Avatars may help children with social anxiety overcome fears

A principal standing in the hallway says, "You are one of my favorite students!" In class, a smart girl says, "You are the nicest person in our class!" Many children would smile and eagerly return those compliments, but some with social anxiety may be too terrified to respond. Researchers at the University of Central Florida's Anxiety Disorders Clinic and the Atlanta-based company Virtually Better want to give more children with social anxiety the practice they need to become comfortable in social situations. They have developed a new, one-of-a-kind computer simulation program that enables children to interact with avatars playing the roles of classmates, teachers and a principal. The simulation, designed for children ages 8 to 12, allows clinicians to play the roles of the avatars while the children sit at a computer in a different room and respond to situations they encounter routinely. The children practice greetings, giving and receiving compliments, being assertive and asking and answering questions. "These kids come in and say, 'I don't know how to make a friend,'" said Deborah Beidel, director of the Anxiety Disorders Clinic and a psychology professor at UCF. "We have to teach them the skills that most people learn from being around other people." The National Institute of Mental Health, part of the National Institutes of Health, provided a $500,000 grant to fund the development of the software and a 12-week study that will begin this summer. The study will involve 30 Central Florida children ages 8 to 12. Many children are nervous and slow to warm up in new social situations, but those with social anxiety disorders have severe distress that doesn't go away, Beidel said. "If a fear is so severe that it prevents a child from doing something he or she should be doing, such as going to school, playing on a sports team, being in a dance recital, going to birthday parties or making friends, then a parent should call a mental health professional," she said. Under Beidel's leadership, the UCF Anxiety Disorders Clinic has treated children with anxiety disorders for five years. The clinic offers what Beidel calls the "gold standard" of treatments. Children with anxiety disorders are paired with socially comfortable peers for outings to places such as bowling alleys, restaurants and miniature golf courses. The new study will give parents multiple treatment options at UCF. But parents in most communities aren't so fortunate. Many clinicians who treat children don't have the time or resources to recruit socially comfortable children and organize regular outings. Guiding clients through a simulation in the office may be the only feasible solution for them continuing education for counselors The simulation features a realistic school setting, designed with the help of elementary school teachers. The pre-programmed responses of the avatar classmates – which include a cool girl, a smart girl and a bully -- were recorded by children to ensure the language reflects how they talk. "The most important thing is that this was designed by clinicians with a very specific intention to help people get better. That's the big difference between this and a game, and there is nothing like this on the market," said Josh Spitalnick, clinical psychologist and director of research and clinical services at Virtually Better, an Atlanta-based company bringing interactive technologies to behavioral healthcare for treatment and training. The six characters and the varying levels of difficulty in the simulation allow clinicians to design scenarios appropriate for their patients. More challenging scenarios include dealing with a bully who is demanding that a child give up some of her lunch money. If the initial trial goes well, researchers hope to conduct a yearlong trial with more children. If that is successful, the simulation could then become available to clinicians. The program eventually could be expanded to include other settings, such as playgrounds, and to serve other children who need help improving social skills. ### For more information about UCF's Anxiety Disorders Clinic, go to http://anxietyclinic.cos.ucf.edu. For more information about Virtually Better Technologies, visit www.virtuallybetter.com.

UCLA study uncovers new tools for targeting genes linked to autism

Findings could lead to future therapeutic targets UCLA researchers have combined two tools – gene expression and the use of peripheral blood -- to expand scientists' arsenal of methods for pinpointing genes that play a role in autism. Published in the June 21 online edition of the American Journal of Human Genetics, the findings could help scientists zero in on genes that offer future therapeutic targets for the disorder. "Technological advances now allow us to rapidly sequence the genome and uncover dozens of rare mutations," explained principal investigator Dr. Daniel Geschwind, the Gordon and Virginia MacDonald Distinguished Professor of Human Genetics and a professor of neurology at the David Geffen School of Medicine at UCLA. "But just because a particular genetic mutation is rare doesn't mean it's actually causing disease. We used a new approach to tease out potential precursors of autism from the occasional genetic glitch." Geschwind and his colleagues studied DNA contained in blood samples from 244 families with one healthy child and one child on the autism spectrum. The team used a hybrid method that blended tests that read the order of DNA bases with those that analyze gene expression, the process by which genes make cellular proteins. "Monitoring gene expression provides us with another line of data to inform our understanding of how autism develops," said Geschwind, who is also director of the Center for Autism Research and Treatment at the Semel Institute for Neuroscience and Behavior at UCLA. "Integrating this method with the sequencing of DNA bases expands our ability to find mutations leading to the disease." Gene expression offers a molecular signpost pointing scientists in the right direction by narrowing the field and highlighting specific areas of the genome. For example, if a gene is expressed at substantially higher or lower levels in a patient, researchers will review the patient's DNA to check if that gene has changed. "We found that we can use gene expression to help understand whether a rare mutation is causing disease or playing a role in disease development," said Geschwind. "A true mutation will alter a gene's sequence, modifying the protein or RNA it produces -- or preventing the gene from producing them entirely. "A gene mutation accompanied by a change in expression clues us to a hot spot on the genome and directs us where to look next," he added. "Not all mutations will influence gene expression, but this approach improves our ability to pinpoint those that do." The researchers used the combined method to prioritize gene targets that merit closer investigation, potentially explaining why one person develops autism and their sibling does not. Their search turned up new regions in the genome where genetic variations showed strong links to autism and altered expression patterns. Genes in these regions were more likely to be mutated in the autistic children than in their unaffected siblings. "When we looked at genes associated with nervous-system function we found significantly more genes were expressed at higher or lower levels in the children diagnosed with autism than we did in their siblings unaffected by the disorder," said Geschwind. Finally, the research team discovered that the DNA contained in peripheral blood can help shed light on diseases of the central nervous system. Brain cells and genes related to synaptic function are expressed in the blood, offering a window into gene expression. "Brain tissue from people with autism is not readily available for study, and some people are reluctant to use non-neural tissue in psychiatric disease," explained Geschwind. "But our study demonstrates that even peripheral blood can expand our knowledge of neurological disease." The team's next step will be to replicate their findings in a larger population. ### Autism is a complex brain disorder that strikes in early childhood. The condition disrupts a child's ability to communicate and develop social relationships and is often accompanied by acute behavioral challenges. Autism spectrum disorders are diagnosed in one in 110 children in the United States, affecting four times as many boys as girls. Diagnoses have expanded tenfold in the last decade. The research was supported by grants from the Simons Foundation, the National Institute of Mental Health (5R01 MH081754-04), the Wellcome Trust and Autism Speaks. Geschwind's coauthors included first author Rui Luo, Irina Voineagu, Lambertus Klei, Chaochao Cai, Jing Ou, Jennifer Lowe and Matthew State of UCLA; Stephan Sanders of Yale University; Ni Huang and Matthew Hurles of the Wellcome Trust Sanger Institute; and Su Chu and Bernie Devlin of Carnegie Mellon University. The UCLA Center for Autism Research and Treatment provides diagnosis, family counseling, clinical trials and treatment for patients with autism. UCLA is one of eight centers in the National Institutes of Health–funded Studies to Advance Autism Research and Treatment network and one of 10 original Collaborative Programs for Excellence in Autism social worker ceus

Adaptable decision making in the brain

Front-most part of the cortex involved in making short-term predictions about what will happen next Researchers at the University of Iowa, together with colleagues from the California Institute of Technology and New York University, have discovered how a part of the brain helps predict future events from past experiences. The work sheds light on the function of the front-most part of the frontal lobe, known as the frontopolar cortex, an area of the cortex uniquely well developed in humans in comparison with apes and other primates. Making the best possible decisions in a changing and unpredictable environment is an enormous challenge. Not only does it require learning from past experience, but it also demands anticipating what might happen under previously unencountered circumstances. Past research from the UI Department of Neurology was among the first to show that damage to certain parts of the frontal lobe can cause severe deficits in decision making in rapidly changing environments. The new study from the same department on a rare group of patients with damage to the very frontal part of their brains reveals a critical aspect of how this area contributes to decision making. The findings were published June 19 in the Journal of Neuroscience. "We gave the patients four slot machines from which to pick in order to win money. Unbeknownst to the patients, the probability of getting money from a particular slot machine gradually and unpredictably changed during the experiment. Finding the strategy that pays the most in the long run is a surprisingly difficult problem to solve, and one we hypothesized would require the frontopolar cortex," explains Christopher Kovach, Ph.D., a UI post-doctoral fellow in neurosurgery and first author of the study. Contrary to the authors' initial expectation, the patients actually did quite well on the task, winning as much money, on average, as healthy control participants. "But when we compared their behavior to that of subjects with intact frontal lobe, we found they used a different set of assumptions about how the payoffs changed over time," Kovach says. "Both groups based their decisions on how much they had recently won from each slot machine, but healthy comparison subjects pursued a more elaborate strategy, which involved predicting the direction that payoffs were moving based on recent trends. This points towards a specific role for the frontopolar cortex in extrapolating recent trends." Kovach's colleague and study author Ralph Adolphs, Ph.D., professor of neuroscience and psychology at the California Institute of Technology, adds that the study results "argue that the frontopolar cortex helps us to make short-term predictions about what will happen next, a strategy particularly useful in environments that change rapidly -- such as the stock market or most social settings." Adolphs also hold an adjunct appointment in the UI Department of Neurology. The study's innovative approach to understanding the function of this part of the brain uses model-based analyses of behavior of patients with specific and precisely characterized areas of brain damage. These patients are members of the UI's world-renowned Iowa Neurological Patient Registry, which was established in 1982 and has more than 500 active members with selective forms of damage, or lesions, to one or two defined regions in the brain. "The University of Iowa is one of the few places in the world where you could carry out this kind of study, since it requires carefully assessed patients with damage to specific parts of their brain," says study author Daniel Tranel, Ph.D., UI professor of neurology and psychology and director of the UI Division of Behavioral Neurology and Cognitive Neuroscience. In a final twist to the finding, the strategy taken by lesion patients was actually slightly better than the one used by comparison subjects. It happened that the task was designed so that the trends in the payoffs were, in fact, random and uninformative. "The healthy comparison subjects seemed to perceive trends in what was just random noise," Kovach says. This implies that the functions of the frontopolar cortex, which support more complex and detailed models of the environment, at times come with a downside: setting up mistaken assumptions. "To the best of my knowledge this is the first study which links a normal tendency to see a nonexistent pattern in random noise, a type of cognitive bias, to a particular brain region," Kovach notes. The researchers next want to investigate other parts of the frontal cortex in the brain, and have also begun to record activity directly from the brains of neurosurgical patients to see how single cells respond while making decisions. The work is also important to understand difficulties in decision making seen in disorders such as addiction. ### The study, "Anterior prefrontal cortex contributes to action selection through tracking of recent reward trends," also included authors David Rudrauf from the University of Iowa, John O'Doherty from the California Institute of Technology, and Nathaniel Daw from New York University. The research was funded in part by grants from the National Institute of Neurological Disorders and Stroke (Grant P50 NS19632), the National Institute on Drug Abuse (Grant DA022549), the National Institute of Mental Health (Grant MH080721) and the Tamagawa University Global Centers of Excellence Program of the Japanese Ministry of Education, Culture, Sports, and Technology CADC I & II Continuing Education

Survey Finds More Evidence That Mental Disorders Often Begin in Youth

About 8 percent of U.S. teens meet current criteria for having a serious emotional disturbance, according to two NIMH-funded studies published in the April 2012 issue of the Archives of General Psychiatry. Background A September 2010 study using data from the NIMH-funded National Comorbidity Survey-Adolescent Supplement (NCS-A) found that about 20 percent of youth are affected by a mental disorder sometime in their lifetime. The NCS-A is a nationally representative, face-to-face survey of more than 10,000 teens ages 13 to 18. Parents or caregivers were also asked to complete a corroborating questionnaire after teens were interviewed. The NCS-A used criteria established by the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-IV) to assess for a wide range of mental disorders including mood and anxiety disorders, behavior disorders like attention deficit hyperactivity disorder (ADHD), eating disorders, and substance use disorders. In this most recent analysis, Kathleen Merikangas, Ph.D., of NIMH, Ron Kessler, Ph.D., of Harvard University, and colleagues examined the prevalence of mental disorders, as well as the severity of the disorders, within a 12-month period to estimate the rate of serious emotional disturbances (SED) in youth. SED was defined by the Substance Abuse and Mental Health Administration (SAMHSA) as a “mental, behavioral, or emotional disorder … that resulted in functional impairment which substantially interferes with or limits the child’s role or functioning in family, school, or community activities.” Results of the Study The researchers found that about 8 percent of all respondents had SED. Those with behavior disorders were most likely to be considered to have a severe disorder. Those with three or more coexisting disorders were also more likely to be severely affected. Similar to adults, anxiety disorders were the most common conditions in adolescents. Echoing many other studies, girls were more likely to have a mood or anxiety disorder or eating disorder, while boys were more likely to have a behavior disorder like ADHD or substance use disorder. Contrary to regional studies, this report showed a lower rate of depression among Hispanics compared to whites. Significance The findings in this study reflect the widely held belief that most psychiatric disorders first manifest in childhood or adolescence and tend to persist or recur throughout a person’s life. The researchers conclude that the high prevalence rate of mental disorders in U.S. adolescents underscores the need for more research focused on changing the trajectory of mental disorders in youth. What’s Next More research is needed to better understand the differences in prevalence rates among cultural and ethnic groups in different regions of the country ceus for nurses Citations Kessler R, Avenevoli S, Costello J, Georgiades K, Green JG, Gruber M, He J, Koretz D, McLaughlin K, Petukhova M, Sampson N, Zaslavsky A, Merikangas K. Prevalence, persistence and Sociodemographic correlates of DSM-IV disorders in the National Comorbidity Survey Replication Adolescent Supplement. Archives of General Psychiatry. April 2012; 69(4):372-380. Kessler R, Avenevoli S, Costello J, Green JG, Gruber M, McLaughlin K, Petukhova M, Sampson N, Zaslavsky A, Merikangas K. Severity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication Adolescent Supplement. Archives of General Psychiatry. April 2012; 69(4):381-389.

Marital problems in childhood affect teen adjustment

Marital discord is a significant social problem for children, sometimes leading to problems in health and well-being. A new longitudinal study finds that the impact of marital problems on children in their kindergarten years is long lasting and can lead to emotional problems that contribute to difficulties in adolescence. The study, by researchers at the University of Notre Dame and the University of Rochester, appears in the journal Child Development ceus for social workers "The results further highlight the possibility that there will be persistent negative effects of children's early experiences when there is conflict between their parents, at least when their emotional insecurity increases as a result of the conflict," according to E. Mark Cummings, professor and Notre Dame Endowed Chair in Psychology at the University of Notre Dame, the study's lead author. "This study has important implications for clinicians and parents," he added. Cummings and his colleagues examined 235 primarily middle-class mothers, fathers, and children over seven years, focusing on the links between marital conflict when the children were in kindergarten, children's emotional insecurity in the early school years, and subsequent problems when the children were teens. Children's emotional security about family ties is related to their sense of protection, safety, and security, and has implications for how they do socially and emotionally. The researchers observed parents discussing a topic they had identified as hard to handle, rating specific conflict behaviors. They also asked parents to report on their conflicts. The study found that conflict between parents when their children are young predicted children's emotional insecurity later in childhood, which, in turn, predicted adjustment problems in adolescence, including depression and anxiety. "Emotional insecurity appears to be an explanation for the effects of marital conflict on children's later problems," Cummings explained. "This mechanism lasts across relatively long periods of time and across the transition between childhood and adolescence." ###

Less couch time equals fewer cookies

Just 2 simple changes in health behavior spurs big and lasting results CHICAGO --- Simply ejecting your rear from the couch means your hand will spend less time digging into a bag of chocolate chip cookies. That is the simple but profound finding of a new Northwestern Medicine study, which reports simply changing one bad habit has a domino effect on others. Knock down your sedentary leisure time and you'll reduce junk food and saturated fats because you're no longer glued to the TV and noshing. It's a two-for-one benefit because the behaviors are closely related. The study also found the most effective way to rehab a delinquent lifestyle requires two key behavior changes: cutting time spent in front of a TV or computer screen and eating more fruits and vegetables. "Just making two lifestyle changes has a big overall effect and people don't get overwhelmed," said Bonnie Spring, a professor of preventive medicine at Northwestern University Feinberg School of Medicine, and lead author of the study published in Archives of Internal Medicine. "Americans have all these unhealthy behaviors that put them at high risk for heart disease and cancer, but it is hard for them and their doctors to know where to begin to change those unhealthy habits," Spring said. "This approach simplifies it." With this simplified strategy, people are capable of making big lifestyle changes in a short period of time and maintaining them, according to the study. Spring wanted to figure out the most effective way to spur people to change common bad health habits: eating too much saturated fat and not enough fruits and vegetables, spending too much sedentary leisure time and not getting enough physical activity. She and colleagues randomly assigned 204 adult patients, ages 21 to 60 years old, with all those unhealthy habits into one of four treatments. The treatments were: increase fruit/vegetable intake and physical activity, decrease fat and sedentary leisure, decrease fat and increase physical activity, and increase fruit/vegetable intake and decrease sedentary leisure. During the three weeks of treatment, patients entered their daily data into a personal digital assistant and uploaded it to a coach who communicated as needed by telephone or email. Participants could earn $175 for meeting goals during the three-week treatment phase. But when that phase was completed, patients no longer had to maintain the lifestyle changes in order to be paid. They were simply asked to send data three days a month for six months and received $30 to $80 per month. "We said we hope you'll continue to keep up these healthy changes, but you no longer have to keep them up to be compensated," Spring said. The results over the next six months amazed Spring. "We thought they'd do it while we were paying them, but the minute we stopped they'd go back to their bad habits," she said. "But they continued to maintain a large improvement in their health behaviors." From baseline to the end of treatment to the end of the six-month follow-up, the average servings of fruit/vegetables changed from 1.2 to 5.5 to 2.9; average minutes per day of sedentary leisure went from 219.2 to 89.3 to 125.7 and daily calories from saturated fat from 12 percent to 9.4 percent to 9.9 percent. About 86 percent of participants said once they made the change, they tried to maintain it. There was something about increasing fruits and vegetables that made them feel like they were capable of any of these changes," Spring said. "It really enhanced their confidence." "We found people can make very large changes in a very short amount of time and maintain them pretty darn well," Spring said. "It's a lot more feasible than we thought." ceus for social workers ### Other Northwestern authors included Donald Lloyd-Jones, M.D. Arlen Moller and Juned Siddique. The research is supported by the following National Institutes of Health grants: National Institute of Heart, Lung and Blood grant HL075451, for Multiple Behavior Change in Diet and Activity; the Robert H. Lurie Comprehensive Cancer Center of Northwestern University grant from the National Institute of Mental Health P30 CA060553; the National Institute of Mental Health grant F31 MH070107.

Most Children with ASD Diagnosed After Age 5, Use Multiple Services and Medications

Fewer than one out of five school-aged children with special health care needs were diagnosed with autism spectrum disorder (ASD) by age 2, according to new data from an NIMH-funded study. These diagnoses were made by a variety of health care providers, and most children in the study used multiple health care services (such as speech or language therapy) and multiple medications social worker continuing education Background Identifying ASD at an early age allows children to start treatment sooner, which can improve their later development and learning, and may also reduce a child’s need for specialized services or treatments later in life. To determine the experiences of school-aged children with special health care needs, Lisa Colpe, Ph.D., M.P.H., and Bev Pringle, Ph.D., of the NIMH Division of Services and Intervention Research, collaborated with colleagues who conducted more than 4,000 telephone interviews with parents or guardians of a child between the ages of 6-17 who had a confirmed diagnosis of ASD, intellectual disability, and/or developmental delay. These survey interviews were a part of the Pathways to Diagnosis and Services Study, sponsored by NIMH using funds available from the American Recovery and Reinvestment Act of 2009 (Recovery Act). Additional collaborators on this project include the National Center for Health Statistics at the Centers for Disease Control and Prevention (CDC) and the Maternal and Child Health Bureau at the Health Resources and Services Administration (HRSA). Results of the Study Key findings include: The median age when school aged children with special health care needs and ASD were first identified as having ASD was 5 years. Those identified as having ASD at younger than 5 years were diagnosed most often by generalists (such as pediatricians, family physicians, and nurse practitioners) and psychologists. Those identified later than 5 years were diagnosed primarily by psychologists and psychiatrists. Nine out of ten school-aged children with special health care needs and ASD used at least one health care service, such as behavioral intervention or modification services, sensory integration therapy, cognitive based therapy, occupational therapy, physical therapy, social skills training, or speech or language therapy. Social skills training and speech or language therapy were the most commonly used service, each used by almost 60 percent, or three out of five, of these children. More than half of school-aged children with special health care needs and ASD used at least one psychotropic medication. “Psychotropic medication” refers to any medication used to treat a mental disorder. Almost 33 percent of these children used stimulant medications 25 percent used anti-anxiety or mood-stabilizing medications 20 percent used antidepressants. Further findings are available in the NCHS Data Brief and Frequently Asked Questions. Significance The new data detail the experiences of young children with ASD, describing when they are first identified as having ASD, who is making those identifications, and the services and medications the children use to meet their developmental needs. What’s Next NIMH encourages researchers to access and analyze the new dataset to produce more studies on the early life experiences and the diagnostic, service, and treatment issues relevant to children with ASD and special health care needs. The Pathways to Diagnosis and Services Study dataset can be accessed at http://www.cdc.gov/nchs/slaits/spds.htm. Reference Pringle BA, Colpe LJ, Blumberg SJ, Avila RM, Kogan MD. Diagnostic History and Treatment of School-Aged Children with Autism Spectrum Disorder and Special Health Care Needs. NCHS data brief, no 97. Hyattsville, MD: National Center for Health Statistics. 2012.