Technology-based Behavioral Vaccines To Prevent Child And .
Technology-based "Behavioral Vaccines" to PreventChild and Adolescent Mental Disorders in HealthSystems: Are We There Yet?University of Chicago School of Social WorkAdministrationDavis Lecture, October 28, 2014Benjamin Van Voorhees, MD, MPHHeather Risser, PhDJennifer Nidetz, LCSWStephanie Cordel, BS
Children’s Hospital University of Illinois/ TIKES CenterMany thanks to my SSA teachers andcolleagues William Borden, Ph.D. Mathew Epperson, Ph.D. Susan McCracken, Ph.D Harold Pollack, Ph.D. Dexter Voisin, Ph.D.
Caring for people – what ever thecircumstance
People and the challenge of living-therole for the physician
Grant Support1Centers for Disease Control, Prevention Research Centers, Grant #U48/CCU309674(2002)2National Association for Research on Schizophrenia and Affective Disorders YoungInvestigator Award (2004)3Robert Wood Johnson Foundation Depression in Primary Care Value Grant (2005)4K-08National Institute of Mental Health Physician Scientist Career Development Award(2006)5RWJ Foundation Finding Answers Grant (2010)61 R01 MH090035-01A1 Primary Care Internet-Based Depression Prevention forAdolescents (CATCH-IT) (2011)7CMMI Healthcare Innovations Grant, 2015
Mevident, Inc– Received 4,000 to assist inrevising version of CATCH-ITfor schoolsPrevail Health Solutions, Inc.Social Kinetics, IncChinese International School,Hong KongUniversity of Hong KongAlberta Medical AssociationDalhousie UniversityHong Kong Government, SA,PRCDisclosures: Rise Consulting, LLC
Children’s Hospital University of Illinois/TIKES Center
Children’s Hospital University of Illinois/TIKES CenterInfant Mental Health
A Staten Island teenager fell into amanhole while textingLast of Teen Sex Ring SuspectsArrestedTeenagers learn importantsocial, technical skills online:studyTeen Locked Up In Closet For YearsFrequent Family Meals Might ReduceRussia considers ban on emosTeen Substance Useand gothsWhen Flirting Becomes Pornography –SextingTV, other factors lead to early teensex: StudyStudy reveals teen self-harm
Children’s Hospital University of Illinois/ TIKES CenterCore concepts Modern people dwarfed and alienated by urbanizationand overwhelmed complexity Mental and developmental disorders in childhood arisein this context Potential solutions undermined by the same precipitatingfactors and reluctance to fund these services Behavioral intervention technologies offer novelsolutions Simplified distribution and low cost Build self-determination (connection, autonomy andcompetency) Can we build these models into health systems?
Alienation and Complexity ofModernity “Life, as we find it, is too hard for us; it bringsus too many pains, disappointments, andimpossible tasks”Civilization and its DiscontentsSigmund Freud, MD, 1930
Children’s Hospital University of Illinois/ TIKES CenterTrends in Depression by Birth Cohort Cumulative lifetimerates of MDD by birthcohort and age of onsetfrom ECA(EpidemiologicCatchment Area Study) Burden of depression inadolescence is risingacross the last centuryJAMA. 1992. The changing rate of major depression. Cross-national comparisons. Cross-National Collaborative Group. 268(21):3098-105.
Children’s Hospital University of Illinois/ TIKES CenterBurden of Child and AdolescentMental Disorders Increase in recent years in morbidityof behavioral and mental disorders 75% of cases have initial onsetbefore the age of 24 20% (US) of children have disorders 294 billions dollars in direct and indirect costsBriggs-Gowan MJ, et al, Prevalence of social-emotional and behavioral problems in a community sample of 1- and 2-year-old children. J Am Acad ChildAdolesc Psychiatry. Jul 2001;40(7):811-819.
Prevalence of the Disorder-SimilarAcross CulturesProblem/DisorderPoint PrevalenceChinaUnited StatesUnitedKingdomAny disorder16.9%20%?ADHD3.9%3%2.2%Oppositional Defiant Disorder6.8%6%5.8%Depressive Disorder1.3%2.5%2.5%Anxiety disorders6.9%8%3.3%Substance Abuse1.7%5%?Leung PW, Hung SF, Ho TP Lee CC, Liu WS, Tang CP & Kwong SL, 2008; Merikangas, KR, Nakamura, EF & Kessler, RC, 2009)
And the Promise“Resilience arises fromordinarymagic of humanadaptation and capability”Resilience andVulnerabilitySuniya Luthar, Ph.D, 2002
Need narrativesandPictures toengageStories andself-diaryvalueJohn HopkinsFellowship andCDC/Foundation 7,000Quality ofexperiencedrivespotentialefficacyPhase 3clinicaltrial planandinterventiondevelopment ofComplexityintegratingmultiple designelementsUniversity ofChicago/KAward and R-34 1,000,0002012-1016Phase 2ClinicalTrialAnalysis2011-2012Phase 2ClinicalTrial2007-2010Phase 1ClinicalTrialAnalysis ofpilot studyresults2005-20072002-2004Overcoming resistance and raising funds is a majorpart of this challengePhase 3ClinicalTrial PATHStudy andCURBStudyDigital ennui –need for strongrelationalcomponentUniversity ofIllinois/RO-1 andRWJ Foundation 4,000,000
Children’s Hospital University of Illinois/ TIKES CenterCore concepts Modern people dwarfed and alienated by urbanizationand overwhelmed system complexity Mental and developmental disorders in childhood arisein this context Potential solutions undermined by the same precipitatingfactors and reluctance to fund these services Behavioral intervention technologies offer novelsolutions Simplified distribution and low cost Build self-determination (connection, autonomy andcompetency) Can we build these models into health systems?
Why Prevent Adolescent Depression? Treatments for adolescent depression work, but onlyabout half the time. Relapse is quite common, with 40% of teensrelapsing within 2 years, and 75% relapsing within 5years. Prevention is less expensive, and less disruptive,than waiting for an episode to emerge and trying totreat it. Prevention research suggests that there is evidencefor long-term benefits from depression preventionefforts (e.g., Beardslee et al., 2013).
Children’s Hospital University of Illinois/ TIKES CenterLayered Vulnerability Factors for ChildMental Disorder Child characteristics : gender, age, ethnicity, physical health, cognitive andpsychological function, pre- and peri-natal exposures toillness, physical stress, alcohol, drugs, nutrition, infectionsand other environmental agents, and lifetime history ofenvironmental exposures to toxins, stress, infections Life events: stress, social environment and stressful life events Family and parent characteristics: parental education, age, social class, employment, psychiatricand medical history, and family function, structure Neighborhood and broader contextual influences: violence, educational systemMerikangas KR, Nakamura EF, Kessler RC. 2009. Epidemiology of mental disorders in children and adolescents. Dialogues Clin Neurosci. 11(1):7-20.
Children’s Hospital University of Illinois/ TIKES CenterComplex Causation in Space ecommunity,school,individual andfamily tingacross time fromvulnerability todisorder tyand meAdapted from Van Voorhees,et al, JAH, 2008
Children’s Hospital University of Illinois/TIKES CenterAnd Across Inter-lockingDevelopmental Domains
Children’s Hospital University of Illinois/TIKES CenterDevelopmentPhysicalRisser & Issa, 2014
Children’s Hospital University of Illinois/TIKES CenterWith Substantial Neuro-developmentalImpactPerry, 1997
Children’s Hospital University of Illinois/TIKES CenterIntervening Effectively Requires ChoreographingMultiple Interventions Across Time and Space atOptimal Early Time Points and SettingsDevelopmentInterventionsto close thegap betweencurrenttrajectory andpotentialAgeRisser & Issa, 2014
Children’s Hospital University of Illinois/ TIKES CenterCore concepts Modern people dwarfed and alienated by urbanizationand overwhelmed system complexity Mental and developmental disorders in childhood arisein this context Potential solutions undermined by the same precipitatingfactors and reluctance to fund these services Technology Based Behavioral Vaccines offer novelsolutions Simplified distribution and low cost Build self-determination (connection, autonomy andcompetency) Can we build these models into health systems?
Children’s Hospital University of Illinois/ TIKES CenterCost and Feasibility of ConventionalTreatmentConventional Prevention canbe Effective, but Costly andunfeasible The hazard of depressiononset was significantly lowerin CB than UC (X2 4.90,p 0.03; Hazard Ratio(HR) 0.63, 95% CI: 0.40–0.98) 32.7% of adolescents in the UCcontrol condition werediagnosed with a probable ordefinite MDE 21.4% of youth in the CBprogram had a MDE Gladstone, Beardslee, Clark, Brent, Garber, JAMA, 20090.5One Minus Cumulative Survival0.4UC0.3CBP0.20.10.0010203040Week of onset of depressive episode (DSR 4)50
Children’s Hospital University of Illinois/ TIKES CenterTechnology Interventions AsAlternatives Technology interventions areinexpensive and close tomodifiable vulnerability factors Conceptualized as integratedcomponents of the ecologicaldevelopment process thatleads to social capitalformation Health promotion, prevention,and treatment interventions Provides for possible mentalhealth screeningO'connell M, Boat T, Warner K. Preventing Mental, Emotional and Behavioral Disorders Among Young People: Progress and Possibilities.Washington, DC: Institute of Medicine;2009.
Children’s Hospital University of Illinois/ TIKES CenterCost of Primary Care Internet-basedApproach and Face-to-Face Models Cost of implementation: 597.50 per patient(higher than hypothesized 100 and higher thanwillingness-to-pay) Cost of implementing a15-session grouptherapy intervention: 1632 (Lynch, 2007) Therefore, CATCH-IT stillover 1000 cheaper
Children’s Hospital University of Illinois/ TIKES CenterBehavioral Vaccine Model-4 KeyComponentsVan Voorhees, BW, et al, Internet-Based Depression Prevention over the Life Course: A Call for Behavioral Vaccines, Psychiatric Clinics of North America,2011 Mar;34(1):167-83
Children’s Hospital University of Illinois/ TIKES CenterEffective Intervention Components Combine interventions with other modalitiesevidence based components Adapt inexpensive standard interventions to specificcultural settings-socio-cultural relevance Determine what can be shared across large culturalareas vs. local areas Is it as effective as face to face- comparativeeffectiveness? How long will it work-duration of benefits? What components contribute to efficacy mediatorsand moderators ?Hospital Universityof Illinois/TIKES CenterAnderson G, et Children’sal. Internet-basedself-helpfor depression:randomized control trial. BR J Psychiatry 2005; 187:456-61.
CATCH-IT Primary care basedinterventional Web site Principles based in CBT, IPT,and BA Substantial engagement withthe site Moderate pre/post effectsizes for depressed moodVan Voorhees BW, Fogel J, Reinecke MA, et al. Randomized clinical trial of an Internet-based depression prevention program for adolescents (Project CATCHIT) in primary care: 12-week outcomes. J Dev Behav Pediatr. Feb 2009;30(1):23-37.Van Voorhees BW, Vanderplough-Booth K, Fogel J, et al. Integrative internet-based depression prevention for adolescents: a randomized clinical trial in primarycare for vulnerability and protective factors. J Can Acad Child Adolesc Psychiatry. Nov 2008;17(4):184-196.
“I’m feelingdown”Children’s Hospital University of Illinois/ TIKES CenterHow the BehavioralVaccine Model WorksNurse visit followedby enrollment ofteenOnlineinterventionPatient hasreduced riskof disorderOnlineinterventionDoctor visitImplementationStructurePhone followupMotivationalFrameworkEffectiveComponents
33CATCH-IT 3 ORIGINAL RENDERING
Cognitive Behavioral Therapy Picture, Design, Color, Text linked
Children’s Hospital University of Illinois/ TIKES CenterDuration of Benefits –CATCH-IT LongTerm Follow-upCenter for Epidemiologic Studies Depression Scale (CES-D) comparison forboth groups baseline to 120 weeks P-value 0.00135.00CATCH-ITInterventionCES-D10 00.00baseline6 weeks12 weeksTimeChildren’s Hospital University of Illinois/ TIKES Center24 weeks52 weeks120 weeks
Children’s Hospital University of Illinois/TIKES CenterSally N Merry associate professor1, et.al, The effectiveness of SPARX, a computerised self helpintervention for adolescents seeking help fordepression: randomised controlled non-inferiority trial
Children’s Hospital University of Illinois/ TIKES CenterDepression MoodGym & Blue Pages Unguided self-help program based onprinciples of CBT, interpersonaltherapy and relaxation techniquescombined with evidenced-basedinformation about depression (BluePages) Significant improvements in 2-monthfollow up Depis.net Recent development of Internet-basedsupport system for adolescents withdepression tailored to improve selfmanagement skills Consists of elements identifyingadolescents’ needs, and offering selfmonitoring, access to healthinformation and self-reflective writtenexercisesHøifødt, R. S., Lillevoll, K. R., Griffiths, K. M., Wilsgaard, T., Eisemann, M., Waterloo, K., & Kolstrup, N. (2013). The clinical effectiveness ofweb-based cognitive behavioral therapy with face-to-face therapist support for depressed primary care patients: randomized controlled trial.Journal of medical Internet research, 15(8).Välimäki, M., Kurki, M., Hätönen, H., Koivunen, M., Selander, M., Saarijärvi, S., & Anttila, M. (2012). Developing an Internet-Based SupportSystem for Adolescents with Depression. JMIR Research Protocols, 1(2).
Children’s Hospital University of Illinois/TIKES CenterEating Disorders My Body My Life Body image program foradolescent girls Demonstrated moderateeffect sizes between bulimiaand depression The Student Bodies Program Showed small to mediumeffect sizes for bothadolescent and parentoutcomesBruning Brown J, Winzelberg AJ, Abascal LB, Taylor CB. An evaluation of an Internet-delivered eating disorder prevention program for adolescents and theirparents. J Adolesc Health. Oct 2004;35(4):290-296.Heinicke BE, Paxton SJ, McLean SA, Wertheim EH. Internet-delivered targeted group intervention for body dissatisfaction and disordered eating in adolescentgirls: a randomized controlled trial. J Abnorm Child Psychol. Jun 2007;35(3):379-391.
Children’s Hospital University of Illinois/TIKES CenterCombination Programs DEAL Project Development phase of Internetbased program for young people(aged 18–25 years) with cooccurring depression and alcoholuse problems Based on CBT & MotivationalEnhancement COPE Healthy Lifestyles TEEN Educational and cognitive–behavioral skills building (CBSB)intervention that includes 20 minof physical activity in each session Current RCT targets teens 14-16years enrolled in health classDeady, M., Kay-Lambkin, F., Teesson, M., & Mills, K. (2014). Developing an integrated, Internet-based self-help programme for young people with depressionand alcohol use problems. Internet Interventions, 1(3), 118-131.Melnyk, B. M., Kelly, S., Jacobson, D., Belyea, M., Shaibi, G., Small, L., . & Marsiglia, F. F. (2013). The COPE healthy lifestyles TEEN randomized controlledtrial with culturally diverse high school adolescents: Baseline characteristics and methods. Contemporary clinical trials, 36(1), 41-53.
Children’s Hospital University of Illinois/ TIKES CenterEffect-sizes Comparable to OtherInternet-Based InterventionsCategoryMean Btw Group ESMean Pre/Post ESMean NNTDepression .65NAAnxiety0.240.64NAEating Disorder0.290.29NASubstance Abuse0.250.05NACATCH-IT0.180.545.6Siemer, Van Voorhees, et al, 2011; Van Voorhees, et al, 2011,
Children’s Hospital University of Illinois/ TIKES CenterBehavioral Vaccine Model-4 KeyComponentsVan Voorhees, BW, et al, Internet-Based Depression Prevention over the Life Course: A Call for Behavioral Vaccines, Psychiatric Clinics of North America,2011 Mar;34(1):167-83
Children’s Hospital University of Illinois/ TIKES CenterImplementation Structure Primary care setting as an effective way to reachyouth at-risk for depression Combination of self-directed internet interventionand some amount of face-to-face contact withPCP and study staff Intentional website design using InstructionalDesign Theory and Synchronization of theSensesGagne RM, B. L., Wager WW. (1992). Principles of Instructional Design. Fort Worth, TX: Harcourt Brace Jovanovich College Publishers.Kaplan, M. A. (2005). Transpersonal Dimensions of Cinema. The Journal of Transpersonal Psychology, 37(1), 9-22.
Delivery Mechanisms & Context Goal: Maintain high participation rates More interactive exercises Less textual information Use range of media Restrictions: developing countries may nothave technical infrastructure available Two assessment strategies with bestparticipation were Internet and primary care Recruitment via search of medical recordsAndersson G, et al, Internet-based self-help for depression: randomised controlled trial. Brit J Psychiat. Nov2005;187:456-461.Children’s Hospital University of Illinois/ TIKES Center
Increasing Interaction and Work: SelfEfficacy Exercises
Increasing Interaction and PleasantExperience: Narrative Learning Model Self-Diaries
Increasing Interaction and Work: SkillBuilder47
48
49Using Implementation Structure toIncrease interactivity and participationVariableCATCH-IT 2Mean(SD)CATCH-IT 0) .0001Characters 43.94)Time on 07.40)0.09
Delivery Mechanism: fromSparx-Fantasy GameChildren’s Hospital University of Illinois/TIKES CenterChildren’s Hospital University of Illinois/TIKES Center
Children’s Hospital University of Illinois/TIKES CenterSubstance Abuse-Animation ClimateSchools is a program for the prevention of substance abusethrough an interactive website Small-to-moderate effect sizes were observed between groups forknowledge of alcohol and cannabis and their use Small effect sizes were seen for weekly alcohol consumption andfrequency of cannabis use Computer-facilitated screening and brief advice (cSBA) Computerized screening and educational component before the visit,and provider advice during the visit Compared with treatment as usual, cSBA patients reported lessalcohol use at follow-up ( 3 & 12 months)Newton NC, Teesson M, Vogl LE, Andrews G. Internet-based prevention for alcohol and cannabis use: final results of the Climate Schools course. Addiction.Apr 2010;105(4):749-759.Harris, S. K., Csémy, L., Sherritt, L., Starostova, O., Van Hook, S., Johnson, J., . & Knight, J. R. (2012). Computer-facilitated substance use screening and briefadvice for teens in primary care: an international trial. Pediatrics, 129(6), 1072-1082.
Children’s Hospital University of Illinois/ TIKES CenterSafety Majorly depressedparticipants risks: Not being observedfrequently Not having meaningfulreaction with care provider Increase monitoring ofpatients via email, phone,or direct contact Standard approach tosafety management needsto be developedO'Kearney R, et al,. A controlled trial of a school-based Internet program for reducing depressive symptoms in adolescent girls. Depress Anxiety.2009;26(1):65-72.Children’s Hospital University of Illinois/ TIKES Center
Children’s Hospital University of Illinois/ TIKES CenterDrama video example (timepermitting)
Children’s Hospital University of Illinois/ TIKES CenterBehavioral Vaccine Model-4 KeyComponentsVan Voorhees, BW, et al, Internet-Based Depression Prevention over the Life Course: A Call for Behavioral Vaccines, Psychiatric Clinics of North America,2011 Mar;34(1):167-83
Children’s Hospital University of Illinois/TIKES CenterWho is Using Internet-based models?Children’s Hospital University of Illinois/TIKES Center
Children’s Hospital University of Illinois/ TIKES CenterIncrease Participation PredictsImproved OutcomesAlison L. Calear , et.al, Adherence to the MoodGYM program: Outcomes and predictors for an adolescent school-based population
Children’s Hospital University of Illinois/ TIKES CenterProfessional Guidance IncreasesParticipation on Internet Programs Higher completion rates for guided study vs.unguided study participants Drop rates larger for participants in self-directedpsychotherapy groups Drop out rates in Catch-It after 3 months**: With phone follow-ups: 7% Without phone follow-ups: 43% Physician motivational interview increased Internetparticipation 25%*Christensen H, et al, Web-based cognitive behavior therapy: analysis of site usage and changes in depression and anxiety scores. J Med Internet Res.Jan-Mar 2002;4(1):e3.**Gellatly J, et al,Children’sWhat sityof Illinois/ TIKESCenter in the management of depressive symptoms? Meta-analysis and meta-regression. PsycholMed. Sep 2007;37(9):1217-1228.
Children’s Hospital University of Illinois/ TIKES CenterMotivational Framework-CATCH-IT Model based upon the Theory of PlannedBehavior and depression help-seeking Participants completed a behavior changecontract Three PCP motivational interviews at 0, 2 and12 months and a 1-month safety/motivationalcall from study staff for teens Parents receive a parallel structure of 3motivational interviews and one phone call onlyby study staffCarter, W. B. (1990). Health Behavior as a Rational Process: Theory of Reasoned Action and Multiatribute Utility Theory. In K. Glanz, F. M. L. Lewis &B. K. Rimer (Eds.), Health Behavior and Health Education (pp. 63-90). San Francisco: Jossey-Bass Publishers.Halgin, R. P., Weaver, D. D., Edell, W. S., & Spencer, P. G. (1987). Relation of depression and help-seeking history to attitudes toward seekingprofessional psychological help. Journal of Counseling Psychology, 34(2), 177-185.
PATH Study Design andRandomization
Children’s Hospital University of Illinois/ TIKES CenterMotivational Interview Video (timepermitting)
Results N 234 adolescents enrolled (186 randomized)Mean Age 14.94 (SD 1.49)73.75% Female46.89% Racial Minority17.95% LatinoMean Adolescent Baseline CES-D 17.86(SD 9.28)
Internet Participation: Average Number of ModulesCompleted by TeensAcross Sites15141312111098765432106.76 *3.73*1514131211109876543210By SiteBostonChicago7.895.96 **5.052.84**CATCH-ITTeensHealth EdTeens* Statistically significant difference between Total Teen CATCH-IT use and Total Teen Health Ed use**Statistically significant difference between Chicago Teen CATCH-IT use and Chicago Teen Health Ed use
Internet Participation: Average Number of ModulesCompleted by ParentsAcross Both Sites By 00.00CATCH-ITParentsHealth EdParents2.482.40 2.341.85CATCH-ITParentsHealth EdParents
Internet Participation: Average Number of Minutes Teens Spenton ModulesAcross SitesBy Site14014012012010010093.35 *80802075.0070.98606040126.324020.28 *2044.9223.6817.8900TeenTeenCATCH-IT Health Ed* Teens spent statistically more time on CATCH-IT than on Health Ed.BostonChicago
Children’s Hospital University of Illinois/TIKES CenterSchool Based Teacher Lead- Anxiety BRAVE Online Studies include 1 pre/postdesign and 3 randomizedclinical trials Effect sizes without direct faceto-face contact were small, butthose done in a clinic settingreported as moderate Cool Teens 12-week computerizedcognitive-behavioral therapyprogram for anxietymanagement Small RCT (43 teens) withsignificant reductions in anxietypresence and severityMarch S, Spence SH, Donovan CL. The efficacy of an internet-based cognitive-behavioral therapy intervention for child anxiety disorders. J PediatrPsychol. Jun 2009;34(5):474-487.Wuthrich, V. M., Rapee, R. M., Cunningham, M. J., Lyneham, H. J., Hudson, J. L., & Schniering, C. A. (2012). A Randomized Controlled Trial of the i Cool Teens /i CD-ROM Computerized Program for Adolescent Anxiety. Journal of the American Academy of Child & Adolescent Psychiatry, 51(3), 261270.
Children’s Hospital University of Illinois/ TIKES CenterCore concepts Modern people dwarfed and alienated by urbanizationand overwhelmed system complexity Mental and developmental disorders in childhood arisein this context Potential solutions undermined by the same precipitatingfactors and reluctance to fund these services Behavioral intervention technologies offer novelsolutions Simplified distribution and low cost Build self-determination (connection, autonomy andcompetency) Can we build these models into health systems?
Children’s Hospital University of Illinois/ TIKES CenterHealth System Level ChangesProviders to address on their ownTraining of physiciansTraining of para-professionalsTraining of general practice and Pediatricians mustplay major role Use of technology based interventions Early preventive intervention may be mosteffective in reducing life time burden Ford T. 2008. Practitioner review: How can epidemiology help us plan and deliver effective child and adolescent mental health services? J ChildPsychol Psychiatry. 49(9):900-14.McGorry PD, Purcell R, Goldstone S, Amminger GP. 2011. Age of onset and timing of treatment for mental and substance use disorders: implicationsfor preventive intervention strategies and models of care. Curr Opin Psychiatry. 24(4):301-6.
Children’s Hospital University of Illinois/ TIKES CenterImportance of Early Intervention Early childhood adversity can lead to lifelongimpairments in learning, behavior, and bothphysical and mental health Nurturing environments during early childhoodminimize problem behaviors and promote prosocial and self-regulatory skills A key formation of social-emotionaldevelopment in children is presence of positivecaregiver-child relationshipShonkoff, J. P., Garner, A. S., Siegel, B. S., Dobbins, M. I., Earls, M. F., McGuinn, L., . & Wood, D. L. (2012). The lifelong effects of early childhoodadversity and toxic stress. Pediatrics, 129(1), e232-e246.Biglan, A., Flay, B. R., Embry, D. D., & Sandler, I. N. (2012). The critical role of nurturing environments for promoting human well-being. AmericanPsychologist, 67(4), 257.Shonkoff, J. P., & Bales, S. N. (2011). Science does not speak for itself: Translating child development research for the public and its policymakers.Child Development, 82(1), 17-32.
Intervention Model
Intervention Aims
PromotionAmeliorating factors Parent child relationships prompt medicalcare effective medical managementWell managedconditionPoorlymanagedconditionExacerbating factors Problematic parent child relationships Mental illness Family Chaos1. Support and reinforce familystrengths2. Prepare for nextdevelopmental stage.Prevention1.2.3.4.Step 1 repeatedStep 2 repeatedHealth literacySupport activation andmotivationIntervention1.2.3.4.Step 1Step 2Step 3Developmentally appropriatesolution-focused selfdiscovery5. Improve activation andmotivation
Children’s Hospital University of Illinois/ TIKES CenterIntervention by Developmental PreventionStrongAfricanAmericanStrengthening FamiliesIncredible Years(Primary CareModel)Teaching Kids toCope (TKC)Triple P- Level 4Prevention of depressionHealthy Steps/Bright FuturesYoungAdulthood
Children’s Hospital University of Illinois/TIKES CenterEffectiveness of Early ChildhoodPrograms Incredible Years RCTs showed significant improvement inparenting skills, reduced behavior problemsand reduction in externalizing problemsrelated to parent mental health risk factors Triple P More than 150 studies over 33 years withsignificant effects for parenting practicesalong with children’s social, emotional &behavioral outcomes Healthy Steps Recent findings show Healthy Steps mayserve as moderator of caregiver childhoodtrauma and child social-emotionaldevelopmentWebster-Stratton, C. (2011). The Incredible Years: Parent, Teacher, and Child Training Series (IYS). In Preventing Violence and Related Health-Risking Social Behaviors inAdolescents: An NIH State-of-the-Science Conference (p. 73).Briggs, R. D., Silver, E. J., Krug, L. M., Mason, Z. S., Schrag, R. D., Chinitz, S., & Racine, A. D. (2014). Healthy Steps as a moderator: The impact of maternal trauma on childsocial-emotional development. Clinical Practice in Pediatric Psychology, 2(2), 166.Sanders, M. R., Kirby, J. N., Tellegen, C. L., & Day, J. J. (2014). The Triple P-Positive Parenting Program: A systematic review and meta-analysis of a multi-level system ofparenting support. Clinical psychology review, 34(4), 337-357.
Preventable oral, mental anddevelopmental disorders increase cost andblock developmentDevelopmental Outcome(cognitive, socio-emotional, Fineand Gross Motors)Developmental Outcomes of Children in Urban Settings50% of ethnic minority urbanchildren do not graduate fromhigh schoolTime (t)Developmental OutcomeHigh School Graduate
CMMI Innovation Grant Model Seeks to Closethe Gap and Reduce CostsDevelopmental Outcome(cognitive, socio-emotional, Fine andGross Motors)Developmental Outcomes of Children in Urban SettingsFrom Head to Tooth will boostdevelopmental outcomes throughearly identification, prevention andtreatmentTime (t)Developmental OutcomeHigh School Graduate
Children’s Hospital University of Illinois/ TIKES CenterConclusions Evidence that Internet interventions can playimportant role in the prevention of mentaldisorders continues to develop
Behavioral intervention technologies offer novel solutions Simplified distribution and low cost . gender, age, ethnicity, physical health, cognitive and psychological function, pre- and peri-natal exposures to illness, physical stress, alcohol, drugs, nutrition, in
Similarities between vaccines and drugs Vaccine are also medical products Vaccines, like drugs, can cause adverse events Vaccines and drugs all contain multiple ingredients Each class of ingredient may cause their own adverse events Vaccines and drugs both have the potenti
Contents CBO Summary ix 1 The Market for Seasonal-Influenza Vaccine and the Challenge of Providing Vaccine in a Pandemic 1 The Market for Seasonal-Influenza Vaccine 3 Supplying Vaccine in a Pandemic 5 Overview of HHS’s Plan 5 Risks Associated with HHS’s Plan 7 Additional Public Health Questions 7 2 Developing New Vaccines 9 Adjuvanted Vaccines 9 Cell-Based Vaccines 13
During vaccine development, the mechanisms involved in conferring immunity were unknown. Nevertheless, the use of live attenuated or killed whole organism-based vaccines had enormous . mRNA vaccines were reported to be effective for direct gene transfer for the first time by Woff et al. (15). Currently, two forms of mRNA vaccines have been .
Introduction to Behavioral Finance CHAPTER1 What Is Behavioral Finance? Behavioral Finance: The Big Picture Standard Finance versus Behavioral Finance The Role of Behavioral Finance with Private Clients How Practical Application of Behavioral Finance Can Create a Successful Advisory Rel
International Journal of Vaccines and Vaccination New Quality-Control Investigations on Vaccines: Micro- and Nanocontamination Submit Manuscript Int J Vaccines Vaccin 2016, 4(1): . 2International Clean Water Institute, USA 3Nanodiagnostics srl, Italy *Corresponding author: Dr. Antonietta Gatti, National
Sep 17, 2020 · The IHCP also provides coverage for many immunizations and vaccines. In addition, various free vaccines are available for members 18 years of age and younger through the Vaccines for Children (VFC) program, administered through the Indiana State Dep
K2P COVID-19 SRIS A CLOSER LOOK AT COVID-19 VACCINES: THE KNOWN, THE UNKNOWN, AND THE UNCERTAIN 3. COVID-19 VACCINES AVAILABLE FOR PUBLIC USE Until February 2nd 2021, 63 candidate vaccines are undergoing clinical evaluation with 177 other candidate
Government to support incoming travel across Australia's international borders in the coming months. It will be updated regularly as new evidence on the effectiveness of the currently-reported vaccines emerges, and as assessments on other vaccines is completed. Note that while certain vaccines may be considered by the TGA as
