Child Study Center Grand Rounds 10.05.2021

October 29, 2021

Outer SPACE: Novel Applications of Parent-Based Treatment for Restricted Eating, Somatic Problems, and ‘Failure to Launch'

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00:00Thank you we we're it's every week
00:02a little bit of work in progress.
00:04So thank you for your patience and I'm
00:07just going to say two things before
00:08passing it onto Julie children and
00:11the only the first thing that I'm
00:13going to say it's our reminder of
00:16next week's grand rounds next week,
00:19October 12th is Indigenous Peoples Day.
00:23Formerly known as Columbus Day.
00:25And we're going to have a presentation
00:28that I'm really looking forward
00:29to that's perfectly timed.
00:31By the title of Native American
00:33Mental health and introduction,
00:35and an invitation, and it's going
00:37to be presented by our colleagues.
00:40Now the CHILD Study Center,
00:41we have a big partnership led
00:44by Chris Carter,
00:45who is an assistant professor
00:47and marked by tell,
00:48an associate research scientist,
00:50and they have been doing
00:52really important work.
00:53So we look forward to that.
00:55And the second thing I'm going to
00:57say is introduce our introduce Sir,
00:58and that is Julie Charlton.
01:01Julie Chilton is one of the members
01:03of the new Grand Rounds Committee and
01:06Julie is an alum from our program,
01:09and she in fact has been leading
01:13our alumni group collaboration,
01:15Facebook page etc and she joins
01:18us today from North Carolina to
01:21introduce our speaker Julie,
01:23take it away a lot while I continue
01:24being dis jockey with a technical thing.
01:26So go ahead,
01:27Julie,
01:28thank you Andres, this is.
01:31So special for me to make
01:35this introduction today.
01:37From the from the first time I met him.
01:40He was wise beyond his years and uhm.
01:46Just a bundle of joy,
01:49and it had spark in his eye and.
01:52Just had the most beautiful Gray hair and
01:56in my mind he was the pick of the litter.
02:01He and this is this is Winston and I
02:05wanted Winston to say hi to everybody
02:08to introduce Eli today and Eli has
02:12been a long time mentor of mine.
02:16All kidding aside,
02:18beginning in 2012 when I graduated
02:21from fellowship and.
02:22He pretty much single handedly
02:25filled my waiting room of my first
02:28private practice with all kinds
02:31of wonderful patients with a meta
02:34phobia and school avoidance OCD.
02:37Phobias of other kinds.
02:39And not only did he deliver me
02:42patience as a brand new clinician,
02:44but he met me for coffee and he
02:47taught me how to do right by them and
02:51gave me all the tricks of the trade.
02:54And there is truly no clinician
02:58today that has shaped my personal
03:02practice as a anxiety disorder
03:06specialist more than Eli Lebowitz.
03:10And what was the most interesting
03:13is this past year when I became
03:16a new stepmom to be of a 3 year
03:19old and a 9 year old.
03:21And for the first time,
03:23instead of being a space
03:26clinician helping families,
03:27I got to experience what supportive
03:30parenting for anxious childhood
03:32emotions was like from the other end.
03:34And it was the most wonderful other
03:38side to see Ellie's work and how
03:41much it helped our nine year old
03:44with his RFID and his anxiety.
03:47And Yara really just.
03:50Did a brilliant job and it was such a
03:55pleasure for me to to see it in action.
03:59On the other side of things and I'm
04:01so grateful to Eli and Company for
04:04having developed the space program.
04:06Now that I even have benefited
04:07it on the other side.
04:09So without further ado,
04:10my dear dear friend and
04:12mentor Doctor Liebowitz?
04:33One second.
04:37Yeah.
04:39So difficult.
04:51Can y'all hear me Julie,
04:53can you hear me? OK, I give you.
04:56Can you turn off your camera.
04:58Julie, because we're getting
04:59a different view here.
05:03This is a work in progress my friends.
05:08Ellie, you definitely need person to read.
05:15OK, hold on. Hold on, there's hope
05:18there's hope, ah. Uh, Julie.
05:25Just move it down OK? Here we go OK, ladies
05:29and gentlemen, I give you alleyways.
05:37It's it's recording OK.
05:42Wow.
05:46I thought if I just waited
05:48long enough I wouldn't have to
05:50do this at all at this point.
05:53Well, first of all,
05:55thank you Julie for that eulogy,
05:58that was. That was very nice.
06:01I knew I could count on you.
06:02I thought you were talking
06:03about undress at first,
06:04but then you mentioned the hair.
06:08And thank you to address and committee
06:11for the opportunity to talk with you
06:14about the work we're doing in the area
06:17of child anxiety problems and beyond.
06:19They don't have special disclosures for
06:22this talk or conflicts of interests.
06:25Some grant funding and some royalties.
06:28So in terms of what?
06:30Want to try to do with the time left?
06:34Now I'm trying to think what
06:35we should cut from this.
06:37I want to start by very briefly telling
06:41you what space is apparent based
06:43treatment developed for child anxiety
06:45and obsessive compulsive disorder,
06:46and to update you and some of our clinical
06:49trial research and some interesting
06:52findings emanating from that research,
06:54but with the bulk of the time.
06:57I actually want to talk
06:59about some of the newer.
07:01Expansions and adaptations
07:04of space beyond the child.
07:07Anxiety and OCD which were the original
07:10focus and those include work in the
07:13area of eating problems, specifically,
07:15avoidant restrictive food intake,
07:17disorder or fed.
07:19Work with physical complaints.
07:22Medically unexplained.
07:23Somatic symptoms. So what is space?
07:29Space is.
07:32A parent based treatment for
07:34child anxiety that's informed by a
07:37systemic view of anxiety in children.
07:43At the heart of the treatment are really
07:46a few key principles and insights.
07:50First. The understanding that.
07:55Children respond like other
07:58mammals respond to fear.
08:00In an interpersonal way,
08:02oriented toward their caregivers by
08:04looking to their caregivers, primarily,
08:06parents for protection and for regulation,
08:10and soothing and that parents are
08:12powerfully motivated to respond
08:14to cues of fear in their children.
08:16By stepping in to provide
08:18protection and regulation.
08:22And that seems rather obvious, I think.
08:26But that interpersonal aspect of child
08:29anxiety, the aspect that actually most
08:32differentiates it from anxiety and adults,
08:34has exerted relatively little influence over
08:37the way that we conceptualize and treat
08:39anxiety in children over the years. Ah.
08:44Most child anxiety treatment protocols take,
08:46for example, cognitive behavioral
08:48therapy protocols for anxiety,
08:49and children emphasize the
08:52individual level symptoms.
08:54They mirror very closely.
08:56Protocols for anxiety, treatment of adults,
08:58and they focus on those individual level
09:01symptoms like the dysregulated Physiology,
09:03the distorted cognition, the maladaptive
09:07behavioral avoidance altogether,
09:09usually termed the tripartite model
09:11of anxiety and so influential is.
09:14That model that even when parents have been.
09:18Involved in child anxiety treatment
09:20as has happened many times in multiple
09:23clinical studies over the years,
09:25they're generally involved as
09:26what is called lay CBT therapist,
09:28so they're there to amplify the
09:30messages that the child is receiving
09:33directly from the therapist,
09:34but with little emphasis on their
09:37unique role as parents in relation
09:39to their child's anxiety symptoms.
09:41In space,
09:42that interpersonal aspect is central
09:45to treatment and parents are involved,
09:48not as lazy BT therapists,
09:50but as active clients and agents
09:52of change for their child.
09:54A second important principle for
09:56space is a focus on self change
09:58rather than other change.
10:00What that means is that parents
10:02in space learn a lot of tools
10:04and strategies and skills,
10:06but all of those are focused on
10:08modifying the parents own behavior
10:10rather than instructing them.
10:12To go home and try to directly
10:15modify their child's behavior.
10:17We make a simple promise to
10:19parents in treatment.
10:20We say at no point in this
10:21therapy are we going to ask you to
10:23make your child do anything.
10:25Or to make them not do anything.
10:27And the reason that's important
10:29is that when you do ask parents
10:32to modify their child's behavior,
10:33you're taking a risk.
10:35It can go well when a child is open and
10:37amenable and agreeable to those suggestions,
10:40but when they're not,
10:42you run into problems,
10:43because then there's resistance
10:44and the potential for a process of.
10:47Conflict escalation,
10:49sometimes even aggression,
10:51and so we focus on modifying
10:53the parents own behavior.
10:55And it turns out that when parents are
10:57able to make some changes in how they
10:59are responding to their anxious child,
11:01we can lead to really significant
11:03changes in the child themselves,
11:05even without the need for direct
11:07child therapy.
11:07And without that risk of conflict
11:10and escalation,
11:11and while maintaining a warm and loving
11:13and supportive attitude toward the child,
11:15so we don't have a lot of time, but.
11:18I guess I'm going to try to distill what
11:21happens in space into these two key points,
11:24each of which reflect one of the
11:26changes that parents learn to make.
11:27One is,
11:28parents learn to be more supportive
11:30in response to their anxious child,
11:32and the other is to reduce their
11:35accommodating behaviors and
11:36by support in space,
11:37what we mean is an integration
11:40of acceptance and confidence,
11:42and so parents learn to express acceptance,
11:45meaning to convey acknowledgement and
11:47validation of the child's genuine distress.
11:50And confidence in their child's ability
11:52to tolerate some distress to cope,
11:54get through it, and ultimately be OK.
11:57Neither one of those things is
12:00necessarily intuitive to parents or
12:01particularly common in how parents are
12:04actually responding to anxious children.
12:06Often we respond without validation,
12:08like an anxious child says I'm scared or
12:10it's frightening, and we say no, it's not.
12:12We don't mean to invalidate them,
12:14but we are essentially communicating
12:16that they either don't or shouldn't
12:18be feeling what they do feel.
12:20And confidence is not always there.
12:22Many children will grow up
12:24hearing themselves,
12:24explicitly described as children
12:26who can't handle anxiety who
12:29fall apart in the face of stress.
12:31And so those are the two big
12:33changes becoming more supportive
12:35and systematically identifying,
12:37monitoring and reducing the accommodations.
12:41Now, I'm not going to go deeper
12:43into the treatment.
12:44I thought I would share a really brief
12:47video clip taken from a news article
12:50made about space that captures one
12:53family's experience in our program.
12:55So let's all keep our fingers
12:57crossed right now.
12:59We let's say.
13:05Bedtime for some families can
13:07become a struggle, but when the
13:09goodnight routine for Nicole Murphy,
13:11Sun began to stretch for up to three hours,
13:14she knew she needed help
13:16with his separation anxiety.
13:18His little mind was always racing non-stop,
13:21so it was kind of hard for
13:22him to shut that off.
13:23I think Eli Lebowitz and his
13:25colleagues at the Yale Child Study
13:27Center developed a method of training
13:29parents to support anxious children.
13:32It's called space
13:34or supportive parenting for
13:36anxious childhood emotions.
13:38Parents go through training to help
13:40their child face anxiety. Leibowitz
13:42says the first step is to show
13:44support and not downplay
13:47what their child is feeling.
13:48I get it. This is really hard,
13:51but I know you can handle it.
13:54Leibowitz says.
13:55Parents also learn to help their
13:57child by not accommodating them. For
13:59example, a parent who would limit
14:02visitors for a child who gets.
14:03Anxious around strangers or speaks
14:05for a child who gets nervous speaking
14:08learns not to take those steps in a
14:11study of 124 kids and their parents.
14:14The Yale researchers
14:15examined whether the space intervention
14:17was effective in treating
14:19children's anxiety even
14:20though the children never met directly
14:22with the therapist and all the
14:24work was done through the parents,
14:26we found that space was just
14:28as effective as CBT in treating
14:31childhood anxiety disorders.
14:33The Murphys used the techniques
14:35learned through space to coach
14:37their son through bedtime.
14:38Within a few weeks he was
14:41falling asleep in 30 minutes.
14:43It was like life changing. Honestly.
14:45I'm Nancy Alvarez reporting.
14:50It's a nice example,
14:51though of how even a two or three
14:54minute video can introduce parents
14:56to a new kind of treatment.
14:58This has aired in every state in the country,
15:01and so a lot of people can discover
15:03another treatment option that they
15:04otherwise wouldn't know about.
15:06Now this is a data taken from the
15:09clinical trial mentioned in that video,
15:13and as you heard,
15:14what we found was essentially complete
15:16non inferiority for space relative.
15:18CBT both in terms of response to the
15:21treatment and also in terms of remission,
15:24but alongside establishing the
15:26efficacy of the treatment,
15:28another goal of really major
15:30importance is identifying the
15:32moderators of treatment outcomes.
15:34In other words,
15:34if we can figure out who are the
15:37children who respond best to a
15:38parent based treatment like space
15:40and who are the children who respond
15:42best to a child based treatment
15:44like cognitive behavioral therapy,
15:45we might be able to supercharge the.
15:49Overall,
15:49efficacy of our treatments and that
15:52was the goal in another study with a.
15:56Really brilliant Israeli psychologist
15:58faults Eagleville Manoe where
16:01we analyze the data.
16:02I'm used a random forest method of
16:06machine learning to try to examine
16:09endless combinations of baseline
16:11characteristics to identify the pathways,
16:14the combinations that really
16:16predict best differential outcome
16:18for the two treatments.
16:20This is published in JCP and
16:22some of what we found was,
16:25I think, more intuitively.
16:27Guessable like.
16:29Parental negativity, the other
16:30variables a little bit less obvious,
16:33even biological variable.
16:34So for example,
16:35salivary levels of oxytocin in
16:37both the children and the mothers
16:39ended up interacting with the other
16:42variables to predict differential
16:43outcomes for space and CBT,
16:46and that did not take us
16:48completely by surprise.
16:49We've been interested in oxytocin
16:50for quite a few years now,
16:52and have been measuring it in
16:54kids and mothers because of the
16:57deep implication of oxytocin,
16:58the way it's.
16:59Implicated in both anxiety regulation and
17:02close interpersonal and affiliative behavior.
17:06And when you think about the way that
17:08we're really conceptualizing anxiety
17:09in children as a phenomenon that
17:12exists at the intersection of fear
17:14and attachment and interpersonal behavior,
17:17it's maybe not that surprising,
17:18but it's kind of cool to see it being
17:21selected by this machine learning
17:22algorithm as one of those key variables.
17:25I think it takes us its preliminary needs,
17:27replication etc,
17:28but takes us one step closer to the.
17:33Holy Grail in a sense,
17:35the the long sought after but still
17:38quite distant goal of bringing a
17:41precision medicine model to anxiety
17:43treatment and to a day when we
17:46might be able to actually integrate
17:48behavioral biological variables to
17:50inform clinical decision making and
17:53prescription. Now in. Recent years.
18:00And this is really a.
18:02Favorite collaboration for me
18:04with Dillon Gee from psychology.
18:06We've also been working to try to
18:09understand and learn more about the
18:11mechanisms through which space is
18:13bringing about the clinical improvement.
18:16And this aligns well with NIH's
18:18priorities of establishing not only
18:21efficacy for novel therapeutics,
18:23but also establishing the targets and
18:25mechanisms through which they work.
18:27And so we've been conducting
18:29clinical trials of space,
18:30but integrating brain imaging
18:31using F MRI before and after
18:34treatment to learn about what is
18:36changing in children's brains as
18:38parents go through this treatment.
18:40And we use a novel twist on a well
18:43established brain imaging paradigm.
18:45So instead of having.
18:46Just a child in the scanner and you
18:48show them some images and some of
18:49them are more fear inducing and you
18:51look at their amygdala, reactivity,
18:53and the connectivity of the amygdala,
18:55with regions like the medial
18:57prefrontal cortex.
18:58Instead of doing just that,
18:59we do it but with A twist,
19:01which is we scan each child twice,
19:03once when they're alone and once
19:05when their mother is standing right
19:06next to them and holding their hand
19:08so that we can get some indicator
19:10of how much this child is reliant on
19:13parental proximity and contact for
19:16fear regulation at the brain level.
19:19And by doing that both before
19:21and after treatment,
19:22we can learn about how these
19:25treatments are working now one phase.
19:28Of this study is actually complete,
19:30and there we compared space to a parent
19:33based psychoeducational control condition,
19:36which we nicknamed.
19:39PS and.
19:41We're learning a lot,
19:42but we did run into some interference
19:45in doing this study in the form of
19:48everybody's favorite coronavirus.
19:52I think one of our worst days was
19:55when we all went into lockdown and
19:58realized that we have 20 plus children
20:00actively in treatment who all had their
20:03pretreatment brain scans and we're going
20:05through treatment and wouldn't be able
20:07to complete all the study procedures.
20:09And I do realize that that is a small thing
20:12relative to global impacts of pandemics,
20:15but it was kind of heartbreaking for us.
20:18We quickly adapted.
20:19We went to doing treatment over zoom,
20:21which had been an option even
20:22previously so no child didn't complete
20:24their treatment because of it,
20:26and we even got clinical measures
20:28over zoom and Qualtrics etc.
20:29But all of our efforts to do brain
20:32imaging over zoom resulted in failure,
20:35and so we did end up with a smaller data
20:38set in terms of the neurology then or
20:41neurobiology than we would have liked.
20:43Still, we're using that data
20:45and learning what we can and so
20:47for example looking clinically.
20:49We see significantly greater reduction
20:51in child anxiety severity following
20:53space relative to the educational
20:55support condition you're looking at the
20:57same data on both sides of that slide,
20:59so you can choose if you like lines or bars,
21:01and likewise significantly more
21:04reduction in family accommodation.
21:06Following space, as I mentioned,
21:08we ended up with less brain data
21:10than we would have liked,
21:11but we were able to show
21:14that following space,
21:16the difference between the
21:18child's response when.
21:19They are alone and when the mother
21:22is there really went away so
21:24that we no longer see more.
21:26I guess you could say we no longer see
21:29their reliance on the parents proximity
21:32for fear regulation at the brain level and
21:36that was after space and not so after PS.
21:39So I think that is really
21:41interesting in terms of.
21:43Hey just having some.
21:45Pre and post treatment imaging data,
21:48which is kind of unique in
21:49the child anxiety world,
21:51but more specifically about how space
21:54is bringing about those changes now.
21:57In one attempt,
21:59I think to make some.
22:02Lemonade out of some very sour lemons
22:04that Kovid had served up for us.
22:06We did realize that we had a kind of
22:08unique data set because we had scanned
22:10all these children before the pandemic
22:12and had been following them clinically,
22:14and so we thought.
22:15What could we learn from that?
22:16And here I want to highlight the
22:19work of Elizabeth Kit in Dillons Lab
22:21who took the lead on this and what
22:24we're showing here is that children
22:26whose mothers buffered their anxiety
22:28response before COVID disrupted
22:30their lives were also more buffered.
22:33Next,
22:33we impacts of exposure to COVID
22:36related stress on their anxiety levels
22:38as they're living through this,
22:41you know the lockdowns and pandemic etc.
22:44And finally, before I move on.
22:49In another example of ways in which
22:52we're harnessing this kind of data too.
22:54Learn more about the intergenerational
22:56cross generational effects
22:57in anxiety and here really,
22:59with the generous support of
23:00one of the child study centers,
23:02devoted associates were also.
23:07Collecting brain imaging from
23:08mothers of the anxious children.
23:11This is also very disrupted by COVID,
23:13but in an example of the
23:15kind of things we're seeing,
23:16we see that mothers of more anxious
23:18children are also showing themselves
23:20greater amygdala reactivity to a similar
23:23to a similar task in the scanner.
23:26Alright, with that,
23:26I'm really going to move into the newer
23:29expansions and adaptations that were
23:30supposed to be the bulk of the time
23:32for this talk, but I do want to say that.
23:36The work in those areas,
23:37the RFID etc is much newer.
23:40It's less.
23:41Fully baked, it's less mature.
23:43The evidence base is last mature.
23:45I wanted to talk about it 'cause
23:47I find it really exciting and
23:48invigorating and also reflects the
23:50work of some amazing team members.
23:52But bear in mind that while the
23:55anxiety work is fairly well advanced,
23:57we have a solid evidence
23:58base that's rapidly growing.
23:59Here we are in earlier stages and some
24:02of it we're still figuring out and so
24:04have that in mind as we go through.
24:06But the first area that I wanted to
24:09touch on is the eating and specifically.
24:12Are fit in here really a project
24:14spearheaded by the Amazing,
24:16Wonderful Jarisch in Shawnee that
24:18you heard even in about from Julie
24:20at the beginning? Really an amazing.
24:24Clinician and researcher who was here
24:26for several years at the Child Study Center,
24:28both as a postdoc in house faculty and
24:30now he's back on her kibbutz in Israel,
24:33but he's going to be here next
24:36week and remains on our faculty
24:38and a close collaborator and.
24:40Yeah,
24:40it was a really savvy clinician
24:42and what she capitalized on what
24:44she realized is something that
24:45we have been noticing and talking
24:47about in our program for years
24:49but hadn't really taken action on.
24:51And that was children that we
24:54diagnosed as having food phobias.
24:57But we realized that part of their
24:59problem was an anxiety problem,
25:01but also it was an eating disorder
25:04and this fit with the emergence of
25:07RFID as a new diagnosis in the DSM 5.
25:13And So what is RFID?
25:14Essentially we're talking about
25:17really extreme pickiness in eating
25:20with really significant impairment.
25:23We have nutritional problems because
25:26we're not eating healthy and you
25:29know energy intake but also a
25:32lot of psychosocial impairment.
25:34Now, in a lot of cases,
25:36the selective selectiveness and
25:37pickiness are driven by the sensory
25:40characteristics of the food,
25:42like the color, the texture,
25:44the shape, the smell,
25:45and in other cases a big part of it is
25:48fear of negative consequences of eating.
25:50Like if I eat hard foods, I might choke,
25:52and sometimes it really seems to
25:53be a lot about a low appetite,
25:55low interest in food about that
25:57is a little bit less common.
25:59Now, a certain amount of picky
26:02eating is fairly normative.
26:04In early childhood,
26:05we see it really picked,
26:07taking off at around age 2 years.
26:10At age 3,
26:10it kind of peaks and by school age
26:12it has started to subside with most
26:14cases kind of trailing off and not
26:16continuing to be a big problem.
26:18But in some cases the pickiness persists.
26:21Or we might have later onset
26:24or return of pickiness.
26:26And then it can really wreak
26:28havoc on an entire families.
26:30Life with mealtimes,
26:31becoming these battlefields fraught with
26:34a lot of stress and conflict and tension,
26:37and a lot of other impacts on just
26:39daily life for the child and the family,
26:41there's not a ton of research
26:43on picky eating.
26:44I was going to highlight one study
26:47by Emmett at all who looked at
26:49babies really like just over a year
26:51old who are picky eaters and then
26:54followed again two years later.
26:56And what they what they report
26:58is kind of interesting,
26:59which is that the likelihood?
27:01Still,
27:01being a picky eater two years
27:03later was greater when the mothers
27:05were more concerned about the
27:07picky eating earlier on.
27:09Now that maybe in a lot of cases,
27:11because those mothers were savvy and
27:13they realized that their child had a
27:15more serious problem that might persist,
27:16but it may also reflect to some
27:20extent the impact of the.
27:22Ways you know the dynamics that parents
27:24get sucked into when their child
27:27isn't eating and they do everything
27:29they can think of to get them to eat.
27:31And I mentioned before it's it's not
27:33only the physical effects in our field,
27:35there's a lot of psychosocial
27:37impairment that goes along with it.
27:39Like if you can't go to a
27:41restaurant if you can't go to the
27:43school party or the sleepover,
27:44then those things really
27:45take a tremendous toll.
27:47And I was going to show one more video clip.
27:49This is from a child who is just talk
27:52really briefly about his perception of
27:55the impact of his outfit on his family.
27:58This was a kid who worked with
28:00us with Yara in the program.
28:03The
28:03stuff that I would want to
28:04be able to eat is stuff that
28:06we eat a lot in the family.
28:07So that I would be like mashed
28:09potatoes and chopped liver.
28:11I don't like them.
28:12But we have them a lot and all
28:14kinds of stuff mostly sauces
28:16because we have a lot of sauces
28:18and just makes her mom frustrated
28:19when she has to make part of
28:21it without sauce and like split
28:24it and the old thing and snowing so
28:27it makes me feel bad about it because
28:28she asked to work so hard and it's
28:30only for me to not have the sauce.
28:34And I just feel like I should
28:35be making my own meals and she
28:37doesn't shouldn't be doing anything
28:39'cause it's not her problem.
28:42That's a really sweet kid.
28:44Obviously feels bad and a little guilty
28:46and a little ashamed and frustrated,
28:48and not all the children we saw
28:50were quite as sweet and sensitive,
28:52but I think those feelings of
28:54frustration and the impact on the
28:56family are certainly a recurring theme.
28:59Really, that is to adapt the space
29:01protocol to working with these families,
29:03keeping those two key emphasis of increasing
29:06support and reducing accommodation,
29:08but also introducing another component which
29:11was reducing the stress surrounding eating,
29:14which is so often really big.
29:16And as Yara likes to say,
29:17the goal in our fit is not this right?
29:20We're not trying to make children
29:23the most adventurous adventurous
29:24eaters in the world who will go
29:26right for the seafood paella, it's.
29:29We could define the goal more
29:31like this little bit more humbly
29:33to instill in the child the sense
29:34that I can find something to eat,
29:36and I'll be OK.
29:40And so parents work to reduce the stress,
29:42to increase support and to
29:43reduce the accommodations.
29:44That can be really intense,
29:46like not serving leftovers when
29:48there are or pureeing all a child's
29:51food or spoon feeding it to them,
29:54or not eating in front of the child,
29:56not going to the restaurant,
29:57not taking trips, or like in one case,
29:59literally driving to the child
30:00school every single day at lunch
30:02time to bring them a fresh roll,
30:03because that is the one
30:05thing that they will eat.
30:07So we conducted one clinical trial.
30:10Of space for RFID.
30:12It's an open trial without
30:15randomization in 15 families.
30:17All the children had primary RFID diagnosis,
30:20most of them around those
30:22sensory characteristics,
30:23and one goal was to really examine the
30:25acceptability and feasibility of it.
30:27We had low dropout.
30:28We had high satisfaction rates from
30:31both the child and the parents,
30:34even though the children were
30:35not directly in the sessions.
30:37And when we look from before to
30:39after treatment, you can see that.
30:41Following treatment,
30:42most of the children no longer met
30:44criteria for RFID and among those who did,
30:46almost all were rated as only
30:49mildly impaired relative to,
30:50I think, about 90 would say yeah,
30:53almost 90% of children at baseline who were
30:57severely impaired by their by their RFID.
31:00And we see this also statistically in,
31:02you know,
31:03comparing before and after around
31:06domains of impairment and.
31:08Symptom severity and family accommodation.
31:13So I'm excited about this.
31:14Again, it's early, I'm excited.
31:15I'm excited about it,
31:16partly because there are so many
31:18children who struggle with eating,
31:19and I think that this kind of work
31:22could be helpful not only for those
31:24who meet diagnostic criteria per DSM 5,
31:26but also for lots of other children
31:29and families that struggle
31:30with the issue of picky eating,
31:32even if they're not meeting
31:33those diagnostic criteria.
31:35OK,
31:35I'm going to move on to the
31:37next domain of expansion.
31:39Of space that I wanted to
31:41touch on is one that.
31:43It causes tremendous frustration
31:45and difficulty and quite.
31:48Is quite literally painful for a
31:50great many children and adolescents,
31:53and that is the area of somatic complaints,
31:56and specifically here we're focusing
31:59on unexplained physical symptoms.
32:01And this is also a project that I like a lot,
32:04because in part it's an opportunity to
32:08collaborate with friends in Pediatrics,
32:10like Gene Shapiro and.
32:13I'm.
32:16I think of all of the three
32:17that I'm talking about.
32:18This is sort of the the one,
32:20the project that's most in its
32:21infancy in terms of its development,
32:23and so we're really still in
32:25the figuring out stage and
32:27and collecting the evidence.
32:28I'm going to tell you about it,
32:29but have that have that in mind as
32:32we go through and hear the person
32:35to really highlight is Becca Atkin,
32:39who it really epitomizes the.
32:43Combination of.
32:44A skilled clinician and brilliant
32:47researcher in a way that is,
32:49it's just so fantastic to work
32:52with and Becca together
32:54with Amanda Calhoun from our soul it
32:58integrated Psychiatry program have been
33:01working on refining the space approach
33:03for working with these parents of kids
33:06with these unexplained somatic symptoms,
33:08which can include things like headache,
33:10fatigue, muscle pains,
33:11GI distress, et cetera.
33:13And here are also associated with a lot of.
33:16Sort of ancillary problems like
33:18other mental health conditions and
33:20a lot of functional impairment.
33:22Use utilization of services,
33:24medical services, etc.
33:26And there are treatments
33:28for physical complaints.
33:31Like CBT, biofeedback,
33:34we've even done with Wendy here.
33:36Work around mindfulness interventions,
33:37but one thing that has remained
33:39really vague is how to best
33:41involve parents in that work.
33:42And in fact,
33:43other researchers have commented
33:45on the difficulty that parents have
33:47not accommodating when their child
33:48is experiencing these physical
33:50problems and so back on Amanda
33:52really taken the lead on adapting
33:54space and here also we're retaining
33:57the core principles of space,
33:59but sometimes adding necessary components.
34:02Like teaching parents to be savvy
34:04consumers of medical resources,
34:05or how to advocate for their child's
34:08needs or to do risk assessments
34:10when you're confronted with
34:12these physical issues.
34:16And so far we have completed one group
34:20out of a multi group treatment study.
34:24So this is definitely still on.
34:27Ongoing and the group met seven times for
34:3290 minutes over zoom for obvious reasons.
34:36And one tenet of this group is.
34:40That we assume and acknowledge that
34:42this child's complaints are real,
34:44but they are genuinely suffering
34:46and at the same time that some
34:49level of function needs to be can
34:51be and must be maintained as well,
34:54and that aligns well with our definition
34:56of support in space as that integration
35:00of acceptance together with confidence.
35:02And so the the group focuses on increasing
35:05the support on reducing accommodations,
35:08of which there are many,
35:10like constantly picking up the phone when
35:12you're at trying to do your work at work,
35:14but your child isn't feeling well or
35:15picking them up early from school or
35:17taking them to the doctor even when the
35:19doctor is saying don't bring them in and
35:21letting them sleep with you, etc etc.
35:22Here again,
35:23we wanted to get first some sense of
35:26the feasibility and acceptability of it.
35:29Satisfaction was rated very high
35:30in this group with score of about.
35:3230 out of 32.
35:34So it's very satisfied parents and
35:36I think we had only one drop out
35:37and that was a person who said
35:39their child wasn't really struggling
35:40with somatic symptoms anymore.
35:42By the time the group had started.
35:44Now I I'm showing here some pre
35:46to post comparisons from this
35:49group and they look amazing but.
35:52These are a handful of people,
35:54and so the truth is that statistical testing
35:57here from predisposed it's it's very iffy.
36:00I'm showing it because I think we can
36:02get a sense of like this is encouraging,
36:04right?
36:05It's promising that we're seeing
36:06these improvements,
36:07but I wouldn't take it as a real
36:09efficacy test when we're talking about
36:10one group of you know of individuals,
36:13but it is nice to see parents and kids
36:16reporting improvement across these
36:17domains of quality of life or impairment,
36:21or anxiety and depression.
36:23And accommodation parenting stress.
36:25It's nice to see that improvement.
36:26It's nice to see not only the parents
36:28but also the children reporting that
36:29they are feeling better following it.
36:31And I think one parent really summed
36:34up best the message and the change that
36:36we're trying to bring about through
36:38a group like this when she said it's
36:40not about waiting for the storm to pass,
36:42but learning to dance in the rain,
36:44which I think is really nice.
36:48OK.
36:50Two down and one to go bear with me.
36:55Our next our next space expansion takes
37:00us out of the domain of childhood
37:05and into the world of adult children.
37:10The space for failure to launch is.
37:14Work with parents of adult children
37:16who are really not transitioning into
37:19what we might think of as independent,
37:22functional adulthood. What does that mean?
37:25It means they're over 18 years of age.
37:28They're not in high school,
37:29but they're not employed, not working.
37:32They're not in active education,
37:35and I say active because sometimes they
37:37may be formally enrolled in some programs,
37:40sometimes for years, but without
37:42doing anything in that program and.
37:43Without any progress toward
37:45graduation or accreditation,
37:46etc, they're usually living
37:48at home with their parents.
37:50In some cases living somewhere else,
37:51but at the parents expense,
37:53and so the parent may have bought
37:54or rented a place for them and
37:56kind of installed them there.
37:57But still covering all of their expenses.
38:01And here again,
38:02we see this associated with a lot of
38:05related issues and problems and impairment,
38:08like really disrupted sleep cycles sometimes
38:11awake all night and asleep during the day.
38:15A lot of social isolation.
38:18Really excessive media and
38:21online electronic use.
38:23And physical and mental health problems
38:25like being overweight and blood pressure.
38:28And of course anxiety and depression
38:30being very common as well.
38:32And by the way, I want to emphasize
38:34the social isolation piece.
38:35It's not only for the adult child
38:37that goes for the parents to,
38:39you know when.
38:41The holiday season comes around
38:43and you start getting all of
38:45these greeting cards with all the
38:47beaming faces looking up at you.
38:49And there's an update.
38:50You know this kid graduated from
38:52that school and that kid started
38:55an exciting internship and that one
38:57got married and your kid has spent
38:59another year doing nothing that's
39:02painful and you may retreat into
39:04your shell or just going to like
39:07the family gathering the dinner,
39:09the wedding and fielding questions from.
39:11People about like what's your kid up to,
39:13what are they doing?
39:14And the answer is simply nothing.
39:16And so you start not going to those events.
39:18Not having guests at your house
39:20and it can be extremely isolating
39:23for parents as well.
39:25And it's it's a really painful
39:27thing and one of the things that
39:29really stymies progress in this
39:30area are some myths that I think
39:33surround this phenomenon of adult
39:35children who are stuck in this way.
39:37Like the idea that this is somehow
39:39like a new age millennial problem
39:41because of poor work ethic or because
39:44of unrealistic expectations from life.
39:46Or the idea that these are
39:48just overly indulgent parents?
39:49Or sometimes the idea that it's
39:50parents who don't want their child
39:52to proceed on 'cause they want to
39:54keep them at home for themselves
39:56and not let them grow up,
39:57or that the children are just really
40:00lazy and that they're enjoying living
40:02it up at their parents expense.
40:05And you see that I hear this in
40:07conversations with people but also
40:08portrayed in popular media like
40:10in the eponymous failure to launch
40:12moving where they're literally
40:14clinking martini glasses.
40:15And you know, cackling.
40:17About how they won't leave their
40:19parents house.
40:20That does not match at all.
40:21The experience that I have with
40:24countless families over the years.
40:26I II pulled two quotes from an anonymous.
40:31Like online forum that I
40:33thought captured a little bit
40:35better the experience and.
40:37So M RK74 says I was just wondering if
40:42there's anyone out there who still lives at
40:44home because of their anxiety or depression.
40:46I hate it. I feel like people are saying
40:48what a loser and so on and so forth.
40:51And likewise to D88, says you know it
40:53makes me feel like a loser and pathetic.
40:56That is a lot more.
40:57The experience that I encounter.
41:00They're not living it up
41:02at anybody's expense. Now.
41:03I sometimes think of this
41:05phenomenon of failure to launch as.
41:08Like almost the last really
41:11unaddressed problem in mental health,
41:13you know it's it's, it's.
41:15It's crazy there are so many problems where
41:17we don't have good enough answers, right?
41:19There's lots of areas of
41:20psychopathology where we don't
41:22really have good enough answers.
41:23But usually it's not for lack of trying.
41:27Here we're not even doing the basic
41:29work to even start to address this.
41:31We have tremendous knowledge gaps.
41:35And let me just point to a few of them
41:37and tell you about some of the work that
41:40we're doing to address it so for example,
41:42we don't know the basic
41:44prevalence of this problem?
41:45How many people fit.
41:46This definition, we don't know.
41:49Uh, what are the precursors,
41:51the predictors and risk factors
41:53for not transitioning to adult?
41:54You know, functional adulthood.
41:56We don't know that,
41:57and that means that we can't prevent,
41:59right?
41:59We can't intervene to try to prevent it.
42:02We don't know the trajectories,
42:03how chronic or fixed,
42:05or malleable or plastic is this,
42:07and what can be done.
42:09And we are taking very active steps
42:11to try to address all of those here.
42:13I really want to emphasize the work of
42:16another amazing postdoc or a burger.
42:19Who with the very generous support
42:21of another dear person,
42:22we were able to bring onto the team
42:24and he has taken the lead on a lot
42:26of this and really accomplished a
42:28tremendous amount for one year that
42:30he's been working in the program so.
42:32What are we doing to address
42:34the prevalence problem?
42:34Well,
42:35even as we speak a national a
42:38nationally representative survey is
42:40going out across the country to 10s
42:43of thousands of people to try with.
42:45Working with Ipsos Big Survey
42:48company to try to ascertain how
42:50many people actually have somebody
42:52like this in their lives.
42:54This is really the first large scale
42:58epidemiological attempt to even,
43:00you know, gauge the prevalence.
43:03And.
43:05For those responders who do indicate that
43:07there somebody for them that matches that,
43:10then will also get other information
43:12like the car let's the economic impact,
43:15the burden, etc.
43:16So I think that's going to
43:17teach us a lot and.
43:20Hopefully also provide.
43:22Impetus to for more research in the area,
43:25which is very clearly,
43:27sorely needed and we will see,
43:29and I'll share next time what
43:30the results of the survey are.
43:32But if our best guesses based on
43:33smaller studies a lot in other
43:35countries are any indication,
43:37we're talking about millions of
43:38people and literally 10s of billions
43:40of dollars every year in lost
43:43productivity, tax revenue, etc.
43:44Now, where is also trying to
43:47address those precursor questions
43:50by mining data from other?
43:53Surveys that have been administered
43:55for over for two cohorts over
43:57multiple years and long time spans.
43:59For example, the add health survey
44:01that a lot of you may be familiar with.
44:03That's the adolescent to Adult Health survey,
44:06which is administered all the
44:08way from adolescence into really
44:10mid adulthood at this point.
44:12To thousands of people,
44:13and it wasn't designed to
44:15identify failure to launch,
44:17but we can make some tentative guesses
44:19about people that might be meeting
44:21that criteria based on indicators
44:23like their employment and place
44:25of residence and education, etc.
44:26And when we do,
44:28we can then go back and see what
44:30differentiated them from their
44:31peers when they were adolescence,
44:33and the answer seems to be quite a bit.
44:37I know this is too much to take
44:39in on a slide, but.
44:41The real take home here is that
44:43we're seeing really statistically
44:45significant differences between those
44:47individuals who later are likely
44:49failure to launch cases and their
44:51peers in adolescence across many domains,
44:54like the behavior like school absences,
44:57media consumption, mental health,
44:59like depression, suicidality,
45:01social functioning,
45:01how many friends do they have?
45:03If they ever had a boyfriend or girlfriend,
45:05how well did a live interview or think
45:07they presented themselves academic
45:09things like learning problems and even.
45:12Physical things like their
45:13pubertal status or their height,
45:15and so again we're going to
45:17need to replicate a lot of this,
45:19but this is giving clues of the
45:21kinds of things that might help to
45:22intervene when people are at risk
45:24for not making that transition
45:25rather than assuming that it will go
45:28smoothly and sort of leaving families
45:30to pick up the pieces when it does not.
45:32And we can also use that data
45:35to look at trajectories,
45:38and so for example,
45:39here we can see that somebody who at age
45:4318 to 24 in that wave of the survey was
45:46like a likely failure to launch case.
45:49Still has a two times as likely
45:52chance of not living independently,
45:55even six or 15 years later,
45:58or somebody at age 25 who may
46:01have failure to launch as a four
46:03times greater chance of still not
46:06living independently nine years
46:07later and have not working.
46:09And so we're seeing that this
46:10is a really fixed problem.
46:11It speaks to the risks of settling
46:14into that failure to launch
46:15situation where years can just go
46:17by so quickly without any change.
46:20And it's actually one reason,
46:21I think, that I unlike some others,
46:24I don't think of this as a
46:25young adult problem.
46:26It's really not a young adult problem.
46:27I'd start there,
46:29but there's not an expiration date.
46:31If nothing is done,
46:33which leads us to the what
46:35can be done question.
46:37And here we are again conducting
46:39clinical trial research is
46:41a randomized controlled trial
46:42with a wait list control of
46:44space for failure to launch.
46:46We're doing it over zoom 13 to
46:4820 sessions with the families.
46:50This individual, not group,
46:52and the study is actually still
46:55ongoing and so all I will say
46:57is a very very small sneak
46:59peek at what we were seeing.
47:01So for example of 11 cases will
47:04already completed treatment.
47:0865% don't meet our death or
47:10entry definition of failure to
47:12launch by the end of treatment,
47:14which is really amazing.
47:16These are hard, hard,
47:18hard cases to work to to work with.
47:20It really difficult.
47:21But when you have a person who hasn't left
47:25their room in years hasn't gone to work,
47:27doesn't have anything really happening and
47:29they are able to start living their lives,
47:32it's just worth it.
47:33And what does it mean to go from
47:35having failure to launch to not?
47:37But if you compare people who still
47:39have failure to launch those who don't,
47:42we see really significant
47:43differences in adaptive behavior.
47:45And not surprisingly for the parents,
47:48because like a significant
47:50differences in accommodation.
47:51So we are almost almost almost out of time,
47:54but I wanted to leave you with
47:56one more video and this is I'm
47:59saying to the gods of video to
48:01stop the recording for this piece.
48:04Or we'll cut it after, well,
48:05cut it after.
48:06OK, so because I have permission to show
48:09you this video but not to send it beyond.
48:11And so I'm going to play this.
48:13These were just here from a
48:15couple who struggled with their
48:17son for a really long time.
48:18They weren't in this study.
48:20They worked with me though
48:21using the same approach and I
48:24think it speaks for itself.
48:25Some.
48:29That is essentially the things
48:31that I wanted to cover today.
48:32There's other projects that are
48:33even earlier in development.
48:34Too early to talk about,
48:35like and so you can look at the slide.
48:38I do, though I also want to say of
48:41course thank you to the amazing team
48:44too when they work closely with me on.
48:47Almost everything that we've
48:48talked about to the collaborators,
48:50to our intrepid lab manager,
48:52grace the clinicians and everybody.
48:56And of course,
48:57thank you very much to each
48:59and everyone of you as well.
49:07If you wanna take some questions and
49:10I'm sure that zoom world you know
49:12whoever stays around, I'm sure that
49:13there's going to be some questions.
49:15Hold on one second. However long
49:19they want to stay in three hours.
49:22OK, so any any questions Eli is in
49:25the house and taking questions.
49:27I know because of techno we
49:30were a little bit late but.
49:32Julie, start us off anyone start us off Eli.
49:42Ellie, I think you're particularly good at.
49:47Helping parents appreciate that
49:49they are part of the solution,
49:52but they are not to blame.
49:54They are not the problem.
49:57Actually, earlier in my career that that
49:59was that was a tough balance for me.
50:02Could you talk a little
50:05bit about that? That art?
50:15OK, well first of all, thank you.
50:17That's a nice compliment, you know.
50:21I think we we all.
50:25Represent a field with a very rich history
50:28of blaming parents for everything.
50:30Right, we blame parents fears gets a
50:32free neon schizophrenic mothers casket.
50:34Sabrina and refrigerator mothers cause
50:38autism and time and again empirical
50:41research just fails to support that.
50:44And so I think that.
50:47We don't need to make a false leap from.
50:51We can help you can help your
50:53child to overcome a problem too.
50:55You need to be you know accused.
50:57For the fact that they have the
50:59problem and my experience is that
51:01when parents are get it that way.
51:05It's so gratifying and so empowering
51:07to be able to help to help
51:09your child overcome a problem.
51:11Like, why would you only want to help
51:12your kid with problems that you cost,
51:14but it doesn't make sense, right?
51:16We don't we never think that way,
51:18and I think that's true here also.
51:21I don't assume that I'm a
51:23better parent than my patients.
51:25I see so many patients that
51:26I work with and I think, WOW,
51:28there's such an amazing parents.
51:30Amazing mom are amazing that I wish I
51:32was more like that in my own parenting.
51:34In fact,
51:35that we may be here to work on a
51:37specific issue around your child
51:38anxiety where we have some specific
51:40knowledge that you can apply that.
51:42That's great,
51:44but.
51:45I think there's you know it's a
51:46little seductive to fall into the
51:48I'm doing the parent training,
51:50so I must be better than you at at this.
51:52And frankly,
51:53I think that's kind of BS and bogus.
51:55I think parents that I work with pick up
51:57on the fact that I don't feel that way.
51:59'cause I genuinely don't and
52:00that makes it easier as well.
52:06My kids will confirm I'm not.
52:13I cancelled
52:16how do I know?
52:21The chat. The chat.
52:25Well, probably people are
52:26aware that the time is fast
52:28and they have other things too.
52:31Still there where I was
52:32on mute the whole time. No
52:34one else has another question.
52:36I wonder if you ever will put your
52:41brilliant theories about school
52:44avoidance into a more manualized form,
52:49especially addressing the
52:50secondary gain and and parent
52:53accommodation that often happens.
52:55Or are there plans for that?
53:03Yeah, uh, you know, school refusal.
53:06It's such a. It's such a it's such a
53:08stubborn kind of problem to overcome
53:11to be so stuck takes a lot of energy
53:13and a lot of momentum to overcome
53:16the inertia of school refusal and to
53:18get something moving there when it
53:20can be stuck for a really long time.
53:22There are plans for that actually
53:25were in discussion with.
53:27Well, yes, I think there are plans
53:29for that and I'm hoping to be
53:31able to share more about it.
53:32In the meantime,
53:33I made one YouTube video on
53:34overcoming school refusal so
53:35people can check that out.
53:40Alright.
53:42You wanna close it?
53:45Well, I would just like to thank me
53:47for just really an amazing presentation
53:49in light of all of the antigenic
53:52stimuli that you're experiencing.
53:54So thank you once again and Portugal.