Parallel Agenda

• Evidence-base for Parenting Programs to Support Fathers
• Review of the studies included in a program of research related to father-focused intervention
• Future Directions
• Discuss steps in the establishment of a program of research in a specific content area
• Highlight lessons learned and how to cultivate future directions

Parenting

• There is a strong body of research illustrating optimal parenting practices
• Parents may be key processes in the development and support of kids
• Theoretical Model of Dysfunctional Parent-Child Relationships-Coercive Process
  • Child misbehavior->Maladaptive/Inconsistent/Poor Monitoring Parental Response->Future negative/maladaptive interactions->Child misbehavior reinforced

Parenting and Fathers

• Why Focus on Fathers?
  • Increased, meaningful father involvement in childhood is a clear and long-standing national priority
  • Yet father involvement is lagging behind that of mothers, and the research base on successful intervention is small
  • Fathers uniquely contribute to language development and early literacy skills
  • Uniquely contribute to the development of appropriate socialization skills
  • Over the past 50 years, fathers/ roles in childcare has increased almost threefold
• Why are fathers not involved in BPT studies?
  • Clinical Observations
  • Find a niches
  • Review the Literature
    • No studies specifically dealt with fathers, only a few collected and analyzed father outcome measures separately
    • Expanding to the entire parent training literature, few studies investigate the effectiveness of psychoeducational classes for fathers
  • Why are Fathers under-involved?
    • Clinicians may implicitly exclude fathers by addressing correspondence to only mothers or require only mothers for interviews
    • Because most rating forms are normed to mothers
    • Standard clinical hours (9am-5pm) are not convenient for employed mothers or fathers
    • Father’s participation in recreational activities and unstructured play times is more typical relative to mothers’ activities, therefore BPT class content may fail to address the needs of many fathers
    • Men generally do not seek out or ask for help for health/mental health services (less likely to show up for mental health treatment AND parental training)
    • Fathers report few problems in parenting, even in the face of self-reported dysfunctional discipline techniques (mothers were more aware of their parenting status and role with their child’s problems)
• A BPT Program designed for Fathers
  • The COACHES program combines and synergizes two manualized treatments commonly used for children with ADHD
    • Summer Treatment Program, Community Parent Education Program
    • Coaches Format (had important pilot studies that engaged collaborators):
      • Standard Parenting Course: During the first hour, fathers review how to implement effective parenting strategies in a group class (using praise/time out)
      • Concurrently, children practice soccer drills with para-professional counselors, to increase competencies in the sports domain (teaches social interaction, sports skills, and confidence)
      • During the second hour, fathers and children join together for a soccer game
      • Fathers “coach” the soccer game by employing the strategies discussed during the first half of the program
      • During frequent breaks, fathers receive on-line feedback from trained staff, work together to trouble-shoot problems that occur, and reinforce each other for the successful implementation of parenting strategies
      • Especially useful to only focus on positive reinforcement for ADHD children and not overwhelm them
      • Daily report cards to keep track of kid’s behavior and the fathers’ skill of the week
    • Coping, Modeling, Problem-solving approach
    • Importance of building sports skills
      • 35 million youth play in organized sports
    • How is COACHES different?
      • Does not approach fathers as “deficient” in parenting strategies. Frames treatment as a way to build competencies in an area where many may already have skills (coaching)
      • Framing treatment in this way may reduce stigma associated with initiating and participating in mental health services
      • Helps provide structure for children and parents and teach them helpful parenting skills
      • Empirically proven to be effective and have higher attendance than other programs from children and fathers, and fathers were more satisfied with the process
• Future Directions:
  • Shared Book-Reading in Preschoolers
    • A spanish-language adaptation of COACHES was developed for Head Start preschools
  • COACHES in Schools
    • Adapting COACHES for implementation by school counselors/physical education teachers
    • Positive Parenting Program in Head Start After-School (Labeled Praise exercises)
      • Reduced negative talk
  • General Findings from Systematic Review of Intervention Studies that Include Fathers
    • Incredible diversity across study designs, treatments and assessments
    • Construct of co-parenting rarely investigated
    • Attrition was not uniformly assessed
    • Variability in measures used (Together these factors make general conclusions tentative)
  • Focus Areas
    • Father-focused research agendas include a particular focus on:
      • Inclusion:
        • Begin to enroll all caretakers in studies (set this expectation at the time of study consent)
        • Broaden the definition of “Father”
        • Be aware of side effects of greater father inclusion (impact on other parent, child, family unit)
      • Engagement:
        • Fathers may be less action oriented regarding clinical intervention
        • Treatment preferences also vary between mothers and fathers
        • Meet fathers where they are
        • Developmental transitions important to fathers (high school, college, driving, initiation of out of home activities such as sports)
        • Cultural adaptations should be emphasized in future work to promote appropriate treatment and engagement
      • Retention:
        • Nuanced analysis of drop-out (never showed, early drop-out, late drop-out)
        • Drop out within/across families
        • Participation in some activities, over others
          • COACHES in schools example, stopped attending group instruction but arrives for parent-child interaction
          • Co-parents “tag-team” attendance
      • Measurement of Outcomes:
        • Appropriate interpretation of outcomes needs to understand the parenting lens (differences in parental responsibilities, values, context of interaction
        • Mechanism to meaningfully integrate information across sources
        • Management of discrepancies
        • Treatment satisfaction should be collected from parents
  • Additional Future directions:
    • How to define participant in the study (father, child, co-parents, family)
    • Balancing diversity among fathers and roles
    • Understanding reciprocal and dynamic role of fathers across contexts, time, and families
    • Increased father involvement may not always be welcome by mothers

Q and A

Q: What do you think about using COACHES for video games during the time of this pandemic?

A: What’s important is using an activity that engages the father and child.

Q: Is there any research about parental skill discrepancies among parents?

A: A study from the 90’s found that mothers wanted fathers to improve their involvement with children, but only to an extent that aligns with the mothers’ views. Studies should focus on this, but parents should have diverse parenting strategies

Q: Have you explored outcomes of the COACHES program for nontraditional family structures (divorced, same-sex)

A: Great topic for future research, studies have been done on these nontraditional family structures, but only a small sample.

Q: Moms mostly initiate treatment, so how do you navigate getting fathers’ to initiate care?

A: Made the ad for COACHES targeted to mothers to get father involvement.

Parallel Agenda

• Evidence base for Parenting Programs to Support Fathers
• Review of the studies included in a program of research related to father focused intervention
• Future directions
• Discuss steps in the establishment of a program of research in a specific content area
• Highlight lessons learned and how to cultivate future directions

Parenting

• Theres is a strong body of research illustrating optimal parenting practices
• Parents may be a key promoter of resilience in children
• Decades of rigorous research illustrate the positive impact parents have on children

Theoretical Model of Dysfunctional Parent-Child Relationship- Coercive Process

• If you have a non-compliant child, the magnitude of possible parent mistakes increases, and the damage done to the child increases
  • Children with maladaptive behaviors have parents who have more maladaptive practices
    • Parents become tired etc.
    • Some parents are willing to accept their child breaking rules/acting out and not intervening purpose of stopping any behavior that could be worse if they try to discipline them
• Child misbehavior, difficult temperament, oppositional behavior, conduct problems → maladaptive parental response, inconsistent parenting, punitive parenting, poor monitoring, few to no positive interactions → future negative/maladaptive interactions (it’s a cycle)

Video Example of Dr. Fabiano’s Children

• Video Example: https://youtu.be/7SuCU681EBw
  • The task was to dribble a soccer ball around cones
    • Acted as more of a strict/demanding parent
      • Directive, authoritative
      • Ratio of commands to praise is way off
    • The daughter gets frustrated and then becomes very upset, she doesn’t complete the task
    • The dad tells her to stop pouting and she becomes even more upset
      • His first response is to tell her to stop, it is an example of how easy it is to have maladaptive parenting patterns
      • It is easy to have negative interactional styles

Parenting and Fathers

• Why focus on fathers?
  • Increased, meaningful father involvement in childhood is a clear and long-standing national priority
  • Yet, father involvement is lagging behind that of mothers, and the research base on successful intervention

• Importance of Fathers
  • Uniquely contribute to language development and early literacy skills
    • Fathers speak louder to their children and with more complex words
  • Uniquely contribute to the development of appropriate socialization skills
  • Over the past 50 years, fathers’ roles in childcare has increased almost threefold
• Why are fathers not involved in BPT (Behavioral Parent Treatment) studies?
  • Father’s are under-represented in BPT studies (at the time of starting this line of research in 1999)
  • In the ADHD treatment literature:
    • 30 investigate BPT including 1,993 participants
    • These studies clearly support BPT as a “well established” treatment
  • BUT
    • No studies specifically dealt with fathers
    • Only a few collected and analyzed father outcome measures separately
    • Missing here
    • Expanding to the entire parent training lit, few studies investigate effectiveness of psychoeducational classes for fathers
    • Some BPT studies indicate equivocal results of including fathers in parent training

Why are dads under involved?

• Approach to/Engagement of fathers during initial content
  • Clinicians may implicitly exclude fathers by addressing correspondence to only mothers or require moms for interviews
  • Because most ratuing forms are normed on moms, fathers not asked input
  • Standard clinical hours (9-5) are not convenient for employed mothers or fathers
• Parents of children with ADHD increased likelihood to have ADHD themselves
• ADHD impeded parenting and BPT processes … (missing)
• “Research has yet to identify any child-care task for which fathers have primary responsibility”
  • This is changing
• Fathers participation in recreational activities and unstructured play times is more typical relative to mother’s activities
• The content of BPT classes may therefore fail to address the needs of many fathers
  • No fathers in the study had any role in getting their children ready for school, and that is where many issues in the household arise
• Men generally do not seek out or ask for help for health/mental services
  • This is the same for BPT, dads less likely to show up
• Fathers report few problems in parenting, even in the face of self-reported dysfunctional discipline techniques
  • Dad’s took on less responsibility for their children’s issues

The COACHES program

• The COACHES program combines and synergies two manualized treatments commonly used for children with ADHD
  • Summer treatment program
  • Community parent education program
• Treatment components from these programs are adapted for use in the father-based parenting class, the child based skills trill, and something else im missing
• Format
  • In the first hour, fathers review how to implement effective parenting strategies in group class (ex. Using praise, using time out)
  • Concurrently, children practice soccer skill drills with para-professional counselors, to increase competencies in the sports domain
  • During the second hour, fathers and children come together for game
    • Fathers use the skills they learn
  • Fathers “coach” the soccer game by employing the strategies discussed during the first half of the program
  • During frequent breaks, fathers receive on-line feedback from trained staff, work together to trouble-shoot problems that occur, and reinforce each other for the successful implementation of parenting strategies
    • Focus is on using more positive reinforcement, instead of being overly critical and telling the child what to do

Coping, Modeling, and Problem Solving Approach

• Parenting program uses style pioneers and developed by Cunningham
  • Group and subgroup based
  • Facilitated, not prescribed provision of information
  • Missing

Importance of Building Sports Skills

• 35 million youth in sports
• 33% of youth K-8 participate in afterschool programs
• More here

GAme procedures

• Fathers coach their own children
  • They can go out on the field and coach their own children
  • With “report card” they keep track of their positive progress, and if they are using positive praise with their child
    • At first they have no praise on their report card, but by the 3rd week the dads use praise with both their kids and other’s children

How is it different from other interventions?

• Does not approach fathers as “deficient” in parenting strategies. Frames treatment as a way to build competencies in an area where many may have already skills
• Framing treatment in this way may reduce stigma associated with initiating and participating in mental health services

Outcomes of Coaches Program vs. Waitlist Studies

• COACHES program participants praised more than those on the waitlist
  • About 2 more praises but this is in a half hour time line which is on a trajectory
• Rated kids behavior as better after treatment
• Dads seemed to like the program
• Dads in the program rated their kids as improved
• Attendance was greeter in the COACHES program than any traditional intervention as well as with child attendance
• Fathers Less likely to drop out
• Fathers more satisfied with progress
• Fathers more likely to complete their “homework”

Future Directions

• Shared book-reading in preschoolers
• A Spanish language adaption of COACHES was developed for Head Start preschools
  • Fathers watched video taped vignetted of parenting strategies and dialogic reading to TEACH
  • Randomly assigned to program or waitlist
    • Moderate effect on parenting skills
    • Kid’s language did improve COACHES in Schools
    • Adapting COACHES for implementation by school counselors/physical education teachers
      • Train these people to run it, instead of the clinical staff
      • Task- sharing
    • Similar to results of the clinical samples
      • There were some very positive results
    • In their positive parenting program in head start after school
      • Shorter study
        • Did not see any difference in praise, but saw a reduction in commands and negative talk Future Directions in Father Focused Research
    • General Findings from Systematic Review of Intervention Studies Including Fathers
      • Incredible diversity across study designs, treatments, and assessment
      • Construct of co-parenting rarely investigated
        • Work needs to be done to integrate this into typical parent intervention studies
      • Attrition was not uniformly assessed
      • Variability in measures used
        • Together these factors make general conclusions tentative
    • Focus areas
      • Father focused research agenda areas to focus on:
        • Inclusion
          • Begin to enroll all caretakers in studies
            • Set this expectation of the time of study consent
          • Broaden the definition of “Father”
            • This term is a placeholder for any male caregiver
          • Be aware of the side effects of greater father inclusion
            • Impact on other parent; child; family unit
        • Engagement
          • Fathers may be less action oriented regarding clinical intervention
          • Treatment preferences also vary between mothers and fathers
            • Mothers are open to meds, fathers not for example
          • Meet fathers where they are
          • Developmental transitions important to fathers (high school, college, driving, initiation out of the home, activities such as sports)
          • Cultural adaptations should be emphasized in future work to promote appropriate treatment and engagement
        • Retention
          • Nuanced analysis of drop-out
            • Never showed
            • Early drop-out
            • Late drop-out
              • Could be good and negative drop outs (someone who doesnt need it anymore or another reason)
          • Drop out within/across families
          • Participation in some activities, over others
            • COACHES in schools example- stopped attending group instruction but arrives for parent-child interaction
            • Co-parents “tag team” attendance
              • How does this impact outcomes?
              • Neither parents gets the full effect of the intervention
        • Measurement of outcomes
          • Appropriate interpretation of outcomes needs to understand the parenting lens
            • Differences in parental responsibility, values, context of interaction
          • Mechanism to meaningfully integrate information across sources
          • Management of discrepancies
          • Treatment satisfaction should be collected from all caregivers Additional Future Directions
    • How do we define participant in study
      • Father, child, co-parents family etc,
      • This will have consequences for design and measures
    • Balancing diversity among fathers and roles
    • Understanding reciprocal and dynamic role of fathers across contexts, time, and families
      • Ex. COVID-19 pandemic, fathers are at home with their children, children are not in school or extra curricular activities
    • Increased father involvement may not always be welcomed by mothers Questions
    • What do you think about COACHES during the pandemic for online activities such as video games like Animal Crossing?
      • Dr. Fabiano thinks it’s a good idea, sports is just the medium, it is about the parenting skills, and getting children and dads engaged in an activity they will enj
      • Mothers wanted fathers to be included if they subscribe to their parenting strategy already, didn't want them involved if it was different (found in research)

• • Inter parent consistency is something that needs to be studied more for co-parenting success
  • Is there a right combination of mother/father parenting strategies that work together?
• Have you studied the COACHES program for non traditional families?
  • We have included single dads, divorcd, separated, same sex but not at the sample size that we can say they moderated outcomes
  • Good research direction, but he expects results will be the same
• Do moms often initiate treatment?
  • Moms are gatekeepers and decision maker and moms would initiate dads coming in for the studies
  • Think about designing interventions around the scheduling procedure in many families
    • Usually mother arranges the treatment for the child, so they could possibly be exclushing fathers that would otherwise participate

• We will be walking through the literature to see the foundation of interventions
• Outline:
  • Defining normal and rethinking deficits
    • Hegemony theory
    • ‘Normal’ is culturally defined
  • Development in context
    • Modern development theory
    • Context-specific development
  • Importance of so called stress response system and by extension the importance of coping
  • Identify existing assets within diverse communities and working class culture
  • Increasing agency and purpose via collective social action  
• What is normal?
  • How do we know?
  • Normal is ways of being that predict success/happiness
  • Behaviors outside of normal are abnormal, deficit, wring, immoral
  • Is it time to dump this deficit model
  • In western society
    • Normal behaviors align with being white and upper class
    • Wealth accumulation viewed more importantly than balance, health, family, relationships
  • Hegemony- an ideology/cultural discourse
    • Our institutions/structures tell us about how we are
    • Based on meritocracy values
      • Says those at the top got there in a fair way, and those at the bottom didn’t work hard enough (it’s their own fault)
      • Obscures racial/class inequities
    • Hegemony=status quo
    • If you fit you don’t notice it exists (like a fish in water)
    • But if you don’t fit, like a fish over water, you see it and see you can fall in (like a person of color or low SES)
  • So, normal is culturally defined
    • This helps us understand development in context
• Development
  • Experience dependent brain development
    • Development is shaped by the environment that causes us to develop specific skills/abilities
  • Experiential canalization
    • As a baby grows, they encounter challenges and there are forks in the road based on temperament, previous development, and environmental circumstances
    • These environmental inputs like opportunities/interactions send them along a pathway at a junction  
  • Developmental cascades
    • Repeated developmental experiences accumulate and determine what future paths will open/close
  • Coping and regulation skill sets
    • Are stress response systems
    • Characteristic way of responding to challenges
  • Development with an eye toward the future
    • There’s no one right pathway
    • Equips the child for future world, but which future world
    • For example, a world of technology prepares kids for using the technology for the rest of their lives, whereas others may need to learn to hunt or cook at a young age
  • Adaptive calibration
    • Some kids grow up in dangerous, unpredictable environments
    • Develop neural networks/responses for operating in chaotic environments
    • Don’t necessarily develop behaviors that would help success in other environments like delayed gratification
  • Fundamental adaptation framework
    • The skills we develop help in our environment
    • So there’s a mismatch between our learning environment and others we need to function in
  • Development in context summary
    • Not just ‘deviant context’- we are all functionally adaptive
    • There’s no one right skill set that fits cultural hegemony
    • Not deficits- don’t need to be ‘fixed
    • In fact, could we build on their skill sets instead of trying to unlearn them
  • Children living in poverty- exposures
    • Hunger, gun shots, seeing dead bodies,  family members killed, homeless..
  • Examples
    • If you live in a food insecure environment- would you show delayed gratification in a marshmallow test? Probably not
    • What about if adults are never reliable for you, will you trust adults? Probably not
  • Developmental trade offs
    • We develop abilities that match our environment
  • Identifying skills to build on
    • What if we try to capitalize on differences rather than remediate deficits?
    • Children in poverty have strengths in:
      • Signal detection, reading emotions, relating to others/aligning to a group, seeking novel experiences
    • Three avenues to research
      • Could their skills help them in other contexts if promoted appropriately?
      • What additional skills are necessary?
      • What resources are available to help these kids?
        • Lessen negative developmental pathways
        • Forge more paths for positive development
      • Also need to look outside of clinical psychology
    • Working class culture (from sociology)
      • Working class self- for people who grow up with uncertainty develop and interdependent sense of success (of family and community, endurance, strength, hard work, optimism
      • These values promote positive development in the face of stressors, buffer against poverty-related health problems
    • Cultural identity
      • Racial/ethinc identity is a coping resources for minority youth
      • Pride in belonging to a group that validates one’s experiences and gives scaffolding for individual agency
      • Also provide familism, religiosity, interdependence
      • Stories, practices, ideals, and values also
    • Cultural identity and intersectionality
      • People are members of many social groups, some with more privilege than others
      • Collective social action is enacted intersectionality
        • Cuts across identity categories, finding common ground
    • Empowerment theory and social justice
      • Social justice education emphasizes that children’s voices must be heard and teach skills while emphasizing unfairness of stressors they face
      • Intervention should sow seeds of transformation that can grow to social action- shouldn’t shut kids down
      • Empowerment theory- collective social action is a way to cope with systemic stressors. Have to meet kids where they are and then build them  
    • Intervention
      • There are necessary inputs and outputs
      • Outputs- skills, identity development, community action
• The intervention
  • Building a strong identity and coping skills
    • Seeks to foster positive development, prevent negative outcomes, and alleviate negative effects of discrimination and poverty
  • Target 6th graders with 16 2 hour sessions
  • Three pillars
    • Stress/coping, cultural identity, and empowerment
  • Coping in the context of toxic stress
    • Their skills may be underdeveloped
    • May ‘punch first ask questions later’
    • Need to increase coping options and be able to match context with response
    • Must attend to their experiences of marginalization and validate their emotions while decoupling them from their actions
  • Module 1 Stress and Coping
    • Different types of stress
      • Everyday and major life events as well as societal stressors
    • Emotion identification
      • Validate responses to stress
    • Relaxation stations
      • Breathing, biofeedback, guided imagery, PMR
    • Problem solving steps
    • Cognitive restructuring
  • Module 2 Cultural Identity
    • Socialization in a particular class or race context
    • Just like racial identity, working class identity represents
    • Working class values
    • Photovoice- identify community assets and stressors
    • Work together to increase community assets
    • Identity trees- who in the family/community gives them strength
    • Identify family/cultural stories of struggles and strengths
  • Module 3 Collective Empowerment
    • Social action as collaborative coping
    • To cope with toxic stress
    • Can’t just stay calm in the face of violence/racism
      • Let kids have ideas and execute social action projects (taking action oriented response to make their slice of the world a little better)
  • Collective coping: community project
    • To reduce stress/build assets in the community
    • Learn leadership, planning, budgeting, etc.
    • Group identity combines member assets
• Future directions of research
  • Identify strengths of kids in poverty
  • What skills poor kids have that other might benefit from
  • What resources are effective in helping poor kids cope with poverty related stress
  • How can kids enact collaborative coping
  • Future directions for intervention
    • Optimal ways to meet poor kids where they are
    • Use more clinical skills in prevention work like dialectics and validation
• Concluding thoughts
  • Need a multifaceted approach
  • No one intervention/policy will solve everything
  • Programs like BaSICS are designed to accompany other programs
  • Marginalized kids’ wisdom is underutilized
    • Those swimming in the hegemony don’t have the same insights
• Questions
  • How to build trust with these families/communities
    • It takes time and commitment to being there
    • Have to go to community events, give special talks, etc.
    • Have to care and mean it
  • Recommendations for recruiting/retaining low SES youth?
    • Need to be a helpful community presence
    • They feed families, provide transportation, provide childcare to eliminate barriers to participation
    • Be patient with cancellations/no shows
    • Go in with a non-deficit mentality
    • Communicate respect and compassion without being patronizing
  • What can clinical psychologists learn from other disciplines (like sociology)?
    • You can’t understand poverty from a purely individual perspective
    • They are better at seeing contexts and layers
  • Recommendations for funding mechanisms for such expensive/long term work?
    • Need broad and diverse funding portfolio
    • She has had a lot from NIH, state government, and foundations

Washington DC: Black Lives Matter = “If you have power, then your job is to empower somebody else”- Toni Morrison

• It’s a historic time right now
• Major DC wrote black lives matter → powerful way to send a message
• Why future directions forum is unique and important
• We all will be future leaders where work will be funded
  • Think about what you will do with your power
  • What science is important for society

Lab: Brain Connectivity Lab

• Study brain development from adolescence to adulthood→ Cognitive Development
• Question: what happens in atypical brain development and how does that influence cognitive development

• • Range of clinical populations that are characterized by atypical dev
  • Use fMRI, look at structural magnetic, diffused imaging, connectivity modeling, and analyses for causal connections between brains
• Focusing on cognitive flexibility
  • Those with autism: sameness behaviors
    • Inflexibility impeded daily activities → high cognitive brain ability

Why is Cognitive Flexibility Important in Autism?

• About 80% on spectrum don’t end up living outside of home communities and stay with parents
  • High compared to other dev disorders  
  • High unemployment 75%: between 21-25 ages
• Clinical interventions focus on social skills training
  • But Other aspect is repetitive behaviors (related to insistence on routines)
    • Understudied but really important direction to go
• Measuring Flexible behaviors: Task performance
  • Child has to shift sets and rules in lab studies
• Daily life and real world flexible behaviors: engaging with peers and classroom behavior: ask parents or teachers
• Autisitc in a Pandemic:
  • “The pain of change is real, and in many ways autistic adults have felt this pain intensely than their neurotypical peers. But this change can also be growth.
  • Learning to be in changed routines
  • “Neurotypicals for the first time, experiencing the overwhelming fear of uncertainty that I experience very day)--> we can empathize with autistic children for how they act everyday
  • New study: COVID-19 Psychological impacts survey

Brain Dynamics

• Important to see brain flexibility
  • Red areas: language and attention and memory and visual networks→ use in day to day lives
    • Understand large brain networks
• Sliding Window
  • Take 45 sec window and move to another window to see the characteristic of those brain changes
  • Correlation of one region to another region of the brain
  • Quantify these regions: K-means Clustering
    • Different brain states
    • Frequency of occurrence
    • Dwell time
    • State transition
• Coactivation Pattern Analysis
  • Take every time point on how much data you have and assign each time with each cluster
  • Clustering to identify states that are optimal
    • Dwell time, persistence, frequency of occurrence
  • Field rapidly growing and explosion of methods

Brain Dynamics in Autism

• Typical individuals have many transitions between brain states
• Lower Brain state transitions in Autistic children?
• Autism Brain imaging data exchange
  • Cut up brain in different pieces and look at all connections between brain areas
  • At least 4 states from least to most recently occurring
  • Briains with autistic people→ Not as many brain transitions as normal brain developing children
• Salience/Mid Cingulo-insular Network
  • Look at salience network
  • Look at coactivation patterns with multiple other networks of brain
  • Find 5 states that are coactive
    • Frequency of one state (salience network was ) was less frequent than other states
  • Coactivation in mid cingulo-insular, lateral frontoparietal, and medial frontoparietal network
    • All networks do different things and not always activated
    • Those with autism have to co-engage to perform at same level as normal people

Take Home message

• Dynamic functional connectivity approaches reveal atypical patterns of brain dynamics in prevalent neurodevelopmental disorders characterized by cognitive inflexibility
• The extent to which these brain dynamics underlie individual differences in flexible behaviors is currently under investigation

Future Directions

Data and Resource Sharing

• Sharing of data sets in neuroscience
  • Child Mind Institute
  • ABIDE: Autism Brain Imaging Data Exchange
  • Adolescent Brain Cognitive Development
  • ADHD 200
  • NKI
• Find phenotypic info
  • Made it possible for researchers who are not collecting themselves and know barriers and restrictions with these data sets
• How their Lab has used data sets: BCCL Projects using NKI data
  • Evolution of spatial and temporal features of functional brain networks across the lifespan
  • Moment-to-moment BOLD signal variability reflects regional changes in neural flexibility across the lifespan
• BCCL Projects using ABIDE data
  • Developmental changes in large-scale network connectivity in autism
  • Atypical Fronto Amygdala connectivity in youth with autism
    • Ages 7-young adulthood

• BCCL Projects using HCP Data
  • Structural connections of functionally-defined human insular subdivisions
  • Data-driven extraction of a nested structure of human cognition

Machine Learning for Classification, Prediction, and Parsing Heterogeneity

• Go beyond DSM categories and look at integrated data with life experiences and to understand co-morbidity
• Integrated data
  • Genetic risk: Polygenic risk score
  • Brain activity: Insula Cortex
  • Physiology: Inflammatory markers
  • Behavioral Process: Affective bias
  • Life Experience: Social, cultural, and environment factors

• Heterogeneity and Comorbidity in ASD and ADHD
  • If you get subtypes: one subtype may be different than other subtypes (of autism
  • Community detection based subgroups for ADHD  
  • In their lab
    • Children with comorbid ADHD and Autism and just ASD and just ADHD and normal fx
    • Are there subgroups in those in mixed co-morbid and heterogeneity of Executive fx in ASD and ADHD ?
      • Not any kid had impaired executive function
      • 35% of kids with ADHD
      • Not all children showed same levels of impairment
      • Comorbid impacts children daily functions differently
    • Autism vs. typical
      • Great deal of heterogeneity
      • Not all of get same treatment and benefit the same with treatment
  • Parsing Heterogeneity in ASD and ADHD: Behavior
    • Above Average class vs. Average class vs. Impaired class
      • Showed differential social and attention problems --whether or not they were in clinical category
    • Grouped same data set as before and started with typical group, ASD, ADHD, and mixed ADHD and ASD

• • • Not significant differences in the different groups in contrast with different studies that have shown differences
    • Flexible Item Selection
      • Flexibility vs. Control: would certain brain regions be activated as anticipated
      • Is there something about aconnectity that will allow us to subtype people with comorbid or autism or adhd or normal development groups ?
        • Found some differences
        • But not stable or valid
        • Found stronger connectivity

Take Home Message

• ASD and ADHD must be considered in the context of considerable phenotypic heterogeneity
• RDoc approaches considering the spectrum of behavior and brain metrics across clinical and non-clinical groups are now encouraged by funding agencies
• However, these studies highlight the difficulties associated with parsing heterogeneity in neurodevelopmental disorders
• We suggest that novel data-driven approaches must be developed to inform a revised diagnostic nosology

New Studies: Bilingualism as a “natural intervention”?

• A lot of participants with Autism are bilingual: mostly Spanish
• There might be advantage for being bilingual: Executive fx strength outside the domain of brain
• But how does this influence brain development in autism?
  • Mostly suggest teaching only one language for those with autism?
    • Not much evidence
    • Some new studies claiming no harm and bilingualism can actually help with cognitive flexibility
• Typically developmentally kids don’t show advantage from being bilingual
  • But those with autism: have improved boost to be same as normal develop kids

**Collaboration is important for any science expertise or field

Questions

• We try to cover many aspects of brains and use multiple scales
  • Get as much data as you can to get to reliability
• How would you recommend public data sets for other research areas?
  • Number of data sets have increased a lot
  • Her Public data database wiki: https://sites.google.com/site/publicdatadatabase/
  • UK biobank
    • Many phenotype data
  • Pubmed search on the topic and find published papers with those datasets

Contextual Premises and Disclaimers

• Disclaimer: some of what you’ll hear is a remix of what he presented last fall
  • Will cross lines between science and values because today’s times call for that
• Good news (as related to COVID-19):
  • Most of us have dedicated our careers to understanding adversity and struggles
  • We have many tools at our disposal that have decades of support
  • Science and reason have solved many of our biggest public health and social challenges
  • Things have improved dramatically since science has come along
  • But, there is more to do and we can all do better
• “To tackle large social problems we cannot be intimidated into working at the fringes or allowing ourselves to feel satisfied with small steps forward. We need big leaps for humanity… we are equipped with more information and material resources than ever before in history”
  • We need to point fingers at ourselves and think “what are we doing?”
  • In COVID terms, our evidence stockpile for how to help youth mental health is large
    • There are over 1,200 RCTs for youth and family mental health treatment
    • Most people don’t use it, most people can’t get it
    • Imagine if we were told we have all the vaccines ready, but there’s no way to hand them out
• Our goal
  • To transform lives
  • To build healthy families, stronger communities
  • To alleviate human suffering
  • To enhance health and well-being through science
• Our existing situation
  • 20% of the world has a mental health challenge at some point
  • Most people with mental health needs receive no services
  • The vast majority of delivered cae is not evidence-based
  • About half of those who receive evidence-based treatment drop out
  • We have an insufficient workforce to meet the world’s mental health demands
  • Global cost is estimated to be $1.15 trillion
• Designing organizations for an information-rich world
  • In 1971 a group of people gave a talk in D.C. about how we will deal with the information age
  • In an information-rich world there is a poverty of attention (e.g., how much news and information is in your face every day on your phone)
  • A poverty of attention is critical. It has to do with managing our stockpile of information. We have ideas, we just don’t use them.
  • At the talk in D.C., participants discussed a variety of things to do:
    • Ignore things
    • Go slowly
    • Accept many errors
    • Chunk things to condense information
    • Filter things for relevancy
    • Discover (look up when you need it)
      • What if information was left discoverable and we only learned what we needed to right before we needed  it?
      • This may be the future
• Design
  • If you’re interested in changing the current world into a better world, you are a designer
  • Design is not just what something looks like, design is also how something works behind the interface
  • Most accidents are design problems rather than human error
• Which do you prefer?
  • Control and complexity versus simplicity
    • This is a concept of diversity
    • Provider 1 may prefer the prior and provider 2 may prefer the latter
  • Development
    • People change over time
    • Providers who initially wanted simple may grow to want complex
  • We need a variety of interfaces and to allow those things to change over time as providers (and clients) develop/change
  • In the past, our work has tried to figure out what happens at the intersections of client and provider development and manualize it
    • We can only develop a “one size fits some”
    • We need to remember our knowledge is constantly changing
    • Our way of translating knowledge into action is not working
  • Dynamics
    • We need a plan B, life is dynamic and things go wrong
    • If plan A fails, our model is typically to repeat plan A or we panic and engage in a high rate of error
    • When people encounter a crisis in an EBT they either improvise and lead the treatment off track of repeat the procedure in a way that does not work
  • Diversity, Development & Dynamics
• Design example 1
  • How do you develop an array of services that help as many children as possible?
    • Developed a software to see which treatment would serve the most children in a given area (incredibly different math problem)
    • Found that there was 1 EBT that matched 34% of youth characteristics in Hawaii
    • There are a substantial amount of kids who don’t have an EBT that matches their characteristics (69%)
    • In this analysis of 98 treatments, over 157 billion different combinations had to be evaluated
      • This is a poverty of attention issue
  • Design implications
    • Diversity
      • Do we have evidence-based options for everyone, regardless of demographics? No
    • Development
      • Do we have a trained workforce? How do we handle growing literature?
    • Dynamics
      • What about dropout/non-responders?
• Design example 2
  • We group treatments into families based on characteristics
  • Parent training -> incredible years, CIT & HNC
    • Idea of chunking would be looking at the procedures they have in common
  • 60% of effective treatments for disruptive behavior practices use praise
  • Can we get an idea of what’s effective in this way?
  • Poverty of attention and wealth of information: many more protocols, generally stable amount of practice elements
  • We need to figure out how to get our heads around so much information
• Practice elements:
  • Many say practice elements are not treatments
  • Recipes matter a lot
    • Elements get the collection of ideas but it does not make a treatment until we know how to stir, bake, etc.
• Recipes can be chunked and filtered too
  • There are common recipes and a pattern to solutions that we see over and over again
  • MATCH in One Minute example
    • Selected by developer
    • Flowcharts
    • Dashboards
    • Therapy modules
    • Structure the encounter
    • These elements all include chunking, filtering and discovering
  • MAP in One minute example (to match people to EBTS)
    • Type in child’s characteristics to receive matched EBTs
    • Treatment planner
    • Dashboard
    • Practice guide
    • Session planner
    • This is also filtering, chunking and discovering
• Managing poverty of attention
  • We don’t use maps anymore because GPS has the entire stack of evidence in it and is efficacious, personalized, dynamic, accommodating of diversity (tools, voice, etc.) and easy to use (developmental)
• Beyond chunking, filtering and discovering
  • Coordinated systems must also:
    • Be strategic
    • Define roles
    • Create a shared language
    • Outline decision logic
    • Connect knowledge sources to these decisions
• When we don’t coordinate: a treatment view
  • In supervision, when told there is a problem about engagement, recordings were coded to see if a discussion about the identified problem, selected intervention and intervention matched problem occurred
    • Most times they do not know why their clients aren’t engaged, and therefore, don’t select an intervention or matched problem
    • When we give folks a structure on how to focus on these three facets (chunking, filtering and discovering tools) with one day of training, they do much better
• When we do coordinate: Child STEPs Multi Site RCT
  • Schools and clinics in HI, MA
  • Combined modular design, feedback, and expert process management
  • This dynamic, modular design performed better than EBTs and Usual Care
    • Really a matter of organizing the treatment elements differently
  • Child STEPs in California
    • Intensive urban poverty, child welfare, trauma, majority Latinx sample
    • Modular treatment outperformed Community Implemented EBTs
  • MATCH-ADTC in Maine
    • Did not do better than usual care
    • Did not use usual consultation model and may need more support around process management
  • MATCH-ADTC through JBCC
    • Benchmarking against original trial
    • First commercial application
  • MATCH-ADTC in Connecticut
    • Community clinics
    • MATCH-ADTC had the highest improvement rates (68-75% greater than for other treatments)
    • Reversed ethnic disparities
  • Managing and Adapting Practice (MAP) in Hawaii
    • Just using elements
    • Tripled the median effect size for functioning of all youth in public mental health system over a 3-year open trial with no exclusion criteria
• Examining my Failures
  • Treatment engagement
    • About half of youth in the MATCH trials dropped out before finishing treatment
  • Crisis
    • Most cases had at least one, and providers always struggled with the protocol and when they did, youth had worse outcomes
  • Ethnic and cultural diversity
    • We have a limited instrumentation for when to adapt and a limited evidence base for how to adapt
• Examining our orthodoxies
  • What are the structures that are holding us back?
    • Idea that protocols are treatments
    • Simpler is better
      • Utility is better
      • Need more complex systems that are easier for the user
    • Everything should be free
      • Many things should, but structures for giving those things away might cost money
    • Only therapists can be therapeutic
    • Industry is incompatible with helping people
      • Industry knows how to scale
• Imagine a future
  • Chunking, filtering and discovering knowledge that will empower all human helpers to at on the best ideas first and will help them self correct swiftly
  • Machines will listen to and guide us without harming us, which will require help from industries and public organizations to help scale solutions
  • We will not stop until we have a world informed by robust knowledge to make the best decisions
• Imagine a world
  • All of this has to start with imaging the world we want to live in, and if you don’t like the current world, step back and think of how we can be a part of building that
• Q&A
  • How do students access these materials?
    • Practicewise.com
  • In the study with differences in outcomes across racial groups, what do you make of that in terms of tailoring treatments to different backgrounds?
    • We’re constantly adapting, the problem is that we don’t have a specific structure/set of resources to make the adaptations. You have to have deep competencies to make the adaptations due to this.