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. 

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.

Who does the cleaning in your house? And why it matters.

With all of the #LeanIn and #HeForShe movements going on lately, division of housework has become a common topic of conversation. The typical family in the United States is comprised of two working adults, averaging about 91 paid hours (combined) per week. So, at the end of the work day, both adults are tasked with recovering from the work day, managing their home, and often caring for their children. Moreso than for any other generation, the division of housework matters. 

In 1965, women spent 30 hours per week devoted to housework while men spent about 5 hours per week. In the year 2000, the National Survey of Families and Households found that women spent about 18 hours per week doing housework while men spend about 10. This suggests a lot of things. First, the amount of hours the average family is spending on housework has declined by 20% since 1965, perhaps due to the introduction of time-saving technology such as microwaves, dishwashers, and washing machines into most American homes. It also says that as women have increasingly joined the work-force, men have increasingly participated in more housework. Yet, among households where both adults work full-time, men still report spending significantly more time "relaxing" and doing leisure activities after work, while women report spending more time doing housework and care-giving.  

Unfortunately, I find conversations about the division of housework to be mostly limited to issues of who does what and seldom about the potential consequences for health, wealth, and well-being. To me, the fact that men and women spend their time doing different activities is obvious and not very interesting. Whether the activities men and women engage in after work have implications for physical and psychological well-being interests me very much. Luckily these are empirical questions that psychologists care about and are actively trying to answer. 

In particular, Dr. Darby Saxbe, University of Southern California, and her colleagues asked the question: 

Does the division of labor in a household have implications for physical health in either partner? 

To answer this question, the research team recruited 30 healthy couples, both members working full-time, who own their own home, have a mortgage, and have at least one child between 8-10 years of age. With these participants, the research team tried to capture a "week in the life" of these couples by tracking their behaviors for 4 days from around 6:30-8:30am and then again from about 4pm to whenever the participants went to bed. Their goal was to capture what participants did before work, and after work. Tracking in this study constituted a research staff member recording each member of the household's location (e.g., kitchen, living room) and activity (e.g., cooking, watching TV) every 10 minutes into a handheld computer. Compared with previous studies that had used self-report assessments of how people spend their time at home, these observations allowed the research team to have a more objective measure of what participants' time at home looked like. 

Participants in this study also provided saliva samples on 3 days at waking, in the late morning (at work before lunch), afternoon (before leaving work), and right before bed. Saliva samples were used to measure the concentration of cortisol. Cortisol is final product of the body's physiological stress response system.* Cortisol in the body should be high in the morning and decline throughout the day. Not showing a steep decline in cortisol throughout the evening has been associated with poor sleep, several diseases, and is a predictor of mortality. In fact, many researchers see dysregulated cortisol as a pathway through which chronic stress leads to illness. The research team was interested in understanding whether the day-to-day activities of men and women at home were related to their body's ability to down-regulate this stress hormone in the evenings. 

They found that women were doing housework in 30.5% of observations, whereas men were doing housework in 20% of observations. In contrast, women were engaging in leisure activity in 10.6% of observations, whereas men were engaging in leisure activities in 19.4% of observations. Surprisingly, perhaps only for me, men and women were both engaging in communication in about 18% of observations. 

They then looked at whether activities at home predicted physiological stress in the evening. They found that both men and women who spend more time doing housework, have higher cortisol in the evenings. Perhaps more interesting, the amount of housework a wife does had no association with their husband's cortisol in the evening. In contrast, husbands observed doing more housework had wives with lower cortisol in the evening. 

When it came to leisure, husbands had lower cortisol in the evening when they spent more time doing leisure activities, especially when their wives were NOT engaging in leisure. In contrast, how much time women spent doing leisure activities was not related to their cortisol in the evening. 

So what does it all mean? The research team concluded creating a true division of labor at home may have real physiological benefits for wives, and suggested that these benefits (or the lack of them) can add up over time.         

So what's the solution? Perhaps it's that wives should make an executive decision to do less housework. A lot of households can accomplish this by making a decision to invest in their health by outsourcing housework to robots and third parties. My favorite examples of this are Roomba and Fluff-and-Fold laundry services. Perhaps it's that husbands need to make an effort to jump in when they see their wife doing housework. This includes, but is not limited to, cooking, vacuuming, doing laundry, dishes, changing sheets, and regularly scanning the house for stray belongings (read: socks). The good news is that many of these solutions are small but still make a big difference. 

This research study definitely doesn't provide all of the answers, and probably introduces more questions than it answers (as all good research does). For example, this study focused on heterosexual couples and therefore the role of "wife" vs "husband" is somewhat confounded with "male" vs "female." It's possible that women have higher physiological stress in the evenings than men, independent of housework. More studies looking at a more diverse sample of couples that include homosexual couples would help us understand how to disentangle the male-female differences from the role of housework-leisure behaviors. Also, this study only included couples where both parent works full-time. While this represents the average American family today, this study doesn't tell us much families with stay-at-home moms or dads.   

*Click here for past articles about/related to cortisol. 

Saxbe, D. E., Repetti, R. L., & Graesch, A. P. (2011). Time spent in housework and leisure: links with parents' physiological recovery from work. Journal of Family Psychology, 25(2), 271.

Many thanks to unsplash for the photos!

At risk for diabetes? Here's how to prevent it.

Psychology holds a strange position in modern medicine because we live in a time when everyone believes there is a pill that can solve their problems, and yet many common illnesses in medicine (e.g., pain, depression) are treated more effectively with behavioral medicine than pharmaceuticals. This week, I would like to share with you one of the original studies that showed us just how profound an impact psychologists and other mental health professionals can have on medical problems, specifically diabetes. 

American Diabetes Association

According to the CDC, 30 million people in the United States have diabetes. For more on diabetes from the CDC click here.  

In 2002, the Diabetes Prevention Program Research Group published the results of a 5 year study examining treatment outcomes for people at risk for diabetes. They asked the questions can you prevent diabetes? And what works: drugs or lifestyle change?

To answer these questions, they recruited 3,234 individuals who were at risk of diabetes based on their fasting glucose levels. These individuals were about 51 years old, 68% female, 45% belonged to an ethnic minority group, and the average BMI was 34 (BMI > 30 is considered obese). 

Each participant was then randomly assigned to 1 of 3 groups: placebo, Metformin, or Lifestyle change. The placebo group took 2 pills per day for the duration of the study. Metformin is the most commonly prescribed, 1st line treatment for Type 2 Diabetes. Participants in the Metformin group took an 850mg pill of Metformin twice daily for the duration of the study. 

Participants in the Lifestyle change group were assigned to a mental health professional who guided them through a 16-lesson curriculum in weekly, one-on-one meetings for 24 weeks. The goals of this program were to help the participant maintain 150 minutes of physical activity per week and reduce their body weight by 7%. By the end of the 24 week curriculum, 50% of participants had maintained the 7% weight loss and 74% of participants had maintained their physical activity regimen. After 24 weeks, participants continued to meet with their behavioral therapist monthly for the duration of the study in order to review and reinforce these lifestyle changes. 

To determine the effectiveness of these treatments, each participant was tested annually for diabetes using an oral glucose tolerance test. Over the next 5 years, the incidence of diabetes was 11% in the placebo group, 7.8% in the Metformin group, and 4.8% in the Lifestyle change group. In other words, Metformin was effective in reducing the incidence of diabetes by 31% whereas the behavioral Lifestyle change program was effective in reducing diabetes by 58%. 

Needless to say, these results caught the medical world by storm. First, no one really expected that behavioral medicine could be more effective than the gold standard medical treatment. Second, the world hadn't really considered how to leverage the power of mental health professionals in healthcare. Luckily, this was almost 15 years ago, and integrated primary care is becoming more commonplace. 

The WHO defines health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity," but we still have a long way to go. It seems as though many people still believe working with a mental health professional is only meant for extreme cases. Yet, these data are pretty clear that working with an expert in behavioral medicine, such as clinical psychologists, can be extremely effectively in maintaining health goals that going far beyond depression and anxiety. 

Diabetes Prevention Program Research Group. (2002). Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl j Med, 2002(346), 393-403.

Does your personality fit your city? Does it matter?

Where do you live? Why do you live there? For most people, choice of where to live comes down to a few obvious and important factors: family, job, money. Have you ever wondered whether your self-esteem takes a hit when you live in a city that doesn't jive with your personality? Psychologists have. 

Just last month, Dr. Weibke Bleidorn, University of California Davis, and colleagues published a study looking at the whether a person's self esteem varies as a function of the fit between a their personality and the personality of their city  To do this, they used data collected online from the Gosling-Potter Internet Personality Project between December 1998 and December 2009. Participants in this study were between the ages of 16-60 and were included in the study if they lived in a city (based on self-reported zip code) that had at least 199 other respondents. The resulting sample included data from 543,934 individuals living in 860 cities in the United States. 

The online questionnaire included measures of personality and self-esteem. Psychologists typically measure personality across 5 dimensions: openness, conscientiousness, extroversion, agreeableness, and emotional stability (also known as neuroticism). Click here for Wikipedia's definition of each of these domains of personality. Each participant answered 44 questions whose answers placed them on a continuum for each of these domains. If you're interested, you can take the test for free here. To measure self-esteem they asked participants to indicate the degree to which they agreed with the statement, "I see myself as someone who has high self-esteem," on a scale from 1 (strongly disagree) to 5 (strongly agree). As simple as it sounds, self-esteem used to be measured in psychology research using more questions, but this single item tends to be all you need to ask. 

With this data, the research team was able to compute scores for the personality of each participant, as well as scores for each of the 860 cities represented. Using these scores, they were then able to disentangle the contributions of an individual's personality, their city's personality, and person-city personality match as predictors of self-esteem. Not surprisingly, the more emotionally stable (less neurotic), extroverted, open, agreeable, and conscientious a person was, the higher their self-esteem. Interestingly, individuals who lived in cites where the average person was higher in emotional stability, lower in openness, higher in agreeableness, and higher in conscientiousness, the higher their self-esteem. However, these weren't necessarily the question the researchers wanted to answer. The research team was more interested in whether fit between an individual and that of others in their city was important for self-esteem. 

As it turns out, it is, but only for openness, agreeableness, and conscientiousness. They found that individuals higher in openness have higher self-esteem when living in cities filled with open people, people higher in agreeableness report higher self-esteem when they live in cities filled with agreeable people, and people higher in conscientiousness report higher self-esteem when living in cities filled with conscientious people. But also, the other side of that coin may be true; less open people may have higher self-esteem in cities with less open people. 

So what might this mean for all of us wherever we live, by chance or by choice, and/or who may have to decide where to live in the future? Well, it means that there are many contributors to our self-esteem. First is our personality, but also the personalities of those around us. As a clinical psychologist, I can't help but point out that this means there are many pathways to higher self-esteem. One can practice emotional stability, conscientiousness, agreeableness, extroversion, and openness. One can seek out cities that promote emotional stability, agreeableness, and conscientiousness in their potential and current residents. Look to their elected officials, their mascots, their city-sponsored events. And as a result of this study, one can learn to appreciate his/her own personality strengths and seek out cities that are matched in those qualities (particularly openness, agreeableness, and conscientiousness). 

There are limitations to the conclusions we can draw from this study. In particular, there is no way to rule out the possibility that having higher self-esteem influences a person's personality and also the cities they choose to live in. Nevertheless, self-esteem is an important psychological resource that psychologists want to understand how to cultivate in individuals and societies alike. So here it is sensible to try and understand what predicts self-esteem, rather than what self-esteem predicts. Hopefully, the next time you consider moving to a new city, you will think about more than just the practicalities of living there but also the personalities of its residents before you sign on the dotted line. It matters. 

Bleidorn, W., Schönbrodt, F., Gebauer, J. E., Rentfrow, P. J., Potter, J., & Gosling, S. D. (2016). To Live Among Like-Minded Others Exploring the Links Between Person-City Personality Fit and Self-Esteem. Psychological science, 27(3), 419-427.

Our gratitude to unsplash  for the beautiful photos. 

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.

The verdict is in: Coffee is good for you again!

Coffee and I go way back. Some of my earliest memories are of sitting at the kitchen table with my grandmother while she ate grapefruit for breakfast and drank a cup of coffee. I would sip my own cup of what was probably 10% coffee and 90% cream. Coffee even inspired my professional path when I learned as a hospital volunteer that premature babies are prescribed caffeine citrate to catalyze respiratory development. Even today, I spend a good portion of my time either trying to get more coffee, enjoying coffee, or making plans about when I will have coffee next. Luckily, I am not alone. This behavior is well-integrated into my family, American culture, and has been a major part of the human experience since its discovery in Ethiopia around 850 A.D. Despite its ubiquity, somewhere along the way, coffee developed a bad reputation where our physical health is concerned. But, like many trends in health advice, those opinions were based on anecdotes and not evidence, and the tides are turning.

 
This week, I thought I would share what we know about coffee and different health risks and even benefits. Last year, there were two great articles published on this topic. The first reviews what we know about the links between coffee and health by Elvira Gonzalez de Mejia and her colleagues from the University of Illinois Department of Food Science and Human Nutrition.

In the past decade, several studies have consistently shown that drinking coffee is associated with weight loss due to increased metabolism and lipid oxidation, a 7% reduction in risk for Type 2 Diabetes, enhances memory consolidation, and is protective against the development of prostate, colon, liver, and endometrial cancers. However, there are some diseases that may be more likely in people who drink too much coffee, mix caffeine with alcohol, or who have other risk factors. For example, drinking coffee may be related to bone loss and osteoporosis later in life. The authors suggest that this association may be offset by drinking coffee with milk as opposed to black. There are other studies showing that coffee can increase cholesterol and blood pressure, which may increase risk for heart disease. There are other studies suggesting that drinking coffee can worsen pre-existing conditions, such as heart disease or anxiety. What remains to be understood in many of these studies is whether these effects are related to caffeine or specific to coffee. Coffee, compared with other sources of caffeine, actually have a number of health benefits like reducing inflammation that are independent of caffeine, especially when you avoid adding sugar.

The overall conclusion of the article was that drinking coffee can confer more health benefits than risks, but that moderation is critical. But, what is moderation anyway? The authors recommend that adults drink fewer than 400 mg of caffeine per day. A cup of coffee can range from 95-330 mg per cup, while an espresso can range between 50-150 mg. The recommendations for pregnant women and children are a bit different. Pregnant women should limit daily caffeine intake to less than 300 mg, while children and adolescents should limit their daily caffeine intake to less than 2.5 mg/ kg of weight. This means that the average 10 year old in the US, who weighs ~70 lbs or 32 kg, should have less than 80 mg of caffeine per day. Also, it's important to keep in mind that caffeine isn't only found in coffee. There are meaningful doses of caffeine in tea, chocolate, soda, and energy drinks. Kids, unlike adults, generally get caffeine from soda, which also contains high doses of sugar that contribute to risk for Type 2 Diabetes considerably.

The second article I found was a meta-analysis conducted by Alessio Crippa and colleagues at the Institute of Environmental Medicine at the Karolinska Institute in Sweden. The purpose of this study was to aggregate all of the studies that have looked at the association between coffee consumption (measured in number of cups per day) and mortality between 1966 and 2013. This ultimately included data from 997,464 individuals, 120,915 of whom had passed away. They divided their findings up into studies that examined all-cause mortality, cardiovascular disease, and cancer. They found that drinking coffee was associated with lower all-cause mortality risk compared with individuals who drank none, but the mortality related benefits of drinking coffee stopped increasing after about 4 cups per day. With respect to cardiovascular disease, similar results were observed. Specifically, mortality risk was highest among individuals who did not drink any coffee, lowest for individuals who drink 3 cups per day, and the benefits of drinking coffee taper off and even begin to reverse after 4 cups per day. Unfortunately, the same pattern was not observed for cancer, and drinking coffee was not related to any differences in cancer-related mortality.

One limitation of everything I've just shared with you is that I am unapologetically biased. It would take an enormous amount of evidence to convince me to quit drinking coffee, however I have learned quite a lot from reading these articles. Before now, I assumed that coffee was good for my own health because I enjoy it so much, and because walking to get coffee constitutes much of my daily exercise. However, these data speak to additional health-benefits that I wasn't aware of. Now obviously the most important limitation of these studies is the lack of causal associations. The only way we would know that caffeine prevents disease or causes anything is by randomly assigning one group of humans to drink coffee daily and one group to drink something else. But then we would have to follow them for the rest of their lives, and alas we are only guaranteed one life to live. In the absence of good causal data, these are enough to reassure us coffee-drinkers that if we keep our enjoyment below 400 mg per day, with some exceptions, we not harming ourselves and can continue as T.S. Eliot and measure out our lives with coffee spoons.

Crippa, A., Discacciati, A., Larsson, S. C., Wolk, A., & Orsini, N. (2014). Coffee consumption and mortality from all causes, cardiovascular disease, and cancer: a dose-response meta-analysis. American Journal of Epidemiology, kwu194.

de Mejia, E. G., & Ramirez-Mares, M. V. (2014). Impact of caffeine and coffee on our health. Trends in Endocrinology & Metabolism, 25(10), 489-492.

I hate exercise too.

Photo credit: https://unsplash.com/

I shouldn’t admit this because I am a health professional, but I don’t like exercise. Don’t get me wrong, I enjoy being active. I love living in a city because you can walk everywhere, hiking in the canyons with my dog, and I will usually take the stairs over the elevator to get from Point A to Point B. Despite generally enjoying living an active life, I really hate structured, overt exercise. I’m talking about the kind that requires you to buy a new wardrobe of workout clothes and visit a gym several times a week where you are strapped into machines that contort your muscles to-and-fro while someone who runs ultramarathons for fun yells “imagine carving out that panty line” and “get that leg a little higher” at you while you try not to cry or vomit. For me, all of this feels and seems completely ridiculous. That being said, the data consistently shows that engaging in 30 minutes of aerobic exercise at least 3 times per week will, literally, save your life. If you do that, you will live longer, get injured and sick less, spend less money on medical bills, look younger, feel happier, and sleep more restfully. As far as investments go, exercise is a safe bet. So, professionally, I make recommendations that people exercise, like I did here, and I also participate 2 hours per week in the Los Angeles cult that is CardioBarre. For better or for worse, it is the nearest to my house.

But sometimes, despite this laundry list of benefits, I find it difficult to muster up the motivation to engage in overt exercise activities. There are so many hours in the day, and just under a million other things I could be doing instead that would feel more productive or that I would actually enjoy. If there is anyone out there who thinks and feels the same way, this post is directed at you. In fact, only 26% of people in the United States actually meet the recommended weekly exercise dose, so this is directed at most of you.

In 2008, Hillman, Erickson, and Kramer published a review of what we know about the effects of exercise on the brain. While they reviewed the results of many findings, I will limit my explanation to 3 findings that are particularly motivating for me. First and foremost, exercise creates new brain cells. If you have two cages of rodents, one cage with a running wheel, and one cage without, the rodents in the cage with the running wheel will run on it and create new neurons. Throughout your life, you are creating and losing neurons, with an imbalance toward creating in the first half of life and an imbalance toward losing in the second half. However, exercise promotes the creation of new neurons, thus allowing for more learning early in life, and less deterioration in later life. Second, exercise makes daily tasks less difficult. If you have older adults (ages 60-85) participate in aerobic training multiple times per week over several months, they will process information more quickly, have better spatial reasoning, and have much better executive functioning than people who did not participate in the exercise program. Executive functioning skills most robustly improved compared with the control group as a result of exercise, which include complex thinking such as planning, problem solving, holding multiple pieces of information in memory, and switching between tasks. These results are actually so convincing that researchers are looking into whether exercise interventions can prevent or even reverse the effects of Alzheimer’s Disease. Stay tuned for more on that in the future. Finally, exercise makes you smarter. These effects can even be intergenerational. For example, mothers who exercise during their pregnancy have offspring with more brain cells in the parts of their brain responsible for learning and memory (hippocampus & dentate gyrus). As children continue to develop, kids who engage in more physical activity have higher IQs, better achievement scores in both verbal and math assessments, and have better memories.

So there you have it, even if it’s silly and feels like a sweaty, waste of time and money, exercising with regularity will put you in a better mood, help you think more clearly while you work, and will continue to promote your ability to learn (whatever you want) throughout your life. When you put it in perspective like that, 30 minutes every couple of days isn’t so bad.


Hillman, C. H., Erickson, K. I., & Kramer, A. F. (2008). Be smart, exercise your heart: exercise effects on brain and cognition. Nature reviews neuroscience,9(1), 58-65.

Holiday Weight Gain: Some Truth and Some Hope.

This week, we are proud to feature guest writer, and resident expert on preventive health, Kelly Jordan Kuhlman, RN. Kelly recently became a Registered Nurse in the state of California and has 2 bachelor’s degrees: Human Development and Nursing. Given that the holidays are a time when we tend to put our health aside for festivities, Kelly wanted to share with you a little known fact about holiday weight gain and her ideas about how to get through the season with your health in tact.  

Since we are in the middle of the holiday season, I have been thinking about all the wonderful things I love about this time of the year: parties, classic Christmas movies, decorating cookies, festive lights, fireplaces, singing carols with candlelight, giving gifts, having a pajama party every Christmas eve with my sister, Belgian waffles on Christmas morning, decorating the tree with family, egg nog, cooking and spending time with family.

Though there are many positives about the holidays, they are also notorious for weight gain. During the holidays, foods that are high in fat and sugar are more readily available, eaten more frequently, and consumed in greater proportions. Approximately 28% percent of the US adult population is either overweight or obese and that number continues to rise each year. Being obesity is a serious health hazard and puts those individuals at risk for high blood pressure, coronary artery disease, type II diabetes, stroke, cancer and several other health complications. One way to prevent or reduce weight gain is to identify critical periods when weight gain is most likely to occur, such as the holidays. In an effort to try and understand holiday weight gain this article came to my attention.

In 2013, Jada L. Stevenson and her colleagues from the Human Nutrition Laboratory at Texas Tech University published a study titled, “Effects of exercise during the holiday season on changes in body weight, body composition and blood pressure.” To do this, they recruited 148 participants between 18 and 65. The participants attended two test visits where their height, body weight, blood pressure, heart rate and self reported daily physical activity were recorded. The first visit was in mid November before the Thanksgiving holiday and the second test visit occurred in early January. The goal of the study was to understand how weight, blood pressure, and body fat percentage change over the course of the holidays, and whether physical activity influences those changes.  

Basically, they found that people gain weight during the holidays, and that exercise doesn’t really help that much. They found an average increase in body weight of 1.7 lbs and a 0.5% increase in body fat percentage in all participants regardless of exercise habits. Interestingly, they found that initial body weight was significantly correlated with changes in body weight and percentage of body fat versus age, gender, initial body fat or exercise which means the heavier you are the more likely you are to put on weight at the holidays. Talk about kicking you when you’re down.

Additionally, all the participants showed an increase in blood pressure despite weight gain but regular physical activity presented some protection to participants who were physically active. People who do not exercise showed on average a systolic blood pressure increase of 4.8mmHg, while people who exercise had an average increase of 0.3mmHg in blood pressure.

For an adult, a normal healthy blood pressure should be below 120/80 mm Hg. The top number, systolic, measures the pressure in the arteries while the heart contracts or beats. The bottom number, diastolic, measures the pressure in the arteries between each heartbeat or when the heart is not contracting. Though 4.8mmHg may not seem like a large increase, if an individual’s normal blood pressure is 120/80 mm Hg and after the holidays they have a blood pressure that reads 125/80mmHg, they are now considered pre-hypertensive which may lead to high blood pressure. Blood pressures do tend to rise with age, which is why it is even more important for people to follow a healthy lifestyle. Though exercise may help maintain healthy blood pressure, in this study physical activity was not effective in preventing weight gain during the holiday season.

While this study provides some eye opening data about what happens to our bodies during the holiday season, there are certainly some limitations to consider. First, the interpretation of their findings was that holiday eating is the culprit in the observed changes to weight, blood pressure, and body fat percentage. However, they didn’t really measure what people were eating over the holidays, which leaves a lot of room for other explanations.  For example, the holidays are marked with a number changes to everyday life, including travel, change in daily routines, more access to high carb and high sugar treats, and weather-related limits to outdoor activities. Furthermore, they found that the effect of holiday weight gain was the worst for individuals who started the study in the overweight or obese category. This means that their findings may actually be specific to overweight and obsess individuals, but a larger study would be able to clarify.  

Despite the limitations to what this team of researchers measured, they make a strong statement about how the average individual gains about 1 kg or 2.2 lbs in a year, and that holiday weight gain makes up most of that. This is good news and bad news. On the one hand, holiday weight gain may be inevitable, on the other, if you can get through the holidays without damaging your health too much, you may have an advantage for the rest of the year.

Even though exercise is important to maintaining a healthy lifestyle it may not be enough to counteract holiday weight gain, which means in order to effectively limit holiday weight gain we need to be mindful of how much we eat and what we are eating.  Here are three strategies I use to keep my holiday intake under control.

·         Limit alcohol: Avoiding alcohol entirely at the holidays can be difficult but it is something that should be monitored. Alcohol is known for having a high caloric content and will dehydrate you. To fight these two elements, try to alternate between water and choice of beverage because this keeps the body hydrated and limits the calories.

·         Avoid unnecessary eating: Holiday appetizers are usually caloric teases since it’s the preparatory food for a gigantic meal. If you can’t resist the appetizer table, try going for vegetables and nuts since they are great healthy snacks to have while waiting for the meal. Vegetables are full of fiber and nuts are contain healthy fat that will help to keep you feeling full for longer which might help prevent overeating at the meal. Also, remember that moderation is key! Think about your favorite holiday foods, for me its mashed potatoes, and save room for those favorites. Try to resist the urge to take everything, so there is more room and less guilt for the favorites that you only get once or twice per year.

·         Hosting or contributing to the meal: Another great way to take control at the holidays is to offer to be the host or contribute to the meal by bringing one of the courses. Being a hostess gives you control over the food, which means you can make healthier options for yourself and your family.

I will leave you with this quote by John Rohn, “ Take care of your body. It’s the only place you have to live.”  

Stevenson, J. L., Krishnan, S., Stoner, M. A., Goktas, Z., & Cooper, J. A. (2013). Effects of exercise during the holiday season on changes in body weight, body composition and blood pressure. European Journal of Clinical Nutrition, 67(9), 944-949.