Is respiratory sinus arrhythmia a modifiable index of symptom change in cognitive behavioral therapy for youth? A pooled-data analysis of a randomized trial

OBJECTIVE

We evaluated whether respiratory sinus arrhythmia (RSA) reactivity and resting RSA-physiological markers reflecting the increase in heart rate with inspiration and decrease during expiration related to parasympathetic influence on the heart-are modifiable and predict symptom change during youth psychotherapy. Methods: Diverse youth (N = 158; ages 7-15; 48.1% female) received the Modular Approach to Therapy for Children and completed pre-treatment (pre), post-treatment (post), and 18-months postbaseline (18Mo) assessments. We measured resting RSA, RSA reactivity during stress induction, and psychopathology symptoms. Results: Pre-to-post and pre-to-18Mo, reactivity decreased, and resting RSA increased. Changes in reactivity and resting RSA, separately, did not predict reduced psychopathology. Yet, decreased reactivity combined with increased resting RSA predicted reduced psychopathology over time, suggesting that observed RSA changes were beneficial for some. Higher dosage of a module utilizing slow-breathing, muscle-relaxation, and imagery predicted greater pre-to-18Mo changes in reactivity and resting RSA, whereas a similar module with less emphasis on slow-breathing did not. Conclusions: Findings raise the possibility that youth reactivity and resting RSA could be modifiable during cognitive behavioral therapy and contribute to the amelioration of psychopathology. More studies are needed to determine whether resting RSA and RSA reactivity are modifiable indices of symptom change in slow-breathing practices and psychotherapy.

CLINICALTRIALS.GOV IDENTIFIER

NCT03153904, registered May 15, 2017.

Feasibility, Acceptability, and Usability of Physiology and Emotion Monitoring in Adults and Children Using the Novel Time2Feel Smartphone Application

The present study tests the feasibility, acceptability, and utility of the novel smartphone application-Time2Feel-to monitor family members' emotional experiences, at the experiential and physiological level, and their context. To our knowledge, Time2Feel is the first of its kind, having the capability to monitor multiple members' emotional experiences simultaneously and survey users' emotional experiences when experiencing an increase in physiological arousal. In this study, a total of 44 parents and children used Time2Feel along with the Empatica E4 wrist-wearable device for 10 days. Engagement rates were within the acceptable range and consistent with previous work using experience sampling methods. Perceived ease of use and satisfaction fell mostly in the moderate range, with users reporting challenges with connectivity. We further discuss how addressing connectivity would increase acceptability. Finally, Time2Feel was successful at identifying physiological deviations in electrodermal activity for parents and children alike, and even though responses to those deviation-generated surveys were largely consistent with random survey responses, some differences were noted for mothers and fathers. We discuss the implications of using Time2Feel for understanding families' emotional and stressful experiences day-to-day.

Typologies of Non-Suicidal Self-Injury Functions and Clinical Correlates Among Inpatient Youth

This study identified typologies of specific non-suicidal self-injury (NSSI) functions among youth admitted for psychiatric hospitalization and investigated clinically relevant correlates. Inpatient youth (n = 68) aged 10-17 years reported on their reasons to engage in NSSI, frequency and severity of NSSI, and symptoms of borderline personality disorder (BPD). A latent class analysis using youth's specific NSSI functions as indicators found two NSSI function typologies, which were differentially associated with clinical correlates. The Multiple Functions class (n = 28) endorsed to "feel something," "punish self," "escape feelings," "relieve anxiety," "stop feeling self-hatred," "stop feeling angry," "show much they are hurting," and "create a hurt that can be soothed." Conversely, the Single/Avoidant Function class (n = 40) endorsed one primary function-i.e., to "escape feelings." Youth in the Multiple Functions class reported significantly more frequent self-injury and greater BPD symptomology. The present study illustrates the importance of examining constellations of specific NSSI functions in inpatient care settings, given their unique associations with NSSI frequency and features of BPD. These findings could inform targeted psychological screening and, in turn, guide the implementation of interventions for elevated NSSI frequency and BPD symptomology among inpatient youth, based on NSSI functions endorsed.

Clinician training, then what? Randomized clinical trial of child STEPs psychotherapy using lower-cost implementation supports with versus without expert consultation

OBJECTIVE

Implementation of evidence-based treatments in funded trials is often supported by expert case consultation for clinicians; this may be financially and logistically difficult in clinical practice. Might less costly implementation support produce acceptable treatment fidelity and clinical outcomes?

METHOD

To find out, we trained 42 community clinicians from four community clinics in Modular Approach to Therapy for Children (MATCH), then randomly assigned them to receive multiple lower-cost implementation supports (LC) or expert MATCH consultation plus lower-cost supports (CLC). Clinically referred youths (N = 200; ages 7-15 years, M = 10.73; 53.5% male; 32.5% White, 27.5% Black, 24.0% Latinx, 1.0% Asian, 13.5% multiracial, 1.5% other) were randomly assigned to LC (n = 101) or CLC (n = 99) clinicians, and groups were compared on MATCH adherence and competence, as well as on multiple clinical outcomes using standardized measures (e.g., Child Behavior Checklist, Youth Self-Report) and idiographic problem ratings (Top Problems Assessment).

RESULTS

Coding of therapy sessions revealed substantial therapist adherence to MATCH in both conditions, with significantly stronger adherence in CLC; however, LC and CLC did not differ significantly in MATCH competence. Trajectories of change on all outcome measures were steep, positive, and highly similar for LC and CLC youths, with no significant differences; a supplemental analysis of posttreatment outcomes also showed similar LC and CLC posttreatment scores, with most LC-CLC differences nonsignificant.

CONCLUSIONS

The findings suggest that effective implementation of a complex intervention in clinical practice may be supported by procedures that are less costly and logistically challenging than expert consultation. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Evaluating a Modular Approach to Therapy for Children With Anxiety, Depression, Trauma, or Conduct Problems (MATCH) in School-Based Mental Health Care: Study Protocol for a Randomized Controlled Trial

Introduction: Schools have become a primary setting for providing mental health care to youths in the U.S. School-based interventions have proliferated, but their effects on mental health and academic outcomes remain understudied. In this study we will implement and evaluate the effects of a flexible multidiagnostic treatment called Modular Approach to Therapy for Children with Anxiety, Depression, Trauma, or Conduct Problems (MATCH) on students' mental health and academic outcomes.

Methods and Analysis: This is an assessor-blind randomized controlled effectiveness trial conducted across five school districts. School clinicians are randomized to either MATCH or usual care (UC) treatment conditions. The target sample includes 168 youths (ages 7–14) referred for mental health services and presenting with elevated symptoms of anxiety, depression, trauma, and/or conduct problems. Clinicians randomly assigned to MATCH or UC treat the youths who are assigned to them through normal school referral procedures. The project will evaluate the effectiveness of MATCH compared to UC on youths' mental health and school related outcomes and assess whether changes in school outcomes are mediated by changes in youth mental health.

Ethics and Dissemination: This study was approved by the Harvard University Institutional Review Board (IRB14-3365). We plan to publish the findings in peer-reviewed journals and present them at academic conferences.

Clinical Trial Registration:ClinicalTrials.gov ID: NCT02877875. Registered on August 24, 2016.

The Cascade Effect of Parent Dysfunction: An Emotion Socialization Transmission Framework

The current study tested a preliminary cascade model of parent dysfunction—i.e., internalizing psychopathology and emotion dysregulation—whereby parent dysfunction is transmitted to children through the impact of parental emotion socialization on child emotion regulation. Participants were 705 mothers (M_age = 36.17, SD = 7.55) and fathers (M_age = 35.43, SD = 6.49) of children aged 8 to 12 years who self-reported on their internalizing psychopathology, emotion regulation difficulties, and emotion socialization practices, and on their child’s internalizing psychopathology and emotion regulation. Using a split sample method, we employed a data-driven approach to develop a conceptual model from our initially proposed theoretical model with the first subsample (n = 352, 51% mothers), and then validated this model in a second subsample (n = 353, 49% mothers). Results supported a model in which the transmission of dysfunction from parent to child was sequentially mediated by unsupportive parental emotion socialization—but not supportive parental emotion socialization—and child emotion dysregulation. The indirect effects from the final model did not differ by parent gender. Findings provide preliminary support for a mechanism by which maternal and paternal internalizing psychopathology and emotion dysregulation disrupt parental emotion socialization by increasing unsupportive emotion socialization practices, which impacts children’s development of emotion regulation skills and risk for internalizing psychopathology.

A systematic review of the effectiveness of behavioural treatments for pica in youths

Pica is the persistent consumption of non-nutritive, nonfood substances and is associated with adverse health complications. However, there is limited research on interventions for pica in youth. The objective of this study is to systematically review the empirical evidence for the effectiveness of behavioural interventions for pica in children and adolescents and to generate treatment recommendations. A systematic search yielded 823 articles extracted from five databases: CINALH, Family and Society Studies Worldwide, Medline, PsycINFO, and Web of Science. Two reviewers completed initial sorting based on article titles and abstracts. Five reviewers completed sorting based on full article review. Thirty articles were included and double coded for demographic information, co-morbid conditions, and intervention characteristics. These studies were case studies involving behavioural treatments for pica. Seventeen behavioural interventions were categorized into four treatment approaches: reinforcement-based, response interruption, "other" interventions, and punishment-based procedures. Interventions that resulted in near-zero rates of pica were deemed effective. Findings showed support for contingent reinforcement, discrimination training as part of a combination treatment, physical restraint, time out, and contingent aversive stimulus. No evidence supported the effectiveness of response interruption procedures, including response blocking and visual facial screen. Other coded procedures did not appear effective. We recommend that the least restrictive procedures are implemented first, including a combination treatment with contingent reinforcement and discrimination training. As needed, more restrictive procedures can be added to the treatment package. This review will facilitate future empirical work and assist clinicians with treatment options for pica in youth. High-quality trials are needed.

Development and Validation of the Parents' Gendered Emotion Beliefs Scale

OBJECTIVES

The aim of the current research was to develop and validate a parent, self-report questionnaire to measure parents' gendered beliefs about emotion.

METHODS

Scale items were first developed based on a previous qualitative study examining emotions, parenting, and gender in a sample of parents. The Parents' Gendered Emotion Beliefs scale (PGEB) was validated in a sample of 704 parents of middle childhood youth.

RESULTS

Item-response theory analyses indicated a three-factor solution with factors measuring beliefs consistent with: gendered emotion expression, gender-neutral emotion expression, and gendered emotion socialization. All factors showed good internal consistency with alphas ranging from 0.79 to 0.90. Analyses then examined convergent validity by correlating PGEB factors to established measures of broad emotion beliefs, emotion socialization, family expressiveness, and child emotion regulation and psychopathology.

CONCLUSIONS

Overall, findings support the PGEB, its factor structure and psychometric properties, and its potential to contribute to our understanding of the role of gender in emotion socialization and children's emotional development.

Development and Validation of the Praise, Indulgence, and Status Parenting Scale

The overarching aim of this study was to develop and validate a new scale (i.e., the Praise, Indulgence, and Status Parenting Scale [PISPS]) to measure modern parenting practices and behaviors consistent with instilling ideals of specialness (i.e., the notion that one is special), self-esteem, and status in children. In 2 studies on emerging adults (Study 1: N = 582, M _age = 19.46; Study 2: N = 464, M _age = 19.58), the PISPS was developed and validated using classical test theory (Study 1) and further refined using item-response theory (Study 2). Results from both studies indicated a 3-factor structure with factors differentially linked with correlates of interest including parenting strategies, self-esteem, narcissism, entitlement, and internalizing symptoms. Study 3 further validated the PISPS in a sample of parents (N = 638, M _age = 35.79) reporting on their parenting and their child's emotion regulation and symptoms of psychopathology. Overall, findings support the PISPS, its psychometric properties, and its unique contribution to child symptoms.

Efficient Monitoring of Treatment Response during Youth Psychotherapy: The Behavior and Feelings Survey

An emerging trend in youth psychotherapy is measurement-based care (MBC): treatment guided by frequent measurement of client response, with ongoing feedback to the treating clinician. MBC is especially needed for treatment that addresses internalizing and externalizing problems, which are common among treatment-seeking youths. A very brief measure is needed, for frequent administration, generating both youth- and caregiver-reports, meeting psychometric standards, and available at no cost. We developed such a measure to monitor youth response during psychotherapy for internalizing and externalizing problems. Across 4 studies, we used ethnically diverse, clinically relevant samples of caregivers and youths ages 7-15 to develop and test the Behavior and Feelings Survey (BFS). In Study 1, candidate items identified by outpatient youths and their caregivers were examined via an MTurk survey, with item response theory methods used to eliminate misfitting items. Studies 2-4 used separate clinical samples of youths and their caregivers to finalize the 12-item BFS (6 internalizing and 6 externalizing items), examine its psychometric properties, and assess its performance in monitoring progress during psychotherapy. The BFS showed robust factor structure, internal consistency, test-retest reliability, convergent and discriminant validity in relation to three well-established symptom measures, and slopes of change indicating efficacy in monitoring treatment progress during therapy. The BFS is a brief, free youth- and caregiver-report measure of internalizing and externalizing problems, with psychometric evidence supporting its use for MBC in clinical and research contexts.

A Review of Behavioral Observation Coding Approaches for the Trier Social Stress Test for Children

The Trier Social Stress Test (TSST) has become one of the most widely-used protocols for inducing moderate psychosocial stress in laboratory settings. Observational coding has been used to measure a range of behavioral responses to the TSST including performance, reactions to the task, and markers of stress induced by the task, with clear advantages given increased objectivity of observational measurement over self-report measures. The current review systematically examined all TSST and TSST-related studies with children and adolescents published since the original work of Kirschbaum et al. (1993) to identify behavioral observation coding approaches for the TSST. The search resulted in 29 published articles, dissertations, and master's theses with a wide range of coding approaches used. The take-home finding from the current review is that there is no standard way to code the Trier Social Stress Test for Children (TSST-C), which appears to stem from the uniqueness of investigators' research questions and sample demographics. This lack of standardization prohibits conclusive comparisons between studies and samples. We discuss relevant implications and offer suggestions for future research.

Profiles of Emotion Deficits and Adolescent Nonsuicidal Self-Injury in an Inpatient Sample

This study examined profiles of specific emotion deficits, including poor emotion awareness, reluctance to express emotion, sadness inhibition and dysregulation, and anger inhibition and dysregulation. Self-report questionnaires assessed adolescents' emotion skills and nonsuicidal self-injury (NSSI) engagement, frequency, severity, methods, and age of onset. Latent profile analysis yielded a three-profile solution: Low Deficit (LD; n = 49), Unaware/Anger Dysregulated (UAD; n = 24), and Anger Inhibited (AI; n = 20) profiles. Adolescents in the UAD profile were more likely to engage in NSSI, displayed a higher NSSI frequency, and reported a higher number of NSSI methods when compared to adolescents in the LD profile. No links emerged for NSSI severity or age of onset.

Specific coping strategies moderate the link between emotion expression deficits and nonsuicidal self-injury in an inpatient sample of adolescents

BACKGROUND

Non-suicidal self-injury (NSSI) is a behavior of increasing prevalence in adolescents with links to various negative mental health and adjustment outcomes. Poor emotion expression has been linked with NSSI use, whereas the use of adaptive coping strategies has been identified as a protective factor against NSSI. The current study examined whether specific coping strategies moderate the relation between poor emotion expression and NSSI, and whether moderation is conditional on adolescent gender.

METHODS

Ninety-five adolescents hospitalized on an acute care inpatient psychiatric unit completed questionnaires measuring NSSI, emotion expression and use of specific coping strategies (i.e., problem-focused coping, positive reframing coping, support seeking, avoidance, and distraction).

RESULTS

Results indicated that poor emotion expression was positively associated with NSSI. Positive reframing and support seeking emerged as significant moderators of the poor emotion expression-NSSI link. This result was not conditional upon adolescent gender. Problem-focused coping, avoidance, and distraction did not emerge as significant moderators.

CONCLUSIONS

Encouraging youth to use particular coping strategies might protect against the negative impact of emotion expression deficits for both boys and girls.

Preschoolers' genetic, physiological, and behavioral sensitivity factors moderate links between parenting stress and child internalizing, externalizing, and sleep problems

This study examined three potential moderators of the relations between maternal parenting stress and preschoolers' adjustment problems: a genetic polymorphism-the short allele of the serotonin transporter (5-HTTLPR, ss/sl allele) gene, a physiological indicator-children's baseline respiratory sinus arrhythmia (RSA), and a behavioral indicator-mothers' reports of children's negative emotionality. A total of 108 mothers (M_age  = 30.68 years, SD_age  = 6.06) reported on their parenting stress as well as their preschoolers' (M_age  = 3.50 years, SD_age  = 0.51, 61% boys) negative emotionality and internalizing, externalizing, and sleep problems. Results indicated that the genetic sensitivity variable functioned according to a differential susceptibility model; however, the results involving physiological and behavioral sensitivity factors were most consistent with a diathesis-stress framework. Implications for prevention and intervention efforts to counter the effects of parenting stress are discussed.

Coparental Affect, Children's Emotion Dysregulation, and Parent and Child Depressive Symptoms

Children's emotion dysregulation and depressive symptoms are known to be affected by a range of individual (parent, child) and systemic (parent-child, marital, and family) characteristics. The current study builds on this literature by examining the unique role of coparental affect in children's emotion dysregulation, and whether this association mediates the link between parent and child depressive symptoms. Participants were 51 mother-father-child triads with children aged 7 to 12 (M age = 9.24 years). Triads discussed a time when the child felt sad and a time when the child felt happy. Maternal and paternal displays of positive affect were coded, and sequential analyses examined the extent to which parents were congruent in their displays of positive affect during the emotion discussions. Results indicated that interparental positive affect congruity (IPAC) during the sadness discussion, but not the happiness discussion, uniquely predicted parent-reported child emotion dysregulation, above and beyond the contributions of child negative affect and parental punitive reactions. The degree of IPAC during the sadness discussion and child emotion dysregulation mediated the association between maternal, but not paternal, depressive symptoms and child depressive symptoms. Findings highlight the unique role of coparental affect in the socialization of sadness in youth and offer initial support for low levels of IPAC as a risk factor for the transmission of depressive symptoms in youth.

Specificity of childhood maltreatment and emotion deficit in nonsuicidal self-injury in an inpatient sample of youth

The present study investigated the function of two specific emotion-related skills, emotion expressivity and emotion coping, as potential mediators in the relations between childhood sexual, physical, and emotional abuse and NSSI. A robust body of work supports the role of emotion regulation in nonsuicidal self-injury, but additional research is warranted to tease apart the role of specific emotion regulation deficits as predictors of NSSI. Participants included 95 youth (Mage=14.22, SDage=1.67; 58% female) hospitalized on one of two acute care psychiatric inpatient units. Participants completed self-report questionnaires related to childhood experiences of trauma, current emotion expressivity and coping, and lifetime frequency of NSSI. Path analytic models indicated that only child emotional abuse was directly associated with NSSI when all abuse subtypes were examined simultaneously. Results also indicated that poor emotion expressivity, but not emotion coping, mediated the relation between childhood experiences of emotional abuse and NSSI.

Emotion socialization and ethnicity: an examination of practices and outcomes in African American, Asian American, and Latin American families

The current review paper summarizes the literature on parental emotion socialization in ethnically diverse families in the United States. Models of emotion socialization have been primarily developed using samples of European American parents and children. As such, current categorizations of "adaptive" and "maladaptive" emotion socialization practices may not be applicable to individuals from different ethnic backgrounds. The review examines current models of emotion socialization, with particular attention paid to the demographic breakdown of the studies used to develop these models. Additionally, the review highlights studies examining emotion socialization practices in African American, Asian American, and Latin American families. The review is synthesized with summarizing themes of similarities and differences across ethnic groups, and implications for culturally sensitive research and practice are discussed.

Family emotion expressivity, emotion regulation, and the link to psychopathology: examination across race

Research has established links between parental emotion socialization behaviours and youth emotional and psychological outcomes; however, no study has simultaneously compared these relations for White, Black, and Asian individuals. In this study, emerging adults identifying as White (n= 61), Black (n= 51), or Asian (n= 56) retrospectively reported on parents' emotion socialization behaviours during childhood, existing emotion regulation (ER) skills, and current psychopathology symptoms. Asian participants reported fewer positive displays of emotions in their families during childhood than White and Black participants. Despite this difference, low expression of positive emotions in families during childhood did not relate to negative outcomes for Asian participants but was linked for White and Black participants. Overall, Asian participants reported more difficulties with ER than Black or White participants, and relations between ER difficulties and psychopathology varied by racial group. The findings emphasize the need to consider race when conducting research on emotion functioning with families and highlight emotion dysregulation as a potential treatment target for White, Black, and Asian individuals.

Links between maternal and child psychopathology symptoms: mediation through child emotion regulation and moderation through maternal behavior

This study examined the intergenerational transmission of psychopathology symptoms with 7-12 year-old children (N = 97; 44 boys, 53 girls, M age = 9.14, SD = 1.38) and their mothers (M age = 38.46, SD = 6.86). Child emotion regulation mediated the links between maternal psychopathology and child internalizing and externalizing symptoms. In turn, the indirect effect was dependent on the level of maternal support in response to youth's expressions of negative emotions when considering particular constellations of maternal reactions and type of psychopathology symptoms. The findings indicate that the relations between maternal and child psychopathology symptoms and child emotion regulation are complex and vary by context. Regardless of the complexity, however, for both internalizing and externalizing symptoms in youth, the results suggest that building adaptive emotion regulation skills is an important target for prevention among children who are at risk for problems due to exposure to maternal psychopathology.

The Emotion Dysregulation Model of Anxiety: a preliminary path analytic examination

Both temperamental (e.g., behavioral inhibition) and environmental (e.g., family emotional environment) factors are associated with etiology and maintenance of anxiety; however, few studies have explored mechanisms through which these risk factors operate. The present study investigation of a developmental model of anxiety (i.e., the Emotion Dysregulation Model of Anxiety; EDMA) that hypothesizes that emotion dysregulation is the mechanism through which temperamental and emotion parenting variables relate to anxiety. Emerging adults (N=676, M age=19.5) retrospectively reported on behavioral inhibition and emotion parenting factors in childhood, and current emotion regulation skills and symptoms of anxiety. Results of path analyses provide initial support for the EDMA. Emotion dysregulation fully mediated the relationship between behavioral inhibition and anxiety and partially mediated the relationship between family emotional environment and anxiety.

Common and specific emotion-related predictors of anxious and depressive symptoms in youth

This study examined whether specific emotion-related constructs may be uniquely related to anxious or depressive symptoms in youth. Although anxiety and depression are comorbid in both youth and adult populations, delineation of these disorders is a worthwhile endeavor given that such differentiation may lead to a clearer conceptualization of the disorders that in turn may facilitate more efficient diagnosis and effective treatment. Children in the 4th and 5th grades (N = 187; M age = 10 years, 3 months) completed measures to assess symptoms of anxiety and depression and emotion-related functioning. Using structural equation modeling, emotion-related variables were identified that were common to both anxiety and depression (poor emotion awareness, emotion dysregulation, poor emotion regulation coping, high frequency of negative affect), most strongly related to depression (low frequency of positive affect), and most distinctly associated with anxiety (frequency of emotion experience, somatic response to emotion activation). The findings suggest that comprehensive theoretical formulations of anxiety and depression in youth should consider emotion-related variables. The results also suggest potential avenues that may facilitate more efficient assessment and treatment of such youth.

Understanding the medically unexplained: emotional and familial influences on children's somatic functioning

BACKGROUND

Many youth experience impairing, unexplained somatic complaints. Psychosocial models of child somatization have primarily focused on parent somatic functioning. Although helpful in understanding child somatization, this narrow focus on parental factors leaves a large proportion of the variance unaccounted for when explaining children's general somatic functioning. The goal of this investigation is to extend current models of child somatization by collectively examining the influence of parent somatization and child emotional functioning.

METHODS

Forty-two children (50% male; M age = 9.11) reported on their somatic symptoms, emotion awareness skills, and negative affect. Parents reported on their own somatic symptoms and their child's somatic symptoms and emotion regulation skills.

RESULTS

Regression analyses indicated that poor awareness of emotional experiences and frequency of negative effect predicted child-reported somatic symptoms. Parental somatic symptoms and parent reports of children's emotion regulation difficulties predicted mother-reported child somatic symptoms. Only parental somatic symptoms significantly predicted father-reported child somatic symptoms.

CONCLUSIONS

These results suggest that models of child somatization should consider both family - (e.g. parent somatization) and child-level (e.g. emotional functioning) variables. The discrepancies between parent and child report of youth somatic symptoms underscore the importance of including multiple reporters on symptomatology in research and clinical settings. Suggestions for future research are provided.