‘Maternal depression, suicide risk and culturally appropriate interventions’ – In Conversation with Dr. Rhonda Boyd

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In this podcast, Dr. Rhonda Boyd, associate professor at the University of Pennsylvania and psychologist at the Children’s Hospital of Philadelphia, talks depression, suicide and culturally appropriate interventions.

Rhonda highlights the growing issue of depression and suicide for youth and discusses the most effective interventions for treatment. She also runs through key points from her JCPP paper which explored the association between family history of suicide attempt and neurocognitive functioning in community youth.

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Dr. Rhonda Boyd

Dr. Rhonda Boyd is a faculty member at PolicyLab at Children’s Hospital of Philadelphia (CHOP) and an associate professor of Psychology in Psychiatry at the University of Pennsylvania School of Medicine. She is also the associate director of CHOP’s Child and Adolescent Mood Program in the outpatient clinic of Department of Child and Adolescent Psychiatry and Behavioral Sciences, where she practices as a licensed psychologist specializing in evaluation and treatment of youth with depression. In addition, she serves as the director of research training for the Child and Adolescent Psychiatry Fellowship at CHOP (bio from PolicyLab).

Transcript

Interviewer: Hello and welcome to the In Conversation podcast series for the Association for Child and Adolescent Mental Health or ACAMH for short. I’m Jo Carlowe, a freelance journalist with a specialism in psychology. Today I’m interviewing Dr. Rhonda Boyd, associate professor of psychology and psychiatry at the University of Pennsylvania and a psychologist in the Department of Child and Adolescent Psychiatry and Behavioural Sciences at the Children’s Hospital of Philadelphia. Rhonda is a specialist in adolescent depression and cognitive behavioural therapy. If you’re a fan of our In Conversation series, please subscribe on iTunes or your preferred streaming platform, let us know how we did with a rating or review, and do share with friends and colleagues. Rhonda, thank you for joining me. Can you start by introducing yourself?

Dr. Rhonda Boyd: Yes, thank you, Jo. I’ve been at the Children’s Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine for about nineteen years now. My research has focused on maternal depression, its impact on children, also conducting preventive interventions in mostly low resource, racially diverse populations of women and families. And more recently, I’ve been expanding my research to be more aligned with my clinical work. So I’ve been focusing more on youth depression and suicide risk in my research. I have been doing this work with colleagues as part of CHOP’s Child and Adolescent Mood Program, which is a clinical programme but also has a research component in which we have a data registry, a repository, of patients who come into our clinic to be evaluated. And so we’ve been doing that for a number of years and are in the process of writing up papers and expanding that research.

Interviewer: And how did you come to be interested in child and adolescent mental health?

Dr. Rhonda Boyd: So it’s interesting, as a child, I used to read a lot and I always had a book, and sometime during adolescence I started reading books about mental health, and that’s when it sparked. I began to understand as I read these books that early childhood experiences are very important, influence later development into adulthood, and that sparked my interest. And when I went to college at Brown University, I was able to major in psychology and my interests took off. I took as many classes as I could that focused on child and adolescent mental health. And then I went into graduate school to study clinical psychology and the focus on child and adolescent psychology.

Interviewer: Right. It sounds unusual to be reading books on mental health when you were quite young?

Dr. Rhonda Boyd: Yes, it wasn’t the only thing I read, but I was one of those people who read a lot of different genres. And I believe it was actually my eighth grade teacher, she began exposing me to different types of books and she gave me, it was like a true story, about someone with mental health problems and that’s what started it. And then I kept reading as I got older.

Interviewer: Rhonda, as you’ve already described, your research interests include adolescent and maternal depression, prevention and health disparities. And you’ve conducted several studies examining at risk children and mothers. Can you explain the relationship between mothers who are at risk and the implications for their children?

Dr. Rhonda Boyd: Yes. It’s been an extensive research literature showing that maternal depression has been associated with a great deal of negative consequences for children in many domains such as increased psychopathology, developmental delays, medical conditions, substance abuse and poor functioning that goes on into adulthood. And so this has been well documented.

Dr. Rhonda Boyd: One of the things in general parental psychopathology, so fathers do matter, that does come up often, it’s not as much research as there are on mothers, but in fathers, psychopathology has been associated with poor outcomes for you. And one of the areas that they’ve looked at is sort of how is this transmitted? And so parenting deficits have been noted. That parents with depression may be more intrusive in their parent, they may have poor attachment to their children. And so the parent-child interaction becomes an important way in which psychopathology may be transmitted. Also, children of depressed moms have increased negative life events, some of those occur because of the mother’s experience, but they’re own individual negative life events. And then there’s these biological mechanisms, their genetic predisposition, and then when you look at a perinatal depression, there may be biological mechanisms that are happening while a woman is pregnant that could put a youth at risk for developing psychopathology later.

Interviewer: We know suicidal behavior is highly familial, and I want to turn to a paper that you co-authored that appeared in the Journal of Child Psychology and Psychiatry, the JCPP, which explored the association between family history of suicide attempt and neurocognitive functioning in community youth. Can you give a brief summary of your explorations and also some of the findings?

Dr. Rhonda Boyd: Yes. One of the things is that, from my interest in maternal depression, it was interesting to be able to look at more suicide risk and how that fit into putting youth at risk. And looking at the mechanisms, as I had mentioned before, I don’t understand what is happening. So colleagues from the Children’s Hospital of Philadelphia and The University of Pennsylvania, we came together to look at this large database – they have a database of almost 10,000 youth and their parents, who also participated – and were able to gather those in that sample who actually had a family history of suicide attempt. So this is first-degree relatives, parents or siblings, and we included both non-fatal and fatal suicide attempts.

Dr. Rhonda Boyd: We were able to identify 501 youth who were between the ages of eight and 21, and so we matched those participants based on age, sex, race and lifetime depression, the participants who did not have a family history. And then we looked at their neurocognitive functioning based on computerised tests. And so what we found is that those youth with the family history of suicide attempts had lower executive functioning than the other youth, and in particular, they had low in areas of attention span and language reasoning. And so we were able to identify…and that supports some of the other literature looking at those neurocognitive deficits, there’s just not a lot of research focused on children and adolescents. And so this was an area which we realized could lead to some implications for interventions, and particularly because it was a large sample that we were able to notice these differences.

Interviewer: So what are the implications, then, of your findings regarding family history of suicide and neurocognitive functioning, in terms of prevention and treatment of suicidal behaviors in young people?

Dr. Rhonda Boyd: It does suggest that executive functioning may be an area that you want to focus on for interventions for at risk youth, because these kids were not treatment seeking youth, they were community youth, and that you already were seeing these neurocognitive deficits, which has implications for later behavior. And so we know when someone has a suicide attempt, we know when people die by suicide in family, and so we could focus on the kids in the family to be able to see how they’re functioning and to be able to work on these areas.

Dr. Rhonda Boyd: Also, the finding about youth, the language reasoning indicate they’re sort of helping you verbalize their thoughts and feelings, problem-solving and understanding the consequences of their behaviors are areas that we can focus on in therapy, and cognitive behavioral therapy is a type of therapy that can address those issues. And being able to help with those kind of neurocognitive executive functioning tasks will be helpful for youth, possibly. Also, I think it’s important for us to gather information about family suicide history when a youth is presenting for mental health treatment. Many times people may have a short time to gather a lot of information, but knowing this, that someone has a family history, would help guide the treatment and treatment planning.

Interviewer: So can I check something? So if you saw a youth with a family history of suicide who showed certain cognitive deficiencies let’s say, would that suggest to you that the risk is higher in that child?

Dr. Rhonda Boyd: I would think that that was an area that I would want to focus on. That could be because it would make me concerned that when they’re stressed, they may not be able to problem solve and talk their way out of certain situations, which is important when someone may have suicidal ideation. As a therapist, we’re there, we may see someone once a week. Many times we’re teaching skills that they can use later. So I would be concerned if a youth would not have the ability to be able to problem solve and think through things.

Interviewer: OK, and from your clinical practice then, what interventions do you find to be most effective when working with adolescents with depression, and I suppose in particular with young people who are struggling to get their sense across?

Dr. Rhonda Boyd: Yes. As I mentioned, I’m a cognitive behavioural therapist and that’s what I’ve been trained, so I typically use cognitive behavioural therapy, treating with depression, it’s been shown to be effective, depression and comorbid conditions such as anxiety disorder. So oftentimes the youth that I see may have depression, anxiety, as well as suicidal ideation and behaviours. Also, interpersonal psychotherapy has been shown to be effective in treating adolescent depression.

Dr. Rhonda Boyd: Currently, there’s limited data in how well these interventions work for youth of colour. And so that is something that many times we’re trying to make sure apply to fit with our population. In my practice CBT is my base, but I also utilise strategies from other evidence based treatments fit the patient. Our clinical team at CHOP, our Child and Adolescent Mood Program, we’re also using dialectical behaviour therapy groups and techniques with our patient to address both depression and suicidal ideation behavior and cutting behaviors that come up. And many times youth may participate in individual therapy, group therapy. So as well as see a psychiatrist for medication, we use combination treatments, especially for the youth who are more severe.

Dr. Rhonda Boyd: One thing that is also very important is the parent involvement in treatment. And this could vary, even for adolescents’ parents, we need to have them involved. It could be check ins about treatment planning. It could actually be focusing on particularly parenting skills, to help them manage a youth with both depression and suicide risk, which is very stressful for parents, and sort of helping with communication skills and things like that. And also the ones providing psycho-education to the family about treatment with depression, suicide risk, safety planning and how all that can be implemented at home. And sometimes some families need more family therapy as a supplement also.

Interviewer: Right, right. When one hears that suicide and suicidal behaviour runs in families, it does feel a bit hopeless. What would you say to young people who may be worried about this because of their family history, and also to clinicians who may encounter young people with those concerns?

Dr. Rhonda Boyd: One of the things that we know, even though there’s a biological risk, it’s not a one to one relationship, so not all youth who have a family history of suicidal behaviours will make an attempt, some of them will be entirely fine. One of the things I do want to emphasise to youth is to make sure that they seek mental health treatment early if they begin to exhibit any socio-emotional difficulties. The goal is to prevent suicide behaviours and attempts. And so getting help early is key. For clinicians, if they’re seeing young people, they’re probably already a problem identified because they’re seeking help, and so they need to provide psycho-education to the family about the risk of potentially suicidal behaviours. But also, if the parents could be or siblings could still have these issues and they may need to get their own treatment. So sometimes you have to take this family approach to being able to help one youth.

Interviewer: Rhonda, you mentioned before that there has been limited research on the effectiveness of interventions such as CBT, on people of colour, and we’re talking about young people of colour. Have you been doing any particular research on this?

Dr. Rhonda Boyd: I have not yet, that is something I’m hoping to do. I was part of a work group recently for the United States Congressional Black Caucus, it’s an Emergency Task Force on Black Youth Suicide and Mental Health, and we reviewed the current research literature looking at what was out there and what was needed. One of the big issues…recent trends is that there’s been increased deaths by suicide for black children 12 and under compared to white children. And then there has been increasing rates of suicide attempts among black teens in the US over the last decade.

Dr. Rhonda Boyd: And so, when we looked at what is happening, we made recommendations and tried to figure out what is happening. I think there’s a lot we don’t know. And so my team and I, that is our goal, what we’re hoping to do is contribute to that research literature trying to understand why this is happening, but also testing interventions that are culturally appropriate, to be able to make sure. The current research suggests that most of the interventions that work with children of colour have been adapted, and so that is probably the way in which to move the research forward, about understanding how to make these cultural adaptations to the interventions that currently work or to actually test to see how they work in different populations of youth of colour.

Interviewer: Right OK, so it’s still a work in progress really.

Dr. Rhonda Boyd: Yes.

Interviewer: But why do you think there’s been such a dearth in the research in this area then?

Dr. Rhonda Boyd: I think things go through different trends of sort of what happens and where research is funded. One issue that comes up is that research with children in adolescence kind of fall behind compared to research with adults in general. And then, also doing work that are cultural adaptations many times take a long time and it’s sometimes hard to get funded to do the work. And so if there’s not research funding to support it, then the people who want to do it…it’s hard to do the work without that support financially to do it.

Dr. Rhonda Boyd: And then sometimes people argue whether you can adapt something for every group, and so sometimes there’s backlash in that, and trying to find that medium of how to do the work. And engaging communities too, is important, it takes a lot of time to do that, to make sure it fits with the population.

Interviewer: Thank you. Rhonda, you are a faculty member at the Policy Lab that the Children’s Hospital of Philadelphia, known as CHOP, and also associate director of CHOP’s Child and Adolescent Mood Program. The Policy Lab has evidence to action approach, can you give some examples of how that works?

Dr. Rhonda Boyd: Yes. This approach is taking the research that the faculty do and translating it to be useful for policymakers, community and other stakeholders. So typically – as you mentioned, I have a paper published – as an academic we put papers and journals, but oftentimes the community never knows about it, and there’s not a way to give access. So Policy Lab, they have a Communications team, a Policy team, to help us think through what our research means, the implications, how to strategise to send it out to different audiences. And so it’s put in kind of a shorter form, so they do policy briefs, blogs, they do social media. Also, there’s times where there’s a current issue that comes up, policy issue, in which they will gather a team together to write up what the current research says and where things need to go. And I find this kind of exciting work, to do a Policy Lab, because we want our work out there. We want people to be able to use the research that we do.

Interviewer: Absolutely. You serve as a Director of Research Training for the Child and Adolescent Psychiatry Fellowship at CHOP. Why is evidence based research so important when it comes to children and young people’s mental health?

Dr. Rhonda Boyd: Our department has a two year psychiatry fellowship which has a research requirement, and so I oversee that component in the [inaudible] [s.l. sister] fellows, in locating appropriate research lab to work during that last year of their fellowship. I think it’s important to understand the process of research and how to critically evaluate the research literature for all mental health professionals, particularly child and adolescent mental health professionals, as I say, the research is not as abundant as it is with adult research literature.

Dr. Rhonda Boyd: And one of the things is that we have a huge research practice gap. And so we want to be able to get the research that we know out into the field, and to practitioners, and so we want to decrease the lag time in which research is out in the field. And we want to make sure the youth are getting the appropriate care for their psychiatric disorder. And so this makes it important to be able to focus on evidence based research. Because it does change, things that we knew 10 years ago have changed. And so we need to make sure that people are updated in the field, and it’s sometimes hard to do that. As I say, people don’t always read journal articles and so we have to find other ways to get things out, through CMEs or CUs, or certain ways, and I think things like podcasts and webinars with the internet has opened up possibilities of training people at larger levels.

Interviewer: Sure. Typically, how long is the research practice gap then, in terms of translating research into practice?

Dr. Rhonda Boyd: It’s over 10 years.

Interviewer: Oh wow, OK. So it may be old by the time its acted upon?

Dr. Rhonda Boyd: Yes.

Interviewer: As in, outdated. What can be done, in your view then, to speed that up and make that translation of research into practice…to ensure it’s more current?

Dr. Rhonda Boyd: Well, part of it, I know people are often now are doing designs, more effective this hybrid research where they’re doing it in practices, because some of the issues, when you think about intervention therapy trials, they’re done with efficacy. So you may start off testing them in a very controlled environment and then you have to test that through multiple trials. And then you get out into the community and practice, which the patient population fits differently. Then you have to figure out how it translates to providers.

Dr. Rhonda Boyd: So now people are trying to quicken the time, develop trials in which they’re testing the efficacy as well as doing it within community settings, with patients that may be more diverse in their clinical presentations, so that we can move it quickly. And also with implementation science, looking at what factors that may impact implementing it in a real world setting. And so I think that area, moving that forward, and making that more common is important. The old style of taking things through all these trials before it goes to the community is not working.

Interviewer: Right, right. Rhonda, what other research areas are coming up for you?

Dr. Rhonda Boyd: I wanted to mention about a trial that I currently am working on – my co-principal investigator, Dr. James Garver and I, he’s a paediatrician and a professor at CHAP in Penn – we’re conducting a randomized controlled trial of a parenting intervention that was adapted onto Facebook for postpartum mothers screening positive for postpartum depression symptoms at the paediatric Well-Child visits. So these are the early visits, two, four and six month Well-Child child visits at the Children’s Hospital of Philadelphia.

Dr. Rhonda Boyd: We conducted a previous trial, it was a pilot, pretty small, in which we adapted the intervention and we compared our adaptive intervention with the in-person intervention. And our findings show that women in the social media intervention had increased parenting competence and they had decreased depression symptoms from baseline post-intervention compared to the in-person group. And the attendance was high for the social media intervention, but very poor for the in-person intervention. And one of the things that we do realise, that it is maybe hard, especially for a mother who just had a baby, to be able to come out for group interventions, and so the Facebook intervention allowed more flexibility to be able to get the parenting intervention.

Dr. Rhonda Boyd: So we’re now currently testing this social media intervention in a larger trial that is funded by the National Institute of Mental Health. The women receive either the social media parenting intervention plus a Web-based CBT intervention, or they receive only the Web-based CBT intervention. And we’re currently in this first phase looking at how it impacts parenting and we’re doing mother-infant interactions that are coded, so it’s more independent of parent report. And we’re also looking at depression symptoms over time. And so we’re excited about that intervention. It was affected by Covid, we had to stop for a while, but we’re back on track recruiting virtually. And so we’re excited about being able to do an intervention that can be done on social media, that can eventually, hopefully, be scalable and disseminated more widespread.

Interviewer: And very timely actually because of Covid…

Dr. Rhonda Boyd: Yes.

Interviewer: …in terms of that sort of need to roll out more remote working. What’s the sort of timescale on that? When can you imagine there’ll be some sort of interim result?

Dr. Rhonda Boyd: Yes, I know I’m trying to think that we’re behind, so I’m hoping that we should be able to probably finish it within maybe six months, that first part. Six months to a year, I guess, and then we can write up the initial findings. Covid affected…as you know, everything shut down research-wise. And so one of the things we are trying to figure out, we think mothers are probably not going to their doctors appointments as frequently as they [inaudible] [s.l. also] because they were screened in the paediatrician offices. So we’ve been figuring it out, but I’m hoping within a year we will have some new data. And the way this grant is written, we have to first affect parenting, and then we move on to the second phase in which we test it to look at child outcomes, and that we will eventually look at whether it affects child developmental outcomes.

Interviewer: Oh wow, OK, it sounds really exciting. Rhonda, what else is in the pipeline you’d like to mention?

Dr. Rhonda Boyd: One of the things is, often I’ve been hoping to collaborate with some researchers to look more at research looking at youth depression and suicide, is one of the areas in which I’ve been hoping to focus. My team, we just published a paper, I guess it just came out online, and with our data registry, looking at sort of different risk factors for youth presenting with mood symptoms in our clinic. Looking at bullying behaviours, trauma, maltreatment, and looking at how it impacts youth functioning.

Dr. Rhonda Boyd: We did a cluster analysis and we showed that youth that were presenting with maltreatment as well as being perpetrators of bullying, as well as being victims of bullying and fighting behaviors. And that those youth who had high levels of both maltreatment as well as the bullying involvement, which we call “the web of violence”, because we noticed that the kids that were actually being victims as well as also perpetrators, that they had worse clinical outcomes. And these are youth that already were presenting clinically, and so they had higher hopelessness, they had higher impairment, higher depression symptoms. And so it makes it important for us to think about how we assess kids, and that we need to look at kind of all violence involvement youth are experiencing. And particularly when kids come in with internalising symptom, we don’t view them as participating in fighting and also perpetrating, but that we need to look at it more comprehensively, I think is important.

Interviewer: Can you give us an example of an internalising symptom?

Dr. Rhonda Boyd: So that is kids with depression and anxiety. We don’t usually view them as youth who may be bullying other people. And externalising are youth who have more aggressive behavior, more attention, acting out, and so those are the youth we tend to associate with some of the bullying behaviors. But many times…youth are not just one thing, and I think sort of the complexity of gathering information, what kids may be experiencing and why, is important to gather because it increase their risk factors and how their symptom presentation.

Dr. Rhonda Boyd: And also, knowing that information then we can do interventions that may focus on how to address those issues. Because oftentimes with youth that have depression, irritability is a symptom that we tend to see, with youth who have depression, which is not typical for adults.

Dr. Rhonda Boyd: So youth have irritability, which also could be in addition to their sadness. But it could be interpreted, if they’re irritable, they may snap at people, get annoyed easily, and that impacts their interpersonal relationships. So they may be mean, or interpreted as mean by other people. And so when youth are presenting that they are having trouble with friends and classmates, sort of understanding what may be going on, that they may be contributing to some of it also because of their depression symptoms, as well as then they’re receiving it back. And so how to stop those negative interactions so that they have more positive interpersonal relationships with people that will help in their recovery from the depression.

Interviewer: Right. And again, what’s the sort of timescale on that project?

Dr. Rhonda Boyd: That paper is out online, it just came out. But we’re still trying to follow up on different information. So it came out probably in May online, and it’s part of a special issue looking at sort of comorbidity across youth violence behaviours. And so because we have a data registry, we’re developing several different projects in which we’re hoping to follow up and look at understanding of risk, and protective factors for youth who are presenting with depression in our clinic.

Interviewer: And finally, Rhonda, what is your takeaway message for those listening to our conversation?

Dr. Rhonda Boyd: One of the things I do want to emphasize is that depression and suicidal behaviours are significant problems for youth. They are increasing, all the current research that comes out, when they update it, that this is a huge problem. Suicide is the second leading cause of death for children and youth and so we need to address this. I think it’s something that needs to become a priority and that particularly we need to focus on interventions.

Dr. Rhonda Boyd: There’s a piece of trying to understand what happens, but we know these youth need to be treated and we need to figure out what are the appropriate ways to screen, to make sure youth are not missed, that we have interventions that are accessible, and in environments in which youth present, whether that’s school, in community settings, and making sure that they’re culturally appropriate for all the populations of youth that are needed. And so I guess that will be my take home message for everything.

Interviewer: Great, thank you. And are you optimistic that that will happen?

Dr. Rhonda Boyd: Yes, I have to be [laughter] otherwise I couldn’t do this. Yes, I’m optimistic. I’m optimistic that people recognise that there’s a crisis that we need to help our youth. And part of it is that depression, suicidal behaviors, they have significant impact into adulthood.

Dr. Rhonda Boyd: Youth who have depression, they many times may go through different episodes all the way into adulthood. Then they’re at risk when they have children, the girls, later, and as I’m studying as I say, postpartum perinatal depression, so it’s all linked together.

Interviewer: OK. Rhonda, thank you ever so much. For more details on Dr. Rhonda Boyd, please visit the ACAMH website www.acamh.org Twitter at ACAMH. ACAMH is spelt A-C-A-M-H. And don’t forget to follow us on iTunes or your preferred streaming platform. Let us know if you enjoy the podcast with a rating or review and do share with friends and colleagues.

 

 

 

 

 

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