JCCAP FDF/2018/Day 2

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Block I: Future Directions Address 1: "Evidence-Based Youth Psychotherapy in the Mental Health Ecosystem" (9:10 am-10:10 am)[edit | edit source]

Dr. John Weisz, Ph.D.[edit | edit source]

Professor of Psychology at Harvard University, and Author of Psychotherapy for children and adolescents: Evidence-based treatments and case examples (Cambridge University Press) and Evidence-based psychotherapies for children and adolescents (Co-edited with Alan Kazdin; Guilford Press). His research involves development and testing of interventions for youth mental health problems, as well as meta-analyses and systematic reviews characterizing and critiquing the science of youth mental health care. His most recent work involves development and testing of transdiagnostic approaches to youth psychotherapy, including treatment that uses modular design and treatment guided by a small number of broad principles of psychological change.

Description[edit | edit source]

Five decades of randomized trials research have produced dozens of evidence-based psychotherapies for youths. These psychotherapies produce respectable effects in traditional efficacy trials, but the effects shrink markedly when tested in practice contexts with clinically referred youths and compared to standard clinical care. The presenter considers why this might be the case, examines relevant research literature, and recommends strategies for future research.

Address 1 Materials[edit | edit source]
Notes[edit | edit source]
Click "Expand" for notes
  • Overview
    • History of EBPs
    • Ecosystem of youth mental healthcare
      • Microsystem
      • Mesosystem
      • Macrosystem
    • How EBPs got built
    • Challenges they face
    • Strategies for addressing those challenges
    • Macrosystem challenge for the future
    • Stuff for careers
  • History of EBPs
    • Quiet work from 60s that built up evidence that was synthesized and then applied to youth
    • Term “evidence based” has mushroomed in and grown since the 90’s
    • Boom in implementation support
    • Mean effect sizes from meta analyses suggest therapy in youth is comparable to that of adults
    • EBP had issues
      • Was not widely used in practice
      • Not as effective in practice as in research- there are many complexities that make effect sizes smaller but not nonexistent
      • Common language effect size- probability average child in the treatment group will be better than the average child in the control group  
        • It is only .58 overall :(
      • Modest penetration in care system because
      • Big standard deviation=big mess (makes the study have too much noise)
        • What to do to reduce this noise (Shrink SD)?
          • Recruit your own participants
          • Use your own students or paid staff (highly selected)
          • Carry out treatment in setting you control
          • Can use control groups that are designed to not be effective  
      • Clinical representativeness of youth RCTs
        • 22% were clinically referred treatment seeking kids
        • 13% were treated by practitioners
        • 10% treated in the clinical service setting
        • 2% had all three
      • Research leads to a vat of everyday clinical practice which is littered with External factors like substance abuse, family problems, comorbidity, etc. that make it hard to focus completely on the treatment being used so the outcome may be severely distorted
    • Two RCTs in LA county
      • One CBT for depression one CBT for anxiety
      • In community clinics
      • Clinic referred youth
      • Clinic practitioner treated
      • Clinicians showed good fidelity
      • CBT in those studies didn’t work nearly as well as in the real-world as in more lab-controlled settings
      • Not significantly better than regular clinical care
    • Why didn’t things work as well? What do you do with failure?
      • Plan is not how it goes in everyday care and doesn’t follow the outlined typical linear model of treatment
      • Very heterogeneous cases- few kids with one textbook diagnosis because of common comorbidity (average was 3 diagnoses per child)
      • Treatment may be helpful with one problem but not the others
      • Kids didn’t sit still- problems shifted during treatment
      • Example- tween swearing at parents and threatening to burn the school down and showing real despair
        • Kids are both internalizing and externalizing, making treatment plans a little more complex than in theoretical examples
        • Single problem treatments that follow a linear model likely not to work well because they’re not agile or reactive to the client
        • Treatment may look more like chopping heads off a hydra
    • What to do to help practitioners with these challenges?
      • Combine components of EBPs to be more modular and transdiagnostic
        • MATCH- Modular approach to therapy for children
          • Cognitive restructuring for depression
          • Exposure for anxiety
          • Clear instructions for conduct problems
          • Modules from different manuals (33 total)
          • Different combination for each kid
          • New modules may be added as problems arise
          • Flowcharts guide decision making
          • Brief weekly assessments form personal dashboard showing how child’s problems are changing
          • Helps therapist monitor progress and personalize treatment
          • Uses assessment published in JCCP focused on problems parents said
          • Tested in Honolulu and Boston- normal clinical referrals, clinic and school practitioners, clinic settings
            • 3 conditions- usual care, MATCH, standard EBP manualized treatment  
          • MATCH performs much better than the standard EBP (essentially doubling the effect size) (CLES=66%)
          • Another MATCH study in LA found nearly as good an effect using fund obtained by millionaire tax in CA (CLES=62%)
          • Therapist satisfaction with MATCH- modular most popular
          • Therapist attitude toward EBP- therapists liked typical EBP less after  
          • Not a panacea- they are testing a finding its limits and need new approaches to compliment MATCH
          • 2 new approaches
            • 5 core principles of change instead of teaching 33 modules
            • Transdiagnostic mindset intervention- changing one key belief that is involved in multiple treatments  
        • What are mindsets?
          • Dweck’s theory
          • Fixed mindset- personal traits static and unchangeable
          • Growth- personal traits are malleable so you can improve
          • Growth mindset intervention- Jessica Schleider- 30 minutes online self-administration using testimonials and science and saying is believing (offer another child advice who was being bullied)
          • Has positive and durable effects so far
        • In sum, treatment of mesosystem options
          • Offer clinician wide menu
          • A small core group of principles
          • One broad applicable belief
    • How to make a difference in the field?
      • Survey and see what’s working and what’s not
      • Childhood cancer, teen smoking, and pregnancy dropping
      • Depression and conduct problems have dropped in average effect sizes recently but many things have changed over the years that could mask positive treatment effects
        • Reduced study bias
        • Reduced publication bias favoring positive effects
      • Bummer… but opportunity
      • Einstein- if you always do what you always did you will always get where you always got
  • Take homes
    • Come along the way for research in young people
    • People more so believe treatment development is science, not art
    • Better documentation of what happens in therapy to test it
    • More treatments that measurably do help kids
    • Effects of treatments change in mental health service centers
    • Depression treatments especially weak
    • Treatments not getting stronger over 5 decades
  • Questions-
    • Has there been research aimed at understanding contextual moderators of treatment related to prejudice? Research often tests moderators but takes a hit on power. No studies he knows of have looked at these specifically
    • How we should be moving treatments through efficacy testing faster to address new concerns? Get intervention tested in real setting ASAP so you can go ahead and deal with factors that will be present in real life. So, focus more on effectiveness than efficacy
    • Insurance companies and reimbursement policies to implement EBP? Insurance pays for categories and amount of care so no payment incentive to do EBP and preparation for EBP is not billable

Block I Break Out Discussions for Future Directions Address 1 (10:15 am-11:00 am)[edit | edit source]

Description[edit | edit source]

Dr. Jonathan Comer, Dr. Joshua Langberg and Dr. Tara Peris will serve as a Breakout Discussion Leader following Dr. John Weisz’s Future Directions Address (“Future Directions in Evidence-Based Youth Psychotherapy in the Mental Health Ecosystem”)

Dr. Jonathan S. Comer, Ph.D.[edit | edit source]

Professor of Psychology and Psychiatry, and Director of the Mental Health Interventions and Technology (MINT) Program at Florida International University, President-Elect of Society of Clinical Psychology, and Associate Editor of Behavior Therapy. His research examines four areas of overlapping inquiry: (1) The assessment, phenomenology, and course of child anxiety disorders; (2) the development and evaluation of evidence-based treatments; (3) national patterns and trends in mental health service use; and (4) the psychological impact of disasters and terrorism on youth. His work has received funding from the National Institutes of Health, Andrew Kukes Foundation for Social Anxiety, International Obsessive Compulsive Disorder Foundation, and Charles H. Hood Foundation.

Notes[edit | edit source]
Click "Expand" for notes
  • How to collaborate with mental health practitioners without a clinical background? Consider their motivations like those who miss appt and their currency of income
  • Important to disseminate to parents as well.
  • Matching treatments for the real world. We want to still change the real world through advocacy and education on policy
  • Do not just serve to the lowest common denominator of a therapist.
  • Get value-based purchasing in the right direction, work with insurance companies,
  • Look at cost effectiveness
  • Private insurers are interested in one year
  • Public insurers care about how the patient is in 5 years and their lifetime.
  • Sequence treatment care, start with behavior then stimulant you get better effects, cost-effectiveness shows you would need the lowest dosage later.
  • Is there an incentive for evidence-based practice for health care system. It is difficult to incentivize when there is not a uniformed system.
  • Dissemination is most successful in Children Hospitals and VA.
  • WHo is going to fund this important work?
  • Intervention research is good but look at the mechanisms that underlie therapy that will work later down the stream.
  • Provide feedback loops, no management of clinical product, don’t think of dissemination on only the providers. Providers are interested in EBP but think about the reality. Partnering with the sites. Find out how site champions can promote EBP.
  • Does your provider have something embedded in EHR?
  • How to reach those who need treatment but not seeking it?
  • Small changes in a large number of people need research too like campaigns...Thinking about Apps. Don’t put all our eggs in the Mental Health System.

Dr. Joshua M. Langberg, Ph.D.[edit | edit source]

Associate Professor of Psychology, and Director of Promoting Adolescent School Success (P.A.S.S.) research group at Virginia Commonwealth University, and Associate Editor for the Journal of Abnormal Child Psychology (JACP). His research focuses on improving the behavioral and academic functioning of children, adolescents, and emerging adults with Attention Deficit/Hyperactivity Disorder (ADHD) and on disseminating evidence-based interventions for youth with ADHD into community settings. He has received over $12 million in funding from the Institute of Education Sciences, National Institutes of Health, and Virginia Foundation for Healthy Youth.

Notes[edit | edit source]
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  • Dr. Langberg works in ADHD but intervention in general. Mostly school and teacher settings because that’s where most kids get help.
  • Treatment fidelity: How to check for fidelity when you can't actually check the sessions. There are studies on how to check for this. However, the question is how do we code them? Some school counselors and community-based clinicians don't get any supervision.
  • What would be a model that would allow a brief simple way to ensure fidelity? How do we on a session by session basis have any metric to base that something is actually happening?
  • One answer could be trying to develop a practicum and training. However, one or two-day professional development training don’t work long term.
  • The problem is, what we have now doesn't work, but what we need really isn't feasible with today’s resource.
  • Core components of treatment:
  • Effective commands and exposures, but also working alliances and works for all conditions.
  • We assume that a school counselor gets good training but they usually do not.
  • Think about measurement. Regular assessment is a very important tool.
  • Is there a way to change mindset for clinicians? There is a prevalence of burnout and exhaustion.
  • Another approach would be to work on changing the home environment :
  • educating caregivers and parents. Oftentimes, they don’t know where to go. Empowering parents to know what to look for is vital to for them to know what to expect.
  • Our entire model is based on short-term treatments. However, this is not helpful for chronic disorders. All we ever test is short-term data. The model shift could include regular checkups after the initial treatment.
  • The measurement may not be able to go across different environments. Could we add measures of self-efficacy or happiness? This could be helpful for patients to reflect on. What if those with ADHD are inattentive while in a therapy session? If telling kids what to do works they wouldn't be in therapy.
  • Patient insight is important. It is not as feasible to merely work with parents when children get into middle school and high school. Stickers don’t work anymore. This time is a paradigm shift for older kids.
  • The notion of flexibility infidelity. The middle ground where the therapist is adhering to treatment manual but able to use wiggle room for different conditions and issues. Being willing to bend approach if it isn’t working could be valuable in certain cases. However, not all therapists are comfortable with enough manuals to pick and choose from different ones.
  • How do you define core components so you have more ability to pick and choose to include all components? How do you make people look at this in a realistic way? Some kids aren’t even absorbing the information.
  • It would be helpful if there was a way to measure and regulate clinician and parent adherence.
  • However, Wise found that lower fidelity scores didn’t necessarily mean that it the therapist was unsuccessful. The therapist was perhaps being more flexible to what is important to the patient.
  • Is fidelity reporting too minimalistic? Some parents are quick to throw in the towel if they don't feel its working and that could affect the outcome. Parents should understand the mechanisms that are being employed.
  • Core principles aren’t merely daily report cards and tools. It is important to teach parents the reason for the tools instead of just the tools.

Dr. Tara S. Peris, Ph.D.[edit | edit source]

Associate Professor of Psychiatry and Biobehavioral Sciences, and Program Director of the UCLA ABC Partial Hospitalization Program at the UCLA Semel Institute. Her research focuses on developing strategies for optimizing treatment outcome for difficult-to-treat cases of anxiety, OCD, and related conditions. She is the recipient of a career development award from the National Institute of Mental Health, a NARSAD Young Investigator Award, and awards from the Obsessive Compulsive Foundation, the Trichotillomania Learning Center, and the Friends of the Semel Institute.

Notes[edit | edit source]
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  • Discussion
    • How do we actually tackle real-world barriers like comorbidity or family problems?
    • Dr. Weisz says to ask people what their problems are with technology or procedures and also sleep is a hidden factor in a lot of treatment
    • Dr. Rescorla says many treatments involve gradually doing things that are hard
    • Context of home and school could have a major impact on results of therapy
    • Difference of education and training- training is just procedure and education is creativity and flexibility to deviate
    • Tension between addressing practical problems of daily living that are coming up every week rather than the underlying goal of therapy (don’t want to be chasing chickens)
      • Suggestion- don’t conceptualize as disorders but rather treatment or problem areas that tap into maintaining these problems  
    • Are you ready? Toolkit for Forming community academic relationships
      • Also Mary Mckay
      • Reciprocity is important for community partners and transparency is key
      • Find an agency that wants something you can help them implement
      • Find a partner in the agency- figure out who knows all the people and you know all the people (have an insider to know the landscape)
    • How to take ESTs from clinic to home?
      • Many treatments require parental involvement so that part is applicable in home and you can see the setting specifically to make suggestions for nuts and bolts as well as being more informed so you don’t try implementing something that won’t work
      • Also benefiting because it establishes a stronger relationship

Block II Future Directions Address 2: "Future Directions in Research on Structural Stigma and Sexual Orientation Disparities in Mental Health Among Youth" (11:00 am - 12:00 pm)[edit | edit source]

Dr. Mark Hatzenbuehler, Ph.D.[edit | edit source]

Associate Professor of Sociology at Columbia University. His research broadly focuses on examining the health consequences of structural forms of stigma and on identifying biopsychosocial mechanisms linking stigma and health. Dr. Hatzenbuehler has published over 100 peer-reviewed articles and book chapters, and his research has been published in several leading journals, including American Psychologist, Psychological Bulletin, American Journal of Public Health, and JAMA Pediatrics. His work has been widely covered in the media, including interviews on NPR and MSNBC, and it has been cited in amicus curiae briefs for court cases on status-based discrimination.

Description[edit | edit source]

Psychological research on stigma has focused largely on the perceptions of stigmatized individuals and their interpersonal interactions with the non-stigmatized. However, this research has also tended to overlook broader, structural forms of stigma (i.e., societal-level conditions, cultural norms, institutional policies, and practices). In this address, the presenter explains structural stigma; reviews evidence documenting its harmful consequences for the mental and behavioral health of lesbian, gay, and bisexual youth; and offers several suggestions for future research in this area.

Address 2 Materials[edit | edit source]
Notes[edit | edit source]
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    • 2011 came out with LGBT disparities
    • Most stigma is broader than hate crimes, bullying, stereotypes, and psychological responses... Mostly involve laws and institutions
    • Multi-level construct
    • Individual- self-stigma,
    • Interpersonal
    • Structural- state policies
    • Dramatic shortcoming in literature
    • Multi-method multi-group approach: Produce an integrated line of work, show trend amongst groups and outcomes.
    • Focus on state levels policies like the absence of hate crime laws and employment discrimination and no protective policies for LGB.
    • Mental health outcomes from NESARC that used sexual orientation component and largest to ask that at the time
    • Dysthymia, GAD, PTSD, and Comorbidity is lower in LGB with protective policies.
    • Adjusted odds ratio for dysthymia in states with 1+ protective policies is NO different based on sexual orientation (unlike GAD, PTSD, comorbidity, for which LBG individuals do have a 1.5+ higher likelihood of dx than heterosexual individuals).
    • Selection by health: county level variations in LG youth, examining policies below the state policies like anti-bullying policies in schools and listing sexual orientation as a protected group in schools and if suicide levels were lower
    • Most inclusive countries have policies naming sexual orientation to protect. The highest Inclusive anti-bullying policies tertiles had the lowest suicide attempt rates.
    • Prevalence of Mood disorders increased in LGB from 2001 to 2005 after the marriage but decreased in states where there was no marriage ban in those states.
    • Disparity in Psychological distress following declines in structural stigma
    • How does prior exposure to structural stigma affect the stress of similar exposure in a controlled setting?
    • Blunted cortisol in those that had been exposed to prior structural stigma
  • 5 key areas for the field to address:
  • Test generalizability of structural stigma to transgender youth
  • Adopt a life course approach to the study of structural stigma
  • Develop and validate new measures of structural stigma to have better assessments
  • Examine structural stigma within the context of intersectionality, measure the systems themselves
  • Evaluate whether structural stigma impairs the efficacy of psychological interventions aimed at improving the mental health of LGBT populations.
  • Structural stigma is an indicator for poor mental health in LGBT people.
  • Using research on structural stigma to inform public policies by citing them in court cases as pieces of evidence to make policies get rid of the structural stigma
  • Show structural stigma is connected to policies not other moderators like SEC.
  • GUTS dataset

Block II Break Out Discussions for Future Directions Address 2 (12:05 pm - 12:50 pm)[edit | edit source]

Description[edit | edit source]

Dr. Deborah Drabick and Dr. Dexter Voisin will serve as a Breakout Discussion Leader following Dr. Mark Hatzenbuehler’s Future Directions Address (“Future Directions in Research on Structural Stigma and Sexual Orientation.

Dr. Deborah A.G. Drabick, Ph.D.[edit | edit source]

Associate Professor of Psychology at Temple University, and Associate Editor for Journal of Clinical Child & Adolescent Psychology (JCCAP). Her expertise is broadly in developmental psychopathology, and more specifically in youth externalizing problems. Her work includes such areas as risk and resilience, co-occurring psychological conditions, contextual influences, and intervention. Dr. Drabick has been funded by the National Institute of Mental Health, American Psychological Foundation, PA Department of Health, and Temple University.

Notes[edit | edit source]
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  • Future direction 1- adapting the life-course approach
    • Discussion about advocacy & policy change to address structural stigma.
    • Question- how to integrate how parents talk about structural stigma?  
      • Good about talking to little kids about not bullying but we drop off by adolescence when these things are actually emerging
      • Get parents involved in the conversation and educate them not just kids but also when they are adolescents.
      • What are the effects of familial reaction to coming out? From nothing changing to being excommunicated (some people may be bullied at home and at school)
      • Bronfenbrenner- consider how contexts relate to families
      • Families might support it more if sexual orientation is not immediately obvious to others so the parents might feel less embarrassed
      • Emma Choplin, HGAPS Ambassador- family-focused therapy with the clinician as an advocate could be beneficial
      • When kids are coming up with their sense of self the parent needs provide support and have a language to understand
        • Don’t want to have a “leave the child at therapy and problem solved” mentality but need cohesive, supportive therapy that helps parents as well
        • CBT for parents of LGBT youth?
        • Include the parents as the solution and integrating them into therapy
        • Some people have hearts in the right place but think the individual needs to change not the system so that they do not have to go through stigma and policies that discriminate and add stress to their lives.
        • We need to have a prepared sound byte beforehand when information is asked of us as a Clinical Psychologist
        • Gap between policymakers and researchers can be helped to some degree by bringing good research evidence to courts
        • Use broad statistics and numbers to support a personal story of stigma to drive the home message and make it salient to policymakers
        • Publicization and advertising for Lobbiers for APA and clinicians
        • Matt Lerner suggested the advocacy organizations like FABBS for helping bridge the gap between research & policy.

Dr. Dexter R. Voisin, Ph.D.[edit | edit source]

Professor in the School of Social Service Administration at the University of Chicago, where he serves as a Faculty Affiliate at the Center for the Study of Race, Culture, and Politics. His fields of special interest include community violence exposure, adolescent sexual risk behaviors, the role of gender in adapting to risks, international HIV prevention, and social work practice. His research has been funded by the National Institutes of Health and W.T. Grant Foundation. His work has appeared in such journals as AIDS, American Journal of Orthopsychiatry, American Journal of Public Health, and Journal of Adolescence.

Notes[edit | edit source]
Click "Expand" for notes
  • When do you step too far over the line into sociology? How do you bridge the gap yet stay grounded in our own discipline?
  • There is a cause for more transdisciplinary research now. It is important to draw from other disciplines to make things more applicable in the real world.
  • What facilitates that cross-discipline? For Dr. Voisin, it started with his dissertation, which helped him bring in many people with different perspectives.
  • It is important to find a tribe of people who see things from different angles. This enriches the work.
  • Putting yourself out there helps bridge the gap and make connections. Mixers at grad school for different types of students were beneficial for Freeman.
  • It helps to be exposed to different disciplines to get other people’s perspectives and insights. Going to talks in other departments that you’re interested in could also be helpful.
  • What are some barriers that people are experiencing? Working with parents who have lost custody of their children ( looking at personal stigma). How could structural stigma be affecting this?
  • Feminist theories may not be everyone’s cup of tea, but how do you rebrand or remarket to make your work more appealing to everyone?
  • Brand your research broadly in terms of health seeking attitudes so it can fall into many categories and can appeal to many different types of people. So instead of “feminism” bridge the gap to allow overlap by changing the term to something like “inequality”. Learn to brand your message to the setting that you’re in.
  • Personal stigma is part one of the more proximal factors in LGBT research.
  • Not what people call you, but what you answer to. How you think about yourself.
  • More proximal factors drive outcomes. Weight stigma = personalized stigma. Because these messages are so broad it’s more about how people view themselves. When the person believes about themselves the bad things is when the damage occurs.
  • One component is the moral defective character, group belonging. When the stigma is something like an illness it is more difficult to separate from identity.
  • Not defining it as your own self-help personal stigma. Mental illnesses where you can conceal vs obvious is on a spectrum.
  • Important for people to see themselves as a multifaceted person and know that they have many different identities. Sometimes get stuck in one identity.
  • Stigma oftentimes prevents someone from getting help or staying in treatment.
  • How do we change that? We must adjust and work with people in their own personal narratives (such as someone who attributes mental illness to religious reasons). We must help use the person’s cultural narrative and be flexible in treatment approaches to ultimately make a difference in the patient. As people start talking about their own history with structural stigma, it is important to get them to talk through this to think about how they’ve internalized these ideas and stigmas. You, as the therapist, are creating the platform to bring these beliefs out of the subconscious.

Block III Future Directions Address 3: "Future Directions in Sleep and Developmental Psychopathology" (2:00 pm - 3:00 pm)[edit | edit source]

Dr. Lisa Meltzer, Ph.D.[edit | edit source]

Associate Professor of Family Medicine at the University of Colorado School of Medicine and Associate Professor of Pediatrics at National Jewish Health, where she directs the Pediatric Behavioral Sleep Clinic and Actigraphy Clinic. Her program of research examines sleep in children with chronic illnesses and their parents, the impact of deficient sleep on health outcomes in adolescents with asthma, and the development and validation of objective and subjective measures of pediatric sleep. She is board certified in Behavioral Sleep Medicine by the American Board of Sleep Medicine, and co-author of Pediatric Sleep Problems: A Clinician’s Guide to Behavioral Interventions.

Description[edit | edit source]

It is critical for psychologists to gain a better understanding about the complex and dynamic relationship between sleep and developmental psychopathology. The presenter considers future directions in research on links between sleep and developmental psychopathology. In particular, Dr. Meltzer will highlight areas important to address for clinicians and researchers who strive to better understand how best to serve the mental health needs of children and adolescents.

Address 3 Materials[edit | edit source]
Notes[edit | edit source]
Click "Expand" for notes
  • What is sleep?
    • Sleep is a reversible behavioral state (we go to sleep and we wake up) where you tune out the world while doing a typical behavior (lie down with eyes closed)
    • Sleep is not a luxury and is not optional
    • You HAVE TO SLEEP. 100% of children and adolescents sleep.
    • One you fall asleep you go into a slow wave sleep; decreases as we age in how much we get
      • Hormones release (like growth hormones)
      • Brain recovery
      • Executive functioning is developing here
      • Memory consolidations
    • At the end of a sleep cycle you wake up (very briefly)
  • Sleep homeostasis
    • Over the course of the day
    • Every hour of the day, the sleep pressure builds
    • You have to have a certain amount of sleep pressure to go to sleep (16 hours)
    • If you push this too far, much of your functioning decreases and changes (after 24 hours)
    • For instance, 24 hours of sleep pressure, you are basically legally impaired while driving
    • While sleeping, the sleep pressure starts relieving
  • Circadian rhythm
    • Counter to sleep pressure
    • Runs on a 24.2 hour day
      • This flexibility is the way we accommodate moving time zones. Cues are light and dark
    • Regulates melatonin, which is inhibited by light
    • Example: light emitted from our devices could interfere with melatonin production
    • In adolescents, melatonin production is delayed by 2 hours compared to adults
  • Recommended sleep duration
    • Decreases a little as you age
  • Insufficient sleep
    • Grumpy, hyper, angry, dopey
  • What is the relationship between sleep and psychopathology
    • Which came first?
    • Which predicts which?
    • Sleep change can be a predictor, a symptom, an outcome?
    • Association studies
      • When you are in the recommended area of sleep, the odds of suicidality is greatly decreased
      • The Greater risk for those getting too much or too little sleep
      • Looked at the school-children report of symptomatology and found those who slept less were having more feelings of sadness, for instance, anxiety
      • Important to keep in mind that the time difference in sleep is pretty minimal
    • Prospective association
      • Insomnia in year one, depression in year two is predicted, though it is not true vice versa
      • A 3 fold increase in depression, 2 fold in anxiety from decreased sleep and relationship is not as clear in the opposite way
    • Experimental studies
      • Took baseline sleep
      • Randomized to get 1 hour more or one hour less
      • Increased group in actuality get 27 min increase and less group got 54 min decrease
      • Blind teachers reported sleep extension group has significant improvement in behavior and sleep reduction group changed for the worse
        • Some of these negative symptoms now have symptoms in the clinical range, just by losing 1 hour of sleep per night
      • Youth with technology in their bedrooms sleep, on average, 30 minutes less per night
    • Another study:
      • Randomized to ideal sleep and sleep restriction
      • View 40 images and rate affect/emotion of the faces
      • Asked to used cognitive reappraisal in looking at the image
      • Shorter sleep time relays less positive affect
      • Report more negative valence and are more reactive and less accurate when restricted sleep
    • Another study:
      • Randomized to sleep extension and sleep restriction (6-hour average)
      • More self-reported anger, anxiety, fatigue, confusion
      • These were healthy kids, but if you start with kids that already have psychopathology it makes it worse
    • Answering the obvious question
      • Prospective studies help is understand directionality
      • Need to consider sleep disturbances
      • Population-based studies highlight important associations
      • Sleep manipulations protocol
    • Somatic experiment studies
      • High-density EEG maps that show what is going on in the brain during sleep
      • Activity of brain reflects synaptic density, brain maturation, depth of sleep
      • Activity moves from posterior (occipital) to frontal lobes with age
      • Mirrors the development and maturation of the brain from back to front and dendrite pruning
      • How this maps onto an atypical development
        • In ADHD the activity is much more central than control
          • Is this delayed maturation
          • Is their motor cortex activated more (in central part)
        • MDD
          • Higher frontal activity in depression
          • Associated with maladaptive thinking and self-deprecating thoughts
          • May reflect deviant developmental pattern
      • Early-onset schizophrenia- Sleep spindles
        • Mark thalamocortical system
        • Associated with early-onset schizophrenia
        • Reduction in sleep spindles
        • Negative correlation- Greater severity correlated with less sleep spindles
      • All of these could serve as markers for onset of psychopathology
    • Nature vs. Nurture
      • Twin studies
        • Association of depression and sleep and genetic components
        • Sleep problems predictive at age 8 or age 10 sleep problems as well as depression; does this mean sleep is precursor/predictor of depression?
        • Many environmental things that affect sleep, however, most of the sleep problems go along with nature
        • But with depression, maintenance is mostly environmental
        • Early help with sleep problems may help negate effect of depression later on
      • Two...
        • Genetic factors account for 40% of the symptoms
        • No gender differences in insomnia
        • Overlap between the heritability of insomnia, depression, and anxiety
          • Possible that treatment of insomnia could help depression and anxiety
      • Three...
        • Childhood ADHD and sleep
        • 8 and 18 years old
        • Childhood ADHD predicts poor sleep quality in young adulthood
        • After adjusting for adult ADHD, childhood ADHD no longer associated with sleep quality at age 18
          • Perhaps because they learn self regulation and calming
      • Extrinsic sleep disruptors
        • Technology
          • Light, stimulating engagement, brains can’t just turn the on-off switch light tech
          • Difficulty falling asleep and amount of tech in room positive correlation
        • Caffeine
          • Recommended dose for kids is 0 milligrams
          • Recommended for adults is 100-200 mg
          • Starbucks medium coffee has 300 mg
      • Adolescents NEED 8-9.5 hours of sleep a night
        • Circadian misalignment
          • In adolescents, their melatonin is very high at 7 am when they are expected to be up and about
      • Healthy people 2020
        • Change sleep start times
        • Increase the amount of student sleep to 8 hours a night to 33.3%
        • Sleep health education: These findings on the impact of sleep restriction really highlight the urgent need for dissemination of knowledge/research results to parents, clinicians, and students.
      • Cherry Creek school district
        • Changing the school start times: Allison Harvey's transdiagnostic treatment research: Sleep and Mood Research Clinic

On changing school start times: "We don't care if traffic's going to change. Traffic is a grown-up problem. We're in the business of educating children."

        • Do multi-method pre-post evaluations of this shift
          • Link child's sleep to test scores to longitudinal surveys
          • Using PROMIS Health measures of sleep and psychopathology
          • Before
            • Bedtimes increase steadily with increasing grade
            • Wake times consistent across school level and are preset by schools
            • Significant signs of sleep deprivation (sleeping 2+ extra hours on the weekends)
          • After
            • Bedtimes increase steadily with increasing grade
            • Wake times later in high school and middle school
            • Increased sleep opportunity
            • Weekend oversleep is MUCH LESS for high schoolers
            • How often sad
              • -3.5% in high schoolers
            • How often nervous
              • -5.0 high school
            • How often worries
              • -7.4% HS
      • Parent-set bedtimes
        • As bedtime gets later, the risk for depression and suicidal ideation increases a ton
      • Considerations
        • Night to night variability
        • Circadian rhythms
        • Individual vulnerability to sleep loss
        • Treating comorbid sleep and psych issues
          • Transdiagnostic model of treatment, and sleep cuts across all disorders
          • Medications for sleep might not be could
            • Also interactions with psychological medications could vary widely
  • Challenges:

The privilege of later start times/impact on working families Putting knowledge to use (D&I):

    • Training teachers/school counselors to teach about health hygiene
    • Getting information to parents & schools - particularly conveying the message to parents about the importance of sleep
    • Increasing clinician awareness of the impact of sleep in assessment & intervention
  • Sleep is not a significant factor in standard intake assessments in a lot of settings.
    • Methodological challenges: assessment of Sleep is interwoven in everything we see in terms of psychopathology; it's not a separate area of training - how do you disentangle sleep from the myriad of other factors? (Beware falling into the trap of "the rule of the tool")
    • If your only tool is a hammer than you treat everything as a nail.
  • Ideas: Infographics by age! Educate kids, as well as adults - e.g., infographics for kids, adding a sleep module to MATCH, coping-cat style intervention

There is a connection between blue light and the pineal gland and sleep. Flux - a program to reduce blue light.

Block III Break Out Discussions for Future Directions Address 3 (3:05 pm-3:50 pm)[edit | edit source]

Description[edit | edit source]

Dr. Candice Alfano, Dr. Reut Gruber, and Dr. Eric Youngstrom will serve as a Breakout Discussion Leader following Dr. Lisa Meltzer’s Future Directions Address (“Future Directions in Sleep and Developmental Psychopathology”)

Dr. Candice Alfano, Ph.D.[edit | edit source]

Professor of Psychology at the University of Houston, where she serves as Director of the Sleep and Anxiety Center of Houston (SACH). Her research program integrates several overlapping fields of study including the role of sleep-wake processes in the pathogenesis of psychopathology, especially anxiety disorders, and the development of evidence-based interventions for children and adolescents. Her research has been funded by the National Institute of Mental Health, the National Institute of Child Health and Human Development, Department of Defense, and the National Aeronautics and Space Administration

Materials[edit | edit source]
Notes[edit | edit source]
Click "Expand" for notes
  • Caffeine has a long half-life.
  • CBCL covers sleep even the preschool version
  • Trans-diagnostic intervention/approach: dismantling study of CBT and eating disorders
  • When working with anxiety patients they may start to hyperfocus on sleep and trying to get enough sleep.
  • The release of melatonin is altered in those with Autism
  • It is hard for those with autism to wind down at night time.
  • Regulation of the frontal lobe is not able to happen when there is a lack of sleep.
  • Timing is critical when it comes to sleep.
  • It does not take much intervention to work with sleep.
  • After 20 minutes max you should get out of bed if you can’t fall asleep.
  • You need to educate parents about appropriate sleep.
  • You need the continuity for 8 hours.
  • Bi-phasic sleeping pattern, evolutionary perspective shows that up until 1000 years ago we were bi-phasic which evidence shows that as we get older we start to wake up at 2-3am. It is normal. This is how we were programmed to sleep.
  • There are no FDA approved sleeping medication for children.
  • No sleep medication is a cure it is a band-aid and can cause dependency.
  • Sleep is a behavior and you have to learn how to do it.
  • Becker focused on sleep-wake variability: sleep irregularity can be a diathesis for mental illness
  • Don’t look at the mean but the standard deviation of sleep, this is a better predictor of developing deficient than sleep hours.

Dr. Reut Gruber, Ph.D.[edit | edit source]

Associate Professor of Psychiatry at McGill University, where she serves as Director of the Attention Behaviour and Sleep Laboratory. Her work seeks to examine the mechanisms underlying the association between sleep and mental and physical health and to use the knowledge gained from her research to develop evidence-based interventions to improve youth mental and physical health. Her work has appeared in such journals as Sleep, Journal of the American Academy of Child & Adolescent Psychiatry, and Pediatrics.

Materials[edit | edit source]
Notes[edit | edit source]
Click "Expand" for notes
  • How do you move the knowledge that sleep is vital to mental health into action?
  • There is not enough education and training. There are really no tools to deal with this issue.
  • One problem is many times we talk to each other instead of reaching out of the discipline and asking for help. (Approach Gruber takes is participatory research.)
  • Be more humble, it is not possible for one person to have ALL the answers. It is equally important to get others’ opinions and perspectives. Other people are experts in their own area.
  • When trying to collaborate, it is important to be equal partners. Know both partners can learn from each other.
  • How do you engage the people you want to make a change? If you want to enlighten someone to a new intervention, you must have a shared interest in the outcome. It is helpful to have the perspective of “let’s join forces.”
  • This is more complicated with policy enforcers because of politics but it is still the same idea. Think about how you can engage people to work with you and think of them as experts in their own discipline.
  • In terms of training opportunities, it would be good to find someone who shares the same interest to help open the door for you.
  • In terms of Adolescent depression and sleep, small changes are impactful. As we know from the previous address, an extra hour of sleep can be vital.
  • Negotiation with adolescent patients on helping them get more sleep without missing out on social aspects is difficult. This must be done incrementally.
  • Electronics are very detrimental to sleep in teenagers.
  • CBTI
  • CBTI Coach - app on iPhone.
  • This could be a modality that might make more sense to teenagers that sleep is necessary for a simple way. This is making CBTI more accessible to those not in the sleep field.
  • A lot of times there could be one aspect that can be changed that could affect sleep in a big way such as electronic use or daytime napping.
  • An app makes it easier to target that one aspect.
  • This could be a very practical way to pick and choose how to tailor treatment to your population of teenagers.
  • Gruber found that teenagers who went to sleep later did not have an issue with a fear of missing out on socializing. In actuality, they were anxious and stressed. Because of this, they would watch a video to fall asleep which would lead to even later sleep.
  • It is easier to start on the concrete side (making the sleep pressure high enough that they feel the need to fall asleep). However, it is important not to neglect the underlying factors that are related and perhaps facilitating it.
  • What exactly is CBTI?
  • Its goal: to address the cognitive and behavioral barriers that could promote insomnia.
  • Going to bed later and getting up earlier increases sleep pressure so the need to go to sleep is higher.
  • You can’t make yourself fall asleep, but you can make yourself get up.
  • Underlying physiology: You want to increase the sleep pressure to adjust sleeping patterns.
  • Over time you’re adjusting the patient to their physiological needs, but you’re limited to what their body can do.
  • Adjust the sleep time to the sleep period. Self-restrictions and stimulus control (Making your bed a stimulus that is only associated with sleep, taking everything else out of the bed, cutting out electronics near bedtime, etc.)
  • You really want to have a developmental perspective.
  • There is a shift in sleep needs as children develop.
  • In addition, individual differences are common, so you must be able to tell the difference between those and a diagnosable sleep disorder.
  • Depending on age, a clinician could use cognitive restructuring.
  • Restructuring thoughts surrounding sleeping. “I can never fall asleep,” etc.
  • Once you understand the principles, it will be more straightforward to implement. You can then put them in your toolbox.
  • Sleep interventions aren’t baby steps, they are giant steps.
  • Progress is visible quickly.
  • Opens a perspective that psychologists have something to offer. Helps give more faith in treatment to try additional treatment for other problems besides sleep.
  • You don’t want to give CBTI to someone who doesn’t need it though because it will not work. Sleep interventions are often comorbid with other problems but will not be successful if both aren’t treated.

Dr. Eric A. Youngstrom, Ph.D.[edit | edit source]

Professor of Psychology and Neuroscience and Psychiatry, and the Acting Director of Center for Excellence in Research and Treatment of Bipolar Disorder at the University of North Carolina at Chapel Hill, Past President (’16) and President-elect (’18) of Society of Clinical Child & Adolescent Psychology, Co-Founder of Helping Give Away Psychological Science, and Adjunct Professor of Psychology at Korea University. His publications have appeared in such journals as the Psychological Bulletin, Psychological Assessment, and the Journal of the American Academy of Child & Adolescent Psychiatry. He also has extensive experience in disseminating knowledge about evidenced-based practices using the Wikipedia and Wikiversity platforms.

Notes[edit | edit source]
Click "Expand" for notes
  • Interesting, the challenge in psychology, connection to work
  • Quick win could be looking at PROMIS measures to see if anything is useful for your age groups
  • Also, actigraphs are expensive, but FitBit will let people look at data now so we can potentially use devices patient already has to track. Or, on smartphones apps can be used to track sleep
    • But technology in the bedroom disrupts sleep so could be negative  
  • Who provides most accurate data for sleep/time in bed during school years? Hard to say, but gather as much data as possible
    • Generally asks about “electronic media,” which relates to sleep. Achenbach is studying media in 20+ countries.
      • New form 26 items 2-3 minutes built in ASEBA- he hopes results to be published in early 2019 after data due December 31 from foreign studies
      • Supplementary form for parents to fill out for their estimated influence of media use (favorably and unfavorably)  to be helpful in clinic advice
    • Studying time in bed is confusing because could be just using media which could be keeping them up
    • So, need data from as many informants as possible  

Block IV Future Directions Address 4: "Future Directions for Clinical Research, Services, and Training: Evidence-Based Assessment Across Informants, Cultures, and Dimensional Hierarchies" (4:00 pm - 5:00 pm)[edit | edit source]

Dr. Thomas M. Achenbach, Ph.D.[edit | edit source]

Professor of Psychiatry, Professor of Psychology and Director of the Center for Children Youth and Families at the University of Vermont. His research focuses on developing, testing, and disseminating multicultural methods for assessing behavioral, emotional and social problems and adaptive functioning. This work includes collaboration with colleagues in many cultures to apply standardized assessment methods, perform multicultural comparisons, and improve understanding, assessment, and treatment of psychopathology throughout the world. He developed the Child Behavior Checklist (CBCL), a widely used standardized measure for evaluating maladaptive behavioral and emotional problems among children and adolescents.

Description[edit | edit source]

Many efforts to develop and test evidence-based treatments fail to take into account the complexity of problems seen in the community settings where most mental health services are rendered. Widely applicable evidence-based assessments (EBAs) can bridge gaps between evidence-based treatments and the diverse providers, cases, and conditions characterizing community services. This address examines directions for future research to bridge gaps between research and services, increase use of EBAs, and help providers base service decisions on EBAs.

Address 4 Materials[edit | edit source]
Notes[edit | edit source]
Click "Expand" for notes
  • Multi-informant: Each informant can provide different insight but the agreement is modest, all provide useful data, the question is not who we should believe, there is a bias for each one.
  • Metrics depend on people’s reports. One informant is incomplete. We can’t expect one informant to provide the whole truth.
  • Agreements and disagreements can both be useful in assessment.
  • We can look for outlier informant and why that is. Is it about there interaction with the person or is it about the informant.
  • We should get a wide assessment of students not just ADHD. Do not rely on teacher’s suggestion because they might be mislabeling what they are observing and might apply to a whole range of things.
  • Look at agreeableness and reasoning behind it
  • Before being seen the parent must fill out self and partner assessments as well as assessment about the child.
  • Showing them discrepancies between each other is to show that variation between each other doesn't mean one is right and one is wrong and use to teach them the value or how to view multi informant
  • Fosters a better alliance to tackle parent and child issues
  • To see if parents behavior and emotion affects the way the child is functioning or if the child’s functioning and perception affects the parents
  • Comparing the Multi informants through bar graphs for each behavior with T scores
  • Question: Using APQ to give info about parent relationship
  • Progress and Outcome App
  • Comparing Internalizing and Externalizing changes and observations t scores
  • We need to test multicultural research in many different societies
  • To get closer to robust findings we need the aggregate data from many different situations
  • More informative than only looking at standardization repeated in one study
  • Depends on who you ask and so Norms are informant specific
  • Future research should try to incorporate multi informant multicultural evidence-based assessment
  • Routine use of EBA for all cases always first no matter what
  • Multi-informant data is needed to personalize treatment just like for cancer patients, this needs to be done in mental health services
  • People change over time so the regular assessment is needed and updated
  • Use of the same instruments in many societies fosters international collaboration.
  • Score their scores as both genders if nonbinary to create norms or use self-identified category
  • Q Correlation: it correlates 2 sets of items instead of a lot of individuals on 2 items.

Block IV Break Out Discussions for Future Directions Address 4 (5:00 pm-5:45 pm)[edit | edit source]

Description[edit | edit source]

Dr. Matthew Lerner and Dr. Leslie Rescorla will serve as a Breakout Discussion Leader following Dr. Thomas Achenbach’s Future Directions Address (“Future Directions for Clinical Research, Services, and Training: Evidence-Based Assessment Across Informants, Cultures, and Dimensional Hierarchies”)

Dr. Matthew D. Lerner, Ph.D.[edit | edit source]

Assistant Professor of Psychology, Psychiatry, & Pediatrics, and Director of Stony Brook Social Competence and Treatment Lab at Stony Brook University. His research focuses on understanding mechanisms of and developing interventions for social and emotional functioning (in particular peer relations) among children and adolescents with autism spectrum disorders and ADHD. He has received over $8 million in funding for his work from the National Institute of Mental Health, Brain & Behavior Research Foundation, American Psychological Foundation, Simons Foundation, Alan Alda Fund for Communication, Arts Connection, and Pershing Charitable Trust.

Notes[edit | edit source]
Click "Expand" for notes
  • Discussion questions:
    • How do we generalize these principles beyond the ASEBA? Feasibility is difficult.
    • The last norms in the U.S. were established 20 years ago - much has changed since then. Means may have changed... additionally, the meaning of constructs may have changed.
    • Are there limitations to multicultural norms?
  • NIH now requires you to push your data into their de-identified and automatized database
  • RFA: a call right now for this particular grant
  • PA: standing announcement, medium term, and long-term opportunity
  • Funding streams from NIH…
  • Training Grant in the Multi-Assessment realm: K award, mentors come together like legos for making someone a better as a PI.
  • There is no absolute truth.

Dr. Leslie A. Rescorla, Ph.D.[edit | edit source]

Professor of Psychology on the Class of 1897 Professorship of Science at Bryn Mawr College, where she serves as Director of the Child Study Institute. Her research interests are the epidemiology and outcome of language delay in toddlers; longitudinal patterns of academic aptitude and achievement; and empirically-based assessment and longitudinal study of psychopathology and competence in children, adolescents, and adults. Her research has appeared in such journals as Journal of Clinical Child & Adolescent Psychology, Journal of the American Academy of Child & Adolescent Psychiatry, Psychological Assessment, and the Journal of Consulting & Clinical Psychology.

Notes[edit | edit source]
Click "Expand" for notes
  • Paste Notes Here