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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 more 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 of 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 so 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 as 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 by 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 um 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 of 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 register and get your CES and if you 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 do 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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