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! 

Violence: What won't stop it.

These days, everything is political. That's really a shame, because on more issues than not, we all pretty much want the same thing. One example of that is violence. I think most people would agree that violence isn't good, and that we would like to live in a world with less of it. If we can all agree to that common ground, I would like to introduce the possibility that we've gone astray in effectively addressing that problem.

At some point, some well-intending person who wanted what we all want (less violence) promoted the hypothesis that people with a mental illness are more likely to be violent. I say hypothesis here because that's what it was, an idea, a suggestion, something that was not yet supported by evidence. The trouble with people sharing their hypotheses is that the media doesn't seem to understand the difference between hypotheses and facts. As a result, people in positions of power are allowed to share their ideas as though they are facts, and people encode them that way.

Well, in science, that's not how things are done. If we want to reduce violence, we set out on a path of figuring out what causes violence. If people cause violence, we set out to understand which people cause violence. If we know which people cause violence, we set out to understand how to identify and help them.

My soap box is in the shop this week, so I'll just get to the point. Recently, Dr. Eric Elbogen, University of North Carolina at Chapel Hill, and his colleagues started with the question, "What predicts acts of violence?" They hypothesized that having a serious mental illness (SMI) would be associated with acts of violence, but they also hypothesized that there were other factors that would be more strongly associated with acts of violence. These included being physically abused during childhood, witnessing domestic violence, having a parent that went to prison, level of education, sex (male or female), use of substances, tending to perceive people as threatening, tendency to feel anger toward others, being divorced, and significant financial distress.

To answer this question the research team used data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). In this study they conducted face-to-face interviews with more than 40,000 individuals in the United States. They conducted initial interviews in 2001-2003 and then follow-up interviews in 2004-2005 and ended up with data from 34,653 participants. In these interviews, participants answered questions about their mental health, including whether they currently (past 12 months) or had ever had schizophrenia, bipolar disorder, any psychotic disorder, or depression. These disorders comprise a cluster of disorders called a "Serious Mental Illness" or SMI. Finally, participants answered questions about whether they have committed acts of violence or physical aggression. Their main question was: what predicts whether a person will engage in violent behavior from the first assessment to the next.

The sample was 42% male and the average age of participants was 46 years. 20% of the people in this study had schizophrenia, depression, bipolar disorder, or a psychotic disorder either in the past 12 months or ever in their lives. That's 1 in 5 people. Some estimates even suggests that at least 1 in every 3 people will suffer from a psychiatric disorder at some point in their lives. I will come back to this point later. In terms of the other predictors, 17% of participants had not completed high school, 4% were physically abused as children, 11% were exposed to domestic violence, and 7% had parents with a criminal history. Between the 1st and 2nd assessments, 355 participants (1%) reported engaging in severe violence and 837 participants (2.4%) reported engaging in acts of physical aggression.

Now for the results. Indeed, individuals with SMI were more likely to report acts of violence than those without SMI. However, SMI was not the best predictor of violent behavior. The best predictors of severe violent behavior were: being male, having a parent with criminal history, being physically abused as a child, having a tendency to perceive others as threatening, and being a recent victim of violence. The best predictors of acts of physical aggression were: alcohol abuse, being physically abused as a child, being male, being recently divorced/separated, and having a parent with criminal history. Actually, the likelihood of engaging in violent behavior for these risk factors was 2-4 times the risk observed for having SMI. Even more importantly, when you account for these risk other factors, there was no association between SMI and violent behavior.

This study is meaningful, informative, and important in many ways, but like all science it has limitations. Most importantly, everything in this study was self-reported. So, the truth that is uncovered from the study is only as good as people are at reporting their mental health and violent tendencies. It's not unreasonable to think that some people may have lied when asked about whether they have ever engaged in violent behavior. This may be a necessary evil in this type of research because as soon as you use something objective, such as police records, the study loses the ability to recruit so many participants. Indeed, with a low prevalence outcome like violent behavior that occurs in only 1-2% of people, you need thousands of participants to study it.

The point here is that the community has come to believe that mental illness and violence are intimately linked, which just isn't the case. There is a small association between SMI and violence, but actually people with SMI are more likely to be victims of violence or be dangerous to themselves than anything else. The false belief that mental illness is associated with violence will not only keep us from actually preventing violence, but also comes at an incredible cost to society.

Like I mentioned earlier, mental illness will affect at least 1 in 3 people. This isn't someone else's problem, and this isn't about people you don't know. This is about you, your friends, your family, your colleagues, and your neighbors. When the media and the public adopt the false belief that mental illness = danger to the community, people who need help are stigmatized. Despite the high rates of mental illness, most people with mental illness (predominantly depression, anxiety, and substance use disorders) will never seek help. The average person will wait, and suffer, for 10 years before seeking help. Yet, mental health professionals know that we can effectively treat at least 65% of those cases within 3-6 months. Stigmatizing mental illness turns what could be a flu into a plague. So let's stop.

Elbogen, E. B., Dennis, P. A., & Johnson, S. C. (2016). Beyond Mental Illness Targeting Stronger and More Direct Pathways to Violence. Clinical Psychological Science, 2167702615619363.

Photos courtesy of unsplash.

Mama Bear: Ever wonder whether breastfeeding changed your behavior?

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

Does breastfeeding increase aggression?

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

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

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

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

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

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

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

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

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

What your body remembers from the first year of life!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

Are you a parent with math anxiety?

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

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

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

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

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

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

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

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. 

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.

Depression is everywhere. Even your company.

There are extraordinary costs associated with depression. The human costs are that depression is the source of extreme human suffering, places our loved ones at risk for suicide, physical illness, and social disadvantage. The economic costs to the global economy and businesses are in the billions of dollars each year. If you are an employer, each depressed employee is contributing to 3 additional sick days each month, or a 10% reduction in productivity. Many people choose to ignore these costs by attaching stigma to people who may be depressed by calling them lazy, weak, and unstable, instead of acknowledging the fact that depression is an illness, and like other illnesses, can be effectively treated. This week, I want to share a study that demonstrates both the human and economic benefits caused by providing mental health services to treat depression. 

To do this, United Behavioral Health contacted almost 8,000 employees of large and diverse companies, including airlines, banks, and state governments. More than six thousand (6,456) of these employees completed an initial assessment, of which 604 were eligible for the study because they were: 1) currently depressed, 2) not receiving mental health care, and 3) not suffering from co-occurring and acute mental health problems that would impair their participation (e.g., current substance use disorders or evidence of bipolar disorder). All participants then completed questionnaires regarding their weekly work habits, such as their perceptions of productivity, hours worked, and performance.

Of these 604 depressed individuals, 304 were randomly assigned to a managed care intervention, while 300 were randomly assigned to “usual care.” The managed care intervention was that each patient was assigned a master’s level mental health case-manager who conducted a thorough phone assessment of the patient’s symptoms, provided them with referrals to psychotherapy and a psychiatrist. If the participant was unwilling to engage in in-person therapy, the case manager then completed a series of motivational phone appointments regarding their hesitation to seek treatment, while continuing to assess any changes in their symptoms via regular phone contact. In addition, participants were provided with a cognitive behavioral workbook to help them learn about strategies to reduce depression at home. After two months, patients who refused therapy and whose depression symptoms continued to worsen were offered a structured 8-session course of cognitive-behavioral therapy. In comparison, the patients in “usual care” were simply informed of their depression diagnosis at the end of the initial assessment, and referred to seek treatment from a mental health professional.

After 6 and 12 months, participants in the study again completed study questionnaires and interviews about their depression symptoms, work performance, and hours spent working. They found that after 6 months, 18% of participants who received the managed care intervention had recovered from their depression, while only 13% of participants in usual care had recovered. After 12 months, 26% of participants in the managed care intervention had recovered from depression, while only 18% in usual care had recovered. In other words, the managed care intervention achieved in 6 months, what usual care took a year to accomplish.

But what about work performance? At the end of 6 months, participants in the managed care intervention group were more likely to have kept their jobs and worked “effectively” for 2.9 more hours each week. At the end of 12 months, employees in the intervention reported working 3.5 more hours per week compared with the usual care participants.

These numbers may seem small to you. Believe me, for all the work that this intervention involved, you would hope that we wouldn’t be left with 75% of people still depressed, and only a 3.5 hour per week bump in productivity, but these numbers add up. 3.5 hours is nearly 10% of a full-time work week, multiplied by 10% of the company’s workforce. The authors of the article estimate that these extra productivity hours annualize to about $2,049* in added benefit to the employer, per employee, which far exceeds the additional cost of covering mental health visits in employee benefits.

Depression is characterized by persistent sad or irritable mood, loss of interest or pleasure in activities, difficulty concentrating, increased anxiety, changes in appetite, changes in sleep, and changes to physical mobility, such as moving very slowly or fidgeting. If a combination of these symptoms co-occur for two weeks or longer, they may indicate that a person is experiencing a depressive episode. The purpose of this article is not to encourage employers to diagnose their employees as depressed, but rather to consider what may underlie noted changes in an employee’s performance or mood and to invest in employee productivity via promoting mental health. If for no other reason, quite frankly, you can’t afford not to.

For other articles on depression and treatments, click here or here or here.

Wang, P. S., Simon, G. E., Avorn, J., Azocar, F., Ludman, E. J., McCulloch, J., ... & Kessler, R. C. (2007). Telephone screening, outreach, and care management for depressed workers and impact on clinical and work productivity outcomes: a randomized controlled trial. JAMA, 298(12), 1401-1411.

*This article was published in 2007. At the time, the authors estimated the additional benefit of 3.5 hours of increased productivity per employee to annualize to $1800. This figure has been adjusted based upon the rate of inflation in the United States and is subject to error.

We can’t really smell fear, but our brains can.

The brain is such a fascinating organ. Despite having spent a decade studying it, I learn more about the brain, its capabilities, and complexities every day. For example, I recently went to a fascinating talk where I learned that the brain recognizes others’ fear through chemicals in sweat. This post is about how we learned that. 

Dr. Lilliane Mujica-Parodi, a professor at Stony Brook University, is interested in how emotions are communicated between individuals. We have 5 senses: visual (sight), tactile (touch), auditory (sound), gustatory (taste), and olfactory (smell). In particular, Dr. Mujica-Parodi is interested in how emotions are communicated through smell. We know that facial expressions help us visually communicate with one another and language helps us communicate with auditory information, but what communicative purpose does smell have?

To answer this question she collected two different types of sweat: fear-induced sweat and physical exertion induced sweat. The fear-induced sweat was collected from 144 individuals who went tandem skydiving for the first time, including a 1 minute free fall from 13,000 feet.. The physical exertion induced sweat was collected while these individuals ran on a treadmill. Their hypothesis was that the fear-induced sweat would contain different olfactory information

They then recruited a group of 16 individuals (50% female) and had them smell 40 different sweat samples (20 of each type) for 2.5 seconds each. Participants smelled each of these samples from inside an fMRI scanner, while the research team recorded activation of their amygdala, the fear recognition center of the brain. They found that participants had great activation in the amygdala when they were smelling the samples taken from people while sky-diving compared with when smelling the samples taken during exercise.

They then recruited 16 new participants (50% female), and repeated the experiment with 40 new sweat samples, half collected during skydiving and the other half during exercise. They found the same thing: participants demonstrated greater amygdala activation, or recognition of fear, when smelling the sweat collected from people while skydiving.

But were the participants aware that they were exposed to two different types of sweat? It doesn’t appear that way.

To test whether the two types of sweat were noticeably different to the participants, they recruited 16 more participants (50% female), and asked them to smell 16 pairs of sweat samples. After smelling each pair of samples, they were asked to decide whether the samples were both the same or different from one another. The results of this experiment suggest that the participants were unable to accurately report any differences between the two types of sweat.

Finally, they conducted a 4th experiment to test whether exposure to fear sweat influenced perception of emotions in others. Because, after all, what good would it be for our brains to recognize fear in others through chemical signaling, if that different give us any behavioral or perceptual benefits? To do this, they recruited 14 more participants and had them complete a computer task where they saw faces with different expressions ranging from neutral to angry and had to report whether the face was “neutral” or “threatening.” The participants completed half of the trials while smelling the fear-induced sweat and half while smelling the exercise-induced threat. They found that after smelling the fear-induced sweat, participants were more accurate at identifying whether a face was threatening or neutral than when they smelled the exercise induced threat.

I am always impressed by all of the things our brain is constantly doing outside of our awareness, and these findings are no exception. Basically, this study demonstrates that while we aren’t aware of it, we can smell fear in others, the fear circuits in our brain are activated, and that activation leads us to more accurately perceive threat in our environment. 

As a person who would never go skydiving, and who barely rides the kiddie-roller coaster at amusement parks, this makes me wonder about the role of these olfactory signals in amusement parks and haunted houses. Part of our anticipation of the ride could be driven by our brains picking up on sensory information that people have been scared here before. But what about other emotions? Might there be chemical signals for happiness, desire, sadness that communicate our experiences with people who will come after us? Are some people more sensitive to olfactory emotional signals? Is that a strength or a vulnerability? This study controlled for potential differences between men and women, but I would imagine that men and women differ quite meaningfully in how receptive they are to olfactory signals of emotions in others.

As is the case with many studies using brain imaging, there were very few people in each of the experiments I described so the findings warrant replication. As is the case with all cutting edge research, we are left with more questions than answers, but that’s what is so exciting about the field of psychological science. Stay tuned!


Mujica-Parodi, L. R., Strey, H. H., Frederick, B., Savoy, R., Cox, D., Botanov, Y., ... & Weber, J. (2009). Chemosensory cues to conspecific emotional stress activate amygdala in humans. PLoS One, 4(7), e6415.

The pervasive influence of stress on your relationship

Stress occurs when the perceived demands of the environment exceed the individual’s perceived resources. So for example, when you have to finish a report for work in one day when it should take a week. Stress takes a toll on the mind and the body. We've already talked about that here and here and here. But people don’t live in a vacuum, we live inside relationships and families and societies. Thus, there is a growing interest in understanding how an individual’s process of experiencing stress influences other people in their lives. Rather than thinking about how having too little time to prepare the report will influence your health, relationship scientists are interested in how having too little time to prepare the report will influence your partner’s health and the health of the relationship.

In other words, How does stress outside the relationship influence stress and satisfaction inside the relationship?

In particular, Mariana Falconier of Virginia Polytechnic Institute and State University and her international colleagues was interested in testing the Systemic-Transactional Stress Model (STM) which posits that stress from daily hassles can have a negative impact on psychological and physical health of the individual as well as the health of the relationship. According to STM, one partner’s stress depends on the other partner’s stress and coping.

To address these questions, they conducted a study of 110 couples, most of whom were in their 40s, had been in their committed relationship for 18 years, and just over 54% had children. Each member of the couple answered questionnaires about stress they experience outside of their relationship, such as financial troubles, stress at work, and conflict with their friends. Then they answered questions regarding stress they experience within their relationship, such as feeling neglected or disturbing habits of their partner. The participants also filled out questionnaires about their current symptoms of depression, anxiety, and physical health. Finally, all participants completed a measure of relationship satisfaction.

Their findings were quite interesting, but also quite complicated. Overall, they were interested in describing whether each member of the couple’s stress outside the relationship influence their partner’s relationship satisfaction. Overall, they found what everyone would expect. When an individual experiences more stress outside of the relationship, they will also report more stress inside the relationship and poorer relationship satisfaction. However, their findings are more interesting when you look at how stress outside the relationship influences their partner, and how those patterns differ for men and women. When women in the sample reported more daily hassles, their partners reported more stress within the relationship, more depression symptoms, and poorer relationship satisfaction. However, men’s daily hassles did not influence women’s reports of stress in the relationship, women’s mental health, or women’s relationship satisfaction.

The next step in this research is to understand how women’s daily hassles are affecting men, and why men’s daily hassles aren’t affecting women in the same way. For example, do men not talk about their stress and thus there is less spill-over of stress from work to home? Do women require more support from their partner when experiencing daily hassles, thus increasing the demands placed on the relationship? Do men not know how to support their female partner’s through stress, and thus experience hopelessness at watching their loved one struggle? We really don’t know yet.

The authors brought up that a past study followed couples for an extended period of time and recorded men and women’s responses to one another in times of stress. They found that on days men experienced stress, women provided more support. In contrast, when women were stressed, their male partners provided support but also responded to the partner’s stress with blame, criticism, or inconsiderate advice. Now we understand that the costs of failed support result in the deteriorating health of both partners and their relationship. Maybe it’s just a matter of appraisal. When your partner is grumpy do you automatically think, “They must be under a lot of stress right now” or is it “What a %&*$!!” If it’s the latter, how is that helping either of you?

Until we know more, perhaps it’s enough for men to be more aware of when their female partner is experiencing stress. Awareness is the first step to providing support to prevent the cascading effects. Alternatively, women can also be more aware of when they are letting daily hassles at work “spill over” into their relationship in a negative way.  

One idea to keep in your toolkit is a clinical exercise called “Opposite Action” where individuals practice smiling even though they are angry, reaching out to someone when you feel like being alone, or providing more love and support to a person even though they are particularly irritable and ornery. This concept can be helpful in couples, where you often feel compelled to draw away from someone when they are being unreasonable or difficult. That may be exactly when they need “just because” flowers or date night. We are here to care for one another and your relationships are your greatest resource. Protect them, nurture them, invest in them.

Falconier, M. K., Nussbeck, F., Bodenmann, G., Schneider, H., & Bradbury, T. (2014). Stress From Daily Hassles in Couples: Its Effects on Intradyadic Stress, Relationship Satisfaction, and Physical and Psychological Well‐Being. Journal of marital and family therapy. DOI: 10.1111/jmft.12073

Go hug someone. Here's why.

Having social support is great for your mental and physical health. We have good research showing that people who have supportive relationships live longer, get sick less often, and recover from illness faster than people who don’t. In particular, the immune system is vulnerable during times of stress, and social support buffers the effects of stress on the immune system, thus reducing your body’s vulnerability to illness. However, social support is a pretty ambiguous construct. Does social support mean people remember your birthday, bring you yogurt when you had your wisdom teeth out (instrumental support), come to your grandfather’s funeral (emotional support)? This seems to be an important question because as a clinician, part of my job is to help young people identify reliable sources of social support, ask for help when they need it, and take care of those relationships by showing their support to others. In order to do that, I want to identify actual behaviors that account for why social support benefits health.

One behavior that is a likely candidate is hugging. Hugging is a likely candidate because nonsexual physical contact is a communication of reassurance, care, and empathy. This type of behavior is linked with better immune functioning within both human and non-human primate families and communities. So, the question that emerges is:

Does hugging protect your health? 

To answer this question, an interdisciplinary group of researchers, led by Dr. Sheldon Cohen at Carnegie Mellon University conducted a study on 404 healthy adults (age 33). In this study, each participant completed a questionnaire about their perceived social support and participated in a physical exam that included a blood test for antibodies and measurement of their mucus to assure they were not sick. Each participant then completed an interview every day for 2 weeks where they reported on what they did that day, who they interacted with, whether they experienced any conflicts, and whether they received any hugs from anyone. At the end of the two weeks, they completed another physical exam and blood test to measure the presence of antibodies. Then each participant received nasal drops of the common cold (rhinovirus 39) or the flu (influenza A/Texas/39/91). For up to 6 days following exposure to the cold or flu, participants were assessed for the development of cold and flu symptoms, and then were assessed again 4 weeks after exposure to the illness.

Cohen and his team found that 78% of participants in this study contracted the illness they were exposed to (as measured by developing some symptoms), and that 31% developed a clinically significant illness of either the flu or the cold. They also found that people in this study were exposed to hugs 67% of the 14 days, while conflict was only reported on about 7% of the 14 days. The main finding of the study was that participants who reported more conflict during the 14 days preceding exposure to the flu/cold were more likely to develop an infection, however receiving more hugs served as a buffer to that effect. Thus, they found that hugs were an effective, protective experience that prevented the cold/flu.

In particular, their findings suggest that hugs are more helpful in improving immunity to the cold, rather than the flu. This may have to do with the rate that the flu replicates in the body. They also found that hugs were protective in whether or not the participant would get sick, not necessarily how sick they would get. Remember, they drew a distinction between people who developed symptoms (78%) and people who had clinically significant syndromes (31%). Hugs were effective in buffering the link between having conflict and developing symptoms, but were not necessarily effective in preventing the severity of the illness if you do contract the infection. To me, this suggests that, not surprisingly, there is more to immunity than hugs, and there are still individual differences in the ways our bodies respond to exposure to germs and viruses.

Of course, this research doesn’t suggest that we should just go around hugging one another instead of going to the doctor to get a flu shot. Rather, giving hugs to our loved ones frequently, especially if they are going through stress is an effective way to provide social support that may boost immunity.

Despite this important and fascinating potential benefit, there are several questions that emerge from this study about application and potential explanation. For example, do people who give and get hugs frequently simply have more efficient immune systems because they consistently have more exposure to germs and bacteria? I wonder whether we could test that question by comparing immunity across cultures who vary in their typical greetings, for example bowing (no physical contact), shaking hands, kissing on both cheeks. Or, is there something special about a hug that improves immunity through psychological well-being like optimism that people care about you?

Another potential limitation of this study was that conflict was reported fairly infrequently in this sample, only 7% of days (less than 1 day on average). I wonder whether these effects would be stronger or weaker among a sample with more frequent exposure to conflict, such as people exposed to domestic violence, or who deal with conflict as part of their job, such as attorneys.

To conclude, this article is just one more example for me of how we can benefit from taking care of ourselves by showing that we care for one another. I’ve always been a bit reluctant around those enthusiastic groups of people around town squares waving FREE HUGS signs. Now, I have a greater appreciation for the work that they do for public health. More free hugs for everyone!

Cohen, S., Janicki-Deverts, D., Turner, R. B., & Doyle, W. J. (2014). Does Hugging Provide Stress-Buffering Social Support? A Study of Susceptibility to Upper Respiratory Infection and Illness. Psychological science, 0956797614559284.

Photo credit: http://coffeeandwhinelife.com/five-in-less-than-5-minutes-fitness-wellness-tips/

Do you know what you're trying to accomplish?

While I will be the first to swoon over Victorian literature, and allured by the romance and grandiosity of 15th century French imperial etiquette, I am beyond grateful to be living in a time where I can benefit from modern medicine. In the past century, we have all-but-eliminated over a dozen deadly illnesses all through preventing their spread from person-to-person. However, if you really think about how medicine is different today than it was 100 or even 30 years ago, it’s not that we’ve gotten so much more skilled at treating disease (in some cases we have, but not most), it’s that we have built a healthcare system that is expert at preventing illness from ever reaching a point that would be life-threatening. 

All you have to do is visit your physician and get check-ups at least once per year, and you can avoid the agony and loss and pain of several ailments that have plagued our grandmothers and grandfathers for centuries. Some examples of common preventive actions are flu shots, cholesterol tests, prostate exams, pap smears, mammograms, and colonoscopies. These handful of assessments were developed for early detection of the majority of illnesses that cause pain and suffering in the developed world.

Unfortunately, despite all of these advances, people don’t participate in preventive health care. In fact, in the U.S. only 30% of adults between the ages 50-65 are “up-to-date” on their preventive health, while only 50% of people 65+ are “up-to-date.” What gives?

There are a lot of reasons that people don’t get these assessments done as they should and they are all good reasons. Most people have jobs and responsibilities, most people don’t think getting a colonoscopy sounds very fun, most people don’t want to get bad news, and the list goes on.

When faced with these striking numbers and a lack of explanation for them, my good friend and expert in psychology and public health, Eric S. Kim at the University of Michigan (GO BLUE!) asked whether there were psychological variables that explain who does and does not keep their health under control using these preventive measures. In particular, he was interested in whether people with higher “purpose in life” were more likely to participate in these preventive health measures.

Purpose in life was first introduced by Viktor Frankl in an excellent and ground-breaking book, Man’s Search for Meaning where he shared his observations on the strength of the human spirit during the Holocaust. In psychology, purpose in life is measured by asking individuals, “On a scale of 1 to 6, 6 being strongly agree, how much would you agree with the statement, ‘I enjoy making plans for the future and working to make them a reality?’ or ‘I don’t have a good sense of what it is I’m trying to accomplish in life?’ Purpose in life has come up in a past post, where we learned that people with higher purpose in life live longer.

To answer this question, Kim used data from the Health and Retirement Study (HRS), which is a large, longitudinal data set of over 26,000 adults who have been recruited at age 50 and followed every two years since 1992. Kim used data from 7,168 of these participants (mean age 69) who were followed for 6 years. In the initial assessment, information on each individuals’ current purpose in life, physical health, mental health, and socioeconomic status was collected. Then, every 2 years, the participants reported on whether they had received a flu shot, a colonoscopy, a mammogram for females, a prostate exam for males, or had their cholesterol checked. They also asked each participant whether they had been hospitalized during the past year, and if so, for how many days.

They found that higher purpose in life was associated with a higher likelihood of receiving all but one of the preventive health measures, the flu shot, and that a 1 point increase in purpose in life related to a 17% decrease in the length of hospital stay. Keep in mind that this finding remains even when accounting for family income, type of health insurance, education, marital status, age, and symptoms of depression and anxiety. In other words, people who reported more purpose in life 6 years ago were more like to get a mammogram or a prostate exam, a colonoscopy, and have their cholesterol checked than people with lower reported purpose in life, not to mention when they got sick they had shorter stays in hospitals. The latter finding fits well with past studies showing that more purpose in life is related to less inflammation in the body, meaning that people who have surgery, get sick, or injured will get better faster from the same ailment.

What’s most striking to me is that purpose in life is measured on a 6 point scale. In this study people generally had purpose in life on the higher side, with the average for the “low” group at around a 3, and “high” at around a 5. This means that very small increases in purpose in life can have significant implications for health. Now that we know purpose in life is a magical, health elixir, the million dollar question is whether we can increase purpose in life in order to improve health on a national or even global scale. Programs such as “Well-Being Therapy” are promising. Well-Being Therapy is a cognitive-behavioral intervention designed to prevent depression relapse by helping individuals improve quality of life and experience more fulfillment.

But what if you don’t feel like you have purpose in life right now? Lots of people feel lost at times, direction-less. The research presented here is not causing better health, it is causing behavior that protects health, participation in preventive medicine. The best way to protect your health is to see your primary care physician and regularly.



Kim, E. S., Strecher, V. J., & Ryff, C. D. (2014). Purpose in life and use of preventive health care services. Proceedings of the National Academy of Sciences, 111(46), 16331-16336.