The NIH Science of Behavior Change Program: Transforming the science through a focus on mechanisms of change

Midlife reversibility of early-established biobehavioral risk factors: A research agenda

Epidemiological evidence links exposure to early life adversities-such as childhood maltreatment-with impaired health and well-being in adulthood. Since these effects are usually unrecognized or untreated in childhood, preventive and remediating interventions in adults are needed. Our focus on adulthood prompted three major questions. First, does our increased understanding of mechanisms accounting for the long-term effects of early life adversities help delineate underlying dimensions that underscore key similarities and differences among these adversities? Second, can adults accurately report on adversities they experienced in childhood? Third, can we identify malleable risk processes in adulthood that might be targets for preventive intervention? Supported by the National Institute on Aging, the U.K. Economic and Social and the Biotechnology and Biological Sciences Research Councils, a network of researchers in human and animal development addressed these questions through meetings and literature review. A small number of dimensions may adequately distinguish among a range of co-occurring childhood adversities. Widely used adult ascertainments of childhood adversity are poorly related to prospective ascertainment. Strategies for preventive interventions should be aimed both at adults who were actually exposed to adversity as well as those who recall adversity, but the targeted risk processes may be different. Now is an opportune time to support research on adult interventions based on unfolding research on critical periods of sensitivity to adversity in fetal and child development, on improved understanding of risk mechanisms that may persist across the life span, and on new insights on enhancing neuroplasticity in adults. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Preliminary examination of the orexin system on relapse-related factors in cocaine use disorder

RATIONALE

Current evidence and literature reviews provide a strong justification for examining the orexin receptor (OXR) system as a therapeutic target in substance use disorders, including cocaine and other psychostimulants.

OBJECTIVES

In this preliminary, proof-of-concept examination of orexin modulation in humans with cocaine use disorder, we measured changes in domains tied to relapse: stress, sleep, cue reactivity, and inhibitory control. Additionally, mood symptoms (anxiety, depression), medication compliance, and side effects were assessed.

METHODS

Twenty non-treatment seeking subjects with cocaine use disorder (CUD) received either the OX₁R / OX₂R antagonist suvorexant PO or placebo at 10 PM daily for two weeks (10 mg week 1, 20 mg week 2). Using psychometrics, smart-watch actigraphy, a cold-pressor stress challenge, and eye-tracking technology, the following domains were examined: sleep, stress/anxiety, cue-reactivity (attentional bias, craving), and inhibitory control. Psychometric data were collected every M/W/F (7 time points). Laboratory data were collected weekly (3 time points).

RESULTS

Bayesian and frequentist generalized linear models were employed in parallel to examine the effects of suvorexant compared to placebo, with a Bayesian posterior probability threshold >80% as evidence of a signal for suvorexant. Notable results favoring suvorexant over placebo included fewer total anti-saccade errors, improved sleep actigraphy (sleep/awake periods), pre/post cold-pressor change in heart rate and salivary cortisol (all posterior probabilities >94%), and craving (posterior probability >87%).

CONCLUSIONS

Initial but restricted evidence is provided supporting the orexin system as a modulator of relapse-related processes in cocaine use disorder. Baseline differences in the main outcome variables were not experimentally controlled and differences in craving were observed at baseline. This, in combination with a limited sample size, constrain the nature of the project. The results may serve to inform more comprehensive future research.

Using an Experimental Medicine Approach to Identify Novel Determinants of Addiction

Our understanding and effectiveness in treating addiction is not fully adequate. Therefore, perhaps developing a pragmatic theory for identifying novel determinants and potential interventions is needed. The experimental medicine approach, derived from Claude Bernard, proposes a methodology for inductive theory development and suggests interventions directed at targets closely aligned with the underlying mechanisms of the disorder. The steps of theory development under this approach are intended to (1) identify an intervention target; (2) develop assays to verify target measurement; (3) engage the target via experiment or intervention; and (4) test the degree to which target engagement produces other therapeutically useful changes in the disorder. In this article, we review these steps in detail using an example from our work. That is, shortened temporal windows (target) is frequently observed among those who are addicted. Delay discounting is an assay used to measure that target. We and others have demonstrated manipulation of the target, delay discounting, is associated with changing the drug valuation among those with addiction. We conclude with a culmination of the experimental medicine approach by proposing a recently developed hypothesis of substance use disorder, Reinforcer Pathology 2.0.

An online randomised controlled trial of mental contrasting with implementation intentions as a smoking behaviour change intervention

Objective: We assessed the effectiveness of mental contrasting with implementation intentions (MCII), an established self-regulatory strategy, as a brief online smoking behaviour change intervention. We expected that MCII would enhance smoking reduction among the highly cigarette dependent because MCII is most effective for challenging pursuits. Design: Participants interested in reducing or quitting smoking were recruited online via Amazon Mechanical Turk. At Time 1, we assessed cigarette dependence using the Cigarette Dependence Scale (CDS-5), then administered one of two brief self-help interventions: MCII (n = 172) or a government-promoted control strategy (n = 174). Participants were invited to complete an online follow-up survey 4 weeks later (Time 2). Main Outcome Measure: At Time 1 and Time 2, we measured recent cigarette smoking with a retrospective, self-report questionnaire. We used these reports to compute smoking reduction scores, with an intent-to-treat approach. Results: MCII increased smoking reduction compared to the control strategy at high, but not low, levels of cigarette dependence. Conclusion: We found preliminary evidence consistent with MCII, delivered as a brief online intervention, as an effective smoking reduction strategy for highly dependent cigarette smokers. Further research is needed on MCII as a smoking behaviour change intervention.

Nonsuicidal Self-Injury and Suicidal Behaviors in Girls: The Case for Targeted Prevention in Preadolescence

Non-suicidal self-injury (NSSI) affects 15-20% of adolescents-disproportionately girls-and is a strong predictor of eventual suicide attempts and suicide. Many girls now initiate NSSI before age 10. These early-starters exhibit greater frequency of NSSI, use more diverse methods, and are hospitalized more often, yet there are no empirically supported prevention programs for preadolescents. Obstacles to prevention include ascertaining who is sufficiently vulnerable and specifying mechanistic intervention targets. Recent research indicates that (1) preadolescent girls with ADHD who are also maltreated are at alarming risk for NSSI and suicide attempts by adolescence, and (2) the conjoint effects of these vulnerabilities are sufficiently potent for targeted prevention. Research also indicates that existing interventions are effective in altering child- and family-level mechanisms of NSSI. These interventions alter neurobiological markers of vulnerability, which can be used as proximal efficacy signals of prevention response, without waiting for NSSI and suicide attempts to emerge.

An Examination of Motivation to Change and Neural Alcohol Cue Reactivity Following a Brief Intervention

Background: Brief interventions represent a promising psychological intervention targeting individuals with heavy alcohol use. Motivation to change represents an individual's openness to engage in a behavior change strategy and is thought to be a crucial component of brief interventions. Neuroimaging techniques provide a translational tool to investigate the neurobiological mechanisms underlying potential mediators of treatment response, including motivation to change. Therefore, this study aimed to examine the effect of a brief intervention on motivation to change drinking behavior and neural alcohol taste cue reactivity. Methods: Non-treatment-seeking heavy drinkers were randomized to receive a brief drinking intervention (n = 22) or an attention-matched control (n = 24). Three indices of motivation to change were assessed at baseline and after the intervention or control session: importance, confidence, and readiness. Immediately following the intervention or control session, participants also underwent an functional magnetic resonance imaging (fMRI) during which they completed an alcohol taste cues paradigm. Results: There was a significant effect of the brief intervention on increasing ratings of importance of changing drinking behavior, but not on ratings of confidence or readiness to change. Ratings of importance after the intervention or control session were associated with neural alcohol taste cue reactivity, but notably, this effect was only significant for participants who received the intervention. Individuals in the intervention condition showed a positive association between ratings of importance and activation in the precuneus, posterior cingulate, and insula. Conclusions: The brief drinking intervention was successful at improving one dimension of motivation to change among non-treatment-seeking heavy drinkers. The brief intervention moderated the relationship between ratings of importance and brain activation in circuitry associated with interoceptive awareness and self-reflection. Together, findings represent an initial step toward understanding the neurobiological mechanisms through which a brief intervention may improve motivation to change.

The Behavioral Medicine Research Council: Its origins, mission, and methods

The Behavioral Medicine Research Council (BMRC) is a new, autonomous joint committee of 4 of the leading behavioral medicine research organizations, including the Academy of Behavioral Medicine Research, the American Psychosomatic Society, the Society for Health Psychology, and the Society of Behavioral Medicine. The BMRC's work has important implications for the science and practice of behavioral medicine. The distinguished senior scientists who comprise this new committee will identify a series of strategic research goals for behavioral medicine and promote systematic, interdisciplinary efforts to achieve them. This special report discusses the developments that led to the formation of the BMRC, describes the BMRC's mission, and explains the methods that its members will use. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Evaluations of a Previous Day as a Pathway Between Personality and Healthy Cognitive Aging

Objective: To examine the association between Five-Factor Model personality traits and how individuals evaluate a recent day in their lives (yesterday) and whether these evaluations mediate personality and cognitive function over time. Methods: Participants were a subsample from the Health and Retirement Study who completed personality measures in 2008/2010, the day evaluation in 2011, and cognitive tasks in 2012 (N = 3,454). Results: Lower Neuroticism and Higher Extraversion, Openness, Agreeableness, and Conscientiousness were associated with a more engaging day, fewer negative feelings, better subjective health, and less time spent alone. Active engagement and subjective health were associated with cognitive function and mediated the prospective associations between Neuroticism, Openness, and Conscientiousness and cognitive function. Discussion: Personality is associated with how individuals evaluated their previous day, which contributes to cognition over time. The present research contributes to a mechanistic model that aims to identify pathways through which personality contributes to cognitive aging.

The ecology of multilevel intervention research

Behavior change research to promote health and prevent disease increasingly relies on a complex set of interacting characteristics across levels of influence such as biological, psychological, behavioral, interpersonal, and environmental. How to best develop health-related interventions that incorporate the individual, the macro-environment, and their interactions remains a challenge. This article considers a set of key dimensions that constitute what we refer to as the ecology of research across a broad context of multilevel research (MLR), spanning fundamental multilevel research (FMLR), multilevel intervention research (MLIR), and multilevel implementation science (MIS). With the goal of promoting improvements in MLIR, we describe the inherent interdependencies among aspects of research and consider how the growth and development of evidence and resources influence the cross-talk among researchers from different perspectives (e.g., disciplines and domains). We propose a framework that highlights opportunities to reduce barriers and address gaps in areas critical to generating an evidence base through MLR, MLIR, and MIS. Overall, we aim to support strategic decisions that can accelerate our understanding of ML health outcomes and interactions among factors within and across levels, with the goal of strengthening the effectiveness of ML interventions across health-related outcomes.

Factors Associated with Levels of Latrine Completion and Consequent Latrine Use in Northern Ghana

Open defecation is still a major health problem in developing countries. While enormous empirical research exists on latrine coverage, little is known about households' latrine construction and usage behaviours. Using field observation and survey data collected from 1523 households in 132 communities in northern Ghana after 16 months of implementation of Community Led Total Sanitation (CLTS), this paper assessed the factors associated with latrine completion and latrine use. The survey tool was structured to conform to the Risk, Attitude, Norms, Ability and Self-regulation (RANAS) model. In the analysis, we classified households into three based on their latrine completion level, and conducted descriptive statistics for statistical correlation in level of latrine construction and latrine use behaviour. The findings suggest that open defecation among households reduces as latrine construction approaches completion. Although the study did not find socio-demographic differences of household to be significantly associated with level of latrine completion, we found that social context is a significant determinant of households' latrine completion decisions. The study therefore emphasises the need for continuous sensitisation and social marketing to ensure latrine completion by households at lower levels of construction, and the sustained use of latrines by households.

Age differences in everyday stressor-related negative affect: A coordinated analysis

Advancing age is often characterized by preserved or even enhanced emotion regulation, which is thought to manifest in terms of age-related reductions in the within-person association between stressors and negative affect. Existing research from ecological momentary assessment and end-of-day daily diary studies examining such age-related benefits have yielded mixed results, potentially due to differences in samples, design, and measurement of everyday stressors and negative affect. We conducted a coordinated analysis of 5 ecological momentary assessments and 2 end-of-day daily diary studies to examine adult age differences in the within-person association between everyday stressors and negative affect. Reported stressor occurrences are robustly associated with higher negative affect, regardless of study design and sample characteristics. Across studies, interactions between age and everyday stressors predicting negative affect revealed a pattern of age-related decreases in the stressor-negative affect association, but this interaction was only significant for 2 studies. Further, examination of statistical power of the included studies suggests that, despite differences in the number of repeated assessments, power to detect within-person stressor-negative affect associations is quite good. In contrast, despite possessing wider age ranges, observed age differences were relatively small in magnitude, and studies are potentially underpowered to detect age differences in these within-person associations. We discuss the importance of study design, interval of repeated assessments and number of participants for examining age differences in everyday stressors and negative affect, as well as the virtue of coordinated analyses for detecting consistent direction of associations, but inconsistent patterns of statistical significance. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Brief Alcohol Interventions for Youth in the Emergency Department: Exploring Proximal and Distal Outcomes

Brief interventions (BI) for alcohol use in the emergency department (ED) have been shown efficacious among adolescents and young adults; however, whether these interventions extend to other outcomes - proximal and distal - are less explored. This study examined outcomes of ED BIs in four completed trials showing reductions in alcohol use. Limited and inconsistent effects were found on proximal outcomes including parental monitoring, and distal outcomes including tobacco use. Identifying the mechanisms that underlie alcohol-focused BIs as well the intervention processes that may lead to generalized, positive effects on other variables is an important area of future research.

A Review of Systematic Reviews Targeting the Prevention and Treatment of Overweight and Obesity in Adolescent Populations

PURPOSE

Adolescent obesity is a powerful predictor of morbidity and mortality, yet amenable to modifiable behaviors. To accurately summarize the effects of behavioral interventions on changes in adolescent body mass index and/or weight status, we assessed existing systematic reviews for reporting transparency and methodological quality.

METHODS

Five databases were searched through September 2017 to identify relevant systematic reviews. Reviews were evaluated for reporting transparency and methodological quality using PRISMA Reporting Checklist and Assessment of Multiple Systematic Reviews Instrument. Evidence was synthesized across high-quality reviews.

RESULTS

Four of twelve systematic reviews were of high methodological quality. All four focused on the treatment of overweight/obesity in adolescent populations, representing 97 international studies. Findings indicate intervention compared with no intervention/wait list showed larger effects for improving BMI/BMI z-scores. Small improvements (averaging a 3.7-kg decrease) in weight/weight percentile were observed following a supervised exercise plus dietary and/or behavior support intervention. Health-related quality of life may improve following interventions, but overall attention to associated psychological variables (depression, self-esteem/perception) is limited.

CONCLUSIONS

Adherence to objective checklists and protocols for rigorous conduct and reporting of systematic reviews is warranted. Consensus evidence is urgently needed to define and report behavior change interventions related to obesity prevention and treatment.

Childhood obesity research at the NIH: Efforts, gaps, and opportunities

Childhood obesity is a major public health challenge. This article describes an overview of the National Institutes of Health (NIH) behavioral and social sciences childhood obesity research efforts. The overview will highlight five areas of childhood obesity research supported by the NIH: (a) basic behavioral and social sciences; (b) early childhood; (c) policies, programs, and environmental strategies; (d) health disparities; and (e) transagency and public-private collaboration. The article also describes potential gaps and opportunities in the areas of childhood obesity and severe obesity, measurement, and sleep.

Examining Canadian Equine Industry Participants' Perceptions of Horses and Their Welfare

The diversity of the Canadian equine industry makes determining baseline attitudes and beliefs a challenge. Adult members of the Canadian equine industry (n = 901) participated in an online survey to report demographic information and views on the role of horses and their ability to experience affective states. Questions regarding the welfare state of all horses in the industry, potential ways to address welfare issues, and eight short scenarios were presented. Qualitative analysis, descriptive statistics, and a Chi-squared test for independence examined survey results and potential relationships. Participants strongly believed horses were capable of feeling positive and negative emotions, particularly pain and fear, but rarely were these beliefs reflected in their answers regarding aspects of equine welfare, which may be due to the large bias in these beliefs. Lack of knowledge and financial difficulties were noted as the biggest threats to equine welfare. Overall, there was widespread agreement regarding the presence of welfare issues within the equine industry, but opinions were more divided regarding how to best address them and which horses were most at risk. Understanding these perceptions may be useful to direct educational programs and industry-wide initiatives to address equine welfare through human behaviour change.

The evaluation of a brief motivational intervention to promote intention to participate in cardiac rehabilitation: A randomized controlled trial

OBJECTIVES

Cardiac rehabilitation (CR) is an effective treatment for cardiovascular disease, yet many referred patients do not participate. Motivational interviewing could be beneficial in this context, but efficacy with prospective CR patients has not been examined. This study investigated the impact of motivational interviewing on intention to participate in CR.

METHODS

Individuals recovering from acute coronary syndrome (n = 96) were randomized to motivational interviewing or usual care, following CR referral but before CR enrollment. The primary outcome was intention to attend CR. Secondary outcomes included CR beliefs, barriers, self-efficacy, illness perception, social support, intervention acceptability, and CR participation.

RESULTS

Compared to those in usual care, patients who received the motivational intervention reported higher intention to attend CR (p = .001), viewed CR as more necessary (p = .036), had fewer concerns about exercise (p = .011), and attended more exercise sessions (p = .008). There was an indirect effect of the intervention on CR enrollment (b = 0.45, 95% CI 0.04-1.18) and CR adherence (b = 2.59, 95% CI 0.95-5.03) via higher levels of intention. Overall, patients reported high intention to attend CR (M = 6.20/7.00, SD = 1.67), most (85%) enrolled, and they attended an average of 65% of scheduled CR sessions.

CONCLUSION

A single collaborative conversation about CR can increase both intention to attend CR and actual program adherence.

PRACTICE IMPLICATIONS

The findings will inform future efforts to optimize behavioral interventions to enhance CR participation.

Pokémon GO Within the Context of Family Health: Retrospective Study

BACKGROUND

Pokémon GO illuminated the potential for mobile phone gaming apps to engage users and promote health. However, much work is needed to fully understand the mechanisms through which digitally supported behavior change interventions operate, particularly for children and families.

OBJECTIVE

The aims of this study were (1) to explore the Pokémon GO user experience from a family perspective and (2) to investigate Pokémon GO within the context of family health.

METHODS

Between January and February 2017, congruent with one of the largest anticipated Pokémon GO updates Gen 2, participants were recruited from parks, word of mouth, and social media to complete a Web-based survey. Participants were surveyed about family characteristics, interest, and experiences playing Pokémon GO and healthy lifestyle beliefs. Using a revised Godin Leisure-Time Exercise Questionnaire, a retrospective pre-post design assessed changes in parent physical activity (PA) before and after playing Pokémon GO.

RESULTS

Self-reported data from 160 parents and 31 children were included in the final analyses (representing 129 parents and 31 parent-child dyads). Gameplay most often occurred between sons aged 10 years or younger and mothers. "Spending time together" was the most cited reason for gameplay by both parents (122/160, 76.3%) and children (24/31, 77%), followed by "it helped me go outdoors" for parents (113/160, 70.1%) and "I am a Pokémon fan" by children (21/31, 68%). Interestingly, open-ended responses indicated that gameplay could trigger both positive and negative emotional parent response. The most cited reason for app disengagement was boredom; conversely, the most cited reason for app re-engagement was in-app events. For parents, there were significant increases in minutes spent in mild (mean 23.36 [SD 66.02]; t₉₇=3.50, P<.001) and moderate (mean 21.76 [SD 53.04]; t₁₃₀=4.70, P<.001) PA per week after playing Pokémon GO. However, child perceptions of parental influence on PA most significantly associated with parents who reported weekly strenuous PA both before (r_s=.514, P=.003) and after (r_s=.536, P=.003) Pokémon GO uptake.

CONCLUSIONS

Pokémon GO transcended traditional understanding of digital health and uniquely reached across generations to engage users. Findings from this study highlight that, for a period of time, Pokémon GO fostered social and physical well-being for children and families through a multifaceted approach.

Commentary on Litt et al. (2018): Identifying treatment-targeted mechanisms-aim and measure the bullseye

The search for mechanisms unique to a specific treatment requires identification of an exact treatment target, instruments that are precise in measuring the target, and a statistical approach that will determine whether the given treatment hit the target.