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

= Day 2 =

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:
What is school readiness? How to know who is ready and when  '''Why is school readiness important? Why should mental health providers care?'''
 * Literacy and numeracy skills/academic skills, Behavior, Social-emotional, Self-regulation, Adaptive skills
 * 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.
 * 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

'''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

What can we do? Take Home messages
 * 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
 * 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 and what we can do about it Background Research Populations that have social challenges
 * 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
 * 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
 * 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’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 and Findings Take-home Interventions Current Evidence  Conclusions
 * 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
 * Social knowledge not as important as we thought
 * Awareness and motivation important but complicated
 * 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
 * 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
 * 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:
ADHD importance to professionals ADHD Core Symptoms- same over 60 years Domains of functional impairment in children Role of functional impairment in treatment Why is it important to treat ADHD in childhood?
 * 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
 * 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.
 * 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
 * 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?)
 * 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

What is effective treatment for ADHD kids in childhood? Psychoactive medicine business is booming so there is more medication use than behavioral or combined Guidelines on treatments and sequencing Bill: "Behavioral Therapy" (BT) has lower risks (side effects) and equivalent efficacy so BT should routinely be the first line of ADHD treatment Components of effective comprehensive treatment Benefits of short-term behavioral treatments Benefits of pharmacological treatments Limitation of pharmacological intervention
 * Evidence-based short-term treatments
 * Behavioral modification
 * CNS Stimulant medication
 * Combined behavioral and stimulant
 * Most of recommendations are for combined approaches
 * 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
 * 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
 * One pill of Ritalin costs $8- aka $3,000/year- this could be a lot of psychosocial treatment
 * Parent training, school interventions, peer-focused interventions
 * Teaching skills to parents, teaching skills to teachers, teaching skills to kids with peers
 * Lots of evidence that these approaches work
 * Behave better in classroom and at home- this removed incentive of parents and teachers to do behavioral treatments
 * 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 in the last 20 years Take-home points
 * 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
 * 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

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:
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)

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

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 2.  Develop discrepancy 3. Avoid argumentation 4. Roll with resistance 5. Supporting self-efficacy
 * Supportive companion and knowledgeable component (not using scare tactics)
 * Highlight where they want to change
 * This can evoke resistance and defensiveness
 * Solutions are usually evoked by the client so you can guide them to that point
 * 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 ACE project – Antecedents and Consequences of Electronic Nicotine Delivery Systems
 * 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

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