Yale Psychiatry Grand Rounds: May 7, 2021

May 07, 2021

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"Augmenting, Dismantling, Disseminating: Clinical Discoveries in Pediatric Anxiety Experimental Psychotherapeutics"

Wendy K. Silverman, PhD, Alfred A. Messer Professor of Child Psychiatry, Yale Child Study Center

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00:00Just want to say how pleased
00:02we are to have you here today.
00:05And it's my honor to introduce Doctor
00:07Wendy Silverman who is a who is the Alfred,
00:11a MSR professor of child psychiatry and
00:13director of the Anxiety and Mood Disorders
00:16Program at the Yale Child Study Center.
00:20Doctor Silverman received her
00:21PhD in clinical psychology from
00:24Case Western Reserve University,
00:25and she's been at the Yale University for
00:29quite some time now following her training.
00:33Over the course of her career, she is really.
00:37She's published numerous scientific
00:38papers and chapters in the area of
00:41child and adolescent anxiety disorders,
00:42including five books of note.
00:44She developed the Anxiety Disorders
00:46interview scheduled for Children,
00:48which is widely used in
00:50research and practice.
00:52In addition to her scholarly papers,
00:54she's been the principal investigator or Co.
00:57Investigator on National Institute
00:58of Mental Health Research Grants
01:00to develop and evaluate treatments
01:02for anxiety disorders in children,
01:04adolescents.
01:04She served as the chairperson of the
01:07NIH Intervention Grant Review Panel and
01:10as an associate editor and editor of
01:12many of the major preeminent journals
01:15in clinical psychology and as a
01:17reflection of her stature in the field.
01:20She is a past president.
01:22The Society of Clinical Child
01:24and Adolescent Psychology of the
01:27American Psychological Association. And
01:29perhaps most importantly,
01:30in some respects she's been
01:32working with anxious youth and
01:35their families and supervising
01:36trainees for over three decades.
01:38So you know she's provided both clinical
01:41service but also has seated the next
01:44generation of researchers in this area.
01:46So today I'm really I want to say
01:49how fortunate we are to have the
01:52opportunity to learn from you today.
01:56From your experience as a clinician,
01:58an innovative researcher in the field of
02:00child and adolescent anxiety disorders.
02:02So thank you very much.
02:04OK, well thank you very much Stephanie
02:06for that very nice introduction and
02:09also thank you for inviting me.
02:11It's an honor to be able to present
02:14today at Grand rounds in psychiatry.
02:17I'm I didn't realize when I was going to
02:20begin preparing for this presentation.
02:23What actually would have?
02:26Wonderful opportunity,
02:27it actually provided me to actually
02:29stop and sit and reflect on what it is
02:33that I've been doing for more than half
02:36of my life which is trying to help and
02:40understand anxiety disorders in children.
02:42And so I think you'll hear throughout
02:45my presentation of reflection
02:47of some of my reflection.
02:49And this also will include a
02:52some historical perspective,
02:53because I think that historical
02:55perspective also helps put the work
02:58that will be presenting in some context.
03:01So this is the title of my presentation,
03:04which I hope will become clearer
03:06what it all means.
03:08As I get through it the type,
03:10the term experimental psychotherapeutics.
03:12I actually really love that term.
03:14It's not.
03:15It's a term from the NIH,
03:17and I actually love it because
03:19I think it does highlight that
03:21we're doing experiment.
03:23We're doing extremely well
03:24controlled experiments,
03:25but it's kind of a handful to be
03:27saying this throughout my presentation,
03:29so I will be referring to
03:32experimental psychotherapeutics.
03:33As clinical trials this morning.
03:37And this, uh?
03:38Stephanie mentioned the interview schedule,
03:40which I will be talking about
03:43in a few minutes,
03:44and I do receive royalties from that,
03:47so my objectives for today is to
03:50summarize knowledge and identify
03:52knowledge gaps in clinical trials
03:54of of cognitive behavior therapy,
03:56which CBT in my slides of
03:59pediatric anxiety disorders.
04:00And then this is a journey.
04:03So I will be highlighting
04:05my journey to enhance CBT.
04:07Outcomes and the way I've been
04:10trying to do this is by augmenting
04:13and dismantling clinical trials
04:15and a lot of this work has been
04:19with parents and within the past
04:22eight to 10 years with attention,
04:24retraining methods.
04:25And then because I am at heart
04:28wanting to really help children and
04:31trained clinicians and supervise
04:33trainees throughout my presentation,
04:35I will be weaving through.
04:37The things that we've learned
04:39that discoveries clinically,
04:40and the implications,
04:41and then I'll conclude with the
04:43ongoing and future research.
04:46Since there is a lot I'm trying
04:48to pack in, it's like you know.
04:51This is the structure of my presentation.
04:54As you'll see some background about the DSM,
04:57some background and CBT sampling,
04:58then the work with the
05:00parents and then and then,
05:02which is much of the emphasis
05:04and then the attention can be
05:06training and some of the takeaways.
05:11So I do need to begin with at the beginning,
05:15actually, because some people in the
05:18audience might not even have been
05:21born in when the DSM three came out,
05:24which was in 1980 because it was
05:26only in 1980 when there was even
05:29some things called anxiety disorders
05:31in children and adolescents.
05:33DSM two just had something
05:35called overanxious reaction,
05:37so all of a sudden, dear, some.
05:39Free in 1980,
05:41there was a whole new set of problems
05:43that came into existence and I don't,
05:46and that's a literal statement.
05:48An an I actually began my
05:50career in the early 80s,
05:52and so this was a ripe opportunity
05:54for me to get into something
05:56that was brand new and that was
05:59exciting and I had done some related
06:02fear studies Graduate School,
06:04but it was really a brand new opportunity
06:07and and we didn't know at the time,
06:10but we now know how prevalent
06:12these problems are and how the on.
06:15Set of these problems begin so early.
06:17Median age of onset is 11 and the
06:20lifetime prevalence of anxiety
06:22disorders is close to 30%.
06:24And anybody who knows people with
06:26anxiety can know how crippling.
06:29And the amount of suffering and
06:31burden that they cause on families.
06:33An intern on society. This list.
06:36There are the slower the anxiety disorders
06:38that currently exist in the DSM five.
06:41I actually put them in developmental order.
06:43So like the ones in the beginning
06:46begin more early childhood and then
06:48you get more into the middle childhood
06:51and then later into adolescence.
06:53It's not carved in stone,
06:54but there is this general
06:56developmental pattern and the in
06:58the three disorders with the astrex.
07:00Separation,
07:01social and geazy.
07:02Those are the most common in children
07:04and adolescents,
07:05and our clinical trials primarily
07:07focus on these disorders,
07:09and so that's these are the disorders
07:12that you'll be hearing most about today
07:15that we that we're trying to help.
07:18Now when I began my career as I said,
07:21there was not much out there and I
07:23knew I wanted to help children and
07:25I began my career career actually
07:27at Suni Albany State University
07:29of New York at Albany.
07:31David Barlow,
07:31who I do view as a mentor and is a,
07:34you know,
07:35very important person in in
07:36the field of adults anxiety.
07:38He developed the Adult Anxiety
07:40Disorders interview schedule and
07:42when I spoke with Dave and I said no,
07:44I want to do this for the kids.
07:46He says, well, you know.
07:48We need an interview for Children,
07:50which I did because at that time and
07:53still to this day you need to be
07:55able to show that you can carefully
07:58phenotype the participants and also
08:00clinically to know who you're working with.
08:03Com ability is rampant and there's
08:05a lot of overlapping symptoms an an
08:08it is a challenge so I developed
08:10the DSM 3 version,
08:11the DSM 3R version and then Anne
08:14Marie Albano who's sitting there in
08:16the corner is my friend and collaborator,
08:19Columbia. And she's been a
08:20coauthor of the date of the DSM
08:22four and season five versions,
08:24'cause it's, you know,
08:25it's actually quite a bit of work.
08:28These anxiety categories are changing
08:29with each version of the DSM,
08:31and I put the slide up also to let
08:34people know for those of you who are
08:36doing clinical trials research like and,
08:39I thought this was actually kind of cool.
08:41Frankly, that since the 80s has become
08:43the main measure used in most trials,
08:46not just in the United States,
08:48but in most in internationally,
08:49and it's been translated in many countries.
08:52I'm a bunch of us got together and develop
08:54this international consensus statement.
08:57How do you deal with the different
08:59children and different payment reports,
09:01the com ability, etc.
09:03And then Joan Luby Rd.
09:04I thought a nice editorial kind of
09:07highlighting that this is a nice
09:09template for other clinical trials,
09:11so I I think that's one important
09:13point about the importance of,
09:15especially when doing clinical
09:17trials research to make sure that
09:19trying to get people, of course.
09:22World on the same page on phenotyping.
09:26In terms of dimensional measures,
09:28which is another important part
09:30of our assessment procedure?
09:31There's a lot of different measures,
09:33and Becca Atkins,
09:35a postdoc in our anxiety program and
09:37and in the past year we put together
09:40this review one there was not too
09:43much to put into two separate papers,
09:45so we did the child and parent
09:47measure separately,
09:48and the main takeaway here is,
09:51first of all, there are many more studies
09:54looking at the use of the Child report.
09:57But but still,
09:58the pan reportedly in his ID,
10:00is also an important indicator,
10:01and I mainly just want to put out there
10:04that when you look at these measures,
10:07the crate they've been looked
10:09at pretty much more thoroughly
10:10than one might suspect norms,
10:12internal consistency,
10:13and you can see the list down there
10:15and we we came away with the conclusion
10:18that these measures actually have
10:19good to excellent cycle metrics,
10:21and we particularly came away with
10:23the idea for the most current for the
10:26current measures that the scared.
10:28The one that you see the seconds of the
10:31end actually has the strongest cycle metrics.
10:36So we have phenotyping with interviews Anne
10:38with rating scales and another important
10:41part of what we do at the anxiety program.
10:44Because we do a,
10:45you know,
10:46we definitely consider all of the
10:49units of analysis as per our doc and
10:51so we have some novel ways illegally.
10:54Poets developed a really cool
10:56kinetic motion detecting test task
10:58to assess approach and avoidance.
11:00And we published some papers on that.
11:02You know, we're also doing eye tracking.
11:05We do parent child interactions
11:07and we measure oxytocin at the
11:10same time we do speech tasks.
11:12So we do a comprehensive
11:14behavioral assessment when the
11:15children come through with us.
11:17Using these types of methods.
11:19We also have been collecting
11:21biological and neural targets,
11:23and so I mentioned the oxytocin that's
11:26the Tiffany necklace at the bottom.
11:28That's not a Tiffany necklace that's actually
11:31oxytocin and and with Jim Lechman we've,
11:33you know, been doing stuff.
11:35Really interesting patterns
11:37of oxytocin relations with
11:39children and their mothers flora.
11:41Vaccarino, you know,
11:43we've been looking into fibro,
11:45glow, fibroblast growth factor,
11:48FGF two and looking into bad.
11:52Help with Hillary.
11:53We've been doing and LNG and psychology.
11:56We've been doing brain imaging and
11:58collecting data on the children when
12:01they're going through our trials.
12:03The rainbow figure is genetic work
12:05with Tom Fernandez, an Emily Olson,
12:07and then we also do collect AEG
12:10and this particular paper actually
12:12was the data for pilot stuff.
12:14The data that served for our current
12:17R 01 on attention processing.
12:19So we you know, so you know so.
12:22The soda is really important to get
12:25this type of multimethod assessment,
12:27and I'm I'm I'm really pleased,
12:29frankly, and I I came in 2013 and
12:32I'm actually really pleased with you.
12:35Know how well we've been reaching and
12:38collaborating with experts in these areas.
12:41So that's the measurement part.
12:43Now I want to get into the most of what
12:45my present my presentation is about,
12:48which is about treatment.
12:49But you know,
12:50assessment.
12:50You can have good treatment and
12:53evidence based treatments with that
12:55that evidence based assessment.
12:56So that's why I I emphasize that
12:59evidence based based assessment and the.
13:02This is.
13:02So once we had the anxiety
13:05disorders interview schedule,
13:06we were able to show that we were
13:08able to phenotype the children and
13:11Phil Kendall actually was the first
13:13person to do the first individual CBT.
13:16We did the second group CBT.
13:18I'm sorry we did the first we did.
13:21First trials showing that you
13:23can do CBT in a group format,
13:26and this is a data from that trial
13:29where we've showed 64% of kids in Group
13:32improve 5013 don't the significant
13:34time by treatment interactions,
13:36but what's interesting is that
13:38this this is 1999 in the latest
13:41Cochran review where they looked
13:43at across the papers of 41 studies.
13:46It was remarkable to me how the rates of
13:49remission with same basically 59% mission.
13:52Versus 15 in the weightless
13:53medium to launch effects.
13:55Although the durability is an issue
13:57and that is varies across the studies,
13:59and that's an issue that we're very
14:02interested in in trying to work on.
14:06And with the cams, is that the largest
14:09multi site multi method paper study that
14:12came out a while ago and they released
14:15their data and so this this is going to?
14:18I'm telling you why this is relevant
14:21in a moment. So with Michael.
14:25Jerome Taylor was a solid fellow and he an
14:28myself and Michael Block and Ellie Leibowitz.
14:32We Annaly analyze some of the cameras
14:34data and we looked at the predictors
14:37of poor outcome and what we found in
14:41terms of CBT predictors of poor outcome.
14:44We found that severe anxiety,
14:46especially social anxiety,
14:47anxiety and low SES and OC D were main
14:51effect predictors of poor outcome.
14:54And the cams people looked at their
14:57long term naturalistic follow-up
14:58and they also found severe anxiety,
15:01especially social anxiety worth
15:02predictors of poor outcome.
15:04I'm going to be coming well.
15:06I share this now because this is
15:09actually the problem as you see
15:11when we do the attention training.
15:14This is a large reason why our
15:16attention retraining work is
15:18focusing on this population.
15:20Severe adolescent social anxiety.
15:22So that's the reason for
15:25bringing this up now.
15:27So I will be focusing primarily on efficacy,
15:30but I also want to lay for people out there
15:34who are interested in effectiveness, work,
15:37and the generalizability of this work.
15:40I had the honor of being involved
15:43in a effectiveness trial.
15:45This is Pia Jeppesen,
15:47who is a psychiatrist in India in
15:50Copenhagen and this she put together
15:53a team to see how we can disseminate.
15:56CBT the intervention was called
15:58mind my mind I was involved in the
16:01design and also in developed in
16:04consulting on the anxiety modules and
16:06you could see here what it's about.
16:08The main thing is with anxiety,
16:11depression and behavioral disturbances.
16:12But using a module eyes approach
16:15with children in from the schools
16:17from the Community,
16:18mental health settings and I underline
16:20that all the parents were engaged
16:23but only as Co agents of change.
16:25So panels were not.
16:27A important part of this story,
16:29and in case people are wondering about
16:31that since I am so interested in parents.
16:35And so,
16:36for example,
16:36this was a prototype,
16:38so we developed different flowcharts
16:40that different children and you
16:42know this might be for one child,
16:44but for some children it might
16:46be a different module of what
16:48might be needed for anxiety,
16:50and it was actually very very cool,
16:53and I think that's a large reason for
16:55the success of this effectiveness.
16:57Trial was because of the systematic
17:00way that we identified and stratified.
17:03Youth and. It identified.
17:09I'm using a two faced ratification
17:11process an it's it's again.
17:13This is more than I want
17:15people to get to get into,
17:17but I do think an important
17:20part of an effectiveness trial
17:21is being able to identify and
17:23make sure you've stratifying the
17:25youth so you know which module,
17:28which dose which sequence to be giving.
17:30That,
17:31I believe was a big reason for the success
17:34of this because the data were actually
17:36really very very good, but Mau was.
17:39With management as usual,
17:41MMM is mind my mind and this this
17:43strength and difficulty question here.
17:46This is the main go to measure in child
17:49psychology and psychiatry in Europe.
17:51We don't use it as much in the states,
17:54but it is the go to measures
17:57in Europe and so sure enough we
18:00found that the the the people got
18:03getting the evidence based modules.
18:06Significantly improved overtime,
18:08including over the 26 follow up
18:11compared to the control condition.
18:15And this Additionally.
18:19The teachers confirm this.
18:21The children confirmed this with the
18:23with their versions of the SDQ and there
18:25were no adverse effects and currently
18:28we're doing a cost effectiveness study
18:30Anwyl doing long term follow up.
18:34So let me pause here for now with
18:36the clinical takeaways that there
18:38is international consensus and
18:40phenotyping pediatric anxiety disorders,
18:42child and parent rating scales are
18:44generally good and excellent across
18:47a wide range of cycle metrics.
18:49CBT is efficacious about 60% limit,
18:51but we do need to enhance,
18:53and that's what we'll be talking about.
18:56They were predictors of poor CBT outcome,
18:58which is severe anxiety,
19:00especially adolescence.
19:00Social anxiety,
19:01an we can successfully disseminate
19:03CBT for anxiety in and,
19:05and this has been shown
19:06through effectiveness trials.
19:08So this so far I've been giving
19:10some good news, I think.
19:12But now I think I need to pause
19:15for some bad news,
19:16and this is the bad news in 2000.
19:19Three Amando Pena was a graduate
19:21student at the time.
19:23He's now an associate professor
19:24at Arizona State,
19:25and this is a paper where we
19:27did this paper and you can see
19:30this table from this paper,
19:31and this was looking at the proportion
19:34of Hispanic Latinos in anxiety trials.
19:36And if you look at this list in 2003,
19:38you see a Nah,
19:40Nah Nah Nah tool is percent tooth
19:42done and then you see a 37% and 46%
19:45in the rest of none and those 237 and
19:4846 were actually two of our trials.
19:51Those in 2003 and 2021 in
19:53this review that came out,
19:55which I'll actually be talking about again.
19:58Three out of 11 CBT plus pound studies.
20:01So this was no longer CBT.
20:03This CBT plus parent,
20:04but still three out of 11 did not
20:07report ethno racial composition.
20:09One study did not report specific
20:11so this is that this is all
20:13groups and actress Hispanics.
20:15Most studies reported less than 10%.
20:18With the exception of one study,
20:20and in this case,
20:21since this was a CBT plus payment,
20:24they sight out of 2009 and I I guess
20:27I need to say I didn't tell you this
20:30after Albany everyone to Miami.
20:32So this is these with Miami samples.
20:35And so this explains the very nice
20:37representation we had of Hispanics,
20:39but it's it's.
20:40It's like not OK frankly that in 2021 our
20:44participation rates of other groups is is.
20:47You know abysmal and it's not acceptable,
20:49and I'm hoping it.
20:50While I'm here and this is
20:52actually a large reason why I I do
20:55continue my collaborations,
20:56this the attention training study that
20:58I'll talk about is a two side study
21:01that it still includes my affiliation.
21:03When I was in Miami because it's,
21:06you know,
21:06it's it's an important part of our
21:09work to try to undo to get these
21:11samples and understand how our
21:13treatments work with diverse samples.
21:18OK, so now parents, how do we involve
21:21parents to improve CBT outcomes?
21:23Look 12 to 14 sessions.
21:25Two is to have almost 60% improving.
21:28That's really, really good.
21:29But you know we need to do better.
21:33The durability needs to be better.
21:35Wingan parents certainly make a
21:37great deal of sense to how to try
21:41to think about their role can be.
21:43Now, Interestingly,
21:44I told you 94 Kendall did the
21:46first individual study in 99.
21:48We did the first group and
21:51the group CBT study in 1996.
21:53In the bottom you see the Barrett study,
21:56the first parent plus CBT versus CBT
21:59study was done only in night was done
22:02around the same time that we did hours 1996.
22:06But I I share that with you
22:08because in 1996 Bill Katinas,
22:09my friend and collaborator for
22:11my 22 years when I was in Miami,
22:14we wrote this book for clinicians
22:15and it was called anxiety and phobic
22:18disorders of pragmatic approach.
22:19And we and what we did there in that book.
22:23We laid out what and we will kind of
22:25making this up because the you know
22:28nobody had been doing anything with
22:30parents yet at the time and we came up
22:33with this idea of the protection trap.
22:35We have a few.
22:36You know,
22:37like maybe half a chapter on
22:39the protection trap and we talk
22:41about how children of vote with
22:43anxiety avoid they show distress.
22:45The parents then behave.
22:46By maintaining this.
22:47They might say you don't want
22:49to go to school.
22:50You don't need to go to school,
22:52you can stay home.
22:53This brings about relief and
22:55it's a child feels protected.
22:57The parents felt protects good that
22:59they're protecting their child and it.
23:00And then it's continued to be a cycle.
23:03It's a protection trap.
23:04It's a negative reinforcement trap,
23:06and that's I.
23:07Is a model that continues to,
23:09you know,
23:09be used a lot and it's really
23:11holds clinically a great deal
23:13and and we actually then talked
23:15about the treatment implications.
23:17We talked about it in that book and
23:19we also talked about it in chapters
23:21and we also wrote this article theory
23:24and trial psychosocial treatment research.
23:27Have it or had a pragmatic alternative
23:29and we called it a pragmatic
23:31because we would take away is look.
23:33There are many ways you probably
23:36can work with children.
23:37And we can.
23:38And we called it a transfer of control model.
23:42I actually prefer to call it
23:44more generalization model now,
23:45but but the idea was that if you
23:47are an evidence based clinician,
23:49you know what treatments you know,
23:51what the you know.
23:53What are the procedures and the
23:55methods that have the strongest
23:56evidence and your job as a clinician
23:59is to generalize this to children,
24:01generalize this information
24:02and knowledge to parents,
24:04and then there are different
24:05ways you can do it and this.
24:08Clinical trial in 1999 was a
24:10dismantling trial because we basically
24:11dismantled the transfer of control.
24:13If you see the full transfer of control
24:16that's working, therapist to parents,
24:18the children and the therapist is
24:21still with the child so you do CBT
24:23and you do some work with parents.
24:25And that's what most of what we do.
24:28That's the full transfer of control in
24:30this particular trial, though we actually.
24:33Dismantled and we did mainly Trump exposure,
24:36is exposure is the main procedure
24:38for producing.
24:39But this is a phobia study,
24:41particularly with phobias.
24:43And then we also trained parents.
24:45In the other arm pound reinforcement
24:47training in in the article,
24:49we called the Contingency Management,
24:50but we compared these two models that
24:53the results are not as important as the
24:55model because I'm going to put this.
24:57But this is the way we think
24:59about working with children,
25:01children and parents.
25:01Just how you work with parents.
25:03But in terms of the results.
25:07We actually found that with phobias.
25:09This is a behavior observation
25:11that all the children in all the
25:13in both of arms showed improvement.
25:15There were no significant differences,
25:17which is kind of not,
25:19which is sort of what we kind of.
25:21Frankly, we're really.
25:22We're really more interested in seeing
25:24clinically and theoretically of this model.
25:26Hope you can work, and we found that yeah,
25:29you could work with both of these.
25:32You can do these.
25:33This type of approach and what
25:35I found really interesting,
25:36actually, is that was in 1999.
25:39In 2014 and I did contribute data to
25:42this data after this meta analysis,
25:45disciplinary men analysis as you
25:46see it is a long list of anxiety
25:50researchers who contributed data.
25:52But what's really interesting in
25:54this meta analysis was that they.
25:57They said that.
26:00The conclusion is they,
26:01like they looked at all the different
26:03ways parents researchers are using
26:05parents and they actually came up with hey,
26:08the way that most people are
26:10working with parents.
26:11They're actually doing
26:12contingency management,
26:13so let's call it reinforcement training.
26:15Although they also called it when I
26:17called in my article continues to
26:19management or a full transfer of control,
26:21and they found that CBT for
26:23entries children is efficacious,
26:25with or without and without
26:26pound involvement.
26:27But if you want to look up a durability.
26:30Some form of parent involvement.
26:33Probably with some kind of reinforcement
26:36training and some type of strong parent
26:40transfer is the strongest evidence,
26:42so I I found that kind of reaffirming,
26:46frankly to see that however.
26:49It still doesn't tell us what are the
26:52specific so specific is so important.
26:54It's in red on my slide.
26:56What are the specific payment
26:58mechanisms that ought to be contained
27:01in a transfer of control approach?
27:03Which is they figure that you see the
27:05therapist to pound the child and the
27:07therapist child two enhanced CBT alone.
27:09What is what should be done
27:11and you might say why?
27:12What's hard about that?
27:13Of course it's going to be X so it's close.
27:16It's going to be why,
27:17but actually this table I I made up
27:20this table but it comes I didn't make
27:22it up but it comes from looking at all
27:24the literatures or the meta analysis.
27:26These are all the different mechanisms
27:29that people have looked at and
27:31have targeted in their treatment
27:33and you could look at the list.
27:35An I'm calling it mechanisms
27:36in my presentation.
27:37An eye image calls it targets.
27:39If you're a statistician,
27:41you call it mediators,
27:42and I actually I often call
27:44it mediators as well.
27:45If your clinician,
27:46you might call a component,
27:48but the bottom line is in a
27:50course these studies that mainly
27:51they're vaguely defined often,
27:53they're often compounded together,
27:54so somebody might say, oh,
27:56I'm, I'm doing acceptance.
27:57In fact, actually,
27:58let me give the example I've done.
28:01I said,
28:01oh I'm going to improve the
28:03parent child relationship.
28:04But then what I actually did was I
28:07had a couple of things in there.
28:10It was a mish mosh so these are lessons
28:12learned but people continue to do that.
28:14It's a big conundrum for researcher
28:16'cause you don't know well as I show it.
28:18What do you do?
28:19What do you study?
28:21How do you operationalize it?
28:22And clinically,
28:22clinicians really don't know,
28:24like, what do I do with the pants?
28:26It still is a big conundrum,
28:27but I also want to say
28:30it's not just the research.
28:32It is difficult and challenging
28:34in specially in 12 to 14
28:36sessions to think that we can.
28:41You know, adequately, fully durably,
28:43change payment behavior in a very
28:45complicated dynamic between an
28:47anxious child and the parents.
28:48This is very, very challenging.
28:50It goes beyond the research.
28:52It goes beyond, you know,
28:54the challenges of the of the dynamics
28:57that have existing in these families.
29:00To make this more concrete,
29:02let me just stop for a moment,
29:04and for those of you,
29:05this is the dilemma.
29:06Is like 1/2 budget.
29:07It's like this when you want
29:09to make a hot fudge sundae.
29:11You know you need the ice cream,
29:13so if you want to do CBT plus parents,
29:15you know you need the CBT which
29:17is the ice cream.
29:19But the problem is with CBT plus pounds
29:21we don't know what the hot fudge is.
29:23You know, and some people have
29:25identified some of the hot fudge,
29:27but some people think it's the
29:29cherry in that Remy is actually a
29:31very small part of the variance to
29:33a hot fudge sundae and a whip cream
29:35is more important than the cherry,
29:37but it's still not as much of
29:39the variance is the hot fudge.
29:40And then you even have some possibilities,
29:42which I think is the case that you
29:45certainly don't want to put salami
29:46or Pickles in your hot fudge sundae.
29:48And some of those payment components in
29:51some ways could be an analog to this,
29:53so the dilemma were faces.
29:54What is going to?
29:56Account for some as much variance
29:58can contribute as much as we can to
30:00enhancing CBT. What is the hot fudge?
30:05Now I came in 2013,
30:06but my when I was interviewed for my.
30:10Well,
30:11this was slide was from my 2011
30:13Yelp presentation.
30:14Although I didn't say for my
30:16Yelp presentation 2011,
30:18but the rest of it was.
30:20This is what I said in 2011.
30:22No supportive evidence for enhanced effects.
30:25Is an the studies measure anxiety
30:28outcome only and it's rare to even even
30:31though people are interested in panels,
30:33people don't even include payment measures.
30:36That's for 2011.
30:382021 that's a man made and Elton and
30:40study I gave you when I look when I
30:43came across this paper and this is
30:45either aging myself or show up well.
30:48I'm sure it's aging myself,
30:49but it's also when I saw it.
30:51I just said man 10 years after
30:53this is deja vu all over again.
30:55So I'm a rock person.
30:57So this is the album continues
30:59after and this is Cosby.
31:00Stills Nash and young deja
31:02Vu because in 2021.
31:04The words correspond with the figures.
31:07This is a direct quote.
31:09CBT and parents did not confer
31:11advantage over individual CBT.
31:13Only six of,
31:14so that's what the first figures are.
31:17The figures at the bottom,
31:19the standard elite defense means
31:21that's the second correspond
31:23to the second bullet.
31:24Only 6 of 11 trials even included a
31:27parent and family measure at pre and post,
31:31not even a follow up post and when measured.
31:35No significant differences found.
31:36So even when you try to
31:39target something,
31:40it didn't make a difference.
31:42The parent measures didn't even change,
31:44and nobody even looked at.
31:45Whether not it is so.
31:47It matters if they if they
31:49change those outcomes.
31:50But they even serve any type of
31:52mechanism or mediational role.
31:54And the only study of the six at
31:56the bottom was hours in 2009.
32:07So if we could just do
32:09our science with cartoons.
32:11Things would be so easy because
32:13these two cartoons are basically
32:15going to summarize now.
32:17What three clinical trials?
32:19So over 15 years of clinical trials research
32:24has taught me and I hope the field.
32:27And the first one is they act like
32:30they own me and this is a depiction
32:32of what I will show is what I'm
32:35beginning to think is one of the most
32:38important payment mechanism which
32:39is payment psychological control.
32:40The one at the bottom is that negative
32:43reinforcement trap that I talked about.
32:45It's the protection trap. This is great.
32:47I'll have to wake up crying in the
32:49middle of the night more often.
32:51OK, so these are.
32:53That was almost.
32:57So I'm going to show you now quickly,
33:00quickly, but you know that
33:01is relatively quickly.
33:02I'm going to go through three trials
33:05that we did and one to the numbers in.
33:08The parentheses showed the trials
33:10and they showed the hypothesis.
33:12So there are three trials.
33:13So the uh, so for example,
33:16the first one is in the first two trials.
33:19If we try to target and improve
33:21parent child relationship,
33:22that will be associated with pediatric
33:25anxiety with suction and the.
33:263rd, the second one is site control
33:28and we targeted that in three
33:30trials with the hypothesis that if
33:32we reduce psychological control
33:34it with the associated pediatric,
33:36and this was a full transfer
33:38of control model in our work,
33:40the therapist worked with the
33:42parents and the children we did CBT,
33:44but we also did some type of these
33:46types of approaches with the pants.
33:51Clinically step back clinically,
33:53because and I'm sorry I want to go back
33:56so you see the astrex by this site
33:58control in the negative reinforcement.
34:01So across these three trials,
34:02this is the cartoon.
34:04Again, these are the mechanisms
34:06and the mediators that I'm.
34:09You know, feeling more and more comfortable
34:12is where we need to put our resources into.
34:16So clinically. Of course, the free trials.
34:19How did we do that?
34:20Well, we work with the kids and
34:22the parents and we would have
34:23them make a list with together.
34:25How does how does the pan and get too
34:27much involved with my child and how
34:29do I let my child do it on their own?
34:32And you can see there.
34:34Some examples.
34:37Like the third one is a specific
34:39field example show my diploma,
34:40but you know a lot of the parents would
34:42say that the kids stop acting like a baby.
34:44Or why can't you be more like your
34:46little brother?
34:47So we would, you know,
34:48talk to them about.
34:49Well, I can tell my child I'm confident
34:51they can handle it in their own,
34:52so this would be ways we would target
34:55this reduction of site control.
34:56In terms of negative reinforcement,
34:58which we which remember,
34:59I did this in 1999,
35:00but we did it again in our third
35:02trial more systematically,
35:04and this is how we would do it.
35:06There we give you know how does
35:08my child try to stay away.
35:10Trial tries is the cartoon,
35:11my child twice about his parents
35:13room at night to sleep with them?
35:15But what can the mom do?
35:17Do not allow the child to sleep
35:19with the pounds at night?
35:22And you can look there first.
35:24Some other examples.
35:31So sweet dismantling files an in 5 minutes,
35:34but this is basically this is
35:36what they all had in common.
35:39They were clinic referred participants.
35:43Randomize the majority of
35:44the participants on mothers,
35:45as mothers are the ones who are more likely
35:49to bring their children in for the treatment.
35:53In the children and the
35:54parents were seen together.
35:55As I said, it was a full transfer of control.
35:59We did CBT with the children,
36:00but we also worked on these parenting
36:03components which you'll see in.
36:04I'll be clear in the next few slides.
36:06So in trial one we compared CBT
36:08and parents with CBT and because
36:10things weren't the way we hoped,
36:12we said you know in the second trial
36:14we said you know let's not have any
36:17parents involved in the second trial.
36:19Let's just do group content behavior therapy.
36:21I also really love coupons
36:23if behavior therapy,
36:24as it was one of my.
36:26Earlier trials an and
36:27let's just do that and and.
36:29It's also the first time CBT plus
36:32pounds has even been compared to GCBT,
36:34so let's compare that.
36:36And then the third trial
36:38is what I call a deer,
36:40dismantling trials where we compared
36:42to CBT's and parents versus CBT and
36:45what's important in all of these
36:47trials is we measured the hypothesize
36:49payment mechanism in all the arms.
36:52So even in CPT we measured
36:54the parent variables with.
36:55Remember that 2021 I said
36:57six trials only has done it.
37:00So we made a point.
37:01I mean,
37:02if you're going to study payment mechanisms,
37:05you need to measure payment valuables.
37:07And as part of your assessment.
37:09So we did that.
37:10And this was the assessment schedule.
37:14At least for today's presentation,
37:15we actually have more data
37:17than that we collected.
37:19Now these analysis and these
37:21models get really complicated,
37:22and so this is a depiction of one of
37:25the models in one of our articles.
37:28And clearly I'm not going to present
37:31the results today with these SCM models.
37:33So for today's presentations I'm
37:35going to present simple means,
37:37but I do want to just let a
37:40shout out to call it Mount.
37:42It was my who is here and yell with me.
37:46But was we?
37:47She trained with me at FIU and Jasmine.
37:50Also, at a trainee of mine
37:52at FIU who sold now it,
37:54if I you running the attention
37:56training study there with a colleague
37:59and Jim jacket is my friend and
38:01who I've known since my old many
38:03days and he was with me in Albany.
38:05And if I,
38:07you and now at NYU and I share this
38:09with you because like I I actually
38:12love SCM modeling because it makes us
38:15as a team said, think about the park,
38:17the proximal mechanism,
38:18the distal, the moderate Ersan.
38:20Really try to.
38:21Think about them in a very thoughtful way,
38:24and then the SCM modeling just
38:26becomes a template from the
38:27conceptual model that we worked on.
38:30So I really love this and the
38:32reason I also want to emphasize
38:34the last point is also important.
38:36Most treatment studies,
38:37if they even have a mediator or mechanism,
38:40they have one media,
38:41one mechanism you will see how
38:43we have multiple mediators,
38:45which makes things even more complicated,
38:47which I can't even go there about how
38:50the media does affect the mediators.
38:52But I think the point is that you know,
38:56we really try to have a a picture
38:59that fits clinically and that
39:01has practical implications for
39:04clinical translation.
39:08So the first two trials.
39:11I also I also say when we
39:13have those multiple mediators,
39:15our requires large sample sizes so
39:17you will see our across all three
39:19trials for a single site study out of
39:22sample sizes are quite nice and give
39:25us sufficient power to look at these
39:27mediation and moderating variables.
39:29So in the first trial we did when
39:31I told you CBT plus payments and
39:34then the second one was compared
39:36to the group the group.
39:39Don't pay attention, even though
39:40it's so interesting and I love it,
39:43but I don't have time to talk about the
39:46mechanisms of group CBT, but we are.
39:48I think it's fascinating,
39:50so that's for another time, another place.
39:52Because today I'm focusing on the
39:55CBT plus parents and what I mainly
39:57want to show you is that in both
40:00of these trials we found that site
40:02control in both of these trials
40:04was associated with a change in the
40:07anxiety outcome and an and it actually.
40:09You know hasn't been shown before.
40:11Obviously you saw from my set up here,
40:13so this was nice to see this in
40:17two different trials.
40:18But what we also found an not
40:22surprising what I showed you before.
40:25Both interventions were
40:26similarly efficacious.
40:27There were no significant differences.
40:28It's great that you can improve,
40:30but we were hoping to enhance
40:32and we didn't enhance.
40:34And this is this came through
40:35not just with the rating scales,
40:38but with the other measures.
40:41So this was a pretty robust pattern,
40:43but it fits what I showed you.
40:47So what we learned except
40:49bullet one we didn't learn.
40:50We already knew this anxiety significantly
40:52reduce in CBT and CBT and parents.
40:55But there are no significant differences.
40:57Anxiety is suddenly reduced
40:58and this was a first.
41:00This was a first 'cause nobody
41:02would ever compared parents
41:03with CPT and pans in the group.
41:05It was nice to know that both are reducing
41:09anxiety and you could do both of them,
41:11they're interchangeable.
41:13And but we also found and this is the
41:16important thing here that changes
41:18in pain control were associated
41:19with changes in pediatric anxiety.
41:22It does suggest that maybe of all
41:24those mechanisms, Pam inside control.
41:25But this is this idea that if you
41:28are reducing site controlled of the
41:30parents enhancing child autonomy,
41:32it will encourage the trial to
41:34be more likely to do the things
41:36they need to do in anxiety.
41:38That's the clinical way to
41:40think about why side control.
41:42If you are a parent telling you kid you know.
41:45This, you know, don't be a baby.
41:47That's not going to give the
41:49child a feeling of autonomy or
41:51granting autonomy so clinically.
41:53It certainly makes a lot of
41:55sense and fits with you.
41:57Know,
41:57many theories of side control
41:59dating back to the 1970s,
42:01so.
42:07In the third trial.
42:09Though you know I wanted to go deeper,
42:12and so we dismantled.
42:14We dismantled CBT plus parents which
42:18had never been done because what do you
42:21need to do in CBT plus parents an I
42:25because of my 1999 trial reinforcement
42:27the important of the protection
42:29trap we dismantled CBT plus parents.
42:32But we also dismantled CBT plus Pam and
42:35Reinforcement where we trained parents
42:38to increase their positive reinforcement,
42:40decrease negative reinforcement the
42:42comparator the CBT and here we.
42:45I wasn't giving up on the relationship,
42:47but I told you I thought we were
42:49doing too much junk in that.
42:51I mean, I should say junk,
42:53but I thought why isn't this working?
42:55How could this not so this time we
42:58dismantled it more carefully and we made
43:00it more careful of really distilled
43:03site control an we improved acceptance like?
43:06I'm not going to have a slide on that,
43:09but since it hasn't been working,
43:11I'm not.
43:12I don't have the slide on that because
43:14what we found here as a meat as
43:17mechanism doesn't associated with change.
43:19The decrease in negative reinforcement
43:21was associated with anxiety in production
43:24and again side control decrease was
43:26associated with child anxiety improvement.
43:28And what if I was there in the room?
43:32You'd see me like jumping and
43:34being happy because I'm very,
43:36very happy about these findings.
43:38It's actually it will be published
43:40any day now.
43:41And kind of this also in
43:44clinical psychological science,
43:45the name of the articles is
43:47training parents and reinforcement
43:49skills or relationships.
43:50Trip skills enhance individual use.
43:52CBT for anxiety outcome
43:53specificity and mediation.
43:55And you don't.
43:56I don't know anybody who puts
43:58the title of an article.
44:00If the answer is no,
44:02so the an we were this we've showed
44:05here that both of these very
44:08distilled concrete CPT plus parents
44:10across the measures were showing
44:12to be significantly enhancing CBT.
44:15This is also true in our
44:18diagnostic recovery rates.
44:19So this is the,
44:21you know something very exciting.
44:23Frankly,
44:23at least for people who are trying to
44:27figure out what to do with parents.
44:30Even more exciting is this.
44:32The first time we showed that if you
44:35do this in a really concrete way,
44:38you can actually show that what you talk it,
44:41it changed an and that it so when we
44:44worked with reducing negative reinforcement.
44:48Our parents told us that yes,
44:50it was reduced in individual CPT.
44:52We didn't train it, but past studies.
44:54Usually anything.
44:55Nothing changes.
44:56So and this was true also in
44:58the control scale.
44:59So we were happy about this too.
45:04So right now what we've learned
45:07so far from these three trials
45:09is if we do two carefully, very.
45:41Very qualitative methods with
45:42families and fair therapists,
45:44and we're going to try to develop
45:46something so it's always with them.
45:49A way of getting parents to always
45:51use these kinds of methods.
45:53And what do you do when you're
45:56stuck with the idea of we can
45:58maybe get more stronger effects?
46:00More durable effects if we can
46:02really make this more, you know,
46:05part of people's everyday lives.
46:07And so with you know,
46:08these are the steps that involved
46:11the participatory methods.
46:12The proof of concept.
46:13Then get some plima Neri effects,
46:15and then of course the next step is
46:17a step which is the big challenges
46:20to augmented and dismantle it and
46:22see you know it really improves.
46:26Really quickly, because some of you
46:29may be familiar with Eli Lebowitz,
46:32my my collaborator and at the Anxiety
46:35program and he has developed a very
46:39innovative intervention and it's a
46:41transfer of control therapist dependent.
46:44No child, no children at all involved,
46:47and I'm just taking this little
46:49detour to mention it because I'm.
46:52You know he we showed that it has.
46:55We compare this to CBT.
46:57His program is called Space Supportive
47:00Parenting for anxious childhood emotions
47:03and what we found was that both.
47:06Interventions using a non inferiority trial,
47:08both produced in equivalent affect,
47:10so this was very this is Eli scale.
47:13What I I should mention when I came
47:16I know he put together this K award
47:19now and this is we now have a nice
47:2361 or 33 and Hillary is Hillary.
47:26Bloomberg is a call investigator
47:28on this along with me and Ellen G
47:31at over in psychology is the copii
47:34with Eli on this and we are now
47:37studying CPT versus parenting.
47:38We're looking at if these findings
47:40replicate and we're also looking
47:42at the brain mechanism underlying
47:43these two interventions because
47:45it's kind of interesting.
47:46This one is just with child when
47:49it's just the parents and looking
47:51at how the change the child's brain
47:53may be impacted by this and then
47:55the next thing after we hopefully
47:57replicate these findings,
47:58that space is as efficacious as CBT.
48:01The next thing, of course,
48:02will be to try to think about
48:05augmenting space with CBT,
48:06or or maybe even dismantling it,
48:08but.
48:08This is the first stage an I
48:10think it's really exciting work
48:12because it's only with parents.
48:14No child work at all.
48:19OK, so that's the work I do.
48:22Want to spend a little time also
48:25talking about the other area
48:27that we're trying to augment CBT,
48:30and that's with attention.
48:31Retraining if you're prone to anxiety.
48:34If you look at that stimulus on your screen,
48:37your attention will go
48:39talk that threatening face.
48:41This is what that first bullet says.
48:44Anxious children, adolescents,
48:45and adults so significantly greater
48:47attention capture to threatening stimuli.
48:49And this has been associated with
48:52friends to amygdala dysfunction.
48:53The translation clinically is trained.
48:55The brain, you know,
48:57use it implicit learning procedures
48:59to modify that attention capture.
49:01That's why it's been called attention
49:04bias modification training.
49:06And there's evidence for that an I
49:09encourage Lazzaro for Yair behind
49:11did excellent with you in the
49:13recent biological psychiatry that
49:15was devoted to pediatric anxiety.
49:17All the articles were fabulous,
49:19I thought,
49:20and your ears meta analysis showed
49:23medium effect sizes in child trials,
49:25and he also talks about the biological
49:29underpinnings for attention training.
49:31So more specifically,
49:32and here are my colleagues.
49:34Actually,
49:35your ear is a collaborator and
49:37Annie Pine at NIH is a collaborator,
49:39and Jeremy Pettit at FIU is another
49:42collaborator.
49:42And basically here's this child
49:45sits in front of the computer.
49:48And she's shown this Lee stimuli and
49:50basically the plus sign is always
49:53placed in the experimental condition
49:55the what's called the attention bias
49:58condition modification condition.
49:59It's always plus by the neutral
50:02100% of the trial and it there
50:05really quick milliseconds.
50:06So basically.
50:07And she's told whenever you see that
50:10plus sign plus press your mouse
50:12so that implicitly training the
50:14brain to look at that neutral face,
50:17the control condition.
50:18Is it appears randomly it's not anywhere,
50:21but there's still attention and it's funny.
50:23It's called an attention control
50:24condition because it's as you
50:26will hear in a moment.
50:27But I'm just going to say it now.
50:30Attention control condition is actually
50:32probably in attention control condition.
50:34Because you are controlling your attention,
50:37so you'll see in a moment
50:39why that's important.
50:40And the nice thing about this,
50:42it's really short and sweet.
50:448 sessions over 4 weeks,
50:4620 minutes and 160 trials each session.
50:48I mean super fast.
50:51So if requires little effort and motivation,
50:54little need for a therapist to be involved.
50:57It's computer base and kids you
50:59know into computers and it's more
51:01accessible in CBT and on medication.
51:05So given what I just said,
51:07we actually did an open trial on this just
51:10to see if how it would work in a stepped care
51:13approach and and a cost effectiveness trial.
51:16So here we gave all kids coming to
51:18the clinic and this is this.
51:20Is the clinic actually in Miami and 124
51:23kids came through and they got four weeks.
51:26Just what I told you of attention,
51:28retraining and after the full weeks
51:30we said to them into open trial.
51:32We said do you want to
51:34continue and not to continue?
51:3660% said I'm good,
51:37I don't need anymore and we assess them,
51:39assess them thoroughly with the
51:41methods I gave you in the beginning.
51:4379% were improved and they were done.
51:46Both, but 45 kids.
51:47Of these 120 of the initial said no.
51:50Actually I want CBT so they found
51:53to be 91% much improved or very
51:56much improved after Step 2 where
51:58we also had a health economist
52:01working on these papers with us and
52:03you could see there that if these
52:06kids had just gotten full CBT,
52:08they didn't get the step care.
52:10They took out full CBT.
52:13It would have been 13 hours when they did
52:17it in the way we did it in the study,
52:20it took 6.7 hours,
52:21so it's almost a 50% reduction in
52:24time and then also computed was
52:26if they got the full CPT it would
52:29have been almost 800 bucks here
52:31with the step care it cost 433 so
52:33it was a 50% overall cost savings.
52:35This is important information because I do.
52:39In another thing I hope to do is
52:41after we do the next trial with
52:43their crony doing I I really do
52:45want to do an effectiveness trial
52:47similar to what we did in Denmark
52:49using the same type of approach in
52:51identifying and stratifying the kids.
52:52So this is really important
52:54information whenever you want to
52:56do an effectiveness trial to show
52:57that you got these kind of data.
53:03The other thing that we did that was
53:06very interesting is I told you that
53:09about 60% of kids will improve with CBT,
53:11but you got about, you know 40% that might.
53:14So you saw the large ends that we had
53:18those launch ends, and so we actually
53:20wrote a grant and all 34 and an an.
53:23We said, you know we're going to have
53:27we're running these launch trials
53:29with looking at CBT and parents.
53:32We're going to have a bunch of
53:34kids who are going to need help.
53:37How quit letting us see if we
53:39can do this attention,
53:41retraining and see if this works.
53:43And sure enough, we did it and we found.
53:46So these are kids at post and
53:48follow up who still met diagnosis.
53:51After they got a full course of CBT an
53:54we then did the attention retraining,
53:57you know those four weeks and we
53:59found that all these kids and it's 64.
54:02But keep in mind these we don't
54:05want a million kids 'cause these
54:07are kids who were in our trial,
54:10so we don't want to have too
54:12many failed kids but these failed
54:14CBT kids or CBT resistant,
54:1650% recovered at the post and
54:1858% of follow up and there were
54:22significant differences.
54:23In
54:26anxiety. But there were no significant
54:31difference. But this is the rub.
54:33The rub is whether they were in the attention
54:36bias condition or the attention control.
54:38The control control kids
54:40improved across the board.
54:41We didn't expect this,
54:43but this is becoming more of a finding
54:46now and I don't have time unfortunately.
54:48But down below you see another
54:51little eyes and say a little,
54:53but we did another trial.
54:55This is actually Marielen
54:57net ski over Tel Aviv.
54:59Supervised by your ear,
55:01and this was also publishing
55:03clinical psych science webdrive
55:05symptom reduction in attention,
55:07bias, modification, treatment,
55:09vandalized, controlled experiment.
55:10And this study is supporting the suggestion
55:14that both the kids are getting better.
55:17In both of these arms,
55:20and some suggestion that it may
55:22not be the training an bias,
55:25the modification bias,
55:26but the training and attention control,
55:29helping kids to better
55:31modulate their attention,
55:32we now have with FIU and ongoing.
55:35Now I don't even I don't even call it
55:38attention bias modification training anymore.
55:41Now we'll just call it attention be training.
55:45It's an efficacy confirmatory trial.
55:48We have an alternative competitor
55:50we have because it's with Miami.
55:52We've launched diverse samples
55:54and we're in this study.
55:56We are collecting the stressful
55:59speech task we're collecting,
56:01e.g an we're collecting eye
56:03tracking an we Viper for color.
56:05Would we got a supplement to obtain
56:08data on healthy controls who will not
56:12receive the treatment but they will
56:14participate in all the assessments.
56:17Just so we could see what is the
56:20natural cost of these measures?
56:22Without any treatment,
56:23so we also have that type of competitor,
56:26so this is ongoing and we're really
56:29actively recruiting participants.
56:31And remember, I told you at the beginning,
56:34adolescence,
56:34social anxiety they spawned poorest, the CPT.
56:37That's why we're focusing on adolescents.
56:41Young adolescents with social
56:42anxiety disorder.
56:43We are actively recruiting for
56:45this trial and actually also
56:47for the space and CBT trial fee,
56:49so please you know please now that you
56:52know what where we are and what we're doing.
56:55If you have possible referrals we
56:57would appreciate it a great deal.
57:00So attention retraining is efficient and
57:02cost effective in a step care approach.
57:05That's important dissemination data.
57:06Attentionally training is a viable
57:08argument for CBT resistant pediatric,
57:10and what awaits discovery is what's the
57:12mechanism underlying attention with training.
57:14Because it's I mean,
57:16I think most of us.
57:17I mean, it's kind of hard to believe,
57:20but I mean people go through it
57:23and the people say hey thanks,
57:25this was really helpful.
57:26So it's not just the data that's
57:29showing this, but the clinical.
57:30Thank you,
57:31so I'm really intrigued by this and
57:34I really am so excited to figure out
57:37what is the mechanism underlying this.
57:39So the takeaways for today as I wrap
57:42up now is anxiety assessment methods
57:44are good to excellent samples.
57:47Inadequately diverse CPT is efficacy
57:49and it can be disseminated in
57:52an effective way.
57:53But we need improvement in
57:55terms of how we can
57:57enhance. After these trials that I
58:00showed you, I'm feeling more and more
58:02comfortable and I think the theory
58:05that research is supporting this idea,
58:07that of all those ways that people work
58:10with parents with duesing parents side
58:13control and negative reinforcement,
58:15might be a way to enhance it.
58:17And if we can do it using the
58:20type of more potent method like
58:24to sell digital intervention.
58:26Trying I'm hopeful.
58:27Also we can maybe enhance CBT
58:29with via attention retraining,
58:31either with step Care, CPT,
58:33business sense and that efficacy.
58:35Trial that I talked about
58:37is getting at the mechanism.
58:42Now I didn't, not Stephanie,
58:4310 years from now, maybe not,
58:45I'm joking, but you know not next year.
58:48But I do have when putting this together.
58:51This presentation I had,
58:52these other dad there,
58:54but I just didn't have time because
58:56moderators are really important
58:58part of the story which treatments
59:00for home and so and we're working
59:02on and trying to delve into that.
59:04And that's important.
59:05We also have.
59:06I also have shared my data with
59:08other people which which has allowed.
59:11Large studies of looking at the rates of
59:13change because some of these interventions.
59:15It's not just enough what
59:17works and how does it work,
59:19but also like what's the speed
59:21in which they were?
59:22Can we have some interesting find?
59:24You know, some interesting stuff on that?
59:26I told you about group CBT which I love
59:29and I didn't get into shelling them.
59:31But I also think that's a really
59:33important way of improving and
59:35working with children with anxiety.
59:37We also have a paper under
59:39review now 'cause we also had a.
59:41Project where we did attentionally
59:44training with subclinical subthreshold
59:46anxiety and we actually the bottom
59:48line is we found that it's helpful
59:50for this population too and then
59:53the behavioral and biological neural
59:55targets and then the work that's
59:58ongoing is the two side study the
01:00:00space trial with with Allie and Dylan
01:00:03and Hillary an elion with a grant
01:00:06with a postdoc with doing failure to
01:00:09launch where we're doing parent work.
01:00:11With young adults,
01:00:12so getting parents not to do what
01:00:15they do with their little kids,
01:00:16which is to do a lot of negative
01:00:19reinforcement or when Eli refers to
01:00:22his accommodation with doing that with
01:00:24young adults and then the proof of concept.
01:00:27So I have too many people here on this
01:00:31slide to thank Elianne Colorado most
01:00:35important people of the anxiety team and.
01:00:39Marissa help has a astrex next to her
01:00:42name because she helped me with my slide.
01:00:45So and she's a postgraduate
01:00:47associate and I have too many people.
01:00:50But I have to give here at the
01:00:52psychiatry a big shout out to both.
01:00:55Hillary answer Vegeta,
01:00:56you know I love the work I'm doing
01:00:59with Vegeta on mindfulness with
01:01:01a different population,
01:01:02but I'm actually really hopeful that
01:01:04Vegeta and I can think about doing attention,
01:01:07retraining and mindfulness and
01:01:09how those two attentional.
01:01:10Interventions work,
01:01:11and with Hillary I learn all the
01:01:14time so much about the brain and
01:01:16the brain and the behavior.
01:01:18And it's just a really super super
01:01:21exciting collaboration an you know
01:01:23and I have to say. Full disclosure.
01:01:25Hello,
01:01:26Ian and Vegeta are both really have
01:01:29become really super close friends and
01:01:32I just really I'm so thankful for that.
01:01:35Speaking of friends,
01:01:36I know this is very,
01:01:38very unusual to do this in ground rounds,
01:01:42but it's also really unusual
01:01:44to do ground rounds on zoom and
01:01:47so during this past year,
01:01:48two among my collaborators passed away.
01:01:51The first is the young woman
01:01:53who was a young mother,
01:01:55and they have their names.
01:01:57Bethany Sutherland, who passed away
01:02:00after not covid related, but I you know,
01:02:03I do want to memorialize this to her.
01:02:06She was a Co investigator doing
01:02:08the EG work in the in the attention
01:02:11Training study and then Bill Katinas,
01:02:13who you heard me mention was my best
01:02:16friend and collaborated FIU and he did
01:02:19pass away covid related and so I don't cry.
01:02:22I'll just leave this line from
01:02:24Wicked Witches because I knew you.
01:02:26I've been changed for good but I
01:02:28also know that they wouldn't want me.
01:02:31Bill wouldn't want me to end,
01:02:33he would want me to keep doing my work.
01:02:37And he'd be very happy that the
01:02:39Flowers are out an my second
01:02:41grandson was born during Covid Levi,
01:02:43and I know he'd be happy.
01:02:45And Ann,
01:02:45I know people have also adopted dogs,
01:02:48so I just want to say,
01:02:50for those of you like me, have lost people.
01:02:53You know, I know.
01:02:54I share my condolences,
01:02:55but our life and our work goes on and I just
01:02:59want to thank you very much for today's.
01:03:02Opportunity to present my work to you.
01:03:04Thank you.
01:03:11They thank you
01:03:12so much. What a spectacular
01:03:14presentation of your life's work,
01:03:16and I think it embodies
01:03:18sort of a very systematic.
01:03:21And thoughtful and clinically
01:03:22astute way to investigate the
01:03:24most effective ways to intervene,
01:03:26an important clinical population.
01:03:28I think we could all learn from
01:03:31this in the areas that we work in.
01:03:34So thank you so much for sharing all
01:03:37of this with us. My pleasure.
01:03:39I hope it was helpful and
01:03:41interesting. Thank you.
01:03:44We doing questions.
01:03:46Yes, Wendy, that was fabulous.
01:03:48It was great. Thank you vegeta.
01:03:50Will you my friend,
01:03:51it was great, but you know I
01:03:53have not heard you talk about.
01:03:55You know all of your work in this way.
01:03:57And so it was just.
01:03:59It was fantastic to really
01:04:01see what an important body
01:04:02of work in your thinking and
01:04:04an and growth through.
01:04:05It was
01:04:06just fantastic. Thank you.
01:04:07It means a lot for me
01:04:09to hear that from you with you.
01:04:11Thank you, of course. I'm
01:04:12totally mean it at one thing
01:04:14that kept coming up in my mind.
01:04:16And I'm sure you've thought
01:04:18about this and that.
01:04:19Maybe you have data and didn't.
01:04:22Then is are the effects and so
01:04:25our work together on parenting.
01:04:27It was really helpful to see your
01:04:30development on on including parents.
01:04:34And So what kept coming up in
01:04:37my mind was parents often,
01:04:39and I'm sure you've seen this,
01:04:41and we've talked about
01:04:43it. Parents of children with anxiety
01:04:45have anxiety themselves. A lot
01:04:47of times, and the question I
01:04:50had was even just being parents
01:04:52in your child anxiety studies.
01:04:54Did you assess parents,
01:04:56anxiety changes and whether
01:04:57the the there was some of this
01:05:00transfer in reduction in anxiety
01:05:02for parents? That was occurring,
01:05:04'cause I would actually be
01:05:06really cool because even
01:05:07though the target was a child,
01:05:09the parent is learning new ways.
01:05:11You know, giving up control.
01:05:12For example when you had that
01:05:14piece in there and a piece
01:05:16about negative reinforcement.
01:05:17And so anyway wanted to do.
01:05:19Do you see my slides again? Yes.
01:05:23Maybe you said it and I'm not well,
01:05:25no, because it's you know,
01:05:26I thought a lot at you.
01:05:28I mean how I can't even keep track?
01:05:30How could you keep track?
01:05:31Look at this first trial.
01:05:33We targeted payment anxiety.
01:05:34Vegeta yeah OK we targeted payment
01:05:37anxiety an we've been and so
01:05:38let me stop sharing the screen.
01:05:40And so, and this is where this is.
01:05:43Before I knew as much as I
01:05:45knew now I mean to be honest,
01:05:47and this is part of this is that we
01:05:49were trying to do too much and this is
01:05:52too much to do with the parents OK?
01:05:55Plus the CBT,
01:05:56that's one thing I need to say.
01:05:58However, now I'm going to start my share.
01:06:00However, this is really interesting
01:06:02because we actually this is in.
01:06:04This is close to being published.
01:06:05We actually have looked at Pam and anxiety
01:06:08and what we're finding is first of all.
01:06:11It's really.
01:06:12It's also hard to change.
01:06:14That's number one, but even then,
01:06:16even in all the studies that
01:06:18we've been measuring it,
01:06:20we only tried to change it in that one study.
01:06:24It didn't change,
01:06:25but in all the other studies we've been
01:06:28measuring it what we have found is it
01:06:30has not been a direct associated mediator.
01:06:33The Child Anxiety reduction,
01:06:35however, what we have found
01:06:36is that the anxious parents,
01:06:38if you reduce their site,
01:06:40the site control is really related.
01:06:43And by reducing the site control and
01:06:45easing up on the parents I control,
01:06:48it's actually need leading to a
01:06:50change in the anxiety of the parents.
01:06:53And I mean,
01:06:55of course you know it's more
01:06:57complicated than that.
01:06:58But my point is that I think the
01:07:01mediational changes more from
01:07:03side control to anxiety then.
01:07:05But it's an empirical question,
01:07:07but you know,
01:07:08but I actually think that because
01:07:11we have never found parent
01:07:13anxiety to be the direct link,
01:07:15but only fruit control and
01:07:17then answer your question.
01:07:20Yes, absolutely.
01:07:20And it's so interesting, but you know what?
01:07:22It sort of makes sense when
01:07:24you think about it.
01:07:25The task because you know,
01:07:26as the parents are letting
01:07:28up and control the child,
01:07:29has more otonomy the parent and they're
01:07:31seeing the kid doing more than maybe
01:07:33the parents are getting less anxious.
01:07:35You know?
01:07:35I mean, because you know
01:07:37another whole part of my work,
01:07:38which you know about is,
01:07:39you know,
01:07:40one of those articles was called
01:07:43directionality of change.
01:07:44So you know the whole directionality issue
01:07:46is part of what I'm speaking about now,
01:07:49yeah?
01:07:50Very interesting because so it
01:07:52sounds like it's complicated
01:07:53and some components change,
01:07:55but really perhaps the parent
01:07:57has to be the target to have the
01:08:00more maximum. I mean, that's empirical,
01:08:02but you know exactly you have the
01:08:04maximum amount of of of change,
01:08:07and so that's an interesting and maybe
01:08:09through space exactly. Well, that's the
01:08:11exactly. That's probably why you know
01:08:14we have that new intervention with
01:08:16space and we'll see how that goes.
01:08:19Thank you, it's very interesting,
01:08:20but it's a really interesting question.
01:08:22Thank you for that.
01:08:33Wendy, this is Chris Pittenger.
01:08:34Thank you for a wonderful talk and such.
01:08:37It was great to see it all put together.
01:08:41Message I'm sorry I can't put
01:08:42your name up as a collaborator.
01:08:44It almost happened these days.
01:08:46Will work on that.
01:08:48It was sort of implicit.
01:08:49It's at least it seemed implicit to me in the
01:08:52way you were presenting that you're
01:08:53thinking of anxiety appropriately.
01:08:54So trans diagnostic construct.
01:08:55You know you're looking at
01:08:56these different populations,
01:08:57but the concepts and the structures
01:08:59that you're targeting are the same.
01:09:00Whether it's social anxiety or phobia,
01:09:02whatever. At least that was my.
01:09:04My impression is to the extent
01:09:06that that's true, I wonder.
01:09:08What you think about how these
01:09:10structures and targets of treatment
01:09:12generalize to other disorders that
01:09:13are characterized by prominent
01:09:14anxiety but also other things?
01:09:16And the two obvious ones that are
01:09:18occurring to me or anxious OC D and
01:09:21trauma associated anxiety where you
01:09:22have anxiety is a prominent source of
01:09:24clinical distress in a targeted treatment.
01:09:26But you also have something else.
01:09:29That that's going on, and so so.
01:09:31So what do you think?
01:09:32I mean, starting with this sort of the pure,
01:09:35the anxiety make makes a lot of sense,
01:09:37but I wonder about generalization of this
01:09:39structures to those adjacent conditions.
01:09:42Yeah, I mean it's a really great
01:09:44question and I and it hasn't been
01:09:47studied and it certainly is important.
01:09:49Thing to study I I guess my own so I don't.
01:09:52I think it's a really great question.
01:09:54I I will just throw out one thought
01:09:56though that I have and what I've learned
01:09:59frankly and actually I was in the first
01:10:01to say this Alan Kasten back in 99.
01:10:03You know mode about this but when I
01:10:05go back then I go well you know he
01:10:07always had such foresight because he
01:10:09actually said this and I've learned
01:10:11this in the work that I presented.
01:10:13You know that the mechanisms of an onset
01:10:15of a disorder is not necessarily the
01:10:17same mechanism in a treatment reduction.
01:10:19Approach.
01:10:20You know, and I see that now because
01:10:23you know Pam and anxiety clearly is
01:10:26involved in maintaining anxiety clearly,
01:10:28but whether or not that's the
01:10:31most proxamol mechanism.
01:10:32That's an empirical well.
01:10:34I've already shown empirically,
01:10:35it's it doesn't seem to be.
01:10:37It doesn't mean it's not
01:10:38important for maintenance,
01:10:39but whether or not you want to make that the
01:10:41proximal mechanism in your intervention.
01:10:43So I guess the back to you like
01:10:46I think it could make sense,
01:10:48but I I guess I'm just saying that
01:10:49even if those mechanisms are involved
01:10:51in the maintenance of those problems,
01:10:54it's an empirical question.
01:10:55Just like an anxiety.
01:10:56If they were maintained in the
01:10:58reduction in a treatment intervention.
01:11:01Thanks, thank you for the question.
01:11:03Yeah it makes me think we
01:11:04should be measuring under.
01:11:05We do measure depression and we do have
01:11:07the aidas and all the other treatments.
01:11:09So you know we certainly can
01:11:10look at that more carefully.
01:11:11But and also like yeah anyway, thank you.
01:11:15Thank you, thank you very much.
01:11:17Yeah thanks. Hi Randy, Andy
01:11:18Morgans. I thought I have a question for you.
01:11:21I really enjoyed the presentation. Thank you.
01:11:24I I wanted to ask you a little more
01:11:26about the thread attention bias you know,
01:11:29does it change from people who've
01:11:31gone through CBT because they know it
01:11:33is so quick that's the threshold of
01:11:35consciousness responding and I was just
01:11:37wondering if if you know anything about
01:11:40does it shift after people have done
01:11:42a course of Skippy? There's the attention.
01:11:45His attention by us, so the
01:11:47measuring of attention by so you
01:11:49know the reason why we got this R
01:11:5101 this to side R1 is because the
01:11:53measure of attention bias has been
01:11:55really crappy with this that probe
01:11:57and so you know it's not reliable.
01:11:59It's really not good,
01:12:00and so and so now we're doing the
01:12:03EG and we're doing the eye tracking.
01:12:05So I I honestly don't know
01:12:06the answer with children.
01:12:08I don't know if it's been done,
01:12:10it might be done with adults, but you know,
01:12:12I I'm sorry I don't know the answer.
01:12:15Do like a saver pal and I'll
01:12:17get back to you on that.
01:12:19You know, no sure.
01:12:20Yeah, I.
01:12:20I mean I I don't know off the top
01:12:22of my head if if attempt but I only
01:12:24can say that the measurement is bad.
01:12:27You know, you know that that pro indexes,
01:12:29yeah?
01:12:31Years programming yeah yeah,
01:12:32we use your ears and you know and yeah
01:12:33he is also like doing what we're doing.
01:12:36You know he does AEG and he does eye tracking
01:12:38and with Danny of course you know he.
01:12:40I mean we're involved with Danny and with
01:12:42Danny with doing it also with the imaging.
01:12:44Wonderful, I'll follow up with you that
01:12:46I will follow up with you. OK, thank
01:12:49you. Thank you, thank you.
01:12:59So I am sorry I had
01:13:02a question. Last question, do I have time?
01:13:06Yeah, this would be the last question,
01:13:08so thanks. So Doctor Silverman is there.
01:13:12Do you see this working is
01:13:14in a prevention model too.
01:13:18Yes. The absolutely,
01:13:20absolutely, absolutely.
01:13:21Especially since I told
01:13:22you we did the attention.
01:13:24Retraining was sub clinical
01:13:25subclinical I mean I said like I
01:13:27know my I you know I do really want
01:13:30to do an effectiveness trial with
01:13:32attention retraining and I wanted
01:13:33to set care and now I'm going
01:13:35to bring the jitter in to do the
01:13:38mindfulness part of it and Hillary
01:13:40to do the brain measurements.
01:13:42But that's I,
01:13:42I definitely think it's a step care step.
01:13:45CPK is sort of like a prevention
01:13:47approach to some extent.
01:13:49It can be conceptualized that way.
01:13:51Thank you. Application area.
01:13:56Great, well thank you so much and
01:13:59thanks to everyone for attending and
01:14:01traffic tarcan Wendy. I'm going to
01:14:03send you dates for four years from
01:14:06now so we should schedule it now.
01:14:08No no, no give me more than four years.
01:14:13What give me more employees?
01:14:17I I know I was flossing.
01:14:19Sure could call it that title,
01:14:21but I said what the heck,
01:14:23terrific well anyway.
01:14:23Thank you so much.
01:14:25Appreciate OK, thank.