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! 

In defense of humor.

Do you love to laugh? For decades, psychologists have studied the role of positive emotions in health and well-being. So far, it’s pretty clear that positive emotional experiences, including those that make you laugh, are related to better emotional and physical health. Yet, very few of those studies can make causal claims. In other words, they don’t really tell us whether healthier people seek out humor or whether laughter causes better health. Recently, Sarah Wellenzohn, University of Zurich, and colleagues set out to test the causal role of humor in the emotional health of individuals. In short, they designed an experiment to answer the question:  

Does humor increase happiness and decrease symptoms of depression?

To do this, they randomly assigned 632 adults to 1 of 6 interventions to complete daily for 1 week. The interventions were:  

Three funny things: Write down the 3 funniest things you experienced during the day and your feelings during those experiences.

Collecting funny things: Remember 1 of the funniest things you have experienced in the past, write it down with the most possible detail.

Counting funny things: Count all of the funny things that happen throughout the day and write down the number.

Applying humor: Notice the humor experienced throughout the day and add new humorous activities, such as reading comics, telling jokes, watching funny movies.

Solving stressful situations in a humorous way: Think about a stressful experience today and think about how it was or could have been solved in a funny way.

Early memories (placebo control): Write about early memories.

Before starting the intervention, participants completed questionnaires measuring their authentic happiness and symptoms of depression. Authentic happiness is measured using participant agreement to 24 statements such as “My life is filled with joy.”  Depressive symptoms include sad or low mood, loss of interest or pleasure, appetite and weight change, sleep problems, worry, difficulty concentrating, or feelings of hopelessness. Participants also received training in the intervention and were instructed to do their intervention activity each day for one week.

At the end of the 1-week intervention, and then 1-, 3-, and 6-months after completing the intervention, participants again completed the happiness and depression questionnaires. This enabled the research team to look at whether humor interventions led to increases in happiness and declines in depressive symptoms, and also look at how durable those effects are over time.

At the end of 1 week, all of the humor-based interventions were associated with increases in happiness and decreases in depressive symptoms compared to the placebo group. So one important take home message is that humor helps, no matter how you incorporate it into your life.

With respect to increasing happiness, Counting funny things and Applying humor were the most effective, and those effects lasted for up to 6 months! The effects of the Three funny things intervention also lasted through the 6-month time period, but were not as robust. There are a number of reasons that these humor-based interventions had such long-lasting effects on happiness. Most likely, it was because participants continued to engage in the behaviors for longer than just the initial week. Positive emotions are addictive in the same way food and drugs are. So it’s possible that these 1-week interventions were enough to promote a humor-addiction, so to speak.

The effects of these interventions on depressive symptoms were not as durable. Despite all of the humor-based interventions being leading to reductions in depressive symptoms at the end of the 1-week intervention compared with the placebo group, none of these effects remained 3-months after the intervention. This finding isn’t too surprising since there were no individuals with depression in this study. In fact, 250 people were excluded from the study for having elevated symptoms of depression at the baseline assessment. This means that there was very little range in depressive symptoms in the sample to begin with, and thus very little chance that the intervention could have an effect at all. That being said, humor on its own is unlikely to be an effective treatment for depression. Depression is an illness; often initiated in the wake of a major life stressor. With the exception of Solving stressful situations in a funny way, none of the humor-based interventions offered skills that help manage the source of that life stress.

The authors argue that one of the important, active ingredients in humor is the focus on increasing positive emotions in the present moment. Each intervention, particularly the durable ones, accomplished that through increasing daily experiences that involved humor but also increasing individuals’ attention to those experiences over time. You can imagine that just a few days of Counting funny things would cause you to pay more attention to, and enjoy, when funny things are occurring.

Until next time, keep on laughing! Here’s a compilation of funny videos of kids learning about physics: https://youtu.be/-TjtoP6-mcQ

Wellenzohn, S., Proyer, R. T., & Ruch, W. (2016). Humor-based online positive psychology interventions: A randomized placebo-controlled long-term trial. The Journal of Positive Psychology, 11(6), 584-594.

*Many thanks to Unsplash.com for the gorgeous photos. 

Does Google know about a suicide before it happens?

According to the CDC, suicide is in the top 10 leading causes of death for people in the United States between the ages of 10 and 64. Among individuals in age groups 10-14, 15-24, and 25-34, it is the 2nd leading cause of death. In the year 2014 alone, we lost 42,772 Americans to suicide. Truthfully, this is probably somewhat of an underestimate because suicide is often miscategorized by as "unintentional injury," leading to false records.

If you are a clinical psychologist, you spend a lot of time thinking about ways to detect when a patient is entertaining thoughts that life is no longer worth living. Unfortunately, many completed suicides are unpredictable, and occur in moments where extreme hopelessness intersects with impulse and access to means. As a field there are many brilliant scientists and clinicians working on ways to identify and help individuals at this extreme of human suffering.

Among them is Dr. Christine Ma-Kellams, University of La Verne, and colleagues who were interested in understanding whether Google search trends can be used to predict suicide, and whether these trends are more effective in predicting suicide rates than our existing measures.

To answer this question, they pulled together data from several different sources. First, they found data from the CDC National Vital Statistics System on the number of completed suicides in the United States. From the U.S. Census Bureau, she collected demographic data that included information like income, population, home-ownership rates, unemployment, and percent of the population under the poverty line,  age, and racial categories. From the National Survey on Drug Use and Health, they collected nationally representative data on suicide vulnerability as reported on the existing gold-standard, clinical measures for suicide risk. Finally, from Google trends, they recorded the relative frequency of google searches for the terms "suicide," "how to suicide," "how to kill yourself," and "painless suicide" compared to the search term "weather." All of the data used in the study were from the years 2008-2009.

They found that the frequency of these Google search terms was significantly associated with the rate of completed suicides recorded by the CDC. They also found that frequency of these search terms was more predictive of suicide rates than the existing self-report measures we use to estimate suicide risk.

The Google search terms weren't perfect, though. They were less effective at accurately predicting suicide rates in states with lower incomes, higher crime rates, and a larger minority population. Also, it's important to acknowledge the limitations of this study. Even though this data was pulled from many different sources, is nationally representative, and cover two years, there is no way for us to know which direction the effect is going. We think these data mean that people are searching for "how to commit suicide" and then those same people are completing suicide, but it is just as plausible that individuals completed suicide, and then people in their community went online and searched for these terms. It is true that a single suicide in a community can inspire increases in discussions of suicide among the members of that community, but either way the problem to be solved is the same. Find a way to help people who feel like life isn't worth living, and prevent suicide. Google can help us find those people.

So, what does this mean? Google knows where you've been, where you're going, what you want, and how you want it. As it turns out, Google also knows who is thinking of committing suicide. Knowledge is power, and here power is life. Google is already implementing the use of sponsored ads for suicide hotlines that target individuals searching for terms just like the ones in this research study. But we are only at the beginning of understanding how to leverage this type of data in ways that can save lives. For example, can we target specific communities in the wake of a tragedy or disaster when suicide rates increase? Can we create sophisticated programs for online chatting for people going through a moment of hopelessness? Can we use the data to identify communities for whom more mental health resources would prevent these feelings of hopelessness? What ideas do you have about how to harness the power of the internet to reduce suicide rates?

Need Help? Know someone who does? Contact the National Suicide Prevention Lifeline
at 1-800-273-TALK (1-800-273-8255) or use the online Lifeline Crisis Chat.  You’ll be connected to a skilled, trained counselor in your area. Both are free and confidential. For more information, visit National Suicide Prevention Lifeline
Ma-Kellams, C., Or, F., Baek, J. H., & Kawachi, I. (2015). Rethinking Suicide Surveillance Google Search Data and Self-Reported Suicidality Differentially Estimate Completed Suicide Risk. Clinical Psychological Science, 2167702615593475.

Photo credit: Garrett Sears via www.unsplash.com

How Dogs Highjack Your Brain with Love Hormones

A little over 3 years ago, we rescued this puppy and named him Tolstoi. I have had dogs most of my life, so I have always taken for granted that special bond one has with a pet. However, Tolstoi is my husband's first dog, and watching that bond develop so quickly and so deeply was quite a special experience.

Dogs are wonderful in so many ways, and I've written about some of the ways dogs can enhance your health here. This week I thought I would share some recent #justplaincool research on the neuroscience behind the human-dog bond. 

There is a hormone in all mammal brains called oxytocin. Oxytocin is thought to play an important role in relationships. For example, oxytocin surges during cuddling and other intimate activities, in mothers when meeting their new infant for the first time, and while breastfeeding. I won't pretend that we fully understand the ins and out of oxytocin yet, but that's what makes science so exciting. 

Anyway, we have a pretty good understanding that the amount of oxytocin in your system fluctuates in ways that are salient to relationships, but so far those relationships have always been within the same species; human-human, rodent-rodent. Wouldn't it be cool if the neuroscience of how humans bonded with their dogs was dependent on the same processes through which humans bonded with other humans? Well, apparently that's exactly what happens. 

Dr. Miho Nagasawa, Azabu University, and her colleagues were interested in whether oxytocin in the body changes in humans and dogs when interacting with one another. To understand this, they recruited 55 healthy individuals and their dogs. All participants provided a urine sample and then were randomized to one of two conditions. Urine is one place you can measure oxytocin. In the first condition, participants were told to play with their dog for 30 minutes. In the other condition, participants were told not to look directly at their dog for 30 minutes. At the end of the 30 minute experimental condition, participants provided another urine sample. 

They found that the owners and their dogs that interacted during the 30 minutes showed large increases in oxytocin before and after the experiment. They also found that the largest increases in oxytocin occurred in owners who dogs initiated "gazes" with them frequently. This likely means that humans experience a similar neurochemical signal  when bonding with their dogs as with other humans, but that this signalling varies based on how much time owners and their dogs spend looking at eachother. 

My first thought when reading this finding was, well sure. Humans are very bonded with their dogs, and maybe surges of oxytocin just occur with humans interact with anything they are bonded with. Then I wondered whether the dogs experience this same surge in oxytocin. Luckily, Dr. Nagasawa has also conducted that study. 

In the 2nd study, they use the same procedure only this time they included a comparison group of hand-raised wolves and measured oxytocin in the urine of the canines in addition to their owners. They found that the increase in oxytocin after 30 minutes of interacting with their owner occurred in dogs but not wolves, and that the magnitude of oxytocin change was directly related to the length of time the owner and dog gazed at one another. 

Gazing is interesting for several reasons. We tend to take it for granted as a form of communication, but mutual gazing is considered the most fundamental manifestation of social attachment, especially between a mother and infant. Dogs and humans can't communicate verbally, so they rely on engaging socially with humans in other ways that tend to mirror how humans interact with their infant offspring. Another fun fact I learned from these articles was that dogs are apparently more skilled at using human social communicative behaviors than their will counterparts, wolves, but also chimpanzees. This suggests that dogs are uniquely capable of bonding with humans in ways no other species can.  

So basically, the next time Tolstoi stares at me, he communicating with me in a way that send natural "love drugs" throughout my brain to ensure I will keep taking care of him. Sneaky puppy, but man is it powerful. 

Unfortunately, some dogs havent been lucky enough to get rescued yet. If you want your brain highjacked with love hormones, some of these guys are up for the job. 

Nagasawa, M., Kikusui, T., Onaka, T., & Ohta, M. (2009). Dog's gaze at its owner increases owner's urinary oxytocin during social interaction. Hormones and Behavior, 55(3), 434-441.

Nagasawa, M., Mitsui, S., En, S., Ohtani, N., Ohta, M., Sakuma, Y., ... & Kikusui, T. (2015). Oxytocin-gaze positive loop and the coevolution of human-dog bonds. Science, 348(6232), 333-336.

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

What works: Anxiety and Depression Treatments

Depression and anxiety are emotional disorders that reduce quality of life, increase suffering, impair our relationships, and endanger our long-term health. What's worse is that they are also extremely common. Depression and anxiety are known to affect 19 and 29% of individuals, respectively, not to mention that depression and anxiety co-occur at a rate of almost 50%. These statistics are particularly astonishing to me as a clinical psychologist because our field has developed a number of effective, non-invasive treatments that just don't seem to get into the lives of the people who need them most. In fact, a large national study recently found that most people suffer with anxiety and depression for about 10 years before they get treatment. A decade of unnecessary suffering. 

There are many reasons for this: some people don't live close enough to mental health providers, many people don't believe they have a problem (after all anything that sticks around for 10 years would just become the new normal), many people don't believe that seeing a psychologist would help, and many people can't afford the time or money it would cost. Luckily, how to effectively treat anxiety and depression is an active area of research, including questions such as what works for whom, and how can these effective treatments be delivered. 

An older approach to treating anxiety and depression was to identify which problem was more pressing and severe, and then treat the disorders sequentially. However, basic psychological science research suggests that underlying brain structures, symptoms, and behaviors for depression and anxiety are the same. This means that they can likely be treated with the same interventions. With this realization, clinical psychological scientists began to test the effectiveness of depression treatments on anxiety disorders, and anxiety treatments on depressive disorders. What emerged from these studies were "transdiagnostic" treatments for depression and anxiety. The transdiagnostic approach to treating emotional disorders is to identify and address the common maladaptive psychological, behavioral, and interpersonal processes that underlie psychological distress and impede well-being. But the million dollar question is, "Do they work?" 

Last year Dr. Jill Newby at the University of New South Wales and her colleagues published a meta-analysis examining the effectiveness across all of the existing clinical trials using transdiagnostic treatments for depression and anxiety. After scouring the published literature, they identified 47 studies that examined the effectiveness of transdiagnostic treatments for depression, anxiety, and quality of life for adults. The 47 studies varied in the type of treatment used (e.g., mindfulness vs cognitive behavioral therapy (CBT)), size (e.g., group vs individual), and delivery (e.g., internet-based vs face-to-face). The results of this meta-analysis represent effectiveness for transdiagnostic treatment for 1,109 patients compared to 992 controls. 

They found that transdiagnostic treatments had a large and significant overall effect on decreasing depression and anxiety symptoms as well as increasing quality of life. They also found that these benefits were maintained for up to 6 months following treatment completion. They also examined delivery characteristics for treatments and found that anxiety symptoms improved the most when treatment was delivered individually or over the internet compared with in a group format. Depression symptoms were most effectively treated over the internet, followed by face-to-face and group formats. They also looked at whether the content and approach to therapy influenced patient outcomes. They found that anxiety symptoms improved more in CBT-based treatments, while there was no difference in effectiveness between CBT- and mindfulness-based treatments for depression symptoms. In other words, both work just as effectively for treating depressive symptoms. 


To summarize, patients with anxiety and depression were better off if they received transdiagnostic treatment than if they didn't. Further, internet-based CBT is likely the best bet for how to effectively treat your symptoms. This is good news because internet-based treatments are wiping out many of the common barriers to getting treatment. They are flexibly scheduled, cost-effective, and accessible. It's not surprising then that internet-based treatments for depression and anxiety are becoming a topic of national discussion. We wrote about it at the launch of Maven, the future of health care, and UCLA's Raphael Rose Ph.D. was featured on the topic in Vogue magazine just this month. Based on the national statistics, one in three of you is struggling with depression and/or anxiety. Getting mental health services used to be nearly impossible and quite stigmatizing to navigate. All of that has changed. The only question now is what are you waiting for? 

Newby, J. M., McKinnon, A., Kuyken, W., Gilbody, S., & Dalgleish, T. (2015). Systematic review and meta-analysis of transdiagnostic psychological treatments for anxiety and depressive disorders in adulthood.Clinical psychology review, 40, 91-110.

"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.

Teens, Anti-depressants, and a bit of context

Recently, there has been increasing media attention toward use of antidepressant medications to treat depression in adolescents. On August 3, 2015 an article was published in the New York Times arguing that antidepressants are safe and should be used more widely in the treatment of depression in young people (here's the link). On September 16, 2015, an article was published, also in the New York Times, alerting the public that a recent study identified Paxil (an antidepressant) as potentially dangerous for young people based on a re-analysis of an old study (here's the link to that article). 

Both of these articles were well-written and convey interesting information and interpretations of the science involved in evaluating treatments for mental illness. However, neither article provides the context within which these findings should be interpreted.  As a result, we are being distracted from the real problem: Depression is a life-threatening illness.

Why would antidepressants be unsafe for youth? 

Currently, there is an FDA black box warning on antidepressant medications. This first sentence reads, "Antidepressants increased the risk compared to placebo of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults in short-term studies of major depressive disorder (MDD) and other psychiatric disorders." Let's unpack this. This warning was developed following publication of a study that examined changes in suicidal thoughts and behavior for more than 100,000 youth undergoing antidepressant treatment trials for depression across more than 300 studies. They found that 2% of youth taking the placebo medication, but 4% in people taking the antidepressant, reported suicidal thoughts or behaviors. 

There are two important points to be made about the result of this study. First, the term suicidal thinking and behavior is misleading. Thoughts about suicide are common in depression, and more common among young people than the world likes to acknowledge. There were no differences in suicide completions between the two groups, only increases in thoughts related to suicide. Thoughts can be addressed in therapy. The truth is that a person with depression should see a mental health professional once per week during treatment, regardless of whether they are on antidepressants or not. For this reason, the best practices for treating an adolescent with depression include weekly visits with a psychologist, and bi-weekly to monthly visits with a psychiatrist. Unfortunately, among all of the young people with depression today, half of them are receiving no treatment, and those who are receive antidepressant medications from their primary physician, instead of a psychiatrist, which comes with its own set of risks. These risks are best managed by seeking mental health professionals, psychologists and psychiatrists, who specialize in treating children and adolescents.  

The second point to be made is that 4% is still low. This black box warning is quite misleading, as many statistics can be. The results of this study could be presented, accurately, by saying that youth taking antidepressants are twice as likely to have suicidal thoughts than depressed youth taking a placebo medication. Saying it this way is alarming. However, one could also say that 96% of youth taking antidepressant medications did not report suicidal thoughts, which is actually encouraging. In truth, 2% and 4% are statistically different from one another, but both are very small percentages. Yet, as a result of this black box warning, use of antidepressant medications for young people with depression plummeted. 

This brings me to another important point, which is that there are serious risks to not treating depression in young people as well. Like I said before, suicidal thoughts are common among individuals with depression. So common in fact that between 2 and 15% of individuals with untreated depression complete suicide. Yes, I said complete. Thus, we are brought to the second, less often considered sentence of the black box warning which reads, "Anyone considering the use of [Insert established name] or any other antidepressant in a child, adolescent, or young adult must balance this risk with the clinical need." In fact, we can see the unintended negative consequences of this black box warning over time. Between 1990 and 2000 adolescent suicide completion rates were steadily declining, and have been steadily increasing since 2004 when the black box warning was added. Click here for a figure of these suicide rates.  

To summarize, youth with depression are likely already experiencing suicidal ideation, and the risk of the teen completing suicide is highest when untreated. Obviously, treatment decisions are extremely personal and there will always be pros and cons of every treatment decision. However, we know that the most effective way to treat depression is a combination of weekly CBT and antidepressant medication, and risks are most effectively managed by mental health professionals who specialize in child and adolescent mental illness. For more on depression and it's treatment, click here. 

Choose empathy.

Empathy is the capacity to understand or feel what another person is experiencing. The capacity for empathy is, above all, human. Empathy allows human beings to communicate and build societies, empathy is what allows parents to anticipate the needs of their children, and appealing to the empathic part of humanity is a powerful strategy for motivating behavior, such as charitable giving and activism. Psychologists have been studying empathy for decades. Is the capacity for empathy human? Are there some people who do not experience empathy? Are more empathic people more moral? More intelligent? More successful in their communities? And so on.

Generally, people agree that the capacity to take another's perspective, within which emotions are implicit, is innate. However, this innate capacity appears to have declined in recent history. But if empathy is innate, then what might explain the changes in capacity for empathy in society? These clues and questions led psychologists to wonder whether the capacity for empathy is malleable, and therefore can be incrementally developed, rather than fixed. This is an empirical question. In other words:

Does effort increase our capacity for empathy? 

To answer this question, Karina Schumann and colleagues at Stanford University conducted 7 studies that systematically tested empathy under conditions designed to disentangle whether people who believe that empathy requires effort will experience more empathy, as well as the consequences of those beliefs and effort. 

The first few of these studies aimed to simply test and then replicate whether believing that empathy is malleable is related to more empathy. It is. They found that individuals who reported beliefs that empathy was malleable, rather than fixed, also reported putting forth more effort and persistence in interactions with others. For example, people who reported that the capacity for empathy is malleable were more likely to strongly agree with statements such as, "When I disagree with someone, I try to understand their emotions," or "When I do not understand someone's feelings right away, I put effort into trying to understand them." So there was strong enough evidence that believing that empathy is malleable was related to the amount of effort people put into being empathic. 

The fourth study was my favorite, though. In this study, they wanted to know whether people could be primed to believe that empathy was either malleable of fixed, and whether that influenced their empathic thoughts and behaviors. To do this, they randomized 119 participants to either read a sham Psychology Today article about how empathy is malleable (can be cultivated), or a sham article about how empathy is fixed (doesn't change) within an individual. Next, participants were randomly assigned to imagine having a discussion with another person about an issue. The person is someone who holds the opposite view as them on an issue that the participant previously ranked as highly important to them, or unimportant to them. So to review, the participants ended up spread randomly across 4 groups:

1. Read an article about how empathy is malleable + disagreeing with someone about an important issue
2. Read an article about how empathy is malleable + disagreeing with someone about an unimportant issue

3. Read an article about how empathy is fixed + disagreeing with someone about an important issue

4. Read an article about how empathy is fixed + disagreeing with someone about an unimportant issue

They found that people in group 1 exerted more effort toward being empathic compared with group 3, suggesting that inducing beliefs about the malleability of empathy caused individuals to exert more effort to be empathic than those induced to believe it was fixed. Then they replicated this finding in experiments measuring different types of empathic, effort-related behaviors. For example, inducing people to believe that empathy is malleable led to more listening to another person's position in an argument, altruistic behavior, and making attempts to improve their empathic ability through online training. 

In short, this series of studies systematically demonstrated that believing empathy can be improved will cause people to use more effort to be empathic, which translates into more empathic behavior. Thus, the title of this article: choose empathy. Believing that empathy is flexible is the key. This has widespread implications in our society, from parents to teachers to the media. There appears to be a tendency today to assign people labels as empathic or not. I've seen people assign these labels to themselves, their children, politicians, and colleagues. Apparently, it is the belief that some people either are or are not empathic that holds us back. Hopefully, this article is a small step in changing that tendency. Instead, especially with children, we ought to be promoting the idea that our innate human capacity to take another's perspective and experience their emotions is a skill that can be practiced and even mastered, but it takes effort. 

Now, it is important to keep in mind that this study was conducted with presumably health adults who represent the normal population. Within clinical psychology, there are certainly clinical populations that are characterized by difficulty taking another's perspective or even the inability to experience empathy. So, as a clinical psychologist, I have to acknowledge that the findings of this article may not be universal, and that at the very least there are subpopulations where the effort necessary to experience empathy is greater. Even so, these sub-populations constitute less than 5% of the population, and more importantly no harm comes to this group by living  in a society where there is a expectation that empathy is a cultivated skill, requiring and worthy of effort. 

Now the real question is, how will you cultivate your empathy? Here are a few ways to start for both kids and adults. What's fabulous is that one of the best ways to cultivate empathy is through reading fiction. Yes, please! 

Schumann, K., Zaki, J., & Dweck, C. S. (2014). Addressing the empathy deficit: Beliefs about the malleability of empathy predict effortful responses when empathy is challenging. Journal of personality and social psychology,107(3), 475.

Happy tweets, healthy hearts.

Heart disease is the leading cause of death in the United States. The most prominent risk factors for heart disease are smoking, obesity, hypertension, diabetes, low income, and low education. However, psychological science has taught us that living in a social environment that is hostile and un-supportive also contributes to poor health, specifically heart disease.

In the past ten years, the social environments we interact with have grown exponentially with the introduction of social media such as Facebook and Twitter. This introduces an entirely new dimension of social interaction but also a window of opportunity for psychological science researchers. Specifically, a recent study pursued the question:

Does language on Twitter relate to heart disease mortality?

To answer this question, Johannes Eichstaedt and colleagues collected 50,000 words tweeted between 2009 and 2010 from users all across the United States. They systematically review the words for frequency, content, and the location of the user based on their user profile. Then they gathered county specific data on rates of obesity, smoking, marital status, hypertension, income, education, race, and mortality due to Athlerosclerotic Heart Disease from the CDC for the years 2009 and 2010. The data represented in the study represents 148 million county-mapped tweets across 1,347 counties, and CDC data from 88% of the United States.

They found that combining known physical and social risk factors, including income, education, smoking, diabetes, hypertension, obesity, race and marital status, accounted for about 35% of heart disease mortality within a county. However, language used on Twitter alone accounted for about 42% of heart disease mortality within a county. Combining Twitter language and known risk factors accounted for about 43% of heart disease mortality risk. This suggests that language used on Twitter is an important indicator of health outcomes. But what were these people saying on Twitter that predicted heart disease in their county?

The research team identified 3 categories of language use that specifically predicted increased risk for heart disease mortality in their county: aggression & hostility, interpersonal tension, and disengagement. Anger and hostility was a category comprised of frequent use of expletives. Interpersonal tension was a category comprised of frequent use of words such as “hate,” “jealous,” “fake,” and “drama,” not to mention some more expletives. Finally, disengagement was a category comprised of frequent use of words related to boredom and fatigue. Each of these categories was a significant predictor of increased heart disease mortality in a county.

There were also three other categories. These categories were Skilled Occupations, with words referring to attending conferences, learning, and meeting new people; Positive Experiences, using words that refer to friends, weekends, food, company, and things described as wonderful and fantastic; and finally Optimism, which reflects the use of words reflecting possibilities, achievements, father, goals, success, strength, and courage. Frequency of Twitter content in each of these 3 categories was protective against heart disease risk in counties.

But what does this mean? Saying bad words on Twitter causes you to die of heart disease? Posting angry, hostile tweets causes your neighbors to die of heart disease?

Because this research is cross-sectional, these are just correlations, not causes of heart disease. It’s possible that pre-existing heart disease causes people to be more hostile, angry and pessimistic. In that case, language patterns on social media may be an early sign of undiagnosed heart disease that is an area for future preventive science to explore. It’s also possible that engaging with the world with more anger, hostility, and pessimism causes physiological changes to the body that lead to heart disease. Since we know that stress causes heart disease, this pathway is extremely plausible. However, the people who die of heart disease tend to be older, while the people on Twitter tend to be younger. The people in this study that were tweeting expletives were not the ones dying that year, so there’s something much greater reflected in these findings than what predicts heart disease within an individual.

What these findings really suggest to me is that older people living in communities filled with people who are angry, pessimistic, bored, tired, hostile, and curse a lot, are more likely to die of heart disease. The important assumption being made here is that people behave on Twitter the way they behave in the world. In many ways this isn’t really true. But do you think a person that is mean on social media is also the type of person who honks at older drivers when they hesitate to turn right on red, or run a yellow light? I would venture to say yes. The authors suggest that the “combined psychological character of the community” is being represented by Twitter language in this study, and it has robust associations with health. 

We all live in communities, big and small. Other people matter, but more importantly, your behavior matters in the lives of other people.

Eichstaedt, J. C., Schwartz, H. A., Kern, M. L., Park, G., Labarthe, D. R., Merchant, R. M., ... & Seligman, M. E. (2015). Psychological language on twitter predicts county-level heart disease mortality. Psychological science,26(2), 159-169.