What works and who benefits: Treating behavioral problems in kids on the Autism Spectrum

Sometimes kids can be challenging. They forget rules they've learned, and don't listen to their parents. These types of problems happen with all children, all over the world, but can be even more challenging for parents with kids on the Autism Spectrum. Luckily, this is a problem that psychology is very good at solving. For decades, leaders in the field of behavioral science have been developing and perfecting intervention programs for children with Autism Spectrum Disorders. 

In clinical psychology and medicine, the best way to show that an intervention works is by conducting a randomized controlled trial (RCT). In this type of clinical trial, a team of researchers recruit a sample of individuals in their target population and randomly assign them to one of two or more interventions. Using this scientific approach is the only way of knowing at the end of the intervention whether the improvements you observed were due to the intervention, rather than differences between the individuals in the treatment groups. 

Very recently,  Karen Bearss, Emory University, and her research team published the results of the largest RCT ever conducted looking at the effectiveness of two active treatment programs for disruptive behavior in children on the Autism Spectrum. They compared Parent Training (PT) and a Parent Education Program (PEP) to determine which program resulted in the greatest improvements in disruptive behaviors. Parent Training is described as follows: 

"The first session taught parents to identify the function of a behavior by analyzing its antecedents (events occurring before the behavior) and consequences (events following the behavior). Subsequent sessions presented strategies for preventing disruptive behavior (eg, visual schedules for routine events), positive reinforcement for appropriate behavior, planned ignoring of inappropriate behavior, and techniques to promote compliance. In the last few sessions, the therapist instructed parents on teaching new skills (eg, communication or daily living skills) and how to maintain improvements over time. This sequence was intended to reduce the child’s disruptive behaviors and foster skill acquisition. The treatment sessions used direct instruction, video examples, practice activities, and rehearsal (role play) with feedback to promote parental skill acquisition. In homework assignments between sessions, parents applied new techniques to specific behaviors. 

The other treatment arm, Parent Education Program, involved having a trained therapist provide "useful information on young children with ASD, including the essentials of evaluation, developmental changes in ASD, educational planning, advocacy, and current treatment options." Each intervention arm included 11 or 12 sessions, and sessions in both treatment arms were 12 60-90 minute sessions. They measured improvements in child defiant behaviors, aggression, irritability, social withdrawal, stereotypy, hyperactivity, and inappropriate speech 24 and 48 weeks after starting the treatment program.  Each of these are core behavioral problems that children on the Autism Spectrum and their families commonly deal with on a daily basis. 

The trial ultimately randomized 180 children (ages 3-7, 158 boys, 22 girls) on the Autism Spectrum to one of the two treatments. Twenty four weeks after starting the treatment program, kids assigned to the PEP showed a 31.8-34.2% decline in behavior problems, depending on the behavior examined. Kids assigned to PT showed a 47.7-55% decline in behavior problems. In other words, both treatments worked in reducing problem behaviors, but the Parent Training program worked much better. Further, the benefit of these treatment programs were still visible at the 48 week follow-up. The research team concluded that Parent Training is an effective program for addressing disruptive behaviors in families with children on the Autism Spectrum. 

More recently, this research team published a study of the moderators of treatment response. Moderators are factors that influence how well the treatment program works. In this study, Luc Lecavalier, Ohio State University, looked at whether the Parent Training intervention works better or worse in kids with different individual or family characteristics. For example, they looked at whether IQ of the child, severity of Autism, presence of another co-occurring disorder such as ADHD or anxiety,  living in a single parent family, or parent income and education were related to treatment outcomes. 

They found that the kids who improved the most from Parent Training were the ones without co-occurring ADHD, low anxiety symptoms, and living in families with a family income above $40,000 per year. In other words, there was no difference in benefit from PT or PEP for kids in the study with ADHD, high symptoms of anxiety, or in low-income families. That being said, the PEP was still associated with a 31-34% decline in disruptive behaviors, so treatment was still somewhat effective. 

To their surprise, the research team did not find that IQ or severity of Autism symptoms were associated with differences in treatment benefits from Parent Training. This is important because many people believe that IQ and symptom severity automatically mean that treatments won't work for them. Here, we see that kids in the study with a range of IQ and symptom severity showed improvements in disruptive behaviors, particularly those enrolled in Parent Training. 

So what does this mean? If you have a child on the Autism Spectrum, Parent Training may significantly improve your and your child's quality of life. In fact, Parent Training is a well-established and effective way of dealing with disruptive behaviors for kids (up to around age 12), regardless of being on the Autism Spectrum. The strategies taught to parents in Parent Training are based in basic behavioral science and apply to all behavior, and in these treatment programs the principles of behavioral theory are simply tailored to the most commonly observed problems in specific populations. 

A final thought on the name "Parent Training." In my work, I've found many parents resistant to going through training in parenting. In many ways, it seems as though parenting should be intuitive and not, yet another, thing that requires a degree or certification. In many ways that's very true. Loving and caring for a child is innate. Teaching a child to regulate their impulses and emotions is something entirely different, and often at odds with the immense loving and caring you feel for them. Think about how often you, as a parent or caregiver, feel conflicted between the short-term relief of "peace and quiet" that is almost immediately gained from giving in to a toddlers request for something at the grocery store and the long-term benefit of not hearing these requests every time you go to the store until the end of time. Behavioral science is an immense field of study that resulted in the training of the modern generation of clinical psychologists who can provide Parent Training that will help reduce the impact of these little moments in your daily life. 

If you're interested in learning more, some Parent Training books I highly recommend for parents looking for behavioral strategies that work: 

For all parents: 

The Everyday Parenting Toolkit: The Kazdin Method for Easy, Step-by-Step, Lasting Change for You and Your Child by Alan E. Kazdin and Carlo Rotella

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For the over-achievers out there, Alan Kazdin has also just completed a course on parenting in Coursera called "Everyday Parenting" which I highly recommend for anyone who has or will ever have kids.   Click here to learn more about that course. 

For parents struggling with child defiance: 

The Kazdin Method for Parenting the Defiant Child by Alan E. Kazdin

Your Defiant Child, Second Edition: Eight Steps to Better Behavior by Russell A. Barkley and Christine M. Benton



References 
Bearss, K., Johnson, C., Smith, T., Lecavalier, L., Swiezy, N., Aman, M., ... & Sukhodolsky, D. G. (2015). Effect of parent training vs parent education on behavioral problems in children with autism spectrum disorder: a randomized clinical trial. Jama, 313(15), 1524-1533.

Lecavalier, L., Smith, T., Johnson, C., Bearss, K., Swiezy, N., Aman, M. G., ... & Scahill, L. (2017). Moderators of parent training for disruptive behaviors in young children with autism spectrum disorder. Journal of abnormal child psychology, 45(6), 1235-1245.

Many thanks to unsplash.com for the lovely photos! 

What your beliefs about failure are teaching your child.

A self-fulfilling prophecy describes when a person believes something will happen so they engage in behaviors that increase the likelihood of the expected outcome. There are few more important examples of this than children's learning. Children can either have a fixed or a growth mindset about intelligence. Kids with a fixed mindset believe that intelligence is, well, fixed. Kids with a growth mindset believe that intelligence is something malleable. Whether a child has a fixed or growth mindset predicts how hard that child will try when given a hard problem. Children with a fixed mindset get frustrated easily and give up. Kids with a growth mindset spend longer working on problems and demonstrate more effort while trying to solve it. As you can imagine, this phenomenon snowballs over the years, and indeed, children with fixed mindsets go on to under-perform children with growth mindsets in almost every domain compared to their growth mindset peers. But where do kids get these fixed and growth mindsets? If we know where these mindsets originate, we can begin to cultivate growth mindsets in more and more kids.

Now, the obvious answer is usually the right one. Parents. However, whether or not a child has a fixed or growth mindset is NOT related to whether their parent has a fixed or growth mindset. So,
Kyla Haimovitz and Dr. Carol Dweck, Stanford University, conducted four studies to understanding exactly how parents influence their children's beliefs about intelligence.

To do this, they first conducted a study to answer the question: Do parents' beliefs about failure relate to their child's beliefs about intelligence? They recruited 73 parents and their 4th and 5th grade students. Parents completed surveys measuring their intelligence mindset, failure mindset, and perceptions of their child's competence in math, science, social studies, and English. Failure mindsets were assessed with questions like "Experiencing failure facilitates learning and growth" and participants indicated how much they agreed. Children completed surveys measuring their intelligence mindset and their parents orientation to learning and performance using questions such as "My parents want me to understand homework problems, not just memorize how to do them". 

Parents fixed vs growth mindsets were unrelated to their child's fixed vs. growth mindset, whereas the degree to which the parent believed that failure was a hindrance rather than an opportunity for learning predicted a child's fixed intelligence mindset. They also found that children's perceptions of their parents' orientation to learning and performance  explained how parents beliefs about failure led to children's intelligence mindsets. 

Next, Haimovitz and Dweck conducted a study to answer the question: Do parents who believe failure is debilitating parent their children differently? They recruited 160 parents for an online study who completed questions about their intelligence mindset, failure mindset, and their reactions to a scenario in which their child came home with a failing grade on a quiz. Questions in reaction to the scenario were "I might worry (at least for a moment) that my child isn't good at this subject" or "I'd encourage my child to tell me what she learned from doing poorly on the quiz."

Parents who held a failure-is-debilitating mindset were more likely to endorse reactions to the scenario consistent with worry about their child's abilities, instead of opportunities for growth and learning. 

In a 3rd study, the researchers sought to understand whether a parent's failure mindset is more visible or obvious to their child than their intelligence mindset. To answer this question, 102 parents completed surveys about their intelligence and failure mindsets, while their children completed surveys about their perceptions of their parents intelligence and failure mindsets. Lo and behold, kids were more accurate about their parents' failure mindsets than their intelligence mindsets. 

Finally, they tackled the ultimate question: Do parents beliefs about failure cause their reactions to their child's failures? To do this, they recruited 132 parents for an online study where parents reported their perceptions of their child's competence and then were randomly assigned to 1 of 2 conditions. In one condition, parents were induced into thinking that "failure is debilitating", while the other condition induced a "failure is enhancing" mindset.  Then parents were asked to explain what they would think, feel, and do if their child came home with a failing grade on their math quiz. 

Indeed, parents randomized to the "failure is debilitating" condition were more likely to see the failure as a hindrance to learning and express worry about their child's abilities. Most importantly, this was true regardless of how competent the parent thought the child was at the outset of the study. 

To review, this is how kids develop a fixed or growth intelligence mindset. Parents either view failure as debilitating or an opportunity for learning. A failure is debilitating mindset is apparent to children because the parent rewards them for performance instead of learning. Parents react to their child's failures by questioning the child's abilities and competence. Then the child develops a sense that their abilities are either fixed or can be cultivated through learning and hard work. 

With all of this laid out, the fix is pretty simple. Do you see failure as an opportunity for learning or as a sign of incompetence? If it's the latter, changing that mindset will help your child learn that their intelligence can be cultivated and the self-fulfilling prophecy will snowball in their favor. 

If you think this is interesting work, you will love watching Carol Dweck's TED Talk!

Thanks to unsplash for the lovely images!

Haimovitz, K., & Dweck, C. S. (2016). What predicts children’s fixed and growth intelligence mind-sets? Not their parents’ views of intelligence but their parents’ views of failure. Psychological science, 0956797616639727.

How to be curious.

This week marks the launch of The Positivity Project in 33 schools across 12 different states in the US. Each week, the Positivity Project will introduce 1 of the 24 character strengths that make up the fabric of humanity. The team at The Positivity Project will support teachers, educators, parents, and students in learning how to cultivate each of these strengths with the goal of improving relationships between children and their schools, parents, and local communities. The character strength that will kick off the year is CURIOSITY. 

The first step to cultivating a strength is defining it. Curiosity is a fascinating psychological phenomena to say the least. In preparing this article I found that no one I know has the same definition for curiosity, and depending on the definition you use, the result of cultivating curiosity is very different. 

For example, Drs. Christopher Hsee, University of Chicago, and Bowen Ruan, University of Wisconsin-Madison, recently conducted a study examining the role of curiosity in human behavior. In particular, they conducted 4 experiments to address the question: 

Can curiosity be dangerous?

To answer this question, 54 adults (24 women) who were given a box of 10 ballpoint pens that may or may not deliver an electric shock when clicked. Each participant was randomly assigned to one of two conditions: certain or uncertain. In the certain condition, each pen had a sticker indicating whether the pen would shock them or not shock them if clicked. In the uncertain condition, all pens had the same sticker and the participants were told that the pens may or may not have batteries in them. The research team told the participants that they can click the pens if they wanted to "kill time" while waiting for another part of a different experiment, and then counted how many pens each participant clicked. 

People in the uncertain condition clicked more pens than the participants in the certain condition. The researchers interpreted this as evidence that curiosity might be the human desire to resolve uncertainty, and this desire may lead individuals to expose themselves to danger, or at least pain. 

Then, the research team conducted this same study again with 30 new participants. This time, all participants received the uncertain and certain conditions. To do this, some of the pens had red stickers (shock), some had green stickers (no shock), and some had yellow (uncertain). They counted how many of each type of pen each person clicked. 

Again, they found that people clicked more of the yellow sticker-ed pens than the other two types. And again, the researchers interpreted their results as evidence that curiosity may lead people to expose themselves to danger in order to resolve uncertainty. Indeed, the participants rated their experience of the shocks as negative.  

The research team then conducted 2 more follow-up studies. They changed the potential negative outcome to the sound of nails on a chalkboard in order to show that the effect is not specific to electric shocks. They also included measures of participants' feelings. Participants again were more likely to click on uncertain options even though the uncertain options were likely to expose them to negative sounds, and the more exposure they had to these negative sounds, the worse they felt. Yet, if people were given the option of predicting whether clicking the uncertain button would positively or negatively impact their mood, they were less likely to choose to resolve the uncertainty. 


In review, we are driven to resolve uncertainty at the expense of our mood and the potential for danger. This may be the ugly side of curiosity.  

On the other hand, the VIA Institute on Character defines curiosity as being interested in exploring new ideas, activities, and experiences and having a strong desire to increase their own personal knowledge. In short, they advise that the best way to cultivate curiosity is to "ask questions, and lots of them." 

If we think about both definitions, it seems that both highlight the search for information. What may distinguish curiosity of human nature from curiosity as a character strength is the goal of that search. Are you curious to resolve uncertainty or to add to your personal understanding? If you follow-up your curious urges with "why do I want to know/do this?" and the only answer is "because I just want to know," your curiosity may simply be rooted in human nature. This isn't a bad thing. There are a million reasons that the drive to resolve uncertainty was essential to survival. Think about how we know whether we can fly, which plants are poisonous and tasty, that fire causes pain. The tribe benefits from some people being willing to take these risks. 

Now that we have those basics worked out, it is our job to cultivate curiosity as a character strength. Practice the art of understanding why and how new knowledge will improve your understanding of yourself and the world. Teach children to understand what drives their curiosity. It is this nuanced understanding of how to be curious that will make the difference between practicing curiosity that has negative consequences for mood and safety and practicing curiosity that will lead to the good life filled with strong relationships and purpose. 

To learn more about The Positivity Project, click here.  Many thanks to unsplash for the curious photos. 

Hsee, C. K., & Ruan, B. (2016). The Pandora Effect The Power and Peril of Curiosity. Psychological science, 27(5), 659-666.

More fish = Less aggression.

We've all heard that we should eat more fish. It's chock full of good fats, prevents heart disease, helps with weight loss, and is pretty much as close to a perfect food as you can get. One of the reasons fish is so wonderful is that it's chock full of omega-3 fatty acids. Omega-3 fatty acids help your body regulate inflammation, which means less heart disease, cancer, and memory problems with age. Wikipedia is a good starting point for learning more about this (click here). Less well-known are the effects omega-3s have on behavior. Did you know that countries that consume more fish have significantly lower homicide rates? Also, omega-3 supplements seem to reduce aggression in prisons. These are findings from just a few of the many studies looking at whether omega-3s have profound effects on behavior. Most recently, researchers have begun to wonder whether omega-3s can improve behavior problems in children.

In particular, Dr. Adrian Raine, University of Pennsylvania, and his colleagues conducted a study asking whether omega-3 supplementation causes improvements in behavior problems in children.

To do this, they recruited a sample of 200 children (ages 8-16) and their parents. Parents and their children completed several questionnaires. Parents reported how often their child engages in anxious, depressed, aggressive, inattentive, hyperactive, and antisocial behaviors. Parents also reported how often they engage in antisocial and aggressive behavior. Then children reported their own perceptions of their anxious, depressed, aggressive, inattentive, hyperactive, and antisocial behaviors. The children also provided a small blood sample so the research team could measure their baseline omega-3 fatty acids.

Once they had 200 participating children, the sample was randomized into one of 2 groups: omega-3 or placebo. The two groups had the same amount of omega-3s and behavior problems at the beginning of the study. Children in the placebo group were provided with a 200ml fruit juice drink made of apple, pear, pomegranate, aronia, passion fruit, antioxidants, and vitamin D. The omega-3 group were provided with the same 200ml fruit juice drink with 1000mg of omega-3 added. The omega-3 included 300mg of DHA, 200mg of EPA, 400mg of alpha-linolenic acid, and 100mg of DPA). All participants were instructed to drink this drink every day for 6 months. and record whether they drank it each day.

At the end of 6 months, parents and children completed the same behavioral questionnaires from the beginning of the study, and children provided another blood sample for measurement of omega-3s. Both groups reported that they consumed the fruit juice drink about 6 times per week and indeed, the omega-3 group had greater omega-3s in their blood than the placebo group after 6 months of taking the drink regularly.

Both groups demonstrated equal declines in child behavior problems at the end of the treatment, while parents whose children were in the omega-3 group reported fewer antisocial behaviors. This might suggest what we call a "placebo" effect. In other words, parents and their children believe that the drink is helping them, regardless of whether it has the active ingredient, and therefore their behavior changes. Placebo effects are nothing to sneeze at; they are very real and more powerful than we realize.  At this point, the team might have concluded that omega-3s are not effective for reducing child behavior problems or that the other nutrients in the drink (e.g., vitamin D) affected behavior as much as omega-3s might. But wait, there's more.

Six months after the treatment finished, the research team conducted a follow-up with the families. They asked all the parents and their children to complete the same behavioral surveys. The behavioral problems for kids in the placebo group returned, while the kids in the omega-3 group continued to show declines in aggressive behaviors, anxiety and depressive behaviors, and antisocial behaviors. In fact, omega-3s caused a 41.6% reduction in externalizing behaviors (aggression, inattention, hyperactivity), and a 68.4% reduction in internalizing behaviors (anxiety, depression). Wow... but why? How?

It's still too soon to know. One potential pathway is through parent behavior. Remember that parents in the omega-3 group showed the only significant difference in behavior at the end of treatment. The behavioral questionnaires used in this study were originally designed to detect big differences in behavior between kids with and without mental health problems that warrant treatment. This means that the scales used may not have been able to detect subtle changes in behavior. But, if you have kids, or know any well, a small change in behavior can make a big difference in your day-to-day life. The authors explain in the article that they think some of the benefit of omega-3s was due to children showing slight improvements in behavior that led to less reactive and antisocial parent behavior, which then led to continued improvements in child behavior. In other words, omega-3 supplementation broke the cycle that so often occurs between parents and kids with behavior problems.

Another fascinating pathway has to do with the effect omega-3s have on the brain. Omega-3s are becoming a hot topic in neuroscience because they seem to promote neuroplasticity (growing new brain cells and connections between existing ones) and inhibit inflammation which can cause low mood, confusion, and fatigue. It's possible that the omega-3 supplement allowed a build-up of omega-3s in the body and the brain over a series of months which promoted better learning and behavioral control in the kids. Importantly, it may take months of regular supplementation to build up this store in the body, and even longer to see meaningful differences in behavior.

So should we start pumping omega-3s in drinking water? Not yet. Can we treat children's ADHD and anxiety with omega-3s? Definitely not. Should we eat more salmon and fewer steaks? Probably. I don't want to mislead you. The research in this area is promising but still very new, and there is a lot we don't know. For example, what is the optimal dose? How long should people take it? Is there such a thing as too much? What are omega-3s actually doing in our brain and body? Science will get us there eventually, but in the mean time, sushi anyone?

Raine, A., Portnoy, J., Liu, J., Mahoomed, T., & Hibbeln, J. R. (2015). Reduction in behavior problems with omega‐3 supplementation in children aged 8–16 years: a randomized, double‐blind, placebo‐controlled, stratified, parallel‐group trial. Journal of Child Psychology and Psychiatry, 56(5), 509-520.

Many thanks to unsplash for the gorgeous photos.

What works: Treatment for Anxiety in Children

Anxiety is worry, nervousness, unease or uncertainly, usually about a future event. Anxiety is normal and we all experiences it sometimes. Anxiety becomes "disordered" when it becomes persistent, uncontrollable, and interferes with daily life. 

Children struggle with anxiety at almost unbelievable rates. Anxiety disorders are the most common problems we see in mental health clinics. In fact, youth with anxiety account for about half of all child patients and a third of all teen patients in mental health clinics. Luckily, clinical psychologists have been studying the most effective treatments for anxiety for half a century. What's more, a paper was just published reviewing all of those studies to determine: 

What's the most effective way to treat anxiety in kids and teens? 

Dr. Charmaine Higa-McMillan, University of Hawaii, and her colleagues reviewed all of the studies that have been published between 1967 and 2013 looking at the effectiveness of different treatments for anxiety in kids and teens (ages 1-19). They identified 108 treatment studies that randomly assigned patients to treatment, and coded each of these studies for the patient characteristics (age, ethnicity, symptom severity), type of active treatment, elements of those treatments, and their effectiveness in reducing symptoms of anxiety from pre-treatment to post-treatment and sometimes months later. 

In clinical psychology, we classify treatments into 5 levels that differentiate treatments based on effectiveness. Level 1 treatments are considered "Well-established." These are treatments we have tested and re-tested in different patients and we know they work. Level 2 treatments are "probably efficacious treatments" for which there is pretty convincing evidence that they work so far, but haven't fully been tested on enough patients in enough settings yet. Level 3 and 4 are "possibly efficacious" and "experimental" respectively. We aren't recommending these treatments without further testing. And finally, Level 5 which is the category for "treatments of questionable efficacy." as Far as we can tell, these don't work. 

From the 108 studies that have tested the effectiveness of a treatment for anxiety in children or adolescents, Dr. Higa-McMillan and colleagues identified: 

6 Level 1 (Well Established)

8 Level 2 (Probably efficacious)

2 Level 3 (Possibly Efficacious)

6 Level 4 (Experimental) 

8 Level 5 (Treatments of Questionable Efficacy)

To save us all time and heartache, I'm only going to share the Level 1 and Level 5 treatments with you. It occurred to me that medicine really got something right when pharmaceutical companies started putting advertisements in magazines and on TV. "Ask your doctor about...(insert medicine here)" ads really put a lot of control in the hands of patients. So, I will tell you about the Level 1 treatments so that when a child you know is in need of help with their anxiety you will know what to look and ask for. 

According to this systematic review of every published study of a treatment trial for child or adolescent anxiety, the Level 1 treatments identified were:

Cognitive-behavioral therapy (CBT)

Exposure therapy 

Modeling 

CBT with parents

Education 

CBT Plus medication (usually SSRI) 

No need to get lost in the weeds with some of these names; the common denominator in each of these treatments is CBT. I won't provide a full explanation here because I've talked about this many times before.  Each of these treatments has been tested multiple times, in kids from ages 3-18, in settings such as hospitals, schools, clinics, and online, in samples that represent 10+ ethnicities that comprise the population of the Unites States, and with therapists that range in training from no experience to decades of experience. Even more impressive, the improvements in symptoms continue for at least 1 year after treatment. 

There were also some forms of CBT that fell into the Level 2 category. The authors determined that Exposure was the differentiating treatment ingredient for why some forms of CBT were "Probably Efficacious" for treating anxiety while others were "Well-established". Exposure is confrontation of a feared stimulus (click here for more in Exposure). Exposure was present in 80% of the identified Level 1 treatments and is the "active ingredient" in treatments that end up effectively reducing symptoms of anxiety.  The other common ingredients in Level 1 treatments for anxiety were cognitive strategies, relaxation, and psychoeducation for the child. 

So now you know. Ask your doctor about Exposure.

Now for the Level 5 treatments that are unlikely to help your child's anxiety: 

Assessment and monitoring

Attachment therapy

Client-centered therapy 

Eye Movement Desensitization and Reprocessing (EMDR)

Peer pairing

Psychoeducation

Relationship counseling 

Teacher Psychotherapy 

It's possible that one or any of these treatments may be effective in treating other psychological problems, but let's be clear there is no evidence that they will help anxiety. 

If you have a rash, go to your doctor and get a medication, and the rash doesn't get better, the most common assumption is, "That medicine did not work." Unfortunately, a different set of assumptions emerges when the rash is not a rash, but instead an anxiety disorder or depression. If the medicine doesn't work, people assume that "therapy isn't for me" or "that therapist isn't the best fit." The truth is, it's the medicine. Lots of therapists out there aren't using CBT with Exposure to treat anxiety for kids and teens. Find one that does because the "medicine" works. 

Higa-McMillan, C. K., Francis, S. E., Rith-Najarian, L., & Chorpita, B. F. (2015). Evidence base update: 50 years of research on treatment for child and adolescent anxiety. Journal of Clinical Child & Adolescent Psychology, 1-23. DOI:10.1080/15374416.2015.1046177

Gratitude and credit to unsplash.com for photos. 

Red light. Green Light.

Teenagers; can't live with them, can't get anyone else to take them off your hands. Let's face it, the teen years are a turbulent time for pretty much everyone involved. Quite frankly, I'm surprised I even survived. From a purely biological perspective, the goal of childhood is just to survive to reproductive age, while the goal of adolescence is to reproduce. Modern society, however, has a different set of expectations for teens which include going to school, getting into college, and deciding on an occupation (or at least a path to an occupation). In other words, teenagers kind of have the deck stacked against them biologically, with a lot at stake. As a result, a lot of psychologists and physicians have pursued a better understanding of adolescents, what determines how they behave, how do they make decisions, and so on. In particular, adolescents have a tendency to make decisions that serve short-term goals and immediate gratification (read: sex, drugs, rock'n'roll) at the expense of long-term goals (read: safety, education, sleep). 

Despite this tendency, there are obviously situations and conditions under which teenagers are more likely to make "good" decisions that don't compromise their safety or futures. The most prominent of these conditions are their social influences. For example, we've all heard the statistic that teenagers are more likely to be in motor vehicle accidents. But this is driven by the accidents occurring with teen drivers in the car with other teenagers, not necessarily teen drivers alone or with an adult. 

Last month, Karol Silva, Temple University, and her colleagues published a study asking whether teens take risks differently depending on the age of their peers. To do this, they recruited 300 18-22 year-olds and had them play a computerized Stoplight Game. During this task participants controlled a car along a straight track while being timed. Their goal was to reach the end of the track as quickly as possible. Throughout this straight track there were 32 stoplights, and participants were told that they needed to decide whether to stop the car when any of the traffic lights were yellow, or to proceed through the light. They were also told that if they chose not to stop, they may collide with an oncoming vehicle. If a collision occurred, there would be a loud crash, a shattered windshield and a delay in their completion time for the course. 

Each of the 300 participants were randomized into 3 conditions: playing the game alone, playing the game in front of 3 other participants (age 18-22), or playing the game in front of 2 other participants and a slightly older adult (age 25-30).  

They found that participants in the peer-only condition took more risks than participants playing the game alone. This isn't surprising. Teens take more risks around same-aged peers. This is (partly) why college is so much fun. However, they also found that the presence of one slightly older adult entirely removed the risk-taking tendency that occurs in the presence of peers. In other words, an adolescent in a group comprised of 2 same-aged peers and a slightly older adult behaved similarly to those completing the game alone. 

But what does this mean? Interestingly enough, this study was funded by the United States Army with the goal of informing the structure of soldiers into combat teams and reduce military casualties. You see, 1//6 of the U.S. Marines are between 18-22, so the distribution of this large subgroup across teams is of great importance. With that context in mind, it is easy to see the applicability of these results. Mix 18-22 years-olds with 25-30 year-olds and immediately increase safety, reduce adverse events, and decrease casualties. The authors extend their discussion of this finding as applicable to the fast food industry and others dominated by adolescents. 

More broadly, 18-22 years are legally considered to be adults and often hold positions of responsibility, especially in the military. Yet, this age group continues to be neurobiologically adolescent and therefore susceptible to social pressure and emotional decision-making that favors short-term gratification over long-term goals. Rather than taking an "age-ist" approach to dealing with this reality, this study suggests that there are measurable benefits to more subtly mixing teams to include individuals of different ages such that having just one slightly older member of a group can make a big difference. The authors conclude, "The key for individuals who supervise people in their late teens and early 20s is to find a way to harness the passion of the young without permitting their readiness to take risks to endanger them and their teammates." This, I think, can be extremely helpful to almost anyone that manages individuals or teams in this age group. 

Silva, K., Chein, J., & Steinberg, L. (2016). Adolescents in Peer Groups Make More Prudent Decisions When a Slightly Older Adult Is Present.Psychological Science.  DOI: 10.1177/0956797615620379

Mama Bear: Ever wonder whether breastfeeding changed your behavior?

This week’s article highlights many of the fun things we do in psychology research. Of course, it started with a question:

Does breastfeeding increase aggression?

Many lactating animals (e.g., mice, rats, prairie voles, hamsters, lions, domestic cats, rabbits, squirrels, and domestic sheep) are more aggressive than their non-lactating peers. In animals, lactation increases aggressive behavior, and reduces physiological responses to stress. This makes sense because for many animal, and even humans until 100 years ago, many infants didn't survive. Lactation is a way for the mother's body to know that there is an infant to still take care of. However, humans have built societies and homes, invented seatbelts, and established food protection standards. So, it remains to be documented whether human women become more aggressive after having a baby, and what physiological processes support this change in behavior.

To answer this question, Dr. Jennifer Hahn-Holbrook, now a professor at Chapman University, and her colleagues conducted a very cool experiment to understand whether breastfeeding women are more aggressive, and whether that aggression is accounted for by reduced physiological responses to stress.

To do this, they recruited three groups of women: 20 women with infants between 3-6 months who were exclusively breast-feeding, 20 women with infants between 3-6 months who were feeding their infant a mix of breast milk and formula, and 20 women who had never had a baby. The women came to the laboratory and met what we call a “confederate.” A confederate is a person introduced to the participants as another participant, but in actuality is part of the experiment. The confederate was trained to be rude. Rude behavior involved ignoring the actual participant, chewing gum, and checking their cell phone during the experiment instructions. This was intended to cause the actual participants to make what psychologists call fundamental attribution error, or the tendency to place an undue emphasis on internal characteristics (personality) to explain someone else’s behavior in a given situation rather than considering the situation’s external factors. For example, when you cut someone off you know it’s because you are late and would otherwise miss your exit. When someone else cuts you off, it’s because they are a jerk.

The participants were then instructed to play a game against the other “participant” that involved reaction time. Fastest person to respond wins. The winner of each round got to push a button that released a loud sound at the loser. The participant controlled the volume (up to 150 decibels) and duration (up to 5 seconds) of the sound with their button push. After 8 rounds of the game, participants fed their babies (breastfed, formula fed) or took a break if they were in the non-mother control group. Then, the participants played the game again for another 8 rounds. The mothers’ blood pressure was monitored and recorded throughout the entire procedure.

They found that breastfeeding mothers delivered longer and louder aversive sounds to their rude competitors, compared to both the mixed-feeding mothers and the non-mothers. They also found that breastfeeding women had smaller increases in blood pressure (a measure of stress) while playing the competitive game than women in either of the other groups.

The research team concluded by saying that women who are breastfeeding, not just new moms, were more likely to be aggressive than women who are not. Supporting this idea, they found that there was a significant positive correlation between aggression during the game and the percent of the infant’s diet that was breastmilk (as a measure of how much the mother is lactating). Therefore, they believe that the physiology that supports lactation in new moms supports aggressive behavior that is protective to the infant. And further, lactating mothers show a reduced response to stress, which likely helps facilitate aggression in times of threat and competition.

So, what can we take away from this? I think on a very basic level, knowledge is power. If you or someone you know is breastfeeding, they are likely to be more aggressive than they are usually, and more aggressive than other people. This is normal and adaptive. Don’t hold it against them or yourself. Aggression has many different dimensions. In this study it was the force with which women delivered aversive sounds to competitors, like a punishment. But what might this behavior look like outside of the laboratory? Potentially, it’s perceiving other people as a threat, competing with other moms for no apparent reason, delivering unusually harsh punishments to your partner or older children for potential threats to the new baby. Just remember, increases in aggression are normal, and being driven by the many, many changes to your physiology that allowed you to have the baby and care for it in the first place.

In these modern times, we take for granted all of the physiological changes that come with being able to sustain a pregnancy, have a baby, and breastfeed that have been promoting human survival for thousands of years. As a result, many women don’t learn about these physiological changes until they are going through it, and society doesn’t do much to support them. Don’t be part of that problem.

Hahn-Holbrook, J., Holt-Lunstad, J., Holbrook, C., Coyne, S.M., & Lawson, E.T. (2011). Maternal defense: Breast feeding increases aggression by reducing stress. Psychological Science. DOI: 10.1177/0956797611420729

Promote children's happiness through character

I had the tremendous pleasure of training in psychology with Dr. Chris Peterson at the University of Michigan. Chris was one of the founders of positive psychology and a pioneer in the field when it comes to understanding character strengths. After years of scouring history across cultures all over the world, and thousands of hours of research, he identified what are now known as the 24 character strengths represented by human civilization. These character strengths fall into 6 larger categories: Wisdom & Knowledge, Humanity, Justice, Temperance, Transcendence, and Courage. He then set out with his most-trusted colleagues to understand how character strengths contribute to well-being, happiness, success, and leadership. His work has changed the way psychologists think about individuals, schools deliver lessons to children, and the military identifies and trains leaders.

Part of the challenge of doing this type of science is that character isn't easily measured, so much of the inspiration I get from his success as a scientist is in the creative approaches he took to understand character strengths in different groups of people. I am a child and adolescent psychologist, so there is one project in particular that highlights how he and his dear friend and colleague, Dr. Nansook Park, looked at character strengths in children.

They were interested in understanding:

1) whether character could even be measured in children
2) what character strengths were common among children
3) which character strengths were common among the happiest children

To answer these questions, they recruited parents of children between the ages of 3 and 9 years in pediatricians' offices, toy stores, daycare centers, and through a parenting list-serve. Parents were provided with a link to a password protected website where they were asked to provide demographic information, and then provide a "few hundred words" on their child's "personal characteristics." They were asked, "What can you tell us so that we might know your child well?"

Ultimately, 680 parents described their children in an average of 211 words. Parents reported things like, my child "loves to look at paintings," "always tells the truth," "is not afraid to do things," "always asks questions," "helps out around the house," "is cautious," or is "full of energy." Just to name a few. The research team then conducted what we call a content analysis. This means that they went through each description, and coded whether the description included each of the 24 character strengths, and then a more global rating for how happy the child seems to be based on the description on a scale from 0 (depressed, anxious, unhappy) to 7 (extremely happy).

They found that the most common character strengths among young children are Love, Kindness, Creativity, Humor, and Curiosity. The least common character strengths among young children are Authenticity, Gratitude, Modestly, Forgiveness, and Open-mindedness. Thus, they identified a way to measure character strengths among young children, but also the strengths that are developmentally most common.

They then looked at how the presence of each of these character strengths correlated with the child's happiness. They found that children with the parent-reported strengths in Hope, Zest, and Love were all significantly related to happiness, meaning kids with these character strengths had higher happiness ratings than their peers without them. Hope is defined as "expecting the best in the future and working to achieve it; believing that a good future is something that can be brought about." Kids coded as having the strength in Hope were described by their parents as, "always looking on the bright side." Zest is defined as "approaching life with excitement and energy; not doing things halfway or halfheartedly; living life as an adventure; feeling alive and activated." Kids coded as having the strength in Hope were described by their parents as, "full of energy." And Love is defined as "valuing close relations with others, in particular those in which sharing and caring are reciprocated; being close to people." Kids coded as having the strength in Hope were described by their parents as, "has close friends" and "is devoted to younger brother." You can find the definitions of all of these 24 character strengths, and even take your own free 10-minute assessment of character strengths at the website for the Values in Action Institute on Character by clicking here.

Despite my immense admiration for Drs. Park and Peterson, this study is not without its limitations. In particular, parents tend to describe their children in light of how they would like their children to be. I will likely describe my future children as being intelligent, bookworms, who love science, while that may not necessarily be how they will describe themselves. To this point, the article explains that characters strengths that were painted in a negative light were not coded. For example, kids who played "mean pranks and jokes" were not considered as having the strength of humor. Its possible that those parents simply didn't value humor, and therefore described that strength more negatively than families who do. Overall, this limitation highlights that some aspects of character will always be mysterious because children's ability to explain complicated ideas like gratitude and forgiveness is underdeveloped compared to their ability to behave that way.Consistent with that notion, they also found that older children who had character strengths in gratitude were more likely to have high happiness scores, suggesting that as children get older gratitude becomes a pathway to happiness.

Despite the limitation of having parents report on their children in potentially biased ways, these result still suggest that promoting Love, Hope, Zest, and Gratitude in the lives of young children may be a pathway to happiness. Interestingly, these character strengths are also linked to better health, longevity, and happiness in adults. So the real question is how to cultivate these strengths in children?

Luckily some people, like my friend, colleague, and fellow Michigan alumni, Mike Erwin are tackling that task in public schools around the country with The Positivity Project. The Positivity Project is dedicated to promoting character education by developing an elementary school curriculum based upon Dr. Chris Peterson and his contemporaries' scientific findings on character strengths. For more on Mike Erwin, The Positivity Project and the first school to implement the program watch this short and inspiring video!

Park, N., & Peterson, C. (2006). Character strengths and happiness among young children: Content analysis of parental descriptions. Journal of Happiness Studies, 7(3), 323-341.

What your body remembers from the first year of life!

Now, normally we cover the work of brilliant psychological scientists from all over the world, but our founder Dr. Kate Ryan Kuhlman's most recent paper was featured last week on the International Society for Traumatic Stress Studies' Trauma Blog so we wanted to share it with you by reposting here. Enjoy!

Exposure to trauma during the first year of life may impair the body’s ability to recover from stress

Childhood adversity exposure has been linked to physical and mental health difficulties, such as asthma, arthritis, cardiovascular disease, depression, and suicidality. These health conditions and/or their risk factors emerge throughout childhood and adolescence, and persist across the lifespan. Research over the past two decades has taught us that exposure to traumatic experiences has the potential to alter the way our body responds to stress. When our body experiences stress, there is a cascade of physiological changes that result in the production of cortisol. Exposure to large quantities of cortisol for extended periods of time has serious negative consequences for our brain and our immune system. More recently, researchers have considered whether there are specific periods of development that are more sensitive to trauma and therefore are more impactful to our long-term health.

In a recent article in the Journal of Traumatic Stress, Dr. Kate Ryan Kuhlman and colleagues in Nestor Lopez-Duran’s laboratory at the University of Michigan conducted a study looking at the way 97 adolescents (ages 9-16) responded to stress in the laboratory, and whether responses to the stressor were different based on when the adolescent was first exposed to trauma. These traumatic experiences were assessed using the Early Trauma Inventory, reported by their parents, and included events that constitute non-intentional traumatic events, sexual, physical, and emotional abuse.

Adolescents in the study who were exposed to trauma before they turned one had a significantly different profile of response to the laboratory stressor. Specifically, adolescents exposed to trauma during their first year of life showed a slower recovery from the acute stressor than their peers who were exposed to the same number of stressors beginning later in childhood.

Several studies have shown that timing of trauma exposure during childhood is linked to distinct alterations in the brain as well as clusters of clinical symptoms. This preliminary finding suggests that exposure to traumatic experiences during infancy may disrupt the physiological capacity to “shut off” the stress response. Thus, the evidence that increased attention to trauma exposure timing is necessary to consider within a developmental framework is growing, and may have profound health implications. Until recently, there were few measures available to reliably gather information regarding the timing of traumatic experiences during youth. Just this year, the Maltreatment and Abuse Chronology of Exposure (MACE; Teicher & Parriger, 2015) was published, and we are excited to use in future studies. More research is needed to identify the cognitive and behavioral symptoms that are associated with delayed recovery from acute stress, how long this pattern of responding lasts, and whether psychosocial and pharmacological interventions can help.

For more insights from the frontlines of science on trauma, check out the ISTSS Trauma Blog.

Kuhlman, K. R., Vargas, I., Geiss, E. G., & Lopez-Duran, N. L. (2015). Age of Trauma Onset and HPA Axis Dysregulation Among Trauma-Exposed Youth. Journal of Traumatic Stress. doi: 10.1002/jts.22054

"Spotlight" reminds us that preventing child sexual abuse starts at home

I had the extraordinary pleasure of viewing the new film, Spotlight, this weekend. The critical acclaim of this masterpiece has been loud and unanimous, but more importantly, well-deserved. The film recounts the efforts of the investigative team, Spotlight, at The Boston Globe back in 2001 as they scrupulously uncovered systemic protection of Catholic priests who had repeatedly molested and raped children in their parishes with this article. This isn't a film blog, so I will simply leave you with a strong recommendation to see the film and get straight to the science. 

Children exposed to sexual abuse sustain psychological injuries that persist throughout their lives. In fact, I became a clinical psychologist because my first experience in clinical psychology research was in treating adults who continued to suffer from Post-traumatic Stress Disorder (PTSD) from severe sexual abuse as children. For the most part, a child who is sexually abused will have more physical illnesses, be less educated, have poorer and fewer close relationships, more problems with depression and anxiety, and more likely to attempt suicide than their peers for the rest of their lives. In fact, the World Health Organization (WHO) ranks child sexual abuse as equivalent to other well-known health concerns such as lead exposure and urban air pollution. 

This occurs for a lot of reasons, some of which we understand and some of which we don't yet. As a scientist, I am often more interested in the how and why of psychological phenomenon, but in the case of childhood sexual abuse, the negative consequences are so horrifying that our attentions should be solely focused on intervention and treatment. In the service of that goal, I have identified an article published this year that begins to explain how child sexual abuse prevention can start in the home. 

The main argument of this article is aimed at intervention researchers and emphasizes that child sexual abuse prevention should occur through parenting programs which still need to be developed. And further, these programs should target the parents of young children (ages 3-5). The rationale and evidence for this argument is what I want to share with you and your loved ones.

Currently, there are a number of preventive efforts in place that serve to protect children from sexual abuse. They are: 

1)Punishing offenders with incarceration, required public registration as a sex offender, and restrictions to where they can live and work. 
2)Advocacy and media campaigns that combat the "bystander effect" which basically encourage members of the community to take a "if i don't help, who will?" approach to protecting members of their community and neighborhood. 
3) Treating sexual offenders to prevent future victimizations
4) Treating victims to prevent future victimization

While each of these preventive strategies has been effective in some ways, they argue that more can be done to educate children and families to protect themselves. For example, we know that parenting intervention programs can reduce other types of abuse to children, such as physical abuse, but also that these parenting intervention programs can increase different parenting skills and practices that will help to prevent a child's risk for being sexually abused. 

The most important parenting predictors of positive child outcomes are warmth and control. Parents who are high in both warmth and control have children that grow up to be healthy, happy, and accomplished. This is obviously an over-generalization of what we know in developmental psychology, but either way, a child almost always benefits from their parent exhibiting mutual increases in warmth and control in their daily lives. The good news is that warmth and control can be taught, and child and adolescent psychologists know how to teach it! 


How to use Warmth and Control as a parent to prevent sexual abuse: 

Warmth: Sounds simple, but talk to your young child about sex and everything else. Parents who provide a safe environment for their children to talk about sexual behavior are more likely to delay the onset of having sex and end up more effectively using contraceptives. The authors of the article argue that these benefits could also be extended to helping children understand what type of touching is and is not ok. The truth is that children, especially young children, often do not know they are being victimized. They often believe they are just doing what they are told, or are playing a game. As a parent, your job is to learn as much as possible about the world they live in from their perspective and from there you will learn about their experiences, both good and bad. Also, kids know when something is "taboo" but often misread the signals as they are "in trouble." In fact, the children and adults I have treated who have a history of sexual abuse failed to tell an adult because they were worried they would get in trouble. Create a safe and supportive place for them to talk to you. This starts early. The peak age for sexual abuse exposure is in the early teen years (ages 12-14) but the number jumps from 3% among 0-2 year olds to 14% among 3-5 year olds. If you start the conversation early, you are the most likely to be effective in teaching your child what is and is not ok. 

Control: The highest risk populations for child sexual abuse are single parent families, families who live in poverty, children with disabilities, and families with domestic violence. The common denominator here is parent supervision. Basically, children who spend time with more adults who are not their parents are at highest risk. So, watch your kids, and when you can't watch your kids make sure they are with adults that you know and trust. Not to make you paranoid, but perpetrators are actually less likely to be strangers than your child's friends, their friends' older siblings, and babysitters. 

A scandal like this, and a film like Spotlight can often turn into a dramatized smear campaign against the Catholic Church and everything it stands for. However, perhaps most brilliant and much appreciated about the film was the attempt at an honest portrayal of an entire community that was guilty of negligence. We are all vulnerable to valuing belonging to a group over protecting individuals. From an evolutionary standpoint, that serves us well more often than it hurts us. We live in complex social systems made up of families, and neighborhoods, and cities, and states, and nations, and cultures. When it come to sexual abuse of a child, what we have to remember is that it is not enough to simply separate the perpetrator from the victim. It is not enough to remove the perpetrator from other potential victims. In the anticipation of Spotlight's release, The Boston Globe released an article highlighting the reformed Catholic Church on all issues related to child molestation and handling of church officials suspected of this behavior. Archbishop Michael Jackels in Iowa said it well, "The story told by the movie bears repeating until all of us get all of it right."

Mendelson, T., & Letourneau, E. J. (2015). Parent-Focused Prevention of Child Sexual Abuse. Prevention Science, 1-9.

Are you a parent with math anxiety?

Math is a very important skill. Regardless of whether you became an engineer, basic math skills are essential to modern daily life. At the very least, we all have budgets to manage and we all have to calculate the amount of time it will take us to get to and from the places we do and don't want to go. Despite the ubiquity of numbers and math in daily life, there is always a spike in anxiety when the bill needs to be divided up after a large dinner with friends because lots of people get anxious when they have to do math. Some psychologists are interested in where that anxiety comes from, and how to prevent it. 

In particular, Dr. Erin Maloney at the University of Chicago recently conducted a large study to discern whether parents' math anxiety contributes to developing math anxiety in kids. This is important for us to consider because math performance early in grade school is a robust predictor of long-term education outcomes. 

To do this, she and her colleagues recruited 438 1st and 2nd graders and their parents from 90 classrooms and 29 public and private schools in the Midwest. During the first 12 weeks and the final 8 weeks of the school year, the kids completed standardized math and reading tests, and questionnaires about math anxiety. Questions about math anxiety included items such as how nervous they would feel doing mental math problems or solving a math problem on the board in front of their teacher and peers. During the middle of the school year, the children's parents also completed questions about math anxiety, including items about how nervous they feel when "reading a cash register receipt after you buy something." Parents were also asked to report how often they help their child with math homework on a 7-point scale (1 = never  to 7 = more than once a day). 

They found that parents with high math anxiety who also reported helping their kids with math homework most often had kids with lower math achievement scores at the end of the year. This effect was independent of kids' math scores at the beginning of the year, gender, grade, school- and teacher-related factors. The same association was not found between parent math anxiety and reading scores, suggesting that the effect is specific to math skills. What was also interesting, was that this association between high parent math anxiety, more homework help and math achievement scores predicted increases in the child's math anxiety between the beginning and end of the school year. 

So, what does this mean? It potentially means that children develop math anxiety partially through exposure to their parents' math anxiety while helping them with homework. A dangerous conclusion that could be drawn from this is that parents with math anxiety should not help their children with math homework. While it used to be common for school to explicitly prohibit parents from providing extra instruction on coursework at home (click here to learn some more about history of education in the U.S), this custom has lang since changed. Instead, this may be just one more way untreated problems with anxiety can have unnecessarily long-term consequences. There are very effective ways of treating anxiety, such as CBT. More importantly, avoiding anxiety is the worst possible way to deal with anxiety. It is also prudent to consider the potential third variables that contribute to these findings. Perhaps genetic vulnerability to anxiety is playing a role in both the math anxiety of the parent and the child. Perhaps intelligence, also genetically heritable, is playing a role. Perhaps parents who have time to help their children with their homework also spend more time with their kids in general, and factors that contribute to a parent being more available to the child in general are driving these effects, for example income, occupation, personality. 

Needless to say, this study gives us some guidance about which children may be at risk for early problems with math, and therefore a place to start preventing those problems. 

Maloney, E. A., Ramirez, G., Gunderson, E. A., Levine, S. C., & Beilock, S. L. (2015). Intergenerational effects of parents’ math anxiety on children’s math achievement and anxiety. Psychological Science, 0956797615592630.