, Michael J.; Sampson, Nancy A.; Zaslavsky, Alan M.; Kessler, Ronald C. (2010-02-01). "Childhood Adversities and Adult Psychiatric Disorders in the National Comorbidity Survey Replication I: Associations With First Onset of DSM-IV Disorders". Archives of General Psychiatry 67 (2): 113. doi:10.1001/archgenpsychiatry.2009.186. ISSN 0003-990X. http://archpsyc.jamanetwork.com/article.aspx?doi=10.1001/archgenpsychiatry.2009.186.
  5. 1 2 3 McLaughlin, Katie A.; Sheridan, Margaret A.; Lambert, Hilary K. (2014-11). "Childhood adversity and neural development: Deprivation and threat as distinct dimensions of early experience". Neuroscience & Biobehavioral Reviews 47: 578–591. doi:10.1016/j.neubiorev.2014.10.012. https://linkinghub.elsevier.com/retrieve/pii/S0149763414002620.
  6. ↑ McLaughlin, Katie A; Lambert, Hilary K (2017-4). "Child trauma exposure and psychopathology: mechanisms of risk and resilience". Current Opinion in Psychology 14: 29–34. doi:10.1016/j.copsyc.2016.10.004. https://linkinghub.elsevier.com/retrieve/pii/S2352250X16301361.
  7. ↑ Pollak, Seth D.; Tolley-Schell, Stephanie A. (2003). "Selective attention to facial emotion in physically abused children.". Journal of Abnormal Psychology 112 (3): 323–338. doi:10.1037/0021-843X.112.3.323. ISSN 1939-1846. http://doi.apa.org/getdoi.cfm?doi=10.1037/0021-843X.112.3.323.
  8. ↑ Dodge, K.; Bates, J.; Pettit, G. (1990-12-21). "Mechanisms in the cycle of violence". Science 250 (4988): 1678–1683. doi:10.1126/science.2270481. ISSN 0036-8075. http://www.sciencemag.org/cgi/doi/10.1126/science.2270481.
  9. ↑ "PsycNET". psycnet.apa.org. Retrieved 2019-07-02.
  10. ↑ Caspi, Avshalom; Houts, Renate M.; Belsky, Daniel W.; Goldman-Mellor, Sidra J.; Harrington, HonaLee; Israel, Salomon; Meier, Madeline H.; Ramrakha, Sandhya et al. (2014-03-01). "The p Factor: One General Psychopathology Factor in the Structure of Psychiatric Disorders?". Clinical Psychological Science 2 (2): 119–137. doi:10.1177/2167702613497473. ISSN 2167-7026. https://doi.org/10.1177/2167702613497473.
  11. ↑ Shechner, Tomer; Hong, Melanie; Britton, Jennifer C.; Pine, Daniel S.; Fox, Nathan A. (2014-07-01). "Fear conditioning and extinction across development: Evidence from human studies and animal models". Biological Psychology 100: 1–12. doi:10.1016/j.biopsycho.2014.04.001. ISSN 0301-0511. http://www.sciencedirect.com/science/article/pii/S0301051114000714.
  12. ↑ Pine, Daniel S.; Wojcieszak, Zuzanna; Shechner, Tomer; Heleniak, Charlotte; Matthew Peverill; Lambert, Hilary K.; Duys, Andrea; Gold, Andrea L. et al. (2016-07). "Maltreatment Exposure, Brain Structure, and Fear Conditioning in Children and Adolescents"]. Neuropsychopharmacology 41 (8): 1956–1964. doi:10.1038/npp.2015.365. ISSN 1740-634X. https://www.nature.com/articles/npp2015365].
  13. ↑ Briggs‐Gowan, Margaret J.; Pollak, Seth D.; Grasso, Damion; Voss, Joel; Mian, Nicholas D.; Zobel, Elvira; McCarthy, Kimberly J.; Wakschlag, Lauren S. et al. (2015). "Attention bias and anxiety in young children exposed to family violence". Journal of Child Psychology and Psychiatry 56 (11): 1194–1201. doi:10.1111/jcpp.12397. ISSN 1469-7610. https://onlinelibrary.wiley.com/doi/abs/10.1111/jcpp.12397.
  14. ↑ Troller‐Renfree, Sonya; McDermott, Jennifer Martin; Nelson, Charles A.; Zeanah, Charles H.; Fox, Nathan A. (2015). "The effects of early foster care intervention on attention biases in previously institutionalized children in Romania". Developmental Science 18 (5): 713–722. doi:10.1111/desc.12261. ISSN 1467-7687. https://onlinelibrary.wiley.com/doi/abs/10.1111/desc.12261.
  15. ↑ Hart, B., & Risley, T. R. (1995). Meaningful differences in the everyday experience of young American children. Paul H Brookes Publishing. https://psycnet.apa.org/record/1995-98021-000?mod=article_inline
  16. ↑ Peter R., Huttenlocher (1979-03-16). "Synaptic density in human frontal cortex — Developmental changes and effects of aging". Brain Research 163 (2): 195–205. doi:10.1016/0006-8993(79)90349-4. ISSN 0006-8993. http://www.sciencedirect.com/science/article/pii/0006899379903494.
  17. ↑ Lenroot, Rhoshel K.; Giedd, Jay N. (2006-01-01). "Brain development in children and adolescents: Insights from anatomical magnetic resonance imaging". Neuroscience & Biobehavioral Reviews. Methodological and Conceptual Advances in the Study of Brain-Behavior Dynamics: A Multivariate Lifespan Perspective 30 (6): 718–729. doi:10.1016/j.neubiorev.2006.06.001. ISSN 0149-7634. http://www.sciencedirect.com/science/article/pii/S0149763406000455.
  18. ↑ O'Kusky, John R. (1985-09-01). "Synapse elimination in the developing visual cortex: a morphometric analysis in normal and dark-reared cats". Developmental Brain Research 22 (1): 81–91. doi:10.1016/0165-3806(85)90071-9. ISSN 0165-3806. http://www.sciencedirect.com/science/article/pii/0165380685900719.
  19. ↑ McLaughlin, Katie A.; Sheridan, Margaret A.; Nelson, Charles A. (2017-10-01). "Neglect as a Violation of Species-Expectant Experience: Neurodevelopmental Consequences". Biological Psychiatry. Stress: Mechanisms in Gut and Brain 82 (7): 462–471. doi:10.1016/j.biopsych.2017.02.1096. ISSN 0006-3223. http://www.sciencedirect.com/science/article/pii/S0006322317312180.
  20. ↑ Koga, Sebastian; Parker, Susan W.; Marshall, Peter; Smyke, Anna T.; Fox, Nathan A.; Nelson, Charles A.; Zeanah, Charles H. (2003/12). "Designing research to study the effects of institutionalization on brain and behavioral development: The Bucharest Early Intervention Project". Development and Psychopathology 15 (4): 885–907. doi:10.1017/S0954579403000452. ISSN 1469-2198. https://www.cambridge.org/core/journals/development-and-psychopathology/article/designing-research-to-study-the-effects-of-institutionalization-on-brain-and-behavioral-development-the-bucharest-early-intervention-project/3EFBD6B6D3F4E64512A961E488AED627.
  21. ↑ Nelson, Charles A.; McLaughlin, Katie A.; Zeanah, Charles H.; Fox, Nathan A.; Sheridan, Margaret A. (2012-08-07). "Variation in neural development as a result of exposure to institutionalization early in childhood". Proceedings of the National Academy of Sciences 109 (32): 12927–12932. doi:10.1073/pnas.1200041109. ISSN 0027-8424. PMID 22826224. https://www.pnas.org/content/109/32/12927.
  22. ↑ McLaughlin, Katie A.; Sheridan, Margaret A.; Winter, Warren; Fox, Nathan A.; Zeanah, Charles H.; Nelson, Charles A. (2014-10-15). "Widespread Reductions in Cortical Thickness Following Severe Early-Life Deprivation: A Neurodevelopmental Pathway to Attention-Deficit/Hyperactivity Disorder". Biological Psychiatry. Cortical Development in Attention-Deficit/Hyperactivity Disorder 76 (8): 629–638. doi:10.1016/j.biopsych.2013.08.016. ISSN 0006-3223. http://www.sciencedirect.com/science/article/pii/S0006322313007695.
  23. ↑ Mackey, Allyson P.; Finn, Amy S.; Leonard, Julia A.; Jacoby-Senghor, Drew S.; West, Martin R.; Gabrieli, Christopher F. O.; Gabrieli, John D. E. (2015-06-01). "Neuroanatomical Correlates of the Income-Achievement Gap". Psychological Science 26 (6): 925–933. doi:10.1177/0956797615572233. ISSN 0956-7976. https://doi.org/10.1177/0956797615572233.
  24. ↑ McLaughlin, Katie A.; Finn, Amy S.; Peverill, Matthew; Sheridan, Margaret A. (2017/12). "Dimensions of childhood adversity have distinct associations with neural systems underlying executive functioning". Development and Psychopathology 29 (5): 1777–1794. doi:10.1017/S0954579417001390. ISSN 0954-5794. https://www.cambridge.org/core/journals/development-and-psychopathology/article/dimensions-of-childhood-adversity-have-distinct-associations-with-neural-systems-underlying-executive-functioning/C22A23991FAA28739EA5A6F90CB53E98.
  25. ↑ [McLaughlin, K. (2019). Social Work.]
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