Translating Basic Science on Child Maltreatment
into Optimized Prevention and Intervention Technologies
Chad Shenk, Ph.D.
Assistant Professor
Department of Human Development and Family Studies
Division of Child Abuse Pediatrics
The Network on Child Protection and Well-being
Overview
Concept of ‘Experimental Therapeutics’
Child maltreatment research as an example
Ways to optimize prevention and intervention
“No aphorism is more frequently repeated
in connection with field trials, than that we
must ask Nature few questions, or, ideally,
one question, at a time. The writer is
convinced that this view is wholly mistaken.”
- Sir Ronald Fisher
The Arrangement of Field Experiments, 1926
Experimental Therapeutics
Prevention and Intervention Science
Target
Engagement
Target
Validation
a
Treatment
vs.
Control
Change
in
Target
c
c’
Mechanism of Change
b
Outcome
of
Interest
Treatment vs. Control
TF-CBT
Trauma-Focused Cognitive-Behavior Therapy
Only well-established treatment
17 RCT’s to demonstrate efficacy
Efficacious for multiple outcomes
Multi-component intervention
Silverman et al (2008)
TF-CBT – Multiple Components
Cohen et al (2000)
1. Exposure
2. Cognitive Processing & Reframing
3. Stress Management
4. Parental Treatment
Cohen et al (2006)
1. Psychoeducation
2. Parenting Skills
3. Relaxation Skills
4. Affective Modulation Skills
5. Cognitive Coping and Processing Skills
6. Trauma Narrative
7. In-vivo Mastery
8. Conjoint Parent-Child Sessions
9. Enhancing Saftey & Future Development
TF-CBT – Multiple Components
k = 9 components each with 2 levels (-1, 1)
Outcome: PTSD (d = .50, 1-b = .80, a = .05)
– Individual experiments
• Number of conditions = 2k
• Number of subjects = (2k)N = 1152
– Additive or dismantling designs
• Number of conditions = k + 1
• Number of subjects = (k + 1)N = 640
Collins, Dziak & Li (2009)
– Full factorial
• Number of conditions = 2k
• Number of subjects = 128
(.25 subjects per trial) = 512
Target Identification
TF-CBT – Multiple Targets
Accurate
Appraisals
a
TF-CBT
b
c'
PTSD
Symptoms
TF-CBT – Multiple Targets
Acceptance
a1
Accurate
Appraisals
a2
a3
TF-CBT
b1
b2
Stress
Management
b3
PTSD
Symptoms
c'
a4
Effective
Parenting
a5
b4
b5
Affective
Modulation
TF-CBT – Multiple Targets
Acceptance
a1
Accurate
Appraisals
a2
a3
Exposure
b1
b2
Stress
Management
b3
PTSD
Symptoms
c'
a4
Effective
Parenting
a5
b4
b5
Affective
Modulation
TF-CBT
Wide variability in treatment response
Cohen’s d = .15-.50
Non-response rates as high as 41%
No focus on optimizing components, outcomes
No research on target identification
Silverman et al (2008); King et al (2000)
Optimizing Outcomes
via Target Identification
in Basic Science Research
Experimental Therapeutics
Basic Science
Target
Engagement
Target
Identification
a
Experimental
vs.
Control
Change
in
Target
c
c’
Mechanism of Risk
Target
Validation
b
Outcome
of
Interest
Background
1.2 million cases of child maltreatment
Public health impact of $124 billion
Yet, controversy remains:
Variation in effect size estimates
Contamination effects
Sedlak et al (2010); Fang et al (2012); Rind et al (2001); Gilbert et al (2009)
Background
Contaminated
Self-Report
Substantiated
Combined
(N=512)
(N=422)
(N=469)
(N=403)
Teenage Births
1.69 (1.08-2.66)
1.70 (0.94-3.08)
1.79 (1.05-3.02)
2.20 (1.05-4.63)
Obesity
1.16 (0.90-1.50)
1.27 (0.93-1.74)
1.29 (0.96-1.72)
1.47 (1.03-2.10)
Depression
1.25 (0.78-2.01)
2.84 (1.24-6.51)
1.22 (0.72-2.05)
2.97 (1.22-7.18)
Cigarette use
1.38 (1.08-1.75)
1.56 (1.14-2.14)
1.46 (1.13-1.87)
1.59 (1.15-2.20)
Note. Adjusted for age, minority status, family income, single-parent household, adverse childhood experiences and initial outcome
severity. Bolded estimates indicate P < .05.
Shenk et al (under review)
Background
TEENAGE BIRTHRATES
OBESITY
27.2%
10.9%
20.8%
6.9%
17.1%
3.1%
CONTAMINATED
COMBINED
METHOD
NATIONAL
PREVALENCE
CONTAMINATED
MAJOR DEPRESSION
COMBINED
METHOD
NATIONAL
PREVALENCE
CIGARETTE USE
21.3%
10.0%
CONTAMINATED
Shenk et al (under review)
3.9%
3.4%
COMBINED
METHOD
NATIONAL
PREVALENCE
CONTAMINATED
16.9%
17.1%
COMBINED
METHOD
NATIONAL
PREVALENCE
Target Identification
Prevalence of posttraumatic stress disorder (PTSD):
DSM-IV defined trauma:
General population:
Maltreated population:
Greater healthcare cost than:
Major depressive disorder
All other anxiety disorders
Copeland et al (2007); Merikangas et al (2010); Widom (1999); Marciniak et al (2005); Ivanova et al (2012)
62%
5-7%
37%
Target Identification
Existing theory views child maltreatment as:
A severe and/or chronic stressor
Impacting multiple levels of analysis
‒ Neurological systems regulating stress
‒ Psychological processes
Susman (2006); McEwen (2007); Hayes et al (1996)
Target Identification
Trickett et al (2010)
Target Identification
Childhood
Adolescence
Young
Young Adulthood
Adulthood
(M=11.06, SD=2.98)
(M=18.09, SD=3.47)
(M=24.46,
(M=24.46, SD=3.24)
SD=3.24)
Internalizing
* = p < .05
.30*
Beck
Depression
Inventory-II
.15*
Childhood
Sexual Abuse
.23*
HPA/RSA
Dysregulation
.72*
.50*
.29*
Covariates:
Age
Minority status
Main effects of Cortisol and RSA
Shenk et al (2010)
.21*
Externalizing
Antisocial
Behavior Form
Target Identification
Adolescent Stress Assessment Study
Identify mechanistic pathways to PTSD
Use a multiple levels of analysis framework
Strong test of multiple theoretical models
Simultaneously estimate indirect effects
Inform PTSD prevention and treatment efforts
Target Identification
Recent maltreatment
All females:
Maltreated (n=51)
Comparison (n=59)
Race:
Caucasian - 42%
African-American - 51%
Median family income:
$40,000-$49,000
Age:
Range = 14-19 years
Mean = 17.00, SD = 1.17
Single-parent homes:
58%
Target Identification
Target Identification
Example items assessing experiential avoidance:
“If I could magically remove all the painful experiences I've had in
my life, I would do so”
“It’s necessary for me to control my feelings in order to handle
my life well”
Target Identification
Re-experience: r = .25
Avoidance: r = .34
Arousal: r = .34
Shenk et al (2014)
Translating Basic Research Findings in
the Experimental Therapeutics Model
Experimental Therapeutics
Basic Science
Target
Engagement
Target
Identification
a
Experimental
vs.
Control
Change
in
Target
c
c’
Mechanism of Risk
Target
Validation
b
Outcome
of
Interest
Experimental Therapeutics
Prevention Science
Target
Engagement
Target
Identification
a
Treatment
vs.
Control
Change
in
Avoidance
c
c’
Mechanism of Change
Target
Validation
b
Outcome
of
Interest
Targeted Prevention
Acceptance and Stress Regulation Study
Test effects of acceptance during stress
Willingness to experience aversive private events
Model parent-child communication
Test active treatment components
Inform trauma-focused family interventions
Targeted Prevention
Validation
Promotes emotion regulation
Enhances family relationships
Exposure vs. Acceptance
Invalidation
Promotes emotion dysregulation
Weakens family relationships
Magnify aversive reactions to stress
Fruzzetti, Shenk & Hoffman (2005)
Targeted Prevention
Clinic Families
5
Non-clinic Families
**
Mean
4
3
*
* = p < .05
** = p < .001
2
1
0
Validation
Shenk & Fruzzetti (2014)
Invalidation
Targeted Prevention
Sample
Age: M=22, SD=7
Sex: 58% female
Race: 78% White
Block randomization:
Sex
Emotion regulation
Stressor:
Mental arithmetic
Repeated measures:
Heart rate
Skin conductance
Negative affect
Targeted Prevention
Validation
Invalidation
85
Negative Affect
Heart Rate
84
83
82
81
80
79
b = -.22, p <.001, d = 1.10
78
0
5
10
15
Time
20
25
30
b = -.13, p <.05, d = .77
0
10
20
30
Time
6
Effects of Acceptance:
b = -.04, p <.05, d = .73
5
SCL (µS)
Decrease in heart rate
No change in negative affect
Increase in skin conductance
21
20
19
18
17
16
15
14
13
12
4
3
2
1
0
Shenk & Fruzzetti (2011)
0
5
10
15
Time
20
25
30
Future Directions
Can targeting experiential avoidance prevent PTSD?
What technologies are available to target experiential
avoidance?
Can this be done with maltreated children after the abuse?
Thank you!!