0:00 so I think we're going to get started I
0:01 want to welcome everybody to um our
0:03 webinar series reducing risk for child
0:05 Mal treatment and treating its
0:07 consequences and National Training
0:08 series and the application of causal
0:10 science um this is our second session uh
0:13 for those of you who came to our first
0:15 session um we're really excited that you
0:18 came back and for those of you who are
0:20 new to this um our first session is
0:23 available um online and we actually
0:25 after this webinar and we send out um
0:27 the video from this webinar we also
0:29 include the first one so you can get
0:30 caught up the first session really did
0:32 focus on kind of the basics of causal
0:34 data science um and how that applies to
0:37 um children um and this session is going
0:40 to really focus on what practitioners
0:42 need to know um to help maltreated
0:44 children and their families so we're
0:45 going to be a little bit uh closer to
0:47 like on the ground uh still pretty
0:50 science heavy but a little closer to on
0:52 the ground um so we're really excited to
0:54 have all of you here Glenn if you could
0:56 move to the next slide please that'd be
0:57 fantastic all right just a couple
0:58 housekeeping things before we dive into
1:00 the content today um the slides will be
1:03 available after the webinar and one
1:05 thing I will start with is we are doing
1:07 this as a as a zoom meeting so people
1:09 can ask questions live with their voices
1:13 uh but I will also highlight that
1:14 because it's a zoom meeting that means
1:16 you have the right the ability to take
1:18 yourself on and off mute so I would ask
1:20 everyone um to keep themselves on mute
1:23 uh when they're not talking um you can
1:26 have yourself on camera or off camera as
1:28 you would like uh but
1:30 um please keep yourself on mute uh so
1:33 after the webinar the slides will be
1:35 available we'll send out to everybody
1:36 who register for the webinar we'll send
1:38 out the slides and it is also being
1:40 recorded and we will send that out to
1:41 you as well um this slide is inaccurate
1:45 actually because it says it's a webinar
1:46 but it's a meeting so please keep
1:48 yourself on mute uh you can throw things
1:51 into the chat over the course of the
1:52 webinar if there's a question or comment
1:54 that you have during the webinar at any
1:56 point feel free to throw it into the
1:59 chat we're keeping track all of of all
2:01 of that in the background and so we'll
2:02 log all of those and bring those
2:04 questions up uh Dr saxs is going to have
2:07 a couple spots um where he's going to
2:09 ask for feedback in people's thoughts um
2:12 so at that point um when he opens it up
2:15 if you want to say something via chat
2:17 throw it in the chat if you want to say
2:19 something um by talking just raise your
2:22 hand uh which is down on the bottom you
2:25 can uh raise your hand just raise your
2:26 hand and uh via we you know via the the
2:30 webinar not via you know your own actual
2:32 hand um and we will call on you and you
2:35 can ask your question or make your
2:36 comment um I think with that that is the
2:40 housekeeping um if we want to go on the
2:42 next slide we're not going to have
2:43 everybody uh go around and introduce
2:45 themselves like we did last time but
2:47 this is the The Faculty that's
2:48 associated with this webinar series and
2:51 also with the champ Center and the champ
2:53 Network as well which Kate Sullivan
2:55 leads so I believe with that I'm going
2:57 to turn it over to Dr Glenn saxs who is
2:59 going to present
3:01 today well uh thanks Andy so um welcome
3:05 back everyone uh really excited you're
3:08 here and really excited to share with
3:10 you what we have to share with you today
3:13 and so as you know as we talked about
3:16 last time we're we're talking about
3:21 causality um causal science all of that
3:24 from the framework of what the ground
3:28 what what clinicians what practitioners
3:32 need to know to help people so this
3:35 session is going to be focused on
3:39 practitioners children families what's
3:42 needed because that builds the case for
3:46 causal day the science and for a sort
3:48 sort of science that is needed to add
3:52 value to the work so with that the goal
3:57 today um we'll review key Concepts from
4:01 last time so that we're all in the same
4:04 page if people have joined us and missed
4:07 last time it's good to be grounded in
4:10 the concepts and then for those who were
4:12 here last time this will be a good
4:16 review then I'm going to talk about how
4:19 we generally
4:21 practice and where
4:24 causality might fit into that
4:28 practice I'm going to then go into
4:31 diagnosis and how important it is and
4:36 problems with it in the curring
4:39 practice and then talk about
4:42 personalizing practice which is
4:45 absolutely
4:47 indispensable in cases of
4:50 multicausality as as I'll be talking
4:53 about so here are some
4:58 disclosures about
5:00 uh my support and here's a
5:04 review so remember last time we defined
5:08 child Mal treatment outcomes these are
5:12 deleterious events that undermine safety
5:15 development Health mental health
5:17 adaptive functioning that have to do
5:20 with maltreatment exposure or their
5:23 consequences so this is what we're
5:25 aiming to uh prevent and so the two c
5:29 categories
5:31 exposures consequences and you could see
5:35 examples of
5:37 that now I
5:40 defined what's in the middle of
5:42 everything in practice and it's really
5:45 two things when you're seeing someone a
5:48 kid family is she at risk for a bad
5:52 maltreatment outcome if so what can I do
5:55 to reduce the
5:57 risk one and two
6:01 and I defined one requires predictive
6:05 knowledge two is very different
6:09 requiring causal
6:11 knowledge and then I
6:14 defined and this is you know let's I'll
6:18 be grounded in basic definitions because
6:22 everything Builds on top of this if you
6:24 see two variables two factors A and B A
6:28 would be any risk or protective Factor B
6:31 could be any Mal treatment outcome let's
6:34 think of the difference between
6:36 predictive and causal knowledge for a
6:40 factor a predicts B if knowledge about
6:44 it informs knowledge about B and we see
6:48 statistical associations correlations
6:50 Etc and clinically it's the use of
6:54 assessment information to classify an
6:57 individual for their risk for treatment
7:00 outcome and that's very
7:02 different than causal knowledge where
7:05 Factory is causal of B if Factor the
7:09 value of B is dependent on the value of
7:12 a and this all has to do with
7:15 intervention so if B is dependent on a
7:18 then if I
7:19 intervene uh on a b can change however
7:24 if B is not dependent on a I could
7:27 intervene all I want and B will never
7:30 change and so we there's many many many
7:35 many ways that a can predict B without
7:39 being causal of it and that's an
7:41 essential thing to understand for this
7:45 uh training
7:49 series and you know I defined why this
7:53 is through the common cause principle
7:55 any Factor that's an effect of a cause
7:58 of another variable because are to
8:00 correlate with that variable confounded
8:03 by their common cause I talked about
8:06 lung cancer and yellow
8:08 fingers which correlate and the
8:11 correlation would be replicated in any
8:14 study and of course it there is a common
8:17 cause
8:18 smoking and this is built the this
8:22 triangle of these three variables is
8:25 critically critically important and when
8:28 we talk about mult
8:29 causality boy is of important and I
8:33 showed you an example of how this works
8:36 how confounds work in observational
8:40 data like is telling you about this stol
8:44 metaanalysis of uh child um physical
8:48 abuse and 29 factors in this
8:51 metaanalysis multiple studies and
8:54 showing how easy it is for these factors
8:58 to be confounded
9:00 and misguide our approach to
9:04 intervention and then I reviewed
9:06 problems with the state of our knowledge
9:09 and it boils down to a misalignment a
9:13 poor alignment between how we generate
9:16 knowledge and the needs for knowledge
9:19 and that
9:21 causal knowledge can really help in
9:24 distinguishing predictive from causal
9:27 and then I noted that
9:29 all of us here in the this training
9:32 series all the participants we have such
9:34 a diversity between practitioners
9:37 administrators scientists and everyone
9:41 is necessary so I'm I'm really looking
9:45 forward as we move ahead in this series
9:48 to get people's input to have people
9:50 roll up their sleeves and wrestle with
9:53 the ideas because everyone is important
9:57 to move us forward
10:00 and it's all about scaling the
10:02 translational wall we have our science
10:05 as we read about in our
10:07 literature then we have our practice and
10:11 what's needed and we have this wall and
10:15 that wall needs to be scaled and we we
10:19 really believe that predictive and
10:21 causal knowledge is indispensible for
10:27 this okay oh and the last thing because
10:30 this I'm going to be referring to again
10:33 and again in this series um I wanted to
10:38 Define effective care requires the
10:40 capacity to make accurate predictions of
10:43 Mal treatment outcomes
10:45 under intervention conditions and to
10:48 learn from the predictive results so we
10:52 gather our data we then decide what it
10:55 means we want to reduce risk or say this
10:59 person doesn't need intervention but
11:01 it's all about predicting outcomes under
11:04 intervention conditions so we we
11:06 intervene because we expect things will
11:08 get better it's a prediction then we
11:11 intervene if necessary then we look at
11:14 what happens we compare results about
11:17 what happens to what we
11:20 predicted and then we refine our
11:23 understanding and our approach to
11:25 intervention based on that especially if
11:29 we there were prediction errors so this
11:33 is going to be a central thing that we
11:36 return to again and again and
11:39 again and you know we have to get
11:43 everything
11:45 aligned so let's define how we
11:50 practice and I'm I understand of course
11:53 everyone is different and practices
11:55 differently so I'm making some general
11:58 comments to build to build the case for
12:02 how things could be adjusted differently
12:06 so a general principle We Gather
12:09 clinical assessment data to lessen the
12:12 risk for maltreatment outcomes for if we
12:15 decide there is a risk
12:18 intervention so we start with clinical
12:22 assessment we get to Mal treatment
12:24 outcomes this is a long way to get there
12:27 how do we get there
12:30 well we have to make clinical decisions
12:34 so how does this fit
12:37 together what to assess that's the
12:39 question what would be most informative
12:43 for our clinical decisions and I'm just
12:45 going to give some examples of what we
12:47 might assess but this becomes critically
12:50 important
12:52 because whatever we choose is our
12:55 material for making our decisions
13:01 do does she have symptoms that will help
13:03 us uh diagnose a mental
13:07 disorder do either of her parents have
13:10 symptoms for this
13:12 diagnosis has she been exposed to a
13:15 particular social factor or
13:17 trauma is she a member of a particular
13:20 demographic
13:22 group does her family have a current or
13:25 previous child welfare service plan does
13:29 does she carry an alil for a particular
13:31 Gene does she have an unconscious
13:34 conflict or a particular defensive style
13:37 does she have a particular brain Imaging
13:40 finding you could see this is all about
13:44 information and anything might be
13:47 relevant or irrelevant so we have to be
13:50 very careful in the limited time we have
13:53 for assessment what would be most
13:56 informative because this leads to our
13:59 clinical decision and then it's the time
14:03 we're seeing someone to make these
14:06 decisions and then what's going to
14:08 happen it's all about time and can we
14:11 intervene in
14:16 time and
14:18 again these definitions are about the
14:22 use of the information for certain
14:25 purposes and now let's think
14:29 what does our literature tell us about
14:32 what would be most important and how to
14:35 use
14:37 that so
14:40 let's talk about a kid and let's see how
14:43 this might
14:45 work here is Eddie I'm going to tell you
14:48 a little bit about him but first here is
14:52 you or someone like you um a
14:55 practitioner again has to make two
14:59 basic decisions is he at risk for a bad
15:03 maltreatment outcome if so what can I do
15:07 to reduce the risk everything you do if
15:12 you're working with kids and families is
15:15 reducible to that essentially if if if
15:19 we want to be in the position of
15:26 helping so Eddie is an 8-year-old boy
15:31 who has repetive episodes of of hid and
15:34 kicking biting other kids and adults
15:37 most recently he ran as his teacher
15:40 knocking her off uh her
15:43 stool he is a history of physical abuse
15:47 from his father and was brought to
15:49 assessment by his mother for concerns
15:52 about episodes of pushing teacher off
15:55 her stool kicking his soccer coach
15:57 biting another kid recess at
16:00 school so of course his maltreatment
16:04 outcome is aggressive behavior that's
16:07 our Target for intervent that's our
16:10 Target and we need to figure out how to
16:14 change
16:15 that
16:16 so be thinking now about well what
16:20 information would you gather to
16:25 help here's some further pieces of
16:30 information at times it's hard for Eddie
16:32 to sit still his teacher reports he has
16:35 to go to the bathroom too
16:37 often at times he reports he can't focus
16:40 his teacher reports he Daydreams a
16:44 lot his mother reports he has nightmares
16:47 of his father hitting
16:50 him his mother reports that she believes
16:53 his aggressive episodes are due the
16:56 rejection sensitivity because of how
16:59 much she observed his father rejecting
17:03 him he gets really anxious when he sees
17:07 someone that reminds him of his father
17:10 and sometimes he even feels uh the belt
17:13 landing on him that his father used to
17:16 strike him
17:18 with Eddie's father is in jail now for
17:21 assaulting other
17:26 people and his parents are separated but
17:31 before his father went to jail Eddie was
17:34 very anxious about visits with his
17:36 father and tried really hard to avoid
17:39 them so we have to think about this what
17:43 it means how we're going to help him and
17:45 you know I wish I could say this was the
17:47 most serious case I've ever seen but I'm
17:51 I'm sure people you know in in the the
17:54 room here um you know this if we're
17:58 working with maltreated kids and
18:01 families these are the kids and families
18:04 we're called to help um this is sadly
18:09 tragically not an atypical case and what
18:13 that means
18:15 is what would you do how would you how
18:19 do you think about it and maybe I'll ask
18:22 now for people either in the
18:25 chat or um or even to say
18:30 what what what does this make you think
18:32 of how would you begin to approach the
18:36 case what would you do with this
18:38 information any any
18:41 thoughts so folks can throw it either
18:43 directly into the chat the chat just
18:45 comes back to the moderators but we will
18:46 see it and read it out um or you can
18:49 raise your
18:50 hand and we will call on you
18:59 must be someone out there with a
19:08 thought anything's
19:13 relevant I'm
19:16 waiting all right we'll give people one
19:18 more a little bit more time if they want
19:20 to either raise their hand or uh throw
19:23 something into the chat about what they
19:25 would do if it's okay I am muted
19:28 couldn't find perfect go for iten um I
19:32 would probably look for and talk to Mom
19:34 and Eddie too teachers about pro-social
19:37 behaviors and attributes that we can
19:38 really highlight and celebrate um focus
19:41 a lot on the good to get some Rapport
19:43 building happened for him to feel
19:45 comfortable and safe and then probably
19:47 utilizing some child- centered play
19:48 therapy with some collaterals with the
19:50 parent so they can see opportunities for
19:53 them to inflect that like into the home
19:55 not every day no parent can do child
19:57 centered play therapy all the time time
19:59 um but just to kind of incorporate
20:01 pieces of that into the home so Eddie
20:04 has those safe spots to land you know
20:07 ever so often throughout the
20:08 week yeah
20:10 so part of it is engagement part of it
20:14 it's a really good point is collecting
20:16 more information that you might use
20:19 through play and and through through
20:22 more engagement to get other information
20:24 now how would it help you around are two
20:29 essential questions about getting
20:31 information to know his risk and how you
20:35 might help
20:39 him and you don't have to answer maybe
20:42 if you're thinking about an answer it
20:44 would be but everyone should be thinking
20:47 about the information I might want to
20:50 get how would it help us for those two
20:52 things and I I absolutely agree um
20:57 ultimately helping them feel safer with
21:00 you and also knowing more about the
21:04 positives is going to be eventually
21:08 essential uh for sure and we'll talk a
21:12 lot more about
21:14 that any other any other thoughts before
21:18 I move
21:19 on hello this is Quinta I couldn't find
21:23 where I could raise my hand I apologize
21:25 um thanks sir yeah uh I would want to
21:29 you know uh rule out
21:31 any maybe organic reasons um that could
21:35 explain the behavior any
21:38 neurological issues if possible um I'm
21:41 in Community Mental Health which is it's
21:44 not always possible to get a a medical
21:46 doctor or a neurologist to rule out
21:49 maybe he's had a concussion in the past
21:52 or a TBI from being beaten um so I would
21:56 I would do that um as part of the
21:59 data collection um and then I would get
22:02 a comprehensive history of his behavior
22:07 um just to sort of pinpoint if maybe
22:09 some of this uh behavior that we're
22:12 seeing existed in his formative
22:15 developmental years or if there is a a
22:18 point in time where it started becoming
22:21 more
22:24 prominent yeah th those are great
22:27 thoughts about get more information that
22:30 might be critical and I'm assuming if
22:32 you thought it was organic that that
22:35 might help you know a little more about
22:38 how that reduces risk if the organic
22:40 cause was remediable maybe it's a a
22:43 seizure too and or or or something like
22:47 that that you could intervene on um and
22:50 and also getting more detail about his
22:52 history so those are really good points
22:55 um I what about the information that we
22:59 have right now in front of us is any is
23:03 any of it relevant we think for how to
23:08 know how to help him reduce his risk for
23:13 aggression anything that jumps out at
23:16 anyone about any of the the the pieces
23:19 of data that I've I've offered so
23:22 far well I I this is anws I also don't
23:28 know how to raise my hand here I can't
23:30 see the button for that but it seems
23:33 like you mentioned that he seems to be
23:34 having like U intrusive thoughts about
23:39 his father hitting him past and so
23:44 um it um it seems like you know he's got
23:49 some I mean this seems like so obvious I
23:54 feel kind of ridiculous saying it but he
23:59 clearly has symptoms of postmatic stress
24:02 disorder and so I mean I would focus on
24:06 and he seems to be overwhelmed by those
24:08 things and so um you know I think about
24:12 self-regulation skills about how to
24:15 regulate some of those symptoms
24:19 um and like you know in the classroom I
24:23 think you know you you know like he he
24:28 um ped over his teacher and he kicked
24:30 the soccer coach I suspect that there
24:34 were you know cues maybe that reminded
24:37 him of his of his past experiences and
24:42 so I would want to do like a like a
24:46 analysis of what specifically happened
24:50 which I I
24:52 mean it seems like that's consistent
24:54 with your approach to to like really
24:57 like look yeah well what exactly
24:59 happened when that happened like could
25:02 you tell me more detail about that
25:04 particular incident and and um find out
25:08 well like did was there like a loud loud
25:12 noises or something that precipitated
25:16 those things and then and then CH try to
25:20 try to address the environment and then
25:23 so that that external environment and
25:26 then also build his regulation skills
25:29 like sometimes you know like when you
25:32 hear those things maybe you could you
25:34 know you know like go or his his the
25:38 adults in the environment can say you
25:40 know I forgot his name Eddie that's
25:43 Eddie like maybe you can go to a
25:45 fireplace that was created to you know
25:47 like that to to I mean you can't do that
25:51 overnight but like you know build those
25:54 things to deal with his you know his
25:58 traumatic symptoms I mean you may be
26:00 dissociating or something as well
26:02 something like that and and you we'll
26:04 take time so my thoughts those are those
26:08 are really good points you're you're
26:10 using the clinical data here and
26:12 thinking you know this seems consistent
26:15 with the diagnosis of post-traumatic
26:17 stress disorder you know that there's if
26:20 that's the case then there's probably
26:22 triggers for it that you'd look for
26:24 you'd gather more data and and think
26:27 that it's the PTSD that's caus you know
26:31 is related to the the aggression so
26:35 again this is the exercise is about
26:38 using clinical data and seeing what it
26:41 might tell you about what you should do
26:45 so let's um keep going with that and and
26:49 again our cycle here we're Gathering
26:52 clinical data and then using it to say
26:55 okay maybe I'll do this with it and then
26:59 the aggressive episodes will presumably
27:02 get
27:03 better
27:05 so I I'll just
27:08 um start here by organizing the clinical
27:12 data and people have made comments
27:15 they're consistent and one of the things
27:17 is I totally agree there's more data to
27:20 get and actually we're going to carry
27:23 Eddie into the next session too where
27:26 I'll be talking a lot about other data
27:29 but let's talk about the data we have
27:32 right
27:35 now
27:37 okay
27:39 so there's nightmares in attention
27:42 rejection sensitivity
27:45 impulsivity anxiety hyperactivity
27:48 avoidance intrusive memory okay that's
27:52 what we have so far more data to gather
27:56 but you know might this inform us about
28:00 what to do might any of it be
28:03 causal because then we could use it to
28:06 reduce the risk of um
28:10 aggression and what about our um well
28:15 how does our science help us organize
28:18 this so we might see that some of these
28:24 fit
28:25 together under a diagnosis of PTSD as as
28:29 was just stated
28:31 before we also might see that other
28:35 symptoms fit together the Triad of
28:38 inattention impulsivity and
28:40 hyperactivity it's part of a diagnosis
28:43 of
28:44 ADHD and then you know this clinician
28:47 you know where this is a story about
28:50 her she might go to the literature and
28:54 remember she read something you know the
28:58 Ripple effects of trauma valuing
29:00 vulnerability PTSD symptoms and
29:03 aggression with the Child and Adolescent
29:05 population or she could look at ADHD and
29:10 aggression impulsive aggression it's
29:13 comorbid for adhc and children
29:15 adolescence
29:17 so
29:19 great I think often in the world we try
29:22 and arrive at the diagnosis and and then
29:26 that just points us to the intervention
29:28 so maybe she has it or you know all of
29:32 that so how does this help us CU this is
29:36 often how practice
29:39 works so here's what she
29:42 did based on what she understood as I've
29:45 just talked
29:51 about she has could organize the data
29:55 into two diagnoses both are related to
30:00 aggression we also don't have to think
30:03 too much but we'll presume there's some
30:06 processes that relate to
30:09 this yeah please mute yourselves um and
30:13 then just to remind you about this
30:16 because it's so important effective care
30:19 requires capacity to make accurate
30:22 predictions of outcomes under
30:24 intervention conditions and learn from
30:27 predictive result
30:28 so she thinks of the interventions
30:32 predicting things will get better when
30:34 she delivers them or refers for them so
30:39 she'll use tfcbt for
30:42 PTSD she'll she's a psychiatrist she'll
30:45 deliver methyl venid Rin or conera or
30:49 she'll refer to this and she'll expect
30:52 things will get better our cycle here
30:56 right there deliver the
30:58 intervention predict next time you
31:01 see Eddie things will be a little
31:06 better so what
31:14 happened he's seen two weeks after his
31:18 assessment and he was perhaps a bit less
31:21 hyperactive and
31:24 inattentive but he had two significant
31:26 aggressive episodes
31:29 one in the school yard with those same
31:31 kids he was as the mother said doing
31:34 typical boy stuff yelling in
31:37 schoolyard then Eddie kicked another kit
31:39 with the
31:41 provocation the school monitor reported
31:44 another episode at lunch anded he was
31:46 slow the clean up um his tray um he felt
31:52 rushed by the lentry Monitor and then he
31:55 angrily stood up pushed the tray at her
31:58 and Eddie's drink fell over staying in
32:01 her clothes yeah how do we think Eddie
32:04 is welcomed at school around all these
32:07 type of episodes kids like this tend not
32:11 to be perceived very well in school and
32:15 that that's a real problem the other
32:18 thing is anxiety and Nightmares are
32:20 unchanged so you know you may think see
32:24 this say um you know I want to give it
32:27 more time
32:29 um maybe it didn't you know I'm not
32:32 going to change anything maybe it'll
32:34 take another few weeks for it to work or
32:36 you may want to look and see whe whether
32:41 you missed something that's all part of
32:43 it people you know you know some great
32:46 comments said should we look for organic
32:48 causes should we take more detail about
32:52 what happened should we uh look for
32:55 other diagnosis should we you know
32:58 collect more information should we do
33:00 play to get more information but part of
33:03 it again is when things don't go as
33:07 predicted you think of what you missed
33:10 and and that's just a really important
33:13 thing here and again that fits here okay
33:18 you've intervened measuring the outcomes
33:21 is this is what I'm telling you what the
33:25 outcomes are then you compare results to
33:28 your
33:29 expectations and then you decide whether
33:32 you should be refining your
33:34 understanding or whether you shouldn't
33:36 have expected change to occur in this
33:39 period of
33:42 time
33:45 okay so what would you do and I'll keep
33:49 moving but be thinking about that again
33:52 given this because I want everyone to be
33:55 in the space of
33:58 after you
34:00 assess predict do something an
34:03 intervention to be always ready to see
34:07 what you may have missed and all of that
34:10 and it's also how does our science help
34:13 us to predict well because that's really
34:17 our need to be grounded clinically in
34:21 what's what science how how it might
34:24 guide us so with that I want to
34:27 introduce the concept of the process
34:30 that generated the
34:33 data another word for this is the truth
34:39 you know there is a process out there
34:41 whatever it is that generated the
34:43 clinical data or the research data what
34:47 exactly is it because we want to align
34:50 as
34:52 closely as we can to it so that we could
34:56 predict well under intervention
34:59 conditions so what was the process that
35:03 generated the clinical
35:06 data here it is just take my word for it
35:10 again I this is not a real case but
35:13 there is a process and I want to say
35:16 well what would this mean if this were
35:18 true and it's plausibly true of course
35:22 so in this case in the brain there's a
35:26 survival circuit let's say it's led by
35:29 the amydala the hippocampus involved the
35:32 cortex in some ways you know I could
35:35 make it up but there's a lot of
35:37 literature about it and this is set up
35:41 by the experiences of physical
35:43 abuse uh maybe certain kids are
35:47 vulnerable through genetic
35:49 predispositions and then as was
35:51 mentioned in one of the comments well
35:54 what about triggers so a social fact
35:57 fact or a traumatic reminder clinically
36:00 relevant that leads to intrusive
36:03 memories which spill into impulsivity
36:06 and then aggression that's the path
36:09 what's also important is that there are
36:11 other things here in the clinical data
36:14 that if you were to intervene on them
36:17 like nightmares hyperactivity avoidance
36:21 anxiety and attention they're not going
36:23 to change aggression and that's very
36:26 very important as we move into what
36:30 causality really is it's so important
36:33 clinically for this reason what can you
36:36 intervene on that will make a difference
36:40 and what could you intervene on that
36:42 will not change at
36:44 all so these are intervention
36:49 targets um physical abuse and Gene isn't
36:53 changeable so we need to be thinking
36:55 about this
37:01 but then we need to be thinking
37:05 about there are processes that confound
37:08 our ability to see what's happening that
37:11 obscures our view because nightmares
37:15 hyperactivity avoidance anxiety and
37:18 attention correlate heavily with
37:21 aggression Eddie reported this if we
37:24 look at a research article we'll see
37:27 these
37:28 correlations um but they're not relevant
37:31 for changing aggression they're relevant
37:35 for predicting aggression but not
37:38 changing aggression that was the
37:40 difference between predictive knowledge
37:42 and causal knowledge why is that again
37:47 for the same reason because if you think
37:50 of C as the survival circuit and it's
37:53 lined to be aggression goes through
37:56 intrusive memory and
37:58 impulsivity a is let's say think of a as
38:02 nightmares just think of this
38:05 triangle that's going to correlate but
38:07 it will be confounded as I've said
38:10 before same thing for all of
38:14 these see this process that generated
38:17 the data of the truth if you just look
38:20 at it you cannot intervene on each of
38:23 these things to change
38:26 aggression so
38:28 it's only on anything in green if it's
38:32 changeable any that would possibly
38:37 improve aggression and that leads to a
38:41 rule I want you to burn into your brain
38:48 forever if it's green you can
38:53 intervene if it's red get that out of
38:56 your head
38:58 everyone with me if it's green you can
39:03 intervene if it's red get that out of
39:07 your head and again with
39:11 um this the one in two here R is
39:16 predictive you know you you could know
39:19 about risk from Red it's not
39:21 unimportant but it completely misguides
39:25 too about intervention to change
39:28 anything and that becomes so
39:32 important and
39:34 so let's move
39:37 into how what happens with
39:42 diagnosis because it has to do with
39:45 clustering and comorbidity so if you
39:49 think about ab and c and the triangle
39:52 there inter clusters of
39:55 intercorrelations
39:57 are to be expected and will happen if
40:00 this is necessarily
40:02 true
40:04 so this will all of this will correlate
40:07 intercorrelate with each
40:09 other similarly hyperactivity
40:12 impulsivity and inattention will
40:14 correlate with each other which will of
40:17 course
40:18 justify our
40:21 diagnosis but also explains why our
40:25 diagnosis are way less clinically
40:28 relevant than we might think
40:32 because if you look at what's in red
40:36 it's mixed you might say okay it maybe
40:38 it's not ADHD it's really PTSD and the
40:42 ADHD symptoms come from that so
40:46 intrusive memories lead to avoidance
40:49 they lead to hyperactivity because
40:52 you're he's really active when he's
40:53 having intrusive memories Etc you know
40:57 that that's how it works but again in
41:00 red it's both ADD symptoms and PTSD
41:05 symptoms and
41:07 similarly in
41:09 green one of them is impulsivity the
41:12 other is intrusive memory so if we use
41:17 our
41:18 diagnosis
41:21 to totally guide our treatment we're
41:24 going to miss big things we're not going
41:26 to be able to if we say is
41:29 PTSD uh targeting avoidance isn't going
41:32 to help even
41:34 anxiety it's only intrusive memory that
41:37 goes into
41:39 impulsivity again if this model is the
41:42 process that generated the
41:48 data so again we think of our clinical
41:51 utility
41:55 here so now let's um dive into diagnosis
42:01 a little um more um
42:06 clearly and let me just ask if if anyone
42:09 has any questions right now about
42:12 anything I said because I I I I want to
42:15 make sure that it's um it's clear for
42:20 people and Jenna put this in the chat
42:22 but you can raise your hand by um
42:25 clicking on react and then one of the
42:27 options is raise hand or if you just
42:29 want to unmute or throw any questions
42:31 into the chat by all means feel free to
42:33 do so and if we get questions we will
42:35 answer them and if not we will uh we'll
42:38 keep
42:40 going I just want to make sure that it's
42:43 really clear because we were building on
42:45 this every
42:48 session I have more of a comment than a
42:52 a question um and I put it in the chat
42:54 in the sense that when we look at
42:57 um uh what is considered a mental
43:01 disorder if we're going by diagnosis
43:03 we're essentially looking at being
43:05 symptom free so we're looking at all
43:07 those criteria and we're going do they
43:09 have that do they have that do they is
43:11 there evidence of that um however what I
43:14 worry about is being symptom free
43:17 doesn't necessarily mean mentally
43:20 healthy um so what I'm wondering about
43:24 is that I think we're missing a
43:28 causal framework of what mental health
43:31 really
43:32 is um because only if we if we
43:36 understand what causes mental health
43:38 Then I then we have a better way of
43:41 saying all right this variable and that
43:44 variable may need to be uh targeted
43:47 because it
43:49 explains the aggression and so that's
43:52 what I'm struggling with yeah so it's a
43:55 really good point so I'd say um two
43:58 things about that in in a way you could
44:01 substitute aggression for anything else
44:05 you you might say however you might
44:07 Define mentally healthy for Eddie you
44:11 could put that in here and then you
44:14 would you would have the same problem
44:16 still because then you would need to
44:18 collect whatever information you think
44:21 would be most relevant for how you would
44:25 improve his mental health
44:27 however you might Define it and I agree
44:30 with you for sure and in some of our
44:32 studies we're we're doing exactly what
44:35 you're saying because I think the focus
44:38 on pathology is is a limiting factor no
44:41 doubt about it um one reason I put you
44:45 know aggression here is because you know
44:48 this is you know Eddie's undoing it's
44:52 really affecting his health his mental
44:55 health is in School how socially ease
44:59 regarded obviously we we should be
45:02 thinking as as we think of interventions
45:05 what we may want to put what positive
45:09 things might we collect and fit in here
45:12 again um in next in in the next session
45:17 I'll be talking a lot about what might
45:20 be missing and how that might really
45:23 help you so I'm building a case for some
45:27 of what you're saying for sure um but
45:30 again I want everyone to be thinking
45:33 that whatever the outcome
45:36 is it's it's the same problem everyone
45:40 what's the information that allows you
45:43 to um know what to do to make it
45:48 better and and and it's all about
45:51 causality in that
45:55 case uh
45:57 does does that help for what you were
46:02 saying um it it it does um I think it's
46:06 just a foundational
46:09 issue with mental health in general um
46:13 the framework that we're operating on
46:15 doesn't really have a causal definition
46:18 of mental health so um that leaves us
46:21 with the problem that you're identifying
46:24 cuz my other my other thought was if
46:27 aggression was considered socially
46:30 appropriate this wouldn't be an issue
46:33 then because we can say oh aggression is
46:36 not a maladaptive maladaptive Behavior
46:40 because you know in society we we we
46:42 think aggression is
46:43 fine right so um that's where I I'm um
46:47 but I hear what you're saying though
46:49 yeah a little no I get the social
46:52 construction and I also get the the
46:57 Paradigm focused on pathology misses big
47:00 things and and in a way you
47:04 know I'm looking for a different
47:06 Paradigm as well and then hopefully we
47:09 can all engage in thinking about it but
47:13 I I'll also say and and I hope this will
47:16 become clear as we I lay this out
47:20 whatever Paradigm we land in causality
47:24 is going to need to be in the middle of
47:26 it and we could talk more about it but
47:29 but I I think that's that's very true
47:32 agree yeah thank you
47:35 sure okay so and in fact that's a nice
47:40 uh leadup to um some of the problems
47:45 with our Paradigm having to do with
47:47 diagnosis I've I've just shown you how
47:51 diagnosis can be misleading because it
47:54 misses the essential things and it
47:56 misses like it's based on the clustering
47:59 of symptoms which may or may not be able
48:03 to be targets for
48:05 intervention so here's a definition to
48:09 use for a
48:14 diagnosis the classification of patients
48:18 clients
48:19 people into groups defined by
48:23 pathological processes again this is
48:26 pathology but it's it's there in in at
48:29 least in medicine there's there's a
48:32 problem causing a
48:34 problem and this contributes to
48:36 particular health risks to indicate
48:39 interventions to lessen those risks so
48:43 many of us are in the mental health
48:45 world and in
48:47 maltreatment consequences we're thinking
48:49 of exposure to Mal treatment and mental
48:52 health mental disorders consequential of
48:55 that so that's really important because
48:59 how does that fit with this
49:03 definition big problems and so I want to
49:07 lead into that discussion by talking
49:10 about diagnosis in medicine and um and
49:15 and how this works and why it works and
49:18 why it's so important to help people um
49:24 you know improve their health so I'll
49:27 just tell you 58- year old man presents
49:31 to an emergency room with exertional
49:34 chess pain nausea and shortness of
49:36 breath these are symptoms an EKG and
49:40 blood worker order revealing ST segment
49:43 elevation for people not in the medical
49:46 world that's uh an important sign on the
49:49 EKG about a heart attack and similarly
49:55 elevated blood tro levels that's what
49:58 doctors look for and so a diagnosis of a
50:01 heart attack or what's called acute
50:04 myocardial infarction is made so we have
50:09 outcomes of heart attacks like
50:12 congestive heart
50:13 failure uh arhythmia dangerous
50:17 heartbeats uh pre premature death all of
50:21 that and we have these symptoms and
50:24 signs that fit together together but
50:28 those symptoms and signs are from death
50:33 to a heart muscle from lack of oxygen
50:36 from blockage of
50:38 arteries that's why these symptoms are
50:41 there none of them cause any of these
50:44 outcomes if you intervened on shortness
50:47 of breath you know it it's uh not going
50:53 to help in less get sometimes getting
50:55 more oxygen or nausea or or you know EKG
51:01 you know all of this isn't going to help
51:03 you if you g for chest pain like a
51:08 painkiller it's not going to
51:10 help because the these are the causal
51:15 Pathways so
51:16 again
51:19 red green if it's green you can
51:22 intervene if it's intervenable if it's
51:26 red it's not going to change things and
51:28 again R and
51:31 green and this is all based on
51:34 confounded
51:35 associations now that doesn't mean that
51:39 what's in red isn't
51:41 important it has a role in in the way we
51:45 work with people obviously because this
51:47 tells you this predicts the outcome it
51:51 it helps you know that myocardial cell
51:55 death is
51:57 going on but you can't intervene that's
52:00 again the same difference between
52:03 prediction and
52:06 causation and here's another case just
52:09 to make the point an 8-year-old
52:12 girl goes to her
52:17 pediatrician she complains of
52:20 fatigue she complains of um thirst and
52:25 frequent urin
52:27 ation uh including bed wedding that just
52:31 started blood test elevated um blood and
52:36 urinary test uh Lev blood urinary
52:39 glucose and a blood test for uh high
52:44 glucose and the diagnosis of insulin
52:46 dependent diabetes melodus is
52:49 made so again diabetes
52:54 causes vast peripheral vascular disease
52:58 diabetic retinopathy that can cause you
53:01 know blindness all of that this is
53:04 diabetes but we also see these symptoms
53:07 and signs are not causally related and
53:12 diabetes is related to the autoimmune
53:17 death killing cells in the pancreas that
53:21 make insulin that metabolize glucose so
53:25 insulin you you give insulin because of
53:29 this and it prevents the if the
53:34 downstream outcomes of of
53:36 diabetes it's the same thing you can't
53:40 intervene on any of these
53:42 things here's where you might
53:45 intervene you certainly with insulin so
53:50 again making the same
53:52 point and so we could look at the
53:57 problem with our current diagnostic
54:02 system fermental disorders what are the
54:07 problems it's
54:09 non-causal it's by definite in 1980 with
54:14 dsm3 um Psychiatry decided it shouldn't
54:18 be causal because we didn't have enough
54:21 causal information well it's uh what 45
54:25 years later it's still
54:27 non-causal which is a massive problem
54:30 it's why you know as we talk later in um
54:36 sessions we'll talk about how to build
54:38 the causal mental health through
54:41 research that is able to discover causes
54:45 with the type of data that we have but
54:49 what happens in our practice is we will
54:53 typically conflate three distinct
54:56 Concepts that should be considered
55:00 separately diagnosis is a cause so you
55:04 might ask the question or Eddie's mother
55:07 may ask the question to you if you were
55:09 the
55:10 clinician why is Edie so aggressive and
55:13 your answer could be well if you're were
55:16 using diagnosis in the way that DSM is
55:20 organized well he's aggressive because
55:23 he has PTSD and ADHD
55:27 I've talked about the problem diagnosis
55:30 is outcome what's your goal for Ed's
55:33 treatment well I think this is part of
55:35 one of the comments which is absolutely
55:37 true well if our treatment works he'll
55:41 be symptom free he'll no longer have
55:43 PTSD and add which we assume will help
55:46 reduce his aggression because we make
55:49 lots of assumptions about correlates
55:51 between diagnosis and lots and lots of
55:54 outcomes
55:57 and this is how
55:59 diagnosis developed in medicine in the
56:02 history of medicine a means of patient
56:06 classification which is
56:08 different the question how can I use the
56:11 clinical data to classify him into a
56:15 category of risk for aggressive behavior
56:18 indicating how I could reduce the risk
56:22 and so to do that Eddie has to be
56:25 classified
56:26 by
56:30 causes now it gets more
56:35 difficult with multicausality which
56:38 which really defines also why we need to
56:43 personalize
56:45 things
56:47 so I want you to think about any of the
56:50 maltreatment outcomes I've talked about
56:53 and um any that you you know you you
56:57 know a lot
56:59 about so just think about the factors
57:03 that you believe might cause it think of
57:06 any any sort of factor developmental
57:09 social different sorts of TR whatever it
57:13 is for any of them and think
57:18 about how many factors I think we we
57:21 could do a PLL now
57:23 even um let's let's do the poll J that
57:27 can we do it yeah why don't
57:30 people just you know give your best
57:33 guess of any of
57:37 the uh Mal treatment outcomes you know a
57:39 lot about
57:43 um
57:44 okay yeah just whatever it's just don't
57:48 sweat it
58:02 some more people just put your best
58:05 guess this will be
58:12 intered okay you have 15 more seconds
58:17 and then we'll close the
58:20 poll this is good so we're seeing you
58:25 know
58:27 multicausality most of you and and a lot
58:30 of people it's like 11 to 20 or over 20
58:34 even
58:36 yeah some four the 10 so a lot of
58:39 factors here okay I'm going
58:42 to end the poll
58:46 now
58:50 okay okay so we could see this okay
58:53 let's put our poll away
58:59 so yeah we are in a multicausal world
59:04 and many of you think many of you pick D
59:07 or C you know vastly
59:11 multicausal so let's let's stick with
59:14 that and I'm going to talk about what
59:17 this
59:19 means and I haven't even talked about
59:22 the interaction between causes so the
59:26 greater the number of causes the greater
59:29 the risk of um false conclusions from
59:33 research you might read
59:35 about and I've already defined this so
59:39 let's talk about the Peril and
59:43 promise of malte causality I'm going to
59:47 start with the
59:51 Peril remember the common cause
59:53 principle any Factor that's an effect of
59:55 the cause cause of another variable will
59:58 be observed to correlate with that
59:59 variable confounded by the common cause
60:02 we remember this so we could
60:06 substitute you know heart diseas you
60:08 know it's not just um lung cancer but I
60:11 talked about heart attack yellow fingers
60:13 through smoking causal will
60:18 be have a confounded correlation with it
60:22 we can also think about you know our
60:25 story here urine gluc blood glucose is
60:28 causal but blood glucose causes urinary
60:32 glucose which is
60:34 correlated we also talked about the
60:37 survival circuit
60:39 nightmares it's not going to change
60:42 aggression that's
60:45 confounded
60:46 and this because we are in a multicausal
60:50 world almost certainly you all believe
60:53 that or almost all of you it's this this
60:56 is our Bermuda Triangle where we could
60:59 get lost and never found again so and
61:03 I'll tell you why that's
61:07 true so here's our Bermuda
61:12 Triangle let's here's our Mal treatment
61:16 outcome so any effect of this cause
61:20 maybe it's a survival
61:22 circuit we've already talked about that
61:26 any of these CA any other causes
61:29 EF any of their
61:31 effects so if we're reading you know
61:34 correlational studies in our
61:37 observational
61:39 literature any of them and then any of
61:42 the uh Upstream causes and you know all
61:45 of
61:46 that and
61:49 so all of
61:51 these are
61:53 confounded and then even something not
61:56 measured in any study it's still part of
62:00 reality part of the process that
62:02 generated the data so any of their
62:05 effects will also be confounded it's a
62:09 massive problem I know I haven't talked
62:11 much to the researchers in the room and
62:14 I know there's several of you but so
62:18 let's let's then talk about the
62:20 implications of this for a research
62:23 study you might conduct let's say
62:26 just part of the process that generated
62:28 the data so let's just clean it up a
62:31 little bit again we know what red and
62:35 green mean
62:37 right
62:39 so I'm not going to repeat it but burn
62:42 it into your brain so just think about
62:46 it if you discover that factor H has a
62:49 highly significant correlation with
62:52 Factor B how would you determine that
62:55 factor Factor e confounded it because
62:58 you would need to know that or else you
63:00 would simply you'd write a paper talking
63:03 about H's uh intervention
63:08 implications which happens so often or
63:12 if you discovered that uh group
63:14 stratified by Factor V yielded
63:17 significantly different mean scores on
63:20 Factor
63:21 B how would you determine or rule out
63:24 that factor P can founded it making V
63:28 predictive not causal and meaning
63:31 nothing about
63:33 intervention this is the hardest one if
63:37 you discover that factor R had a
63:39 significant correlation with Factor
63:42 B how would you
63:45 determine that it was caused by an
63:49 unmeasured common common cause here
63:53 because unless we can do this our our
63:58 research isn't trustworthy for the
64:01 reasons I'm talking about here and and
64:05 in not next session the session after
64:08 I'll be then talking more about methods
64:12 to allow us to do this but this is a
64:15 teaser for this and you know and
64:18 something to you know talk to our our
64:21 the researchers in our our our room
64:24 about so
64:26 why does this model matter
64:29 well to predict the outcome to know
64:33 whether someone's at risk for an outcome
64:36 and it could be a healthy outcome a
64:38 positive outcome whatever outcome you
64:41 want predicting it would be about all of
64:46 this but to prevent it through
64:50 intervention these drop out here's
64:53 another thing just because it's a Cause
64:55 doesn't mean it has an effect that's big
64:58 enough that it will matter if you change
65:01 it so we have to measure and estimate
65:05 the the effects and the size of them so
65:08 let's drop out those that in this toy
65:12 model it's uh don't have a large enough
65:16 effect so these are your intervention
65:18 targets It also says that you have 20
65:24 statistically significant
65:27 associations which would replicate in
65:29 every study because it's part of the
65:32 process that generated the data um but
65:35 you only had seven causes with
65:39 clinically significant effects so we
65:42 have to we have to figure this out
65:45 within our data and that's what causal
65:48 data science will help us with and you
65:52 know I'm just um I wrote an editorial in
65:55 the
65:59 my voice is getting scratchy um in the
66:02 orange Journal talking about the
66:05 research is you navigating a causal
66:09 Labyrinth and that we need the sort of
66:11 methods that could really rule out
66:15 confounding uh in a rigorous way in
66:17 order to navigate this Labyrinth but
66:21 this
66:23 also is the justification for why we
66:27 need to be
66:28 personalized why we can't have an
66:31 intervention like it's the same
66:33 intervention for everyone with a
66:35 diagnosis because people are complex and
66:39 their complexity is
66:42 causal that's why they're complex so we
66:47 have our model here and this tells us
66:50 something let's say we have three kids
66:53 for a given
66:54 outcome cu could
66:56 be aggression could be substance abuse
67:01 suicidality or an outcome could be
67:04 adaptive functioning it could be doing
67:08 well in school it could be anything like
67:11 that relate it to the complex people
67:14 anytime you think that what contributes
67:17 to this is is
67:19 multicausal you have to be
67:22 personalized and this is one and two as
67:25 we've talked talked about the same thing
67:27 so one each of these will be predictive
67:31 telling you the risk but to reduce the
67:35 risk we can't assume that everyone would
67:39 have exactly the same ones and so part
67:42 of it is we assess every kid and and
67:46 then we personalize the interventions
67:49 based on that in our last session we'll
67:52 be talking about work we're doing to
67:55 create clinical decision support Tools
67:59 in order to personalize um intervention
68:02 based on knowledge of of causes in a
68:06 complex way and um you know I'm just
68:10 wrapping up here uh I hope we'll have a
68:13 good discussion but again I want to put
68:17 this here about um I've gone over it but
68:20 this this is something to burn in your
68:23 brain because even though
68:26 our our as I've talked about our science
68:29 is lacking to say the least about
68:33 causality it's still you could still use
68:37 these ideas and next session I'll be
68:40 talking a lot about how you use these
68:43 ideas now to help um the people you're
68:47 working with we will you know I'm going
68:50 to continue with Eddie so that and and
68:53 to anticipate we need better scientific
68:56 knowledge but even with knowledge we
68:58 have now we could move forward with it
69:01 so next
69:03 session how to treat Edie through causal
69:07 understanding including assessing some
69:09 of the things that people talked about
69:12 today and introduce a framework that can
69:15 help guide assessment in targeting
69:18 causes for Mal treatment outcomes in
69:20 your practice I'm going to present an
69:23 example of an intervention model that
69:26 uses this framework actually the model
69:28 that I created with my team called
69:31 trauma systems therapy we'll be talking
69:34 about that next
69:35 time and I'll be presenting tools that
69:39 you could use um uh to implement the
69:42 causal framework in your practice
69:45 whether you're using TST trauma systems
69:48 therapy or not or any any to give you
69:52 some tools that will help so why um
69:56 let's open this up for um some
70:00 questions or
70:05 comments thank you Glenn so you can uh
70:08 again you can either uh unmute yourself
70:10 raise your hand um by clicking on the
70:13 react button and then selecting raise
70:15 your hand or you can throw any questions
70:17 or comments into the
70:22 chat Quinta raised her hand so by all me
70:26 quiny you can unmute yourself and ask
70:27 your question or comment um Dr Glenn um
70:31 Dr sax I apologize I I appreciate your
70:34 when is fine don't
70:37 apologize uh appreciate all the
70:39 information I look forward to the next
70:41 session um for me um as a practitioner I
70:46 almost um have in mind when I assess uh
70:49 my clients or or patients depending on
70:52 where people work um I almost want to
70:54 put the diagnosis aside and then say
70:56 okay what's the
70:58 problem yeah because yeah yeah so that
71:02 that's sort of where I've um I'm I'm
71:07 leaning because uh I get a client
71:10 referred to me because they were charged
71:13 with so many know they have a legal
71:15 problem but then okay I have to do a
71:18 diagnosis for the um the uh uh insurance
71:23 companies but the fact that they picked
71:25 up a charge it's not necessarily the
71:27 problem you know so that's where I'm
71:30 leaning no and I I'm with you completely
71:34 and and actually showed you why what
71:36 you're doing makes sense I mean I I
71:39 showed you that with PTSD and add as a
71:43 diagnosis you know they some of the some
71:47 components of them were not useful for
71:50 intervention and some were but you
71:52 couldn't tell from diagnosis alone but
71:55 you need to intervene to change the
71:57 outcome and so part of it is figuring
72:00 out how to do this and so the the
72:03 diagnosis we have in mental health
72:06 because it's non-causal it doesn't give
72:08 you this and part of it is wherever you
72:12 are you're classifying People based on
72:16 the information you get about them and
72:17 what I mean as I've said before by
72:20 classification you take the information
72:23 you get and you look at the kid and you
72:25 say are they at risk for this thing I'm
72:28 worried about or not so are they within
72:31 a group of people given my experience
72:34 that I'm worried about and then
72:38 classification will they respond to this
72:41 intervention I might think about or not
72:43 so the question is you know the
72:46 diagnostic system we have is really
72:49 limited for that so we have to figure
72:53 out which A system that is going to be
72:58 better for helping us classify kids and
73:02 and families like
73:06 this thank you um so while we're waiting
73:09 for other questions or comments um in
73:11 the chat or by raising your hand just
73:12 want to highlight that the feedback
73:14 survey is in the chat um if we really um
73:17 appreciate your feedback this is only
73:18 our second one of these so we're really
73:20 really interested we took your feedback
73:22 very seriously from the first one for
73:23 those of you who attended the first one
73:25 so please fill out the feedback survey
73:27 uh while we're doing questions um and I
73:30 will get to you in one second um and
73:32 then also uh the registration link for
73:36 upcoming webinars is also in the chat
73:38 and if you're interested in CES and you
73:40 attended the whole session um you'll get
73:42 a notification in about a week to
73:45 register and get your CES and if you
73:47 don't mind unmuting and asking your
73:49 question or
73:50 comment yeah so I was just wondering in
73:54 terms of did determining what was what
73:57 is red and what is green did you use
73:59 statistical analysis to do that or is it
74:03 something else so well right now this is
74:07 a hypothetical example that you know
74:10 there is going to be something that's
74:12 true and the way to know it's true is by
74:15 using certain uh statistical and data
74:19 science techniques to be able to know or
74:24 model it's closely as possible the
74:26 causal process that generated the data
74:29 so we'll be talking about in next
74:32 sessions what these techniques are
74:35 giving you different examples of
74:38 different ways of getting models that
74:40 look like this because you you you need
74:43 to use very specialized models uh
74:47 techniques in order to get that okay
74:51 thank
74:53 you other folks with questions or
74:55 comments feel free again to throw them
74:57 in the chat or raise your
75:01 hand I really appreciate everybody's
75:03 thoughts and comments so
75:06 far and if you haven't please fill out
75:08 the feedback survey and register for
75:11 future events and could I just say
75:14 debate is welcome like if anyone wants
75:16 to argue that like this it's hard to get
75:20 this right we're in a complex world we
75:24 have to figure figure out how to get it
75:26 right and so you know I I love that
75:30 we're a mixture of
75:33 providers
75:34 administrators and scientists here and
75:37 and other other other uh uh people are
75:40 represented as well because the solution
75:44 is going to involve us mixing it up
75:47 because everyone has a a piece of the
75:50 elephant so to speak to get it right so
75:54 while we're uh waiting for any other
75:55 questions or comments that come in Glen
75:57 do we want to go just go through the
75:58 next session real quick and and ask
76:00 people you know just so they know what
76:02 that is and question we'll get yes so
76:05 this is you know looking ahead where
76:07 we're going here
76:09 um so we finished one and
76:14 two again
76:16 we're we introduced the concepts again
76:20 we're framing everything by what will be
76:23 valuable for what PR practitioners need
76:25 to help kids all of that now the next
76:30 session as I've said it's going to be
76:33 okay I've talked about problems with
76:35 clinical application what how people
76:38 might be thinking of this and tools they
76:40 have so the next session is about
76:44 well what our ways to use causal and
76:49 predictive knowledge in practice and
76:51 there are there's pieces of information
76:54 there's ways of using predictive tools
76:58 uh and the most to me the most important
77:01 thing because in the complex world we
77:04 should expect that we're going to be
77:05 wrong a lot be wrong a lot we need to we
77:10 try an intervention then we don't keep
77:12 it going in perpetuity or until someone
77:15 drops out of treatment and all of that
77:18 we proactively look at it did the did
77:23 change happen as we expect it would when
77:25 we launched the intervention and if not
77:29 what have we missed so that that's next
77:32 session and again I'll give you very
77:35 practical examples and tools for how you
77:38 do
77:39 this then we're going to be moving more
77:42 into the science and with an examination
77:46 of our Paradigm including
77:50 diagnosis including the methods we use
77:53 in our research uh all of that and and
77:56 looking at
78:00 limitations that will build to session
78:02 five where I'll be talking about very
78:06 powerful tools that might that will make
78:09 a difference here and how they use these
78:12 tools to build knowledge that may put us
78:15 in even a better framework to establish
78:18 a a diagnostic system based on
78:22 causality and then nothing nothing
78:25 matters nothing nothing unless it can
78:28 really help people in practice and in
78:31 the champ Center which is sponsoring uh
78:34 this champ Center and champ Network as
78:36 we've talked about before it's all about
78:39 using these models to build decision
78:44 support tools tools that could be used
78:46 in practice to guide decision making as
78:50 as we've talked about and and our you
78:53 know our six session is going to be
78:55 about about
78:58 that thank you so much and a reminder
79:00 that everybody can register for any of
79:03 the any or all of those events through
79:04 the link in the chat will also include
79:06 it when we send out the slides and the
79:08 video um from today's which we encourage
79:11 you to uh share broadly um if anybody
79:14 has any additional questions or comments
79:16 again please feel free to throw them
79:18 into the chat or raise your hand um we
79:21 appreciate all the folks who dived in
79:23 today um and raise questions and
79:25 comments uh and also please fill out the
79:28 survey the uh provider survey I believe
79:31 last time we sent it out after to but we
79:33 always love to get them today because I
79:35 know that once once you have left today
79:37 um you know opening up a new email is is
79:40 always an extra challenge so um please
79:42 feel free to uh fill out that provider
79:45 survey right or the feedback survey
79:46 right now um and register for any future
79:49 event so I'm just looking through the
79:51 chat and also for any raised hand I am
79:55 not seeing anything Jen I want to make
79:56 sure I'm not missing anything before
79:58 yeah there is one last question um have
80:01 you considered how substance use might
80:03 impact behavior in a
80:06 diagnosis yeah I mean that's that's
80:09 that's a question and again it it fits
80:12 here as well if you think substance
80:14 abuse is important for any outcome it's
80:18 it's really an empirical question we we
80:20 want to see it it needs to be causal it
80:23 can't be a correlate or just a
80:25 predictive Factor um certainly I've seen
80:29 it important for lots of outcomes but
80:33 again we we in this world we have to
80:37 presume nothing and really follow the
80:41 data and the way we may practice where
80:44 we're we're set to always be learning
80:47 and then about substance abuse it's also
80:50 if you you could then put you could also
80:52 put substance abuse as your Mal
80:54 treatment outcome because it could be
80:57 related to Mal treatment but it's the
81:00 same thing you what are the causes of it
81:04 whether only the predictors of it if I
81:07 want to intervene to reduce substance
81:09 abuse I have to intervene on the
81:12 causes that makes sense all right that
81:14 was a really good question I'm glad
81:15 somebody raised that because oftentimes
81:17 we keep our mental health World on one
81:18 side of the aisle and our substitut
81:20 world on the other side of the aisle and
81:22 often they uh intersect and just one
81:25 thing for everyone to think about is you
81:27 could substitute anything for your
81:30 outcome anything you think is relevant
81:34 positive things pathological things uh
81:39 negative whatever words you want to use
81:42 and um substitute anything you think is
81:46 important but it's still the same thing
81:48 it's still causality is in the middle of
81:51 it if you want to change it wonderful
81:55 all right I'm not seeing any more
81:57 comments or raised hands so I think we
81:59 will give um Everybody let them go back
82:02 to their day I really want to thank uh
82:03 Glenn for presenting and thank everybody
82:05 for taking the time today and joining um
82:08 we look forward to our next webinar next
82:11 month um again all of the various ways
82:13 to sign up for that we we like that
82:15 we're carrying people from one to the
82:16 other um I think that's really great uh
82:19 fill out the feedback survey um and if
82:21 you're waiting on cus those will come
82:23 through as well so thank you everybody
82:24 for taking the time to join today and we
82:27 look forward to seeing you at the next
82:29 webinar
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