SCCAP/Miami International Child & Adolescent Mental Health (MICAMH) Conference/2020/Day 2

Day 2

Keynotes

Promoting School Readiness in Young Children: Best Practices Across Home, School, and Community Contexts

Presenter: Katie C. Hart, Ph.D., Assistant Professor, Florida International University

Learning Objectives:

Importance of school readiness (SR) for children’s mental health and later school success

What is school readiness? Literacy and numeracy skills/academic skills, Behavior, Social-emotional, Self-regulation, Adaptive skills How to know who is ready and when Not age- arbitrary determiner because kids develop at different times Behaviors/characteristics Ability to follow routines, structure, follow rules, play with children, math skills with instruction, alphabet with instruction, identify shapes and colors, ability to dress independently, etc. Why is school readiness important? Why should mental health providers care? Harder as kids get older to make an impact Children who develop competencies across domains of SR have more positive outcomes -> outcomes in community also Children who do not develop these competences have higher levels of negative outcomes More than 60% of FL fourth graders are not reading at grade level 28% of preschool children are at risk for emotional and behavioral problems Early problem behaviors (externalizing) interfere with transition to grade school attention is one of the strongest predictors of later academic achievement

Income, racial, and ethnic gaps in school readiness

What are the gaps? (income, ethnic, racial gaps) income disparities 4/5 children from low-income homes are not proficient in reading by end of 3rd grade Racial/Ethnic Gaps in black, Hispanic, Native American children at low reading levels Factors that may influence gaps Income distribution, residential segregation, social policies like access to healthcare, preschool enrollment patterns Some reduction of gaps in math scores, self-control, and approaches to learning- from large national study of over 20,000 children

Evidence-based strategies for promoting school readiness

What can we do? Considerations for best practices Pyramid of social-emotional competence in infants and young children – Response to Intervention (RTI) model When should we start promoting children’s school readiness Infancy, prenatal development Social-emotional skills are developing from birth Talk Read Sing- national campaign for parents with their babies Importance of language nutrition for children’s early reading CDC has free milestone checklist and resources Talk to me baby/ Hablame bebe Vroom Parent Club- free parenting workshops Early screening tools- developmental assessment Early education High quality early education programs- children are more likely to be successful Need to have effective teachers to have successful classroom How to better support early childhood teaching Degrees, compensation, professional development activities Interventions targeting academic readiness Literacy Express Comprehensive Preschool Curriculum- Lonigan Florida Grade level Literacy Campaign- there is a local chapter here Intensive interventions Early Childhood Mental Health Consultation Interventions targeting social-emotional/behavioral readiness Many exist- including incredible years, PCIT Limitations to current interventions Not comprehensive focus of school readiness Gap in time of services- e.g. summer Implementation challenges- not ready and accessible for all schools’ settings Hard to get parents through the door- not representative of racial and ethnic minority families Summer Treatment Program for Pre-Kindergartners (STP-PreK) Goals to help school-readiness across the board Combo of preschool class and kindergarten class with academic activities and summer camp fun Kids in groups of 12-15 children from ages 4-6 Highly trained staff- certified lead counselor and 4-5 undergraduates 4-8 weeks full day program- 360 hours of intervention (7 years of typical intervention) Behavior Modification System- kids earning and losing points based on behavior and tracking behaviors over time- earn and lose rewards based on progress, social-emotional curriculum, academic activities including Lonigan program, recreational activities Parent Training- parents are required to come – modified group PCIT model- parents come for 8 weeks and learn early skills and school-readiness techniques and support children social-emotional development and coaching in session of PCIT skills Positive data- started with children head start preschools Kids who received treatment with socio-emotional part did better so that is critical part No difference between kids who get 8 weeks of program or 4 weeks of program Big difference in kids who get program vs kids who just get school consultation during the year FIU Summer Academy- same program but in Liberty City – funded by Children’s Trust Reading Explorers- another program funded by Children’s Trust – program for rising kindergartners Take Home messages Important for mental health and children’s later school success Important to reduce disparities in children’s school success Best practices support early models and active participation by families and schools Early high-quality education can be really effective Early screening and intervention is key Unique programs to address these gaps

New Directions in Understanding and Supporting Social Competence on the Autism Spectrum

Presenter: Matthew D. Lerner, Ph.D., Assistant Professor, Stony Brook University

Learning Objectives:

Thinking about where social competence challenges come from & what we can do about it?

Thinking about where social competence challenges come from and what we can do about it Background Models of social “skills” problems Doesn’t like this term Theoretical mechanisms- where the challenges come from and evidence around mechanisms What does social competence in ASD mean Interventions Different kinds Research Kim- sample of 300,000 kids in child mental health clinics and mapped symptoms of ASD and found that symptoms of ASD are not discrete to kids with ASD This tells us that social challenges in kids with ASD can and must have implications for kids who don’t have ASD but also those challenges Tailored interventions for what we know about mechanisms Populations that have social challenges ASD, soc com, learning, ADHD, BPD, anxiety, anyone Hobson quote- “the challenges of ASD stem from difficulties in action and reaction, necessary for the development of reciprocal, affectively charged interpersonal relationships with others” (1990) Ex: When you see an old friend come off the airplane- that is a reciprocal, affectively charged interpersonal relationship

What is the mechanism of social competence?

What’s the mechanism of social competence Ex: mechanism of headaches- we know the mechanism and can act on it with aspirin Social skills mechanisms (have long been hypothesized but not as frequently tested) Social knowledge Training in social knowledge is the core of many social skills interventions for ASD Training social rules should kelp kids with ASD But little research has tested the question of do kids with ASD have social knowledge and does it matter In research- doing poorly on the social knowledge measure shows low social knowledge and doing not poorly on social knowledge measure would make it seem like they have friends These measures are not hard to administer but haven’t been until 10 years ago Insight/self-awareness Social motivation (this is the hot term right now in ASD) Hard to measure Not great ecological validity Social information processing Have trouble processing info in real time- have trouble with having the interaction in time even if have the skills to Social creativity Flexibility- coming up with novel solutions to social problems Measurable French psychologist has a measure for this

Social Skills Mechanisms & Findings

Social Skills Mechanisms and Findings Social knowledge Asked kids and teens with ASD and typically-developing how they would approach someone Are those who do better more prosocial? No independent relationship to outcomes (TOM, classroom, etc! Knowing what to do does not appear to be enough for doing it Kids with ASD were just as good at knowing the rules but wider variation within the ASD rules Insight/Self-awareness Asked kids about their own social abilities and asked their parents and teachers Kittens think they’re lions Kids report being average compared to their peers but teachers and parents are rating the kids at least a standard deviation lower than average This difference correlates with Less depression Less hostile view of others and in social scenarios Parents report less self-efficacy How to explain this: Positive illusory bias – tendency for kids with ADHD to overrate their own ability relative to how others rate them Self-protective hypothesis- notion that many of these kids are aware of the difference between themselves and others so they inflate their ratings as a way to protect their sense of self Clinical implications- correcting their misperceptions might have deleterious effects so better to focus on giving them other skills/strengths they do have and help to build confidence around that instead Social motivation Measured in studies looking at kids’ ability to persist in interacting with peers when things not going so well Kids had less efficient neural emotion processing Fewer ASD symptoms Better parent and self-report social skills Poorer on tasks identifying emotions in faces (less emotion recognition) How to explain this Kids who are active but odd- really motivated to tell you about something but not understanding your responses of sitting and nodding head while they’re spitting off info More poor quality or low-level interaction Kids with high social motivation and low social knowledge tend to do more poorly when trying to interact with peers- missing opportunity Social information processing Electrode system of research that he does and shows processing of facial information This is uniquely different in kids with ASD and the facial processing is delayed Better emotion recognition if faster processing Social Creativity Take-home Social knowledge not as important as we thought Awareness and motivation important but complicated

Interventions, Current Evidence & Conclusions

Interventions Research- that interventions help some but not in schools but from self-report- kids report that they have benefit from interventions (but this may have to do with social knowledge effects and not social performance effects- knowing vs doing) and found effects entirely attributable to social knowledge So are the interventions training knowledge or performance? Strengths of teaching social knowledge- good for teaching social knowledge but limits of deficits in application Strengths of performance based – targeting activities, social reinforcement, practice (inside-out approach) Example- clapping at same time as someone else based on eye contact Helps with spontaneous eye contact Getting info from social info processing Current Evidence Socio-Dramatic Affective Relational Interventional Generalized and manualized effects vs TAU Improvements maintain 6 weeks later First study in adolescent ASD to show maintenance effects Replicated in independent sample Good effects on social knowledge without directly teaching RCTS: Community-based RCT effects on kids making friends compared to a knowledge training program- both groups showed improvement in friendship SDARI group at higher rate after a single session but knowledge training catches up Key point: not advocating one thing is better than another- but there are differences in mechanisms and we need to attend to these differences to better target our interventions Knowledge and performance training can help but differently Conclusions Know and performance represent distinct groups Social creativity info processing may matter more Social skills interventions are not all created equal May better match kids to interventions based on better understanding of social mechanisms

Should We Give Psychoactive Medication to America’s Children or Teach Their Parents and Teachers Better Child Management Skills: A Decade of Research on Comparing, Combining, and Sequencing Interventions for Childhood ADHD

Presenter: William E. Pelham, Jr. Ph.D., Director of the Center for Children and Families; Distinguished University Professor, Florida International University

Learning Objectives:

Youth ADHD Background

ADHD importance to professionals Most common diagnosis of children and most common referral for many things- health care professionals, kids with IEPs, child mental health facilities, etc Diagnosis has been around since 60s with different names ADHD Core Symptoms- same over 60 years Inattention, Impulsivity, Hyperactivity Most kids get diagnosed as having both I and H/I Must meet symptom criteria, create impairment in daily life functioning, symptoms in two or more settings, etc. Comorbidities with other disorders- learning, language, CD, ODD, etc. Domains of functional impairment in children Relationships with parents and adults, relationships with other kids- peers and siblings, academic achievement, behavioral functioning in school (may be related to comorbid learning difficulties not hyperactivity in school), family functioning at home, leisure activities Role of functional impairment in treatment Should be targeting peer relationships (teaching skills to the kids), parenting and family variables (teaching skills to parents), and academic achievement (teaching skills to teachers for classroom management) Goal of treatment is to minimize impairment in daily life functioning and maximize adaptive functioning that will facilitate skill development (to what extent does medication do that?) Why is it important to treat ADHD in childhood? People think this is childhood disorder and kids outgrow it but not true- maybe not as hyperactive or fidgety but still have the core deficits over lifetime Prognosis: Many longitudinal studies of kids through their 20s Kids can still have difficulties as they move throughout 20s and into 30s (lit hasn’t gone past 30s) One study looking at financial independence at age 30 – whether or not financial independent of parents- and answer is no- 70% of the ADHD children at age 30 are living with parents or don’t have a job at age 30 (compared to control group of 10% of 30 year olds living with parents or without a job) Giving medication and not teaching functional skills may be the reasons for this

Youth ADHD Treatment

What is effective treatment for ADHD kids in childhood? Evidence-based short-term treatments Behavioral modification CNS Stimulant medication Combined behavioral and stimulant Most of recommendations are for combined approaches Psychoactive medicine business is booming so there is more medication use than behavioral or combined 6-8% of kids in the US are taking medications for ADHD (1/5 of those taking 2+ medications) Stimulants for ADHD are prescribed more often than antibiotics for elementary age kids Skyrocketed increase in use of medication over last 20 years – in early 90s- kids with ADHD were treated with Ritalin- one pill lasted four hours—then other companies made new drugs that lasted longer: Adderall and Concerta Guidelines on treatments and sequencing Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD), the biggest ADHD organization, says simultaneous usage of medications and behavioral intervention therapy American Academy of Child and Adolescent Psychiatry (AACAP) says medications first and then to not add behavioral until the 5th approach American Academy of Pediatrics (AAP) is in the middle- says either/or or the combo preferably- this is the biggest influential guideline Centers for Disease Control and Prevention (CDC) says behavioral treatment for young kids Society of Developmental and Behavioral Pediatricians (SDBP) came out on Fr- first set of guidelines that says that psychosocial treatments are necessary and should be foundation of treatment for ADHD and then later says medication could be a supplement Bill: "Behavioral Therapy" (BT) has lower risks (side effects) and equivalent efficacy so BT should routinely be the first line of ADHD treatment One pill of Ritalin costs $8- aka $3,000/year- this could be a lot of psychosocial treatment Components of effective comprehensive treatment Parent training, school interventions, peer-focused interventions Benefits of short-term behavioral treatments Teaching skills to parents, teaching skills to teachers, teaching skills to kids with peers Lots of evidence that these approaches work Benefits of pharmacological treatments Behave better in classroom and at home- this removed incentive of parents and teachers to do behavioral treatments Limitation of pharmacological intervention Medications rarely normalize their function Acute, immediate effects that go away when medication wears off so very limited and have to continue to medicate the child with no residual benefit Poor compliance in long-term use High school kids do not want to take their medication – they don’t think they have any problems and they don’t like the side effects Uniform lack of evidence for beneficial long-term effects Single biggest problem with relying on medications for treatment Reduction in growth and adult height if taken medications all childhood (MTA study)- on average children were an inch shorter than they would have been otherwise Lack of information about long-term safety (e.g. later substance use) His neurologist friend says we have no idea what effects these medications have on the brain and safety Study on classroom rule violations- many more violations with placebo than kids with medication- showed that medication was helpful but only brought ADHD kids halfway between placebo kids and typically developing kids so shows that medications didn’t get that them close to typical kids Big problem with compliance to medication

Research & Conclusions

Research in the last 20 years Important to combine treatments How you combine the treatments is very important (study from 2017 on sequencing of medications vs BT) Kids who started with BT were better than if they started with medications (on classroom rule violations)- for second randomization- the groups that went from BT to BT still did the best and the worst group went from medications to BT Parents who got medications first and then were assigned to BT next never went to parent training- so starting with medications messes up parents’ motivation to go to parent training Take-home points Sequence matters!- start with psycho-social approach with parents and teachers Most widely used treatment of medication has negative effects and bad effects if given before other treatments

Workshops

What Everyone Needs to Know about E-Cigarette Use and Vaping Among Teens

Presenters: Matthew Sutherland, Ph.D., Associate Professor & Elisa Trucco, Ph.D., Assistant Professor, Florida International University

Learning Objectives:

Dr. Elisa Trucco: Vaping – E-cigarettes

Scope of the Problem There are more teens in South Florida vaping than in the Nation People are significantly more likely to keep using if they used as a teen Teens are especially vulnerable to using nicotine later in life Vaping associated with illness and death September of last year but outdated because now so many more illnesses and death Lung injury and deaths Majority male, 15% < 18-year-olds and majority 35 years and older Majority of lung illnesses reported for people using this for THC and current research suggests related to vitamin E acetate What are e-cigarettes? Electronic nicotine delivery systems; Variety of sizes How do they work? Power source and heating element and tank/cartridge Device, e-liquid, nicotine concentrations 1 Juul pod= same amount of nicotine as 1 pack of cigarettes (20 cigarettes) Are e-cigarettes less harmful than regular cigarettes? Yes but only because regular cigarettes are SO harmful Still has nicotine and is an addictive substance Smoking regular and then transitioning to e-cigarettes? Yes, it can be helpful but people don’t usually stop using regular cigarettes altogether so it does not fix the problem Health Effects Vaping increases risk of regular cigarette smoking PG and VG are food grade products so we don’t know long-term effects but they are allowed to be inhaled Unintended injuries Defective batteries – could explode in face Nicotine poisoning by accidental ingestion- pediatric exposure can be lethal at high levels of nicotine concentration from kid drinking e-liquid bottle but these are currently outlawed Second-hand and third-hard exposure Non-users exposed Third-hand: residue remaining on surfaces absorbed from skin (like oil on phone from hands when smoking with phone)

Dr. Matthew Sutherland: Cognitive Neurological Proof

Brain development and nicotine The prefrontal cortex (PFC) (impulse control and decision-making) and striatum (motivation, reward) are different for teens and adults Brain regions develop at different rates and into mid-20s PFC develops more slowly than other parts and continues to develop into mid-20s and then reaches full maturation and levels off Striatum develops more quickly and reaches full maturation and levels off These 2 brain systems-> risky decisions Teens make more risky decisions when they’re with their peers Example: study with driving simulation where participant decides whether to stop at yellow light or run light or wait until green light and this was done alone and then with peers and with peers, adolescents made way more risky decisions Teen brain and behavior sensitive to social pressures Vaping behavior of family and friends lead to higher risk of e-cigarette use Teen brains are sensitive to nicotine’s addictive effects Addiction can happen quickly We need to define addiction Can define as report addictive symptoms within one to two days of smoking first cigarettes Addiction can happen at low levels of nicotine use – i.e withdrawal symptoms before even smoking two cigarettes a day Nicotine changes the brain -can impact working memory, attention, and increase depression/anxiety Nicotine releases large amounts of the neurotransmitter dopamine in the brain Dopamine- big role of reinforcement (reward and motivation) in the striatum and working memory and self-control in the PFC The brain responds after being exposed to nicotine by reducing dopamine As the brain changes, the person “needs” nicotine to keep brain functioning stable and avoid withdrawal Lead to changes in reward processing- i.e. Hitting winning shot doesn’t feel as good High stats of teens vaping Important risk factors- older age, male, White (including Hispanic), lower grades Risk perception- e-cigarettes are lowest perceived risk of all drugs, including alcohol They go into school and educate- 37 community outreach educational events – school personnel, parents, students

Dr. Elisa Trucco's Breakout

Engaging Teens in Conversations about Vaping Considerations when talking to teens about vaping Have facts ready to answer questions- even if you don’t feel comfortable or know all of the facts Don’t do scare tactics- makes them want to try it Avoid criticism Encourage open dialogue Suggest that teens talk to trusted adults (e.g. soccer coach they are close with) Active listening Consider whether teens are experimenting or using heavily (and may want to stop) Regular user: consider how much of a problem vaping poses for them and whether they can and how that change can impact them Experimenting: consider reasons leading to experimentation or plans for starting use and factors that will likely increase risk (use among fam/friends, etc.) Start with consider a behavior you want to change (VERY Motivational Interviewing (MI) RELATED) Then tell them if they did that behavior at work, they’d be fired, and the person will be very fearful and stressed Change process- generally we are in a state of ambivalence (desire, self-efficacy, urgency, commitment) 5 basic principles for changing behavior 1. Expressing empathy Supportive companion and knowledgeable component (not using scare tactics) 2.  Develop discrepancy Highlight where they want to change 3. Avoid argumentation This can evoke resistance and defensiveness 4. Roll with resistance Solutions are usually evoked by the client so you can guide them to that point 5. Supporting self-efficacy Believe that you can perform the behavior- people who don’t feel like they have the self-efficacy don’t want to engage in that behavior So show them the things that they are doing that shows self-efficacy (by just being here you are promoting your recovery) Build motivation for change Elicit self-motivational statements Ask why they like it and what’s the other side and what the worries are about vaping Affirming the client Tell client you respect them for coming to meet with you and that they are working towards stopping using Change talk and sustain talk Ambivalent teens often change between the two Change-> mowing towards changing the behavior Sustain-> status quo Goals is for your teen to increase change and decrease sustain talk Types of change talk- DARN CATS and how to increase change talk- OARS Showed two videos- one of ineffective athletic director and player- she was very dismissive and didn’t use any change talk or try to elicit any change talk from him other with effective athletic director and player – she waited for awhile to let him speak and then reflected and summarized what he was saying then role play with teen and therapist ACE project – Antecedents and Consequences of Electronic Nicotine Delivery Systems

Dr. Matthew Sutherland's Breakout

Group presentations for students with Miami-Dade County Public Schools (MDCPS) learned about the need in community for vaping-related programming – educational and interventional components started from workshop with Trust Counselors – now do many different events and use discussion-based things like Kahoots questions and then discussion and interactive games to highlight misconceptions Many resources available on e-cigarettes (e.g. NIDA for teens, CDC, educational programs) Outline of his talk to different audiences Games- can game, aerosol game, cliffhanger game

An Introduction to Sociodramatic Affective-Relational Intervention (SDARI)

Presenter: Matthew D. Lerner, Ph.D., Assistant Professor, Stony Brook University

Advances in Selective Mutism: The Language Environment and Intensive Approaches to Assessment and Treatment

Presenter: Jami Furr, Ph.D., Assistant Professor, Florida International University

Clinical Guidelines for Implementing Multimodal Treatment for ADHD: How to Sequence, Dose, and Combine Treatment Modalities in School and at Home

Presenter: William E. Pelham, Jr. Ph.D., Director of the Center for Children and Families; Distinguished University Professor, Florida International University

Other 2020 Days

• SCCAP/Miami International Child & Adolescent Mental Health (MICAMH) Conference/2020/Day 1
• SCCAP/Miami International Child & Adolescent Mental Health (MICAMH) Conference/2020/Day 3