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What Practitioners Need to Know to Help Maltreated Children and their Families

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so I think we're going to get started I

want to welcome everybody to um our

webinar series reducing risk for child

Mal treatment and treating its

consequences and National Training

series and the application of causal

science um this is our second session uh

for those of you who came to our first

session um we're really excited that you

came back and for those of you who are

new to this um our first session is

available um online and we actually

after this webinar and we send out um

the video from this webinar we also

include the first one so you can get

caught up the first session really did

focus on kind of the basics of causal

data science um and how that applies to

um children um and this session is going

to really focus on what practitioners

need to know um to help maltreated

children and their families so we're

going to be a little bit uh closer to

like on the ground uh still pretty

science heavy but a little closer to on

the ground um so we're really excited to

have all of you here Glenn if you could

move to the next slide please that'd be

fantastic all right just a couple

housekeeping things before we dive into

the content today um the slides will be

available after the webinar and one

thing I will start with is we are doing

this as a as a zoom meeting so people

can ask questions live with their voices

uh but I will also highlight that

because it's a zoom meeting that means

you have the right the ability to take

yourself on and off mute so I would ask

everyone um to keep themselves on mute

uh when they're not talking um you can

have yourself on camera or off camera as

you would like uh but

um please keep yourself on mute uh so

after the webinar the slides will be

available we'll send out to everybody

who register for the webinar we'll send

out the slides and it is also being

recorded and we will send that out to

you as well um this slide is inaccurate

actually because it says it's a webinar

but it's a meeting so please keep

yourself on mute uh you can throw things

into the chat over the course of the

webinar if there's a question or comment

that you have during the webinar at any

point feel free to throw it into the

chat we're keeping track all of of all

of that in the background and so we'll

log all of those and bring those

questions up uh Dr saxs is going to have

a couple spots um where he's going to

ask for feedback in people's thoughts um

so at that point um when he opens it up

if you want to say something via chat

throw it in the chat if you want to say

something um by talking just raise your

hand uh which is down on the bottom you

can uh raise your hand just raise your

hand and uh via we you know via the the

webinar not via you know your own actual

hand um and we will call on you and you

can ask your question or make your

comment um I think with that that is the

housekeeping um if we want to go on the

next slide we're not going to have

everybody uh go around and introduce

themselves like we did last time but

this is the The Faculty that's

associated with this webinar series and

also with the champ Center and the champ

Network as well which Kate Sullivan

leads so I believe with that I'm going

to turn it over to Dr Glenn saxs who is

going to present

today well uh thanks Andy so um welcome

back everyone uh really excited you're

here and really excited to share with

you what we have to share with you today

and so as you know as we talked about

last time we're we're talking about

causality um causal science all of that

from the framework of what the ground

what what clinicians what practitioners

need to know to help people so this

session is going to be focused on

practitioners children families what's

needed because that builds the case for

causal day the science and for a sort

sort of science that is needed to add

value to the work so with that the goal

today um we'll review key Concepts from

last time so that we're all in the same

page if people have joined us and missed

last time it's good to be grounded in

the concepts and then for those who were

here last time this will be a good

review then I'm going to talk about how

we generally

practice and where

causality might fit into that

practice I'm going to then go into

diagnosis and how important it is and

problems with it in the curring

practice and then talk about

personalizing practice which is

absolutely

indispensable in cases of

multicausality as as I'll be talking

about so here are some

disclosures about

uh my support and here's a

review so remember last time we defined

child Mal treatment outcomes these are

deleterious events that undermine safety

development Health mental health

adaptive functioning that have to do

with maltreatment exposure or their

consequences so this is what we're

aiming to uh prevent and so the two c

categories

exposures consequences and you could see

examples of

that now I

defined what's in the middle of

everything in practice and it's really

two things when you're seeing someone a

kid family is she at risk for a bad

maltreatment outcome if so what can I do

to reduce the

risk one and two

and I defined one requires predictive

knowledge two is very different

requiring causal

knowledge and then I

defined and this is you know let's I'll

be grounded in basic definitions because

everything Builds on top of this if you

see two variables two factors A and B A

would be any risk or protective Factor B

could be any Mal treatment outcome let's

think of the difference between

predictive and causal knowledge for a

factor a predicts B if knowledge about

it informs knowledge about B and we see

statistical associations correlations

Etc and clinically it's the use of

assessment information to classify an

individual for their risk for treatment

outcome and that's very

different than causal knowledge where

Factory is causal of B if Factor the

value of B is dependent on the value of

a and this all has to do with

intervention so if B is dependent on a

then if I

intervene uh on a b can change however

if B is not dependent on a I could

intervene all I want and B will never

change and so we there's many many many

many ways that a can predict B without

being causal of it and that's an

essential thing to understand for this

uh training

series and you know I defined why this

is through the common cause principle

any Factor that's an effect of a cause

of another variable because are to

correlate with that variable confounded

by their common cause I talked about

lung cancer and yellow

fingers which correlate and the

correlation would be replicated in any

study and of course it there is a common

cause

smoking and this is built the this

triangle of these three variables is

critically critically important and when

we talk about mult

causality boy is of important and I

showed you an example of how this works

how confounds work in observational

data like is telling you about this stol

metaanalysis of uh child um physical

abuse and 29 factors in this

metaanalysis multiple studies and

showing how easy it is for these factors

to be confounded

and misguide our approach to

intervention and then I reviewed

problems with the state of our knowledge

and it boils down to a misalignment a

poor alignment between how we generate

knowledge and the needs for knowledge

and that

causal knowledge can really help in

distinguishing predictive from causal

and then I noted that

all of us here in the this training

series all the participants we have such

a diversity between practitioners

administrators scientists and everyone

is necessary so I'm I'm really looking

forward as we move ahead in this series

to get people's input to have people

roll up their sleeves and wrestle with

the ideas because everyone is important

to move us forward

and it's all about scaling the

translational wall we have our science

as we read about in our

literature then we have our practice and

what's needed and we have this wall and

that wall needs to be scaled and we we

really believe that predictive and

causal knowledge is indispensible for

this okay oh and the last thing because

this I'm going to be referring to again

and again in this series um I wanted to

Define effective care requires the

capacity to make accurate predictions of

Mal treatment outcomes

under intervention conditions and to

learn from the predictive results so we

gather our data we then decide what it

means we want to reduce risk or say this

person doesn't need intervention but

it's all about predicting outcomes under

intervention conditions so we we

intervene because we expect things will

get better it's a prediction then we

intervene if necessary then we look at

what happens we compare results about

what happens to what we

predicted and then we refine our

understanding and our approach to

intervention based on that especially if

we there were prediction errors so this

is going to be a central thing that we

return to again and again and

again and you know we have to get

everything

aligned so let's define how we

practice and I'm I understand of course

everyone is different and practices

differently so I'm making some general

comments to build to build the case for

how things could be adjusted differently

so a general principle We Gather

clinical assessment data to lessen the

risk for maltreatment outcomes for if we

decide there is a risk

intervention so we start with clinical

assessment we get to Mal treatment

outcomes this is a long way to get there

how do we get there

well we have to make clinical decisions

so how does this fit

together what to assess that's the

question what would be most informative

for our clinical decisions and I'm just

going to give some examples of what we

might assess but this becomes critically

important

because whatever we choose is our

material for making our decisions

do does she have symptoms that will help

us uh diagnose a mental

disorder do either of her parents have

symptoms for this

diagnosis has she been exposed to a

particular social factor or

trauma is she a member of a particular

demographic

group does her family have a current or

previous child welfare service plan does

does she carry an alil for a particular

Gene does she have an unconscious

conflict or a particular defensive style

does she have a particular brain Imaging

finding you could see this is all about

information and anything might be

relevant or irrelevant so we have to be

very careful in the limited time we have

for assessment what would be most

informative because this leads to our

clinical decision and then it's the time

we're seeing someone to make these

decisions and then what's going to

happen it's all about time and can we

intervene in

time and

again these definitions are about the

use of the information for certain

purposes and now let's think

what does our literature tell us about

what would be most important and how to

use

that so

let's talk about a kid and let's see how

this might

work here is Eddie I'm going to tell you

a little bit about him but first here is

you or someone like you um a

practitioner again has to make two

basic decisions is he at risk for a bad

maltreatment outcome if so what can I do

to reduce the risk everything you do if

you're working with kids and families is

reducible to that essentially if if if

we want to be in the position of

helping so Eddie is an 8-year-old boy

who has repetive episodes of of hid and

kicking biting other kids and adults

most recently he ran as his teacher

knocking her off uh her

stool he is a history of physical abuse

from his father and was brought to

assessment by his mother for concerns

about episodes of pushing teacher off

her stool kicking his soccer coach

biting another kid recess at

school so of course his maltreatment

outcome is aggressive behavior that's

our Target for intervent that's our

Target and we need to figure out how to

change

that

so be thinking now about well what

information would you gather to

help here's some further pieces of

information at times it's hard for Eddie

to sit still his teacher reports he has

to go to the bathroom too

often at times he reports he can't focus

his teacher reports he Daydreams a

lot his mother reports he has nightmares

of his father hitting

him his mother reports that she believes

his aggressive episodes are due the

rejection sensitivity because of how

much she observed his father rejecting

him he gets really anxious when he sees

someone that reminds him of his father

and sometimes he even feels uh the belt

landing on him that his father used to

strike him

with Eddie's father is in jail now for

assaulting other

people and his parents are separated but

before his father went to jail Eddie was

very anxious about visits with his

father and tried really hard to avoid

them so we have to think about this what

it means how we're going to help him and

you know I wish I could say this was the

most serious case I've ever seen but I'm

I'm sure people you know in in the the

room here um you know this if we're

working with maltreated kids and

families these are the kids and families

we're called to help um this is sadly

tragically not an atypical case and what

that means

is what would you do how would you how

do you think about it and maybe I'll ask

now for people either in the

chat or um or even to say

what what what does this make you think

of how would you begin to approach the

case what would you do with this

information any any

thoughts so folks can throw it either

directly into the chat the chat just

comes back to the moderators but we will

see it and read it out um or you can

raise your

hand and we will call on you

must be someone out there with a

thought anything's

relevant I'm

waiting all right we'll give people one

more a little bit more time if they want

to either raise their hand or uh throw

something into the chat about what they

would do if it's okay I am muted

couldn't find perfect go for iten um I

would probably look for and talk to Mom

and Eddie too teachers about pro-social

behaviors and attributes that we can

really highlight and celebrate um focus

a lot on the good to get some Rapport

building happened for him to feel

comfortable and safe and then probably

utilizing some child- centered play

therapy with some collaterals with the

parent so they can see opportunities for

them to inflect that like into the home

not every day no parent can do child

centered play therapy all the time time

um but just to kind of incorporate

pieces of that into the home so Eddie

has those safe spots to land you know

ever so often throughout the

week yeah

so part of it is engagement part of it

it's a really good point is collecting

more information that you might use

through play and and through through

more engagement to get other information

now how would it help you around are two

essential questions about getting

information to know his risk and how you

might help

him and you don't have to answer maybe

if you're thinking about an answer it

would be but everyone should be thinking

about the information I might want to

get how would it help us for those two

things and I I absolutely agree um

ultimately helping them feel safer with

you and also knowing more about the

positives is going to be eventually

essential uh for sure and we'll talk a

lot more about

that any other any other thoughts before

I move

on hello this is Quinta I couldn't find

where I could raise my hand I apologize

um thanks sir yeah uh I would want to

you know uh rule out

any maybe organic reasons um that could

explain the behavior any

neurological issues if possible um I'm

in Community Mental Health which is it's

not always possible to get a a medical

doctor or a neurologist to rule out

maybe he's had a concussion in the past

or a TBI from being beaten um so I would

I would do that um as part of the

data collection um and then I would get

a comprehensive history of his behavior

um just to sort of pinpoint if maybe

some of this uh behavior that we're

seeing existed in his formative

developmental years or if there is a a

point in time where it started becoming

prominent yeah th those are great

thoughts about get more information that

might be critical and I'm assuming if

you thought it was organic that that

might help you know a little more about

how that reduces risk if the organic

cause was remediable maybe it's a a

seizure too and or or or something like

that that you could intervene on um and

and also getting more detail about his

history so those are really good points

um I what about the information that we

have right now in front of us is any is

any of it relevant we think for how to

know how to help him reduce his risk for

aggression anything that jumps out at

anyone about any of the the the pieces

of data that I've I've offered so

far well I I this is anws I also don't

know how to raise my hand here I can't

see the button for that but it seems

like you mentioned that he seems to be

having like U intrusive thoughts about

his father hitting him past and so

um it um it seems like you know he's got

some I mean this seems like so obvious I

feel kind of ridiculous saying it but he

clearly has symptoms of postmatic stress

disorder and so I mean I would focus on

and he seems to be overwhelmed by those

things and so um you know I think about

self-regulation skills about how to

regulate some of those symptoms

um and like you know in the classroom I

think you know you you know like he he

um ped over his teacher and he kicked

the soccer coach I suspect that there

were you know cues maybe that reminded

him of his of his past experiences and

so I would want to do like a like a

analysis of what specifically happened

which I I

mean it seems like that's consistent

with your approach to to like really

like look yeah well what exactly

happened when that happened like could

you tell me more detail about that

particular incident and and um find out

well like did was there like a loud loud

noises or something that precipitated

those things and then and then CH try to

try to address the environment and then

so that that external environment and

then also build his regulation skills

like sometimes you know like when you

hear those things maybe you could you

know you know like go or his his the

adults in the environment can say you

know I forgot his name Eddie that's

Eddie like maybe you can go to a

fireplace that was created to you know

like that to to I mean you can't do that

overnight but like you know build those

things to deal with his you know his

traumatic symptoms I mean you may be

dissociating or something as well

something like that and and you we'll

take time so my thoughts those are those

are really good points you're you're

using the clinical data here and

thinking you know this seems consistent

with the diagnosis of post-traumatic

stress disorder you know that there's if

that's the case then there's probably

triggers for it that you'd look for

you'd gather more data and and think

that it's the PTSD that's caus you know

is related to the the aggression so

again this is the exercise is about

using clinical data and seeing what it

might tell you about what you should do

so let's um keep going with that and and

again our cycle here we're Gathering

clinical data and then using it to say

okay maybe I'll do this with it and then

the aggressive episodes will presumably

get

better

so I I'll just

um start here by organizing the clinical

data and people have made comments

they're consistent and one of the things

is I totally agree there's more data to

get and actually we're going to carry

Eddie into the next session too where

I'll be talking a lot about other data

but let's talk about the data we have

right

now

okay

so there's nightmares in attention

rejection sensitivity

impulsivity anxiety hyperactivity

avoidance intrusive memory okay that's

what we have so far more data to gather

but you know might this inform us about

what to do might any of it be

causal because then we could use it to

reduce the risk of um

aggression and what about our um well

how does our science help us organize

this so we might see that some of these

fit

together under a diagnosis of PTSD as as

was just stated

before we also might see that other

symptoms fit together the Triad of

inattention impulsivity and

hyperactivity it's part of a diagnosis

ADHD and then you know this clinician

you know where this is a story about

her she might go to the literature and

remember she read something you know the

Ripple effects of trauma valuing

vulnerability PTSD symptoms and

aggression with the Child and Adolescent

population or she could look at ADHD and

aggression impulsive aggression it's

comorbid for adhc and children

adolescence

great I think often in the world we try

and arrive at the diagnosis and and then

that just points us to the intervention

so maybe she has it or you know all of

that so how does this help us CU this is

often how practice

works so here's what she

did based on what she understood as I've

just talked

about she has could organize the data

into two diagnoses both are related to

aggression we also don't have to think

too much but we'll presume there's some

processes that relate to

this yeah please mute yourselves um and

then just to remind you about this

because it's so important effective care

requires capacity to make accurate

predictions of outcomes under

intervention conditions and learn from

predictive result

so she thinks of the interventions

predicting things will get better when

she delivers them or refers for them so

she'll use tfcbt for

PTSD she'll she's a psychiatrist she'll

deliver methyl venid Rin or conera or

she'll refer to this and she'll expect

things will get better our cycle here

right there deliver the

intervention predict next time you

see Eddie things will be a little

better so what

happened he's seen two weeks after his

assessment and he was perhaps a bit less

hyperactive and

inattentive but he had two significant

aggressive episodes

one in the school yard with those same

kids he was as the mother said doing

typical boy stuff yelling in

schoolyard then Eddie kicked another kit

with the

provocation the school monitor reported

another episode at lunch anded he was

slow the clean up um his tray um he felt

rushed by the lentry Monitor and then he

angrily stood up pushed the tray at her

and Eddie's drink fell over staying in

her clothes yeah how do we think Eddie

is welcomed at school around all these

type of episodes kids like this tend not

to be perceived very well in school and

that that's a real problem the other

thing is anxiety and Nightmares are

unchanged so you know you may think see

this say um you know I want to give it

more time

um maybe it didn't you know I'm not

going to change anything maybe it'll

take another few weeks for it to work or

you may want to look and see whe whether

you missed something that's all part of

it people you know you know some great

comments said should we look for organic

causes should we take more detail about

what happened should we uh look for

other diagnosis should we you know

collect more information should we do

play to get more information but part of

it again is when things don't go as

predicted you think of what you missed

and and that's just a really important

thing here and again that fits here okay

you've intervened measuring the outcomes

is this is what I'm telling you what the

outcomes are then you compare results to

your

expectations and then you decide whether

you should be refining your

understanding or whether you shouldn't

have expected change to occur in this

period of

time

okay so what would you do and I'll keep

moving but be thinking about that again

given this because I want everyone to be

in the space of

after you

assess predict do something an

intervention to be always ready to see

what you may have missed and all of that

and it's also how does our science help

us to predict well because that's really

our need to be grounded clinically in

what's what science how how it might

guide us so with that I want to

introduce the concept of the process

that generated the

data another word for this is the truth

you know there is a process out there

whatever it is that generated the

clinical data or the research data what

exactly is it because we want to align

closely as we can to it so that we could

predict well under intervention

conditions so what was the process that

generated the clinical

data here it is just take my word for it

again I this is not a real case but

there is a process and I want to say

well what would this mean if this were

true and it's plausibly true of course

so in this case in the brain there's a

survival circuit let's say it's led by

the amydala the hippocampus involved the

cortex in some ways you know I could

make it up but there's a lot of

literature about it and this is set up

by the experiences of physical

abuse uh maybe certain kids are

vulnerable through genetic

predispositions and then as was

mentioned in one of the comments well

what about triggers so a social fact

fact or a traumatic reminder clinically

relevant that leads to intrusive

memories which spill into impulsivity

and then aggression that's the path

what's also important is that there are

other things here in the clinical data

that if you were to intervene on them

like nightmares hyperactivity avoidance

anxiety and attention they're not going

to change aggression and that's very

very important as we move into what

causality really is it's so important

clinically for this reason what can you

intervene on that will make a difference

and what could you intervene on that

will not change at

all so these are intervention

targets um physical abuse and Gene isn't

changeable so we need to be thinking

about this

but then we need to be thinking

about there are processes that confound

our ability to see what's happening that

obscures our view because nightmares

hyperactivity avoidance anxiety and

attention correlate heavily with

aggression Eddie reported this if we

look at a research article we'll see

these

correlations um but they're not relevant

for changing aggression they're relevant

for predicting aggression but not

changing aggression that was the

difference between predictive knowledge

and causal knowledge why is that again

for the same reason because if you think

of C as the survival circuit and it's

lined to be aggression goes through

intrusive memory and

impulsivity a is let's say think of a as

nightmares just think of this

triangle that's going to correlate but

it will be confounded as I've said

before same thing for all of

these see this process that generated

the data of the truth if you just look

at it you cannot intervene on each of

these things to change

aggression so

it's only on anything in green if it's

changeable any that would possibly

improve aggression and that leads to a

rule I want you to burn into your brain

forever if it's green you can

intervene if it's red get that out of

your head

everyone with me if it's green you can

intervene if it's red get that out of

your head and again with

um this the one in two here R is

predictive you know you you could know

about risk from Red it's not

unimportant but it completely misguides

too about intervention to change

anything and that becomes so

important and

so let's move

into how what happens with

diagnosis because it has to do with

clustering and comorbidity so if you

think about ab and c and the triangle

there inter clusters of

intercorrelations

are to be expected and will happen if

this is necessarily

true

so this will all of this will correlate

intercorrelate with each

other similarly hyperactivity

impulsivity and inattention will

correlate with each other which will of

course

justify our

diagnosis but also explains why our

diagnosis are way less clinically

relevant than we might think

because if you look at what's in red

it's mixed you might say okay it maybe

it's not ADHD it's really PTSD and the

ADHD symptoms come from that so

intrusive memories lead to avoidance

they lead to hyperactivity because

you're he's really active when he's

having intrusive memories Etc you know

that that's how it works but again in

red it's both ADD symptoms and PTSD

symptoms and

similarly in

green one of them is impulsivity the

other is intrusive memory so if we use

our

diagnosis

to totally guide our treatment we're

going to miss big things we're not going

to be able to if we say is

PTSD uh targeting avoidance isn't going

to help even

anxiety it's only intrusive memory that

goes into

impulsivity again if this model is the

process that generated the

data so again we think of our clinical

utility

here so now let's um dive into diagnosis

a little um more um

clearly and let me just ask if if anyone

has any questions right now about

anything I said because I I I I want to

make sure that it's um it's clear for

people and Jenna put this in the chat

but you can raise your hand by um

clicking on react and then one of the

options is raise hand or if you just

want to unmute or throw any questions

into the chat by all means feel free to

do so and if we get questions we will

answer them and if not we will uh we'll

keep

going I just want to make sure that it's

really clear because we were building on

this every

session I have more of a comment than a

a question um and I put it in the chat

in the sense that when we look at

um uh what is considered a mental

disorder if we're going by diagnosis

we're essentially looking at being

symptom free so we're looking at all

those criteria and we're going do they

have that do they have that do they is

there evidence of that um however what I

worry about is being symptom free

doesn't necessarily mean mentally

healthy um so what I'm wondering about

is that I think we're missing a

causal framework of what mental health

really

is um because only if we if we

understand what causes mental health

Then I then we have a better way of

saying all right this variable and that

variable may need to be uh targeted

because it

explains the aggression and so that's

what I'm struggling with yeah so it's a

really good point so I'd say um two

things about that in in a way you could

substitute aggression for anything else

you you might say however you might

Define mentally healthy for Eddie you

could put that in here and then you

would you would have the same problem

still because then you would need to

collect whatever information you think

would be most relevant for how you would

improve his mental health

however you might Define it and I agree

with you for sure and in some of our

studies we're we're doing exactly what

you're saying because I think the focus

on pathology is is a limiting factor no

doubt about it um one reason I put you

know aggression here is because you know

this is you know Eddie's undoing it's

really affecting his health his mental

health is in School how socially ease

regarded obviously we we should be

thinking as as we think of interventions

what we may want to put what positive

things might we collect and fit in here

again um in next in in the next session

I'll be talking a lot about what might

be missing and how that might really

help you so I'm building a case for some

of what you're saying for sure um but

again I want everyone to be thinking

that whatever the outcome

is it's it's the same problem everyone

what's the information that allows you

to um know what to do to make it

better and and and it's all about

causality in that

case uh

does does that help for what you were

saying um it it it does um I think it's

just a foundational

issue with mental health in general um

the framework that we're operating on

doesn't really have a causal definition

of mental health so um that leaves us

with the problem that you're identifying

cuz my other my other thought was if

aggression was considered socially

appropriate this wouldn't be an issue

then because we can say oh aggression is

not a maladaptive maladaptive Behavior

because you know in society we we we

think aggression is

fine right so um that's where I I'm um

but I hear what you're saying though

yeah a little no I get the social

construction and I also get the the

Paradigm focused on pathology misses big

things and and in a way you

know I'm looking for a different

Paradigm as well and then hopefully we

can all engage in thinking about it but

I I'll also say and and I hope this will

become clear as we I lay this out

whatever Paradigm we land in causality

is going to need to be in the middle of

it and we could talk more about it but

but I I think that's that's very true

agree yeah thank you

sure okay so and in fact that's a nice

uh leadup to um some of the problems

with our Paradigm having to do with

diagnosis I've I've just shown you how

diagnosis can be misleading because it

misses the essential things and it

misses like it's based on the clustering

of symptoms which may or may not be able

to be targets for

intervention so here's a definition to

use for a

diagnosis the classification of patients

clients

people into groups defined by

pathological processes again this is

pathology but it's it's there in in at

least in medicine there's there's a

problem causing a

problem and this contributes to

particular health risks to indicate

interventions to lessen those risks so

many of us are in the mental health

world and in

maltreatment consequences we're thinking

of exposure to Mal treatment and mental

health mental disorders consequential of

that so that's really important because

how does that fit with this

definition big problems and so I want to

lead into that discussion by talking

about diagnosis in medicine and um and

and how this works and why it works and

why it's so important to help people um

you know improve their health so I'll

just tell you 58- year old man presents

to an emergency room with exertional

chess pain nausea and shortness of

breath these are symptoms an EKG and

blood worker order revealing ST segment

elevation for people not in the medical

world that's uh an important sign on the

EKG about a heart attack and similarly

elevated blood tro levels that's what

doctors look for and so a diagnosis of a

heart attack or what's called acute

myocardial infarction is made so we have

outcomes of heart attacks like

congestive heart

failure uh arhythmia dangerous

heartbeats uh pre premature death all of

that and we have these symptoms and

signs that fit together together but

those symptoms and signs are from death

to a heart muscle from lack of oxygen

from blockage of

arteries that's why these symptoms are

there none of them cause any of these

outcomes if you intervened on shortness

of breath you know it it's uh not going

to help in less get sometimes getting

more oxygen or nausea or or you know EKG

you know all of this isn't going to help

you if you g for chest pain like a

painkiller it's not going to

help because the these are the causal

Pathways so

again

red green if it's green you can

intervene if it's intervenable if it's

red it's not going to change things and

again R and

green and this is all based on

confounded

associations now that doesn't mean that

what's in red isn't

important it has a role in in the way we

work with people obviously because this

tells you this predicts the outcome it

it helps you know that myocardial cell

death is

going on but you can't intervene that's

again the same difference between

prediction and

causation and here's another case just

to make the point an 8-year-old

girl goes to her

pediatrician she complains of

fatigue she complains of um thirst and

frequent urin

ation uh including bed wedding that just

started blood test elevated um blood and

urinary test uh Lev blood urinary

glucose and a blood test for uh high

glucose and the diagnosis of insulin

dependent diabetes melodus is

made so again diabetes

causes vast peripheral vascular disease

diabetic retinopathy that can cause you

know blindness all of that this is

diabetes but we also see these symptoms

and signs are not causally related and

diabetes is related to the autoimmune

death killing cells in the pancreas that

make insulin that metabolize glucose so

insulin you you give insulin because of

this and it prevents the if the

downstream outcomes of of

diabetes it's the same thing you can't

intervene on any of these

things here's where you might

intervene you certainly with insulin so

again making the same

point and so we could look at the

problem with our current diagnostic

system fermental disorders what are the

problems it's

non-causal it's by definite in 1980 with

dsm3 um Psychiatry decided it shouldn't

be causal because we didn't have enough

causal information well it's uh what 45

years later it's still

non-causal which is a massive problem

it's why you know as we talk later in um

sessions we'll talk about how to build

the causal mental health through

research that is able to discover causes

with the type of data that we have but

what happens in our practice is we will

typically conflate three distinct

Concepts that should be considered

separately diagnosis is a cause so you

might ask the question or Eddie's mother

may ask the question to you if you were

the

clinician why is Edie so aggressive and

your answer could be well if you're were

using diagnosis in the way that DSM is

organized well he's aggressive because

he has PTSD and ADHD

I've talked about the problem diagnosis

is outcome what's your goal for Ed's

treatment well I think this is part of

one of the comments which is absolutely

true well if our treatment works he'll

be symptom free he'll no longer have

PTSD and add which we assume will help

reduce his aggression because we make

lots of assumptions about correlates

between diagnosis and lots and lots of

outcomes

and this is how

diagnosis developed in medicine in the

history of medicine a means of patient

classification which is

different the question how can I use the

clinical data to classify him into a

category of risk for aggressive behavior

indicating how I could reduce the risk

and so to do that Eddie has to be

classified

causes now it gets more

difficult with multicausality which

which really defines also why we need to

personalize

things

so I want you to think about any of the

maltreatment outcomes I've talked about

and um any that you you know you you

know a lot

about so just think about the factors

that you believe might cause it think of

any any sort of factor developmental

social different sorts of TR whatever it

is for any of them and think

about how many factors I think we we

could do a PLL now

even um let's let's do the poll J that

can we do it yeah why don't

people just you know give your best

guess of any of

the uh Mal treatment outcomes you know a

lot about

okay yeah just whatever it's just don't

sweat it

some more people just put your best

guess this will be

intered okay you have 15 more seconds

and then we'll close the

poll this is good so we're seeing you

know

multicausality most of you and and a lot

of people it's like 11 to 20 or over 20

even

yeah some four the 10 so a lot of

factors here okay I'm going

to end the poll

now

okay okay so we could see this okay

let's put our poll away

so yeah we are in a multicausal world

and many of you think many of you pick D

or C you know vastly

multicausal so let's let's stick with

that and I'm going to talk about what

this

means and I haven't even talked about

the interaction between causes so the

greater the number of causes the greater

the risk of um false conclusions from

research you might read

about and I've already defined this so

let's talk about the Peril and

promise of malte causality I'm going to

start with the

Peril remember the common cause

principle any Factor that's an effect of

the cause cause of another variable will

be observed to correlate with that

variable confounded by the common cause

we remember this so we could

substitute you know heart diseas you

know it's not just um lung cancer but I

talked about heart attack yellow fingers

through smoking causal will

be have a confounded correlation with it

we can also think about you know our

story here urine gluc blood glucose is

causal but blood glucose causes urinary

glucose which is

correlated we also talked about the

survival circuit

nightmares it's not going to change

aggression that's

confounded

and this because we are in a multicausal

world almost certainly you all believe

that or almost all of you it's this this

is our Bermuda Triangle where we could

get lost and never found again so and

I'll tell you why that's

true so here's our Bermuda

Triangle let's here's our Mal treatment

outcome so any effect of this cause

maybe it's a survival

circuit we've already talked about that

any of these CA any other causes

EF any of their

effects so if we're reading you know

correlational studies in our

observational

literature any of them and then any of

the uh Upstream causes and you know all

that and

so all of

these are

confounded and then even something not

measured in any study it's still part of

reality part of the process that

generated the data so any of their

effects will also be confounded it's a

massive problem I know I haven't talked

much to the researchers in the room and

I know there's several of you but so

let's let's then talk about the

implications of this for a research

study you might conduct let's say

just part of the process that generated

the data so let's just clean it up a

little bit again we know what red and

green mean

right

so I'm not going to repeat it but burn

it into your brain so just think about

it if you discover that factor H has a

highly significant correlation with

Factor B how would you determine that

factor Factor e confounded it because

you would need to know that or else you

would simply you'd write a paper talking

about H's uh intervention

implications which happens so often or

if you discovered that uh group

stratified by Factor V yielded

significantly different mean scores on

Factor

B how would you determine or rule out

that factor P can founded it making V

predictive not causal and meaning

nothing about

intervention this is the hardest one if

you discover that factor R had a

significant correlation with Factor

B how would you

determine that it was caused by an

unmeasured common common cause here

because unless we can do this our our

research isn't trustworthy for the

reasons I'm talking about here and and

in not next session the session after

I'll be then talking more about methods

to allow us to do this but this is a

teaser for this and you know and

something to you know talk to our our

the researchers in our our our room

about so

why does this model matter

well to predict the outcome to know

whether someone's at risk for an outcome

and it could be a healthy outcome a

positive outcome whatever outcome you

want predicting it would be about all of

this but to prevent it through

intervention these drop out here's

another thing just because it's a Cause

doesn't mean it has an effect that's big

enough that it will matter if you change

it so we have to measure and estimate

the the effects and the size of them so

let's drop out those that in this toy

model it's uh don't have a large enough

effect so these are your intervention

targets It also says that you have 20

statistically significant

associations which would replicate in

every study because it's part of the

process that generated the data um but

you only had seven causes with

clinically significant effects so we

have to we have to figure this out

within our data and that's what causal

data science will help us with and you

know I'm just um I wrote an editorial in

the

my voice is getting scratchy um in the

orange Journal talking about the

research is you navigating a causal

Labyrinth and that we need the sort of

methods that could really rule out

confounding uh in a rigorous way in

order to navigate this Labyrinth but

this

also is the justification for why we

need to be

personalized why we can't have an

intervention like it's the same

intervention for everyone with a

diagnosis because people are complex and

their complexity is

causal that's why they're complex so we

have our model here and this tells us

something let's say we have three kids

for a given

outcome cu could

be aggression could be substance abuse

suicidality or an outcome could be

adaptive functioning it could be doing

well in school it could be anything like

that relate it to the complex people

anytime you think that what contributes

to this is is

multicausal you have to be

personalized and this is one and two as

we've talked talked about the same thing

so one each of these will be predictive

telling you the risk but to reduce the

risk we can't assume that everyone would

have exactly the same ones and so part

of it is we assess every kid and and

then we personalize the interventions

based on that in our last session we'll

be talking about work we're doing to

create clinical decision support Tools

in order to personalize um intervention

based on knowledge of of causes in a

complex way and um you know I'm just

wrapping up here uh I hope we'll have a

good discussion but again I want to put

this here about um I've gone over it but

this this is something to burn in your

brain because even though

our our as I've talked about our science

is lacking to say the least about

causality it's still you could still use

these ideas and next session I'll be

talking a lot about how you use these

ideas now to help um the people you're

working with we will you know I'm going

to continue with Eddie so that and and

to anticipate we need better scientific

knowledge but even with knowledge we

have now we could move forward with it

so next

session how to treat Edie through causal

understanding including assessing some

of the things that people talked about

today and introduce a framework that can

help guide assessment in targeting

causes for Mal treatment outcomes in

your practice I'm going to present an

example of an intervention model that

uses this framework actually the model

that I created with my team called

trauma systems therapy we'll be talking

about that next

time and I'll be presenting tools that

you could use um uh to implement the

causal framework in your practice

whether you're using TST trauma systems

therapy or not or any any to give you

some tools that will help so why um

let's open this up for um some

questions or

comments thank you Glenn so you can uh

again you can either uh unmute yourself

raise your hand um by clicking on the

react button and then selecting raise

your hand or you can throw any questions

or comments into the

chat Quinta raised her hand so by all me

quiny you can unmute yourself and ask

your question or comment um Dr Glenn um

Dr sax I apologize I I appreciate your

when is fine don't

apologize uh appreciate all the

information I look forward to the next

session um for me um as a practitioner I

almost um have in mind when I assess uh

my clients or or patients depending on

where people work um I almost want to

put the diagnosis aside and then say

okay what's the

problem yeah because yeah yeah so that

that's sort of where I've um I'm I'm

leaning because uh I get a client

referred to me because they were charged

with so many know they have a legal

problem but then okay I have to do a

diagnosis for the um the uh uh insurance

companies but the fact that they picked

up a charge it's not necessarily the

problem you know so that's where I'm

leaning no and I I'm with you completely

and and actually showed you why what

you're doing makes sense I mean I I

showed you that with PTSD and add as a

diagnosis you know they some of the some

components of them were not useful for

intervention and some were but you

couldn't tell from diagnosis alone but

you need to intervene to change the

outcome and so part of it is figuring

out how to do this and so the the

diagnosis we have in mental health

because it's non-causal it doesn't give

you this and part of it is wherever you

are you're classifying People based on

the information you get about them and

what I mean as I've said before by

classification you take the information

you get and you look at the kid and you

say are they at risk for this thing I'm

worried about or not so are they within

a group of people given my experience

that I'm worried about and then

classification will they respond to this

intervention I might think about or not

so the question is you know the

diagnostic system we have is really

limited for that so we have to figure

out which A system that is going to be

better for helping us classify kids and

and families like

this thank you um so while we're waiting

for other questions or comments um in

the chat or by raising your hand just

want to highlight that the feedback

survey is in the chat um if we really um

appreciate your feedback this is only

our second one of these so we're really

really interested we took your feedback

very seriously from the first one for

those of you who attended the first one

so please fill out the feedback survey

uh while we're doing questions um and I

will get to you in one second um and

then also uh the registration link for

upcoming webinars is also in the chat

and if you're interested in CES and you

attended the whole session um you'll get

a notification in about a week to

don't mind unmuting and asking your

question or

comment yeah so I was just wondering in

terms of did determining what was what

is red and what is green did you use

statistical analysis to do that or is it

something else so well right now this is

a hypothetical example that you know

there is going to be something that's

true and the way to know it's true is by

using certain uh statistical and data

science techniques to be able to know or

model it's closely as possible the

causal process that generated the data

so we'll be talking about in next

sessions what these techniques are

giving you different examples of

different ways of getting models that

look like this because you you you need

to use very specialized models uh

techniques in order to get that okay

thank

you other folks with questions or

comments feel free again to throw them

in the chat or raise your

hand I really appreciate everybody's

thoughts and comments so

far and if you haven't please fill out

the feedback survey and register for

future events and could I just say

debate is welcome like if anyone wants

to argue that like this it's hard to get

this right we're in a complex world we

have to figure figure out how to get it

right and so you know I I love that

we're a mixture of

providers

administrators and scientists here and

and other other other uh uh people are

represented as well because the solution

is going to involve us mixing it up

because everyone has a a piece of the

elephant so to speak to get it right so

while we're uh waiting for any other

questions or comments that come in Glen

do we want to go just go through the

next session real quick and and ask

people you know just so they know what

that is and question we'll get yes so

this is you know looking ahead where

we're going here

um so we finished one and

two again

we're we introduced the concepts again

we're framing everything by what will be

valuable for what PR practitioners need

to help kids all of that now the next

session as I've said it's going to be

okay I've talked about problems with

clinical application what how people

might be thinking of this and tools they

have so the next session is about

well what our ways to use causal and

predictive knowledge in practice and

there are there's pieces of information

there's ways of using predictive tools

uh and the most to me the most important

thing because in the complex world we

should expect that we're going to be

wrong a lot be wrong a lot we need to we

try an intervention then we don't keep

it going in perpetuity or until someone

drops out of treatment and all of that

we proactively look at it did the did

change happen as we expect it would when

we launched the intervention and if not

what have we missed so that that's next

session and again I'll give you very

practical examples and tools for how you

this then we're going to be moving more

into the science and with an examination

of our Paradigm including

diagnosis including the methods we use

in our research uh all of that and and

looking at

limitations that will build to session

five where I'll be talking about very

powerful tools that might that will make

a difference here and how they use these

tools to build knowledge that may put us

in even a better framework to establish

a a diagnostic system based on

causality and then nothing nothing

matters nothing nothing unless it can

really help people in practice and in

the champ Center which is sponsoring uh

this champ Center and champ Network as

we've talked about before it's all about

using these models to build decision

support tools tools that could be used

in practice to guide decision making as

as we've talked about and and our you

know our six session is going to be

about about

that thank you so much and a reminder

that everybody can register for any of

the any or all of those events through

the link in the chat will also include

it when we send out the slides and the

video um from today's which we encourage

you to uh share broadly um if anybody

has any additional questions or comments

again please feel free to throw them

into the chat or raise your hand um we

appreciate all the folks who dived in

today um and raise questions and

comments uh and also please fill out the

survey the uh provider survey I believe

last time we sent it out after to but we

always love to get them today because I

know that once once you have left today

um you know opening up a new email is is

always an extra challenge so um please

feel free to uh fill out that provider

survey right or the feedback survey

right now um and register for any future

event so I'm just looking through the

chat and also for any raised hand I am

not seeing anything Jen I want to make

sure I'm not missing anything before

yeah there is one last question um have

you considered how substance use might

impact behavior in a

diagnosis yeah I mean that's that's

that's a question and again it it fits

here as well if you think substance

abuse is important for any outcome it's

it's really an empirical question we we

want to see it it needs to be causal it

can't be a correlate or just a

predictive Factor um certainly I've seen

it important for lots of outcomes but

again we we in this world we have to

presume nothing and really follow the

data and the way we may practice where

we're we're set to always be learning

and then about substance abuse it's also

if you you could then put you could also

put substance abuse as your Mal

treatment outcome because it could be

related to Mal treatment but it's the

same thing you what are the causes of it

whether only the predictors of it if I

want to intervene to reduce substance

abuse I have to intervene on the

causes that makes sense all right that

was a really good question I'm glad

somebody raised that because oftentimes

we keep our mental health World on one

side of the aisle and our substitut

world on the other side of the aisle and

often they uh intersect and just one

thing for everyone to think about is you

could substitute anything for your

outcome anything you think is relevant

positive things pathological things uh

negative whatever words you want to use

and um substitute anything you think is

important but it's still the same thing

it's still causality is in the middle of

it if you want to change it wonderful

all right I'm not seeing any more

comments or raised hands so I think we

will give um Everybody let them go back

to their day I really want to thank uh

Glenn for presenting and thank everybody

for taking the time today and joining um

we look forward to our next webinar next

month um again all of the various ways

to sign up for that we we like that

we're carrying people from one to the

other um I think that's really great uh

fill out the feedback survey um and if

you're waiting on cus those will come

through as well so thank you everybody

for taking the time to join today and we

look forward to seeing you at the next

webinar

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What Practitioners Need to Know to Help Maltreated Children and their Families