Richard Heyman, Ph.D. - US grants

The purpose of this project is to propose and test a model of anger escalation and de-escalation in couples with and without husband-to-wife aggression. This model integrates social learning, feminist, and systems theories. The following processes are hypothesized to maintain aggression. Relationships occur in the context of both blatant and subtle sexism. Even if the majority of aggressive men do not approve of aggression, they may still be sensitive to themes of disrespect by their wives. Due to skill deficits, aggressive couples will have a harder time navigating gender-based goal incongruence adaptively, leading to increased frequency of reciprocated hostility. As these negative reciprocity cycles occur more frequently, and are negatively reinforced, they become highly predictable and scripted. Appraisals and behaviors become overlearned, so that it only requires a subtle cue to set off a flood of anger. De-escalation deficiencies then make it difficult to stop the rush of anger once it starts. Spouses beliefs that they can resolve conflict become eroded, leading them to avoid these hot issues. Inevitably, these conflicts reoccur, leaving the couple even less prepared to effectively deal with such issues. With each repetition, the behaviors become more overlearned, coercion is more strongly reinforced, and global perceptions of the partner becomes increasingly negative. This process sets up the couple for husband-to- wife aggression, but typically produced only verbal aggression with the potential for further escalation. This model will be tested by comparing the escalation and de-escalation processes and skills of three groups of couples (n=50 per group): non- distressed/non-aggressive, distressed/non-aggressive, and distressed/aggressive. Participants will be recruited through random digit telephone surveying to increase the generalizability and ethnic diversity of the sample. Among the major hypotheses to be tested are (1) aggressive men demonstrate higher degrees of overlearning in their anger responses, as evidenced by (a) greater magnitude of anger escalation; (b) greater speed of anger escalation; and (c) predictable appraisal patterns; and (2) aggressive men have de-escalation skill deficits, as evidenced by (a) higher peak levels of anger; (b) extended periods of anger; (c) fewer attempts at de-escalation; and (d) fewer successful attempts at de-escalation. Improved treatment efficacy may be obtained by breaking the overlearned anger habit before attempting more cognitive interventions.

Oral health is an important component of overall health (e.g., Tabak, 2008;U.S. Department of Health and Human Services [USDHHS], 2000a) and is one of 28 focus areas in U.S. Government's Healthy People 2010 public health strategy (USDHHS, 2000b). Oral diseases are the most common human chronic diseases (Sheiham, 2005), with dental caries - both infectious and transmissible -being the most prevalent (USDHHS, 2000b). Despite its widespread occurrence, efforts to control caries - especially among diverse ethnic, social, and economic populations - continue to elude clinicians. Research clearly documents that couples conflict has profound effects on the immune and endocrine systems of adults and children. Likewise, parenting problems are a chronic emotional and behavioral stressor on both adults and children, with serious attendant health effects related to chronic arousal (e.g., Kiecolt-Glaser, McGuire, Robles, &Glaser, 2002). We hypothesize that the same mechanisms that result in effects on general health also result in specific effects on oral health. We propose to collect an additional wave of data (including parent reports of child and adult oral health and related behaviors) on a sample of 400 families with young children (now 4-11 years old) who have already completed two waves of assessments in a family study (NICHD grant R01 HD046901). Originally designed to examine the effects of family violence exposure on children and adults, that data set includes family and individual potential mediators and moderators and a range of health and functioning outcomes, but not oral health information. This project has the following specific aims: #1: Test the first hypothesized pathway by establishing the effect sizes of relations between (a) family functioning;(b) child and adult oral health behaviors;[and (c) test whether parental socialization of oral health behaviors mediates these associations in children.] #2: Test the second hypothesized pathway by establishing the effect sizes of relations between (a) family functioning and (b) child and adult oral health outcomes. Test both the direct effects of family function behaviors and whether these effects are mediated by oral health behaviors [and socialization of these behaviors in children]. #3: By applying a moderational framework to identify what makes family functioning sometimes predict oral health and other times not, we can more specifically determine under what conditions which aspects of family functioning predict child or adult oral health outcomes. #4: Determine the extent to which effects of violence exposure in the family on oral health are mediated by (a) non-abusive couple conflict, (b) inept parenting, or (c) both.[#5: Test the hypotheses of Aims 1 - 4 longitudinally to predict change in oral health.]

DESCRIPTION (provided by applicant): Oral health is an important component of overall health (e.g., Tabak, 2008;U.S. Department of Health and Human Services [USDHHS], 2000a) and is one of 28 focus areas in U.S. Government's Healthy People 2010 public health strategy (USDHHS, 2000b). Oral diseases are the most common human chronic diseases (Sheiham, 2005), with dental caries - both infectious and transmissible -being the most prevalent (USDHHS, 2000b). Despite its widespread occurrence, efforts to control caries - especially among diverse ethnic, social, and economic populations - continue to elude clinicians. Research clearly documents that couples conflict has profound effects on the immune and endocrine systems of adults and children. Likewise, parenting problems are a chronic emotional and behavioral stressor on both adults and children, with serious attendant health effects related to chronic arousal (e.g., Kiecolt-Glaser, McGuire, Robles, &Glaser, 2002). We hypothesize that the same mechanisms that result in effects on general health also result in specific effects on oral health. We propose to collect an additional wave of data (including parent reports of child and adult oral health and related behaviors) on a sample of 400 families with young children (now 4-11 years old) who have already completed two waves of assessments in a family study (NICHD grant R01 HD046901). Originally designed to examine the effects of family violence exposure on children and adults, that data set includes family and individual potential mediators and moderators and a range of health and functioning outcomes, but not oral health information. This project has the following specific aims: #1: Test the first hypothesized pathway by establishing the effect sizes of relations between (a) family functioning;(b) child and adult oral health behaviors;[and (c) test whether parental socialization of oral health behaviors mediates these associations in children.] #2: Test the second hypothesized pathway by establishing the effect sizes of relations between (a) family functioning and (b) child and adult oral health outcomes. Test both the direct effects of family function behaviors and whether these effects are mediated by oral health behaviors [and socialization of these behaviors in children]. #3: By applying a moderational framework to identify what makes family functioning sometimes predict oral health and other times not, we can more specifically determine under what conditions which aspects of family functioning predict child or adult oral health outcomes. #4: Determine the extent to which effects of violence exposure in the family on oral health are mediated by (a) non-abusive couple conflict, (b) inept parenting, or (c) both.[#5: Test the hypotheses of Aims 1 - 4 longitudinally to predict change in oral health.]

Close relationships are central to health and happiness. Most research has focused on relationship problems that interfere with well-being. However, a number of recent, rigorous studies have found that it is also important that couples associate their relationship with a sense of growth, that relationship boredom can be a major cause of marital distress, and that relationship quality is enhanced when a couple does things together that are novel and exciting. Yet, the research to date has not examined this important process in a significant real-life context, has not yet identified the fundamental underlying principles of just how this process operates, and has not yet delineated the conditions under which this process is particularly likely to operate. This research takes advantage of a unique opportunity to advance knowledge by addressing exactly these issues, issues that have been almost impossible to test with standard research methods and populations.

This research is a unique collaboration between Dr. Arthur Aron and colleagues at SUNY Stony Brook and a non-profit organization called Welcome Home Troops (WHT). WHT provides thousands of U.S. soldiers returning from combat deployments with tickets to exciting events (e.g., NASCAR races, concerts) to attend with their spouses. WHT hopes to help reduce the high divorce rate in this population by giving them a positive, high energy, shared experience, as a couple. WHT is helping the research team connect with 2,000-5,000 married soldiers to better understand how and why their approach might be working, while also providing a unique platform to test basic theory on the role of shared experiences in relationship health. Soldiers and their spouses, along with a matched comparison group, will complete surveys and indirect measures before and immediately after the event, as well as six months later. The findings will illustrate the specific processes that promote relationship health and satisfaction within married couples who have experienced recent separation and stress. Additionally, the work might directly benefit returning soldiers and their families by promoting relationship health and marital satisfaction.

DESCRIPTION (provided by applicant): Early Childhood Caries (ECC) is of high public health importance because of its (a) associated pain, and elevated risk for infection, emergency department visits, hospitalization, and treatment under general anesthesia (with its attendant risks and expense);(b) increased risk for future caries in primary and permanent teeth;(c) impact on physical development (due to ECC negatively affecting eating and nutrition);and (d) impact on cognitive development (due to increase in school absences and pain-reduced capacity to learn). ECC has increased from 24% to 28% in 2-5 year-old children between 1988-1994 and 1999-2004, with the prevalence of Severe ECC (S-ECC) at 5%, or over 300,000 children (Dye et al., 2007). This increase is disheartening because of both the upward trajectory and an absolute rate more than double the Healthy People 2010 oral health objective of less than 12% for U.S. 2- 4 year olds. Despite its health impact, cost, and widespread incidence and prevalence, preventing ECC - especially among diverse ethnic, social, and economic populations - continues to elude clinicians. Although ECC is instigated by certain acidogenic and aciduric members of the biofilm (Streptococcus mutans) and is nearly entirely preventable, its intractable (and even rising) prevalence indicates the strong influences of what are known as social determinants of health (e.g., familial, cultural, social, economic, political, environmental factors) (e.g., Newton &Bower, 2005;Watt, 2007;Yevlahova &Satur, 2009). This project is the first to employ a time period when couples are maximally open to intervention in the service of oral, physical, and psychological health (i.e., after the birth of a child). It will be the first to intervene with new parents on three hypothesized social determinants of ECC simultaneously: (a) noxious family environments, (b) daily oral health behaviors/promotion for children, and (c) regular, recommended child dental check-ups. Dentistry has discussed building a "dental home" for consistent, ongoing, positive services. This project moves this home out of the dentist's office and into the family abode, where the daily behaviors and environments that either increase or mitigate the risk for ECC are. This paradigm shift, what we term the oral healthy home, could revolutionize outreach to families at high risk for ECC, both by having the home promote oral health on a daily basis and by increasing the use of the "dental home" at recommended intervals. PUBLIC HEALTH RELEVANCE: Early Childhood Caries (ECC) is of high public health importance because of its (a) associated pain, and elevated risk for infection, emergency department visits, hospitalization, and treatment under general anesthesia (with its attendant risks and expense);(b) increased risk for future caries in primary and permanent teeth;(c) impact on physical development (due to ECC negatively affecting eating and nutrition);and (d) impact on cognitive development (due to increase in school absences and pain-reduced capacity to learn). This project is the first to employ a time period when couples are maximally open to intervention in the service of oral, physical, and psychological health (i.e., after the birth of a child) and will plan and pilot interventions with new parents on three hypothesized social determinants of ECC simultaneously: (a) noxious family environments, (b) daily oral health behaviors/promotion for children, and (c) regular, recommended child dental check-ups.

DESCRIPTION (provided by applicant): Adolescent dating violence is alarmingly common and exacts a substantial toll on public health. It exhibits substantial stability and may become deeply entrenched by adulthood. Given these difficulties, the prevention of adolescent dating violence has become a concern of the CDC, NIH, and several noted investigators. We, in concert with several colleagues, offer the following set of observations, which frame the problem at hand and the research that we believe needs to be done: (1) Clearly we've only just begun to learn how to pre- vent dating violence. Rigorous efficacy trials have been rare and have produced sometimes promising but sometimes mixed results. We need to do better. (2) Dating violence prevention would be enhanced by the identification of malleable risk factors that can become new intervention targets. (3) There are clear indications in the research literature that adolescent couples' relationship dynamics are important factors in dating violence. However, the field is just beginning to understand what those dynamics are. (4) We believe it highly likely that the discovery of additional relationship dynamics that undergird dating violence will ultimately lead to enhanced interventions to prevent it. Accordingly, we are proposing an observational [longitudinal] study of 100 New York City 14- to 18-year- old dating couples in order to test the hypothesis that some adolescent couples may inadvertently provide one another with basic training in hostile behavior, ultimately leading to violence. This hypothesis stems from Gerald Patterson and colleagues' groundbreaking work showing the power of such coercive processes in explaining parent-child and sibling dynamics that contribute to child aggression. While some have hypothesized the role of coercive process in adolescent couples' dating violence, the model has yet to be directly tested. To evaluate the role of coercion in youth dating violence, we intend to apply our team's expertise in intimate violence, couples observation, and development to the execution of the following aims: Aim 1: Test the fundamental basic training premise of the coercion model - that the occurrence of aversive and non-aversive behaviors is tied to their effectiveness in terminating conflict. We hypothesize that behaviors more effective in terminating conflict will be performed at a higher rate. If aversie behavior is more effective than non-aversive behavior, it will be performed at a proportionally higher rate; and vice versa. ¿ Aim 2: Test the association of coercive process and dating violence. We hypothesize that violence will be elevated [and/or increasing] in couples for whom aversive behaviors are proportionally more effective than non-aversive ones in terminating conflict, and show higher rates of reciprocation during conflict. ¿ Aim 3: Determine whether other previously identified risk factors (e.g., anti-sociality, family violence) explain dating violence via their impact on coercion, or whether coercion explains [levels and/or change in] dating violence independent of these factors' influences.

? DESCRIPTION (provided by applicant): Corrosive couple conflict (CCC) and coercive parent-child conflict constitute a ubiquitous, potent, and destructive (but modifiable) interpersonal poison to a wide range of adult and children's health outcomes. Such patterns are also linked with poor parent-child relationships and with more harsh punishment, which is associated with disturbed responses to environmental stresses (e.g., disruption in sympathetic nervous system and hypothalamic-pituitary-adrenocortical responses), a wide variety of adverse health outcomes in childhood, including dental caries, obesity, and diabetes related metabolic markers. This phase of NIH's Science of Behavior Change program emphasizes an experimental medicine approach to behavior change necessitating identification of central interpersonal/social targets for maximal impact on far-reaching panoply of health outcomes. This project will focus on factors associated diabetes and oral health (though the processes affect many other disease outcomes). Both are associated with pain, distress, expense, loss of productivity, and even mortality. They share overlapping medical regimens, are driven by overlapping proximal health behaviors, and affect a wide developmental span, from early childhood to late adulthood. As requested by the RFA, we will isolate three proximal health behaviors: (a) medical regimen adherence; (b) eating and drinking high sugar/calorie items; and (c) self-care behaviors. CCC/coercive parent-child conflicts are marked by an interrelated set of affective, behavioral, and physiological signatures. In the UH2 phase, we will identify/develop/validate assays. We will also identify/develop, and test interventions to reduce CCC/coercion targets. In the UH3 phase, we expect to conduct at least 2 studies to test whether reduction in targets results in improvement in adherence and other health behaviors of interest. One study will focus on parents and children, the other on adults in intimate relationships. Health behaviors related to diabetes and oral health problems will serve as dependent variables as will self-care behaviors in both diabetes and oral health. To place these health behaviors in the context of disease conditions and medical regimen adherence, we expect to focus one study on a sample of children with early childhood caries and the other study on an adult sample with diabetes.

PROJECT SUMMARY/ABSTRACT Dental fear affects over 53 million American adults. According to the U.S. Surgeon General, it leads to ?needless pain and suffering, causing devastating complications to an individual's wellbeing, with financial and social costs that significantly diminish quality of life and burden American society.? Standard treatment ? compassionate but ultimately counterproductive ? includes anti-anxiety medication or more substantial anes- thesia, which (a) does nothing to reduce subsequent anxiety or avoidance, (b) leads to continued dental prob- lems, and (c) perpetuates the cycle of fear?>avoidance?>dental problems. Alternatively, cognitive-behavioral treatments (CBT) for dental fear have been developed, subjected to dozens of high-quality trials, and found to be efficacious. However, CBT has, almost exclusively, been offered only in a few specialty clinics worldwide as- sociated with universities and there is no disseminable model for integrating CBT into the workflow of dental practices. To fill this gap, we have created a stepped-care approach to dental fear treatment that can be implemented in private practice dental offices throughout the U.S. and is eminently scalable. Stepped-care in- volves starting with the least intensive option and progressing to more intensive options only when necessary. At the low end is a self-administered intervention: (a) a smartphone ?app? that can be used privately in waiting rooms by an unlimited number of patients combined with (b) a paper-and-pencil ?Pre-Game Plan? in which the patient records ? to be reviewed with the dental staff prior to dental services ? (1) pre-treatment fear levels, (2) the factor generating the most anxiety, (3) a stop-signal the patient will use to alert the dentist,(4) things the dental team can do to maximize this patient's comfort, and (5) a self-generated anxiety management plan. If patients are not in the ?low fear? zone following their dental procedures, they may receive 1-hour (if still in moderate zone) or 2-hours (if still in severe zone) of dental fear CBT in their dentists' offices conducted by a collaborating mental health provider. In the first phase of this study, we will pilot test the approach with fearful patients (N»35,700) at two University dental centers. In the second phase, we will test the it in private dental practices (n = 100 volunteers from a pool of 10,000 practicing dentists in the metropolitan areas of Philadel- phia and New York [and the corridor between them] who graduated from dental school from either New York University or the University of Pennsylvania). The aims are to study factors influencing patients' and dentists' willingness to try stepped-care, to test the efficacy of the approach, to test the dosing of CBT interventions de- pending on patients' fear levels, and to test whether the way in which we believe CBT works (i.e., by helping patients disconfirm their beliefs regarding feared outcomes) is truly the active ingredient. Finally, we will develop dissemination materials for dentists and mental health providers on ?How to Effectively Treat Dental Fear with a Stepped-Care Approach.?