New Research Findings

The teenage years are a challenge to say the least. Teens whose parents stay involved in their type 1 diabetes care have better health than those whose parents do not stay involved. However, not surprisingly, adolescence is a time of turmoil and higher levels of conflict for many families, so keeping parents involved can be tricky. By early adolescence (ages 11-14), most youth with type 1 diabetes are largely in charge of their disease care, aside from making doctor’s appointments and ordering medical supplies. Teens are confident in their ability to complete blood sugar checks and give insulin, but they still require help from parents to make decisions about good food choices and insulin dosages. All parents face the challenge of allowing teens to become more independent while keeping tabs on them. Parents of teens with diabetes face this same challenge compounded with worry about teens achieving independence in their diabetes care and monitoring the many steps required throughout the day.

Findings show when family conflict is held at bay, teens whose parents stay involved in their diabetes care do a better job with their disease overall, and as a result, have better health outcomes. In a group of 257 teens with type 1 diabetes and their parents, parental monitoring and family conflict were linked to health outcomes (i.e., glycemic control) through teens’ diabetes self-care. Thus, intervention programs designed for this age group ought to promote parents to stay in the loop with teens’ diabetes management while providing strategies to reduce or avoid family conflict.

Reference:

Hilliard, M. E., Holmes, C. S., Chen, R., Maher, K., Robinson, E., & Streisand, R. (in press). Disentangling the roles of parental monitoring and family conflict in adolescents’ type 1 diabetes care. Health Psychology.

Heart transplant is a miracle procedure developed in the 1980's that has saved and prolonged thousands of lives in the United States alone. However, the number of individuals who need a heart to survive far exceeds the number of hearts available to transplant. Therefore, policies needed to be made to distribute this scarce resource. Survival rates based on patient characteristics was one logical criterion for making these decisions. During the first 15 years of transplant history, older patients were rarely transplanted because of reduced survival rates.

Since the early days of transplantation, survival rates for all transplant patients have increased due to medical advances and immunosuppressant drug development. The percentage of older adults receiving transplants has gradually increased; however, this percentage has leveled off around at around 13% of all transplants. The most recent comprehensive analysis of heart transplant recipients indicates that mortality is only marginally different between older and younger patients, with 75% of younger patients and 69% of older patients surviving 5-years post transplant. Despite these marginal survival differences and the comparatively higher rate of heart failure in older adults, they are still under-represented among those receiving heart transplants. Decisions about which patients are placed on the national waiting list are determined through individual transplant centers, and each center sets its own criteria. Some transplant centers have an age limit of age 65 or discuss older age as a relative contraindication that requires special circumstances for transplant.

A recent study has added a new piece of information that has the potential to influence the debate about what role age should play in making organ allocation decisions. That study was authored by graduate student, Andrea Shamaskin, along with her mentor Dr. Bruce Rybarczyk and a team of heart transplant researchers around the country. Those researchers collected the largest data sample to date measuring quality of life, adjustment and other long-term outcomes among 555 heart transplant recipients across the country who have been living with the transplant for five years or longer. Compared to younger and middle-aged recipients, older transplant recipients reported better overall quality of life, psychological adjustment, and adherence behavior. These robust findings held up even after accounting for age group differences in education level, race, and marital status. These findings highlight the importance of considering quality of life, not only quantity of life. Older adults may have certain advantages over younger adults that should be considered when transplant centers and organ donation policies determine who is a good candidate for transplant.

Reference:

Shamaskin, A. M., Rybarczyk, B. D., Wang, E., White-Williams, C., McGee Jr., E., Cotts, W., & Grady, K. L. (in press). Older patients (age 65+) report better quality of life, psychological adjustment, and adherence than younger patients 5 years after heart transplant: A multisite study. Journal of Heart and Lung Transplantation. [view article]

Exploration—trying new things—is a fundamental aspect learning and personal growth. Psychologists have studied exploration, often using the framework of attachment theory. Attachment theory proposes that early experiences with one's mother (how responsive she is to the child's emotional needs) shape views of relationships in general—including adult romantic relationships.

To be specific, research has found that people vary on two dimensions: attachment avoidance and anxiety. People high in avoidance are uncomfortable with closeness and have difficulty opening up or supporting their partners. People high in anxiety, on the other hand, want to get very close to their partner, but are preoccupied with the thought that their partner will reject them. Past research investigating exploration and attachment has yielded contradictory findings, but graduate student Anthony Coy (with Dr.'s Jeff Green and Jody Davis) proposed that exploring with one's partner versus alone is a distinction researchers have not made in the past.

Eighty-six couples from the Richmond community explored alone or with their partner. They participated in what they were told was a new kind of meditation, and spent as much time as they wanted on the activity. When exploring alone, more anxious individuals spent less time exploring and felt worse about it. On the other hand, more avoidant individuals spent less time exploring and felt worse about it when exploring with their partner. It seems that anxious people prefer the support and comfort of their partner when trying new things, whereas avoidant people prefer to explore alone and may see their partners as interfering or distracting. This study was also the first to examine how a partner's attachment style may affect people's exploration. Individuals with more anxious partners felt better after exploring alone than with the partner, whereas individuals with more avoidant partners were not affected by the partner’s presence.

Reference:

Coy, A. E., Green, J. D., & Davis, J. L. (2012). With or without you: The impact of partner presence and attachment on exploration. Journal of Experimental Social Psychology, 48, 411-415.

Death can be terrifying. Recognizing that death is inescapable and unpredictable makes us incredibly vulnerable. This disrupts our instinct to remain a living, breathing organism. So what do we do? We try to manage this terror. Generally, when reminded of our mortality, when the potential to experience existential anxiety is heightened, we are extremely defensive. Like little kids who nearly suffocate under blanket protection to fend off the monster in the closet, the first thing we try to do is purge any death-related thoughts or feelings from our mind. We try to think about something else, stuff our face with Cheez Doodles, anything to gain some composure. Only one problem. Ever try to ignore a cockroach that skittered across the bedroom and return to sleep? Doesn't work so well.

Because avoiding the issue is rather ineffective, our death-related thoughts continue to infect us. But unfortunately, we don't know that there is a mental virus pushing and pulling us around in all sorts of strange ways. On the fringes of conscious awareness, we try another attempt to ward off death anxiety. We defend beliefs and practices that provide a sense of stability and meaning in our lives. It might be patriotic fervor for our country, connection to people of a similar gender or racial group, or faith in God. By viewing ourselves as valuable members of similar-minded groups, we connect ourselves to a permanent reality that will persist long after we die. But there is an ugly side effect to this psychological suture.

A common way in which we defend our cultural worldview is to praise people with similar beliefs and act aggressively toward people from different groups with different beliefs. Essentially, we become intolerant and abusive. Our research group wondered what might prevent these defensive, intolerant reactions from occurring. We hypothesized that mindfulness might provide a form of psychological immunity. Mindfulness can be defined as gently focusing attention on what is happening in the present moment with a receptive, open attitude. We wanted to study what happens when mindfulness and the terror of death collide. If mindful people are more willing to explore whatever happens in the present, will they show less defensiveness when their sense of self is threatened by a confrontation with their own mortality?

Based on the results of 7 different experiments, the answer appears to be yes. When reminded about their death and asked to write about what will happen when and after they die, less mindful people showed a greater dislike for foreigners that mention what's wrong with the United States (pro-U.S. bias), greater prejudice against Black managers who discriminated against a White employee in a promotion decision (pro-White bias), and harsher penalties for social transgressions such as prostitution, marital infidelities, and drug use by physicians that led to surgical mishaps. Across these various situations, mindful people showed a lack of defensiveness toward people that didn't share their worldview.

References:

Text adapted from Kashdan, T. (2011). Confronting death with an open, mindful attitude.

Niemiec, C.P., Brown, K.W., Kashdan, T.B., Cozzolino, P.J., Breen, W., Levesque, C., & Ryan, R.M. (2010). Being present in the face of existential threat: The role of trait mindfulness in reducing defensive responses to mortality salience. Journal of Personality and Social Psychology, 99, 344-365.

Researchers at VCU and several other universities conducted an initial randomized controlled trial testing cognitive-behavioral treatment (CBT) for youth anxiety disorders against the usual treatments provided in public mental health clinics in Los Angeles, CA. Many youth suffer from anxiety related problems, such as excessive fears of being separated from their caregivers, intense anxiety in social situations, or excessive worries. CBT, successfully tested in numerous studies in the past for youth anxiety, involves teaching anxious youths a set of anxiety management skills and then providing opportunities for them to practice those skills in anxiety-provoking situations. In this study, CBT was compared to the usual care in the clinics. Therapists providing usual care were free to provide any treatments they saw fit for the clients they treated whereas CBT therapists only provided CBT.

Youths treated with both approaches improved significantly over time across several outcome measures.  Contrary to expectations, the CBT approach did not produce better outcomes. Youth receiving CBT did use fewer additional services (e.g., outside therapy groups), suggesting the possibility that CBT may be a lower cost therapy. To explain the surprising findings, the researchers recommended two future steps. First they noted the need to evaluate whether the quality of the CBT delivered was comparable to that from earlier studies. Second, they discussed the importance of learning which specific therapies provided by the usual care therapists were most effective.

Reference:

Southam-Gerow, M. A., Weisz, J. R., Chu, B. C., McLeod, B. D., Gordis, E. B., & Connor-Smith, J. K. (2010). Does CBT for youth anxiety outperform usual care in community clinics?: An initial effectiveness test. Journal of the American Academy of Child & Adolescent Psychiatry, 49, 1043-1052.

Can pain be reduced by improving sleep in chronic pain sufferers with insomnia?   A study published last year by Dr. Bruce Rybarczyk and colleagues indicates that this may be the case.  Dr. Rybarczyk was the lead investigator in a large scale study conducted at Rush University Medical Center that provided individuals with one of three medical illnesses (osteoarthritis, heart disease or pulmonary disease) with eight weeks of cognitive behavioral treatment for insomnia (CBT-I) in a group format.  CBT-I consists of several components, including sleep restriction to “jump start” the natural sleep system, an elimination of time spent in bed when not falling asleep or sleeping, and a reduction in negative self-talk about insomnia and its consequences.  An initial study was published in 2005 showing that CBT-I was highly effective in reducing insomnia at post-treatment.

The new finding published last year examined the subset of 51 participants who had osteoarthritis.  Compared to the subjects receiving the placebo behavioral treatment (i.e., stress management), those who received CBT-I, as predicted, had better sleep after finishing the treatment.  The more important finding in this follow-up study was that these sleep gains were maintained at 1-year follow-up and that pain ratings were also reduced after treatment and at one-year follow up.  

“The particular strength of CBT-I is that once an individual learns how to improve their sleep, study after study has shown that the improvement persists for a year or more," said co-author Dr.  Michael Vitiello. "What we and others are showing is that CBT-I can not only improve sleep but that improvement of sleep may lead to improvement in co-existing medical or psychiatric illnesses, such as osteoarthritis or depression, and in the case of our study, that these additional benefits can be seen in the long term."

Sleep quality is a major concern for people with osteoarthritis, with 60 percent of people who have the disease reporting pain during the night that interferes with optimal sleep. Chronic pain initiates and exacerbates sleep disturbance; disturbed sleep in turn maintains and exacerbates chronic pain and related dysfunction.

Dr. Rybarczyk is currently collaborating with Dr. Vitiello and colleagues at the University of Washington on an NIH randomized clinical study testing a combined cognitive behavioral treatment for pain and insomnia in a group of 375 patients in a large health plan in the Seattle area.  Rather than simply focusing on pain or insomnia alone, they are testing whether a synergistic effect can be obtained from addressing both simultaneously.  Patients will be followed for two years after treatment to test the hypothesis that treatment will produce long-term reductions in health care utilization and costs.  This study, when completed in 2011, should shed significant light on the question of whether such a treatment should be made available to all pain patients with insomnia.   If it proves to be effective, it could have implications for the millions of older adults who suffer from both osteoarthritis and insomnia and would prefer to use a non-pharmacologic approach. 

References for this study and the initial study:

Vitiello, M., Rybarczyk, B., VonKorff, M. & Stepanski, E. (2009). Cognitive behavioral therapy for insomnia improves both sleep and pain in older adults with co-morbid osteoarthritis and insomnia. Journal of Clinical Sleep Medicine, 5, 355-362.

Rybarczyk, B., Stepanski, E., Fogg, L., Lopez, M., Barry, P., & Davis, A. (2005).  A Placebo-controlled test of CBT for comorbid insomnia in older adults. Journal of Consulting and Clinical Psychology, 73, 1164-1174.

Parents are a diverse group. Some parents are very aware and accepting of their own emotions and their child's emotions, while others are not. In the current study, the first on this topic to be conducted with low-income, urban, African American families with a school-aged child, mothers who had high levels of awareness and acceptance of their emotions had children who were better able to understand and regulate their own emotions. Children who better understood emotions and who regulated them effectively showed positive changes in well-being over a 6-month period, including improved symptoms of depression, anxiety, aggression, and delinquency; social skills; and grades.

Dr. Jera Nelson Cunningham, a 2003 graduate of the counseling psychology Ph.D. program and Dr. Wendy Kliewer, a developmental psychologist, studied 69 African American families with an 8-13 year old child. Families were interviewed twice, and all families lived in Richmond, VA. In the first session, mothers completed the Meta-Emotion Philosophy Interview, which assesses parents' awareness and acceptance of their own and their child's anger and sadness. Six months later children completed an open-ended interview to capture their understanding of emotions, mothers rated children's emotion regulation skill, and both mothers and children completed evaluations of the child's behavior.

Drs. Cunningham and Kliewer, along with collaborator Dr. Pamela Garner, found that the more mothers were aware of and accepted their own and their child's emotions, the more likely children were to understand and regulate their emotions, attesting to the importance of parents as models and coaches. For boys in particular, emotion regulation skill explained why mothers' philosophy of emotions was related to fewer adjustment problems, and greater social skill and academic performance. For girls, their understanding of emotions was key in linking mothers' philosophy of emotions and their social skill.

Although previous research on this topic has been conducted, this was the first study to demonstrate these findings in an urban, low-income, African American sample with school-age youth. The families in the study all lived in neighborhoods affected by violence and poverty. The findings have important implications for programs to enhance parenting in low-income populations. As children transition into adolescence, parental modeling and coaching of emotional competence potentially can help youth navigate this stressful developmental period.

Reference:

Cunningham, J. N., Kliewer, W., & Garner, P. (2009). Emotion socialization, child emotion understanding and regulation, and adjustment in urban African American families: Differential associations across child gender. Development and Psychopathology, 21, 261-283.