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!!