SAN DIEGO – “MY KIND OF TOWN”

            The 118^th APA annual convention, which was held this August in San Diego, was extremely pleasant.  At the APF/APA Awards ceremony, Hawaii's Kathy McNamara and Paul Pedersen were recognized for their decades of outstanding and distinguished service to the public, both nationally and internationally.  And, HPA Council Representative Craig Robinson was elected a Fellow of the APA.  Our sincerest congratulations to our colleagues.  These are well deserved honors and tributes.  These are special and "exciting times."

 

            Children and Youth – Programmatic Involvement:  A frequent visitor to Hawaii, and long time friend of Kathy from theirWright State University days, Rodney Hammond of the Centers for Disease Control and Prevention (CDC) presented his Nicholas Hobbs Award address entitled "Violence Prevention and the 'Futures of Children' Today."  Division 37 (the Society for Child and Family Policy and Practice) annually honors the psychologist who exemplifies the ideals and devotion to child advocacy/policy characterized by this outstanding scholar.  Over the past several years, Rodney has been on the forefront of addressing childhood violence from a public health perspective (i.e., emphasizing its healthcare, as well as its social policy relevance).  Last Fall, the newly appointed Director of CDC expressed his similar perspective: "(C)hild maltreatment is a serious public health problem with extensive short- and long-term health consequences….  (M)altreatment causes stress that can disrupt early brain development, and extreme stress can harm the development of the nervous and immune systems…  Fortunately, there is a growing body of evidence that documents the effectiveness of primary prevention strategies."

 

            Rodney emphasized that Nicholas Hobb's vision for the future of children held many insights for violence prevention and public health policy, stressing the importance of the ecological model, the need for coordination of services, and the value of early intervention.  Rodney proposed the strategy that: On the individual level, * strengthen the personal capacity of youth to resist violence.  On the relationship level, * build and support positive relationships between youth and adults.  On the community level, * promote thriving, safer, and more connected communities.  And, on society's level, * create a safer and healthier society.  In enacting his landmark Health Care Reform legislation, President Obama envisioned a national program supporting home visitation and provided $100 million in funding for this fiscal year, with the expectation that home visitation for high risk families could reduce child maltreatment by up to 40 percent.

 

            Rodney emphasized that there is a definite need for data-driven strategies to measure progress.  Under the leadership of Karen Saywitz, the APA has been working closely with CDC to identify a number of public health strategies and interventions which would promote positive parenting practices within the context of federally qualified community health centers, and particularly seeking opportunities for parenting interventions.  The CDC teen dating violence initiative is currently targeting 11-14 year olds in high-risk urban communities, again adapting evidence-based and promising prosocial skill programs.  Rodney further stressed that violence is preventable and that intervening early is critical.  Conceptualizing violence prevention programs within a public health model, provides the foundation for efforts to integrate parenting programs into primary healthcare which will ultimately be highly cost-effective and is consistent with the President's personal priority on enhancing wellness, prevention, and increasing access to primary healthcare.

 

            Children and Youth – Sports:  On a personal level, I truly enjoyed again having the opportunity to present with another frequent visitor to Hawaii, Colleen Hacker and her colleague Karen McConnell.  Colleen is the mental skills coach for the US Women's World Cup and Olympic Soccer Team and over the years has systematically addressed the importance of physical activity for girls.  Relevant statistics:  one in every six girls is obese or overweight; one in four girls grades 9-12 currently smokes; one in four high school girls reports that she does not like herself; 53 percent of 13-year old girls are unhappy with their bodies, while 78 percent of 12 grade girls are unhappy with their bodies; and, one in three adolescent girls will experience depression, anxiety, or eating disordered behavior.  Among girls, physical inactivity is associated with withdrawn, depressed symptoms; somatic complaints, social and attention problems, and rule-breaking behaviors.  While one in two boys participate in high school sports, only one in three high school girls participate.  Women of color are underrepresented in 20 of the top 25 participation sports.  Gender disparity in participation is even more pronounced when coupled with family income. 

 

            Research shows that involvement in sports can result in lifelong improvements to education, work, and health.  The increase in girls' athletic participation following passage of Title IX (Patsy T Mink Equal Opportunity in Education Act) was associated with a 7 percent lower risk of obesity 20-25 years later.  High school female athletes (compared to non-athletes) are less likely to experience unwanted pregnancy; more likely to get higher grades; more likely to graduate from high school; and more likely to have higher levels of self-confidence, self-esteem, and lower levels of depression.   They are also more likely to be physically active for life.  Those who are active have lower risks for breast cancer, osteoporosis, smoking, and illicit drug use.  Colleen emphasized the availability of mentors is extremely important.  Reflecting, a number of HPA's members pride themselves on being physically active, if not former athletes.  Perhaps HPA could play a catalytic role in facilitating mentorship opportunities, especially through our state's federally qualified community health centers.  These centers (and our Native Hawaiian health centers) are society's "safety net."  Their beneficiary populations represent the underserved that psychology and President Obama seek to serve.

 

            A Maturing Presence (EBTs):  An evolving priority within the Obama Administration is to ensure that our nation's health care practitioners embrace evidence-based practices and treatments (EBTs).  The Institute of Medicine (IOM) has consistently reported that: "The lag between the discovery of more efficacious forms of treatment and their incorporation into routine patient care is unnecessarily long, in the range of about 15 to 20 years.  Even then, adherence of clinical practice to the evidence is highly uneven."  And, that: "(T)he critical importance of evidence-based decision making does not yet seem to be on the radar screen of the majority of physician and hospital leaders, although the tipping point may be near."

 

            The Department of Veterans Affairs (VA) has been in the forefront of this evolution.  Joan Zweben, however, has recently raised several fundamental concerns regarding the implementation process.  * The selection process was neither collaborative nor transparent as the decisions were being made.  Treatments with weak evidence were selected while others with strong evidence were omitted.  Without transparent criteria and an open process, the rationale is mysterious and there is too much room for personal preferences of the decision makers.  * A commitment to a scientific process means that interventions shown to produce good results in efficacy trials (rigorous, tightly controlled) are then studied in effectiveness trials to see if they bring benefit in real world settings.  There appear to be few if any multi-site effectiveness studies conducted on VA populations for the designated treatments, so we don't know much about the level of improved outcomes that can be expected.  * How was it determined that the effect sizes were worth the transition costs?  In general, effectiveness is reduced when treatments are implemented in real world situations, and in many cases the effect sizes in the random assignment studies are modest.  * The "pick from this list" approach stifles innovation and rigidifies the treatment system.  It can promote a return to "cookie-cutter" treatment, rather than individualized treatment.  In the VA, this would also have impact on recruiting and training students, narrowing their range of skills.  * It appears that no attention has been given to the consistent research finding that the therapeutic relationship has a more powerful influence than any specific intervention in determining outcomes.  Multi-site effectiveness trials show variability of outcomes among the clinicians, despite the presence of fidelity checks.  Interventions such as Motivational Enhancement Strategies that strengthen the therapeutic alliance were omitted from the approved list.

 

The VA should seek to: * Establish the baseline.  Look at our current outcomes, determine which programs have the best outcomes, (excluding the possibility of significant differences in patient characteristics), and which need improvement.  * Examine what they are doing that is working or not working.  * Don't freeze the list.  There are usually multiple pathways to the goal.  And, * Include outside experts.  The VA Health Administration operates the largest federal medical care delivery system in the country, with 153 hospitals, 90 VA residential rehabilitation treatment programs, 135 nursing homes, and 1,031 outpatient clinics.  VA's experience and policies with EBTs will have a dramatic impact upon the rest of the nation, including the private sector.  These are "exciting times."  Aloha,

 

 

Pat DeLeon, former APA President – Hawaii Psychological Association – September, 2010