Use of EMA Methods in Adolescents:

Case of Project Pressure Case of Project Pressure

SES &Ethnicity

StressExposure-Conflict

DispositionsHostilityVigilanceAnxiety

CV Reactivity

CV Markers:Total BPBurdenAortic StiffnessLVM

Old Model of Development of CV Risk Factors in Adolescents

Overall BP Burden

Overall exposure to high BP in day and Overall exposure to high BP in day and night, not estimated by clinic pressurenight, not estimated by clinic pressure

Masked hypertension: high AMBY BP in Masked hypertension: high AMBY BP in presence of normal clinic BPpresence of normal clinic BP

Allows studies of disruption of Allows studies of disruption of circadian rhythm and nondippingcircadian rhythm and nondipping

Allows measure of reactivity to stress Allows measure of reactivity to stress by examining covariation of stress and by examining covariation of stress and BP/HR increasesBP/HR increases

Types of hypotheses addressed in relation to BP burden: role of Neighborhood and family SESNeighborhood and family SES Accumulation of uncontrollable chronic Accumulation of uncontrollable chronic

negative life eventsnegative life events Unfair treatment and discriminationUnfair treatment and discrimination Personal characteristics, e.g. Personal characteristics, e.g.

pessimism, tendency to attribute pessimism, tendency to attribute malintent to others, and attachment malintent to others, and attachment stylestyle

Rationale for Use of EMA

Measures types of experiences of Measures types of experiences of adolescents throughout several daysadolescents throughout several days

Focuses on role of interpersonal Focuses on role of interpersonal experiences that cannot be easily experiences that cannot be easily reported retrospectivelyreported retrospectively

Aids understanding of BP and HR Aids understanding of BP and HR measured concurrent with EMA measured concurrent with EMA measures measures

Method: Participants

ParticipantsParticipants 207 adolescents207 adolescents Recruited from 2 Pittsburgh area high Recruited from 2 Pittsburgh area high

schoolsschools 14-16 years old 14-16 years old 50% Female50% Female 50% Black; 50% White50% Black; 50% White Good healthGood health

Self-report data

Sampling in relation to BP Sampling in relation to BP measurement (every 30 min. day)measurement (every 30 min. day)

Fixed interval because of BP Fixed interval because of BP assessment target timeassessment target time

Because of sampling during school, Because of sampling during school, could only use few itemscould only use few items

Assessment Content: Concurrent

Time, hour, min, dateTime, hour, min, date Location: school, home, car/bus, otherLocation: school, home, car/bus, other Posture: lying down, sitting down, on feetPosture: lying down, sitting down, on feet Physical activity (1 to 4)Physical activity (1 to 4) Calm/relaxed; angry/upset; interested Calm/relaxed; angry/upset; interested

involvedinvolved Mood based on data reduction from adult Mood based on data reduction from adult

study of amby BPstudy of amby BP

YES/NO SCALE

Example: At time of BP – are you calm/relaxed?

YES! YES yes no NO NO!

Assessment Content: 10 Min.

Physical activity (none to heavy)Physical activity (none to heavy) Consumption (none, food, caffeine, Consumption (none, food, caffeine,

smoking)smoking) Talking with school personnel, friend, Talking with school personnel, friend,

parent, other relative, other, no one parent, other relative, other, no one (yes/no). (yes/no).

Conflict/disagreement (6 point)Conflict/disagreement (6 point) Pleasant interaction (6 point)Pleasant interaction (6 point)

YES/NO SCALE

Example: In the last 10 minutes, did you have a

conflict or disagreement?

YES! YES yes no NO NO!

Assessment Methods

Electronic diary with no auditory promptElectronic diary with no auditory prompt BP cuff inflation served as promptBP cuff inflation served as prompt Accepted first diary record if BP was valid on Accepted first diary record if BP was valid on

the next try within 5 min.the next try within 5 min. BP and diary time stamped allowed for time BP and diary time stamped allowed for time

linkagelinkage Training conducted first morning of Training conducted first morning of

assessment by staff assessment by staff Compliance: 24.6 out of 29 possible diary Compliance: 24.6 out of 29 possible diary

entries; 34.4 of 37 possible AMBYentries; 34.4 of 37 possible AMBY

Data Analysis

Use of hierarchical linear modeling Use of hierarchical linear modeling using HLM or PROC MIXEDusing HLM or PROC MIXED

Required that BP data have Required that BP data have accompanying diary data for analysis accompanying diary data for analysis (80% both data points)(80% both data points)

Reviewers have a hard time Reviewers have a hard time understanding HLMunderstanding HLM

Background: Attachment Theory

Attachment style predicts satisfaction, Attachment style predicts satisfaction, and behavior, emotion, and cognition in and behavior, emotion, and cognition in adult and adolescent social adult and adolescent social relationships.relationships.

Attachment style may have health Attachment style may have health implications implications (Maunder & Hunter, 2001).(Maunder & Hunter, 2001).

Attachment insecurity predicts elevated Attachment insecurity predicts elevated and prolonged physiological responses and prolonged physiological responses to social stressors in laboratory (e.g., to social stressors in laboratory (e.g., Carpenter & Kirkpatrick, 1996; Nachmias Carpenter & Kirkpatrick, 1996; Nachmias et al., 1996).et al., 1996).

Dimensional model of adult attachment

High Anxiety

Low Anxiety

High Avoidance

Low Avoidance

Security Preoccupation

Dismissive-Avoidance

Fearful-Avoidance

Fraley & Shaver, 2000

Examine effects of attachment on Examine effects of attachment on adolescents’ responses to naturalistic adolescents’ responses to naturalistic social interactions with attachment social interactions with attachment figures (parents and friends). figures (parents and friends).

Anxious Attachment: EAnxious Attachment: Exaggerated xaggerated physiological and emotional stress physiological and emotional stress reactivity to social interaction.reactivity to social interaction.

Avoidant Attachment: Reduced social Avoidant Attachment: Reduced social interaction with others. interaction with others.

Current Study: Purpose and Hypotheses

Method: Procedure

Attachment StyleAttachment Style Measurement of Attachment Qualities Measurement of Attachment Qualities

(Carver et al., 1997) (Carver et al., 1997) Anxious Attachment (“Anxious Attachment (“I often worry that I often worry that

someone I care about doesn’t really love someone I care about doesn’t really love me”), me”), = .75 = .75

Avoidant Attachment (“Avoidant Attachment (“I prefer not to be I prefer not to be close with others”), close with others”), = .70 = .70

Methods: Analytic Approach

Hierarchical Linear Modeling (HLM 5.0), Hierarchical Linear Modeling (HLM 5.0), accounts for nesting of measures accounts for nesting of measures within participants. within participants.

Level 1: Average outcomes (intercepts) Level 1: Average outcomes (intercepts) and effect of interactions with and effect of interactions with attachment figures (slopes) estimated attachment figures (slopes) estimated for each individual.for each individual.

Level 2: Intercepts and slopes Level 2: Intercepts and slopes estimated at Level 1 predicted by estimated at Level 1 predicted by attachment variables.attachment variables.

Adolescents reported talking to friend(s) Adolescents reported talking to friend(s) at 79% of readings at school and 35% at 79% of readings at school and 35% after school; to parents 32% after school. after school; to parents 32% after school.

Higher Avoidant Attachment less likely Higher Avoidant Attachment less likely to be talking with friends at school, to be talking with friends at school, p p < .01< .01..

Higher Anxious Attachment less likely to Higher Anxious Attachment less likely to report talking with parents after school report talking with parents after school and less pleasant interactions, and less pleasant interactions, ps < .01ps < .01..

Results: Interaction Quantity

Attachment Quality and BP/HR

Higher Anxious Attachment the higher Higher Anxious Attachment the higher Amby SBP and DBP when interacting Amby SBP and DBP when interacting with friendswith friends

Higher Anxious Attachment trend Higher Anxious Attachment trend toward higher Amby HR when toward higher Amby HR when interacting with friendsinteracting with friends

Higher avoidant attachment higher Higher avoidant attachment higher Amby DBP during conflictAmby DBP during conflict

Effect of Anxious Attachment by Talking with Friend(s) on SBP

116

118

120

122

124

126

128

130

132A

mS

BP

(m

mH

g)

-2SD -1SD Mean +1SD +2SD

Anxious Attachment

Not talking with friend Talking with friend

R2= .08, p < .05

Implications

Anxious Attachment could influence Anxious Attachment could influence adolescent health risks by altering daily adolescent health risks by altering daily BP regulation, as related to interactions BP regulation, as related to interactions with attachment figures. with attachment figures.

Avoidant Attachment could contribute to Avoidant Attachment could contribute to adolescent health and well-being by adolescent health and well-being by influencing the quantity of peer influencing the quantity of peer interactions and, possibly, friendship interactions and, possibly, friendship development and continuity.development and continuity.

Lessons Learned

More items to measure mood to More items to measure mood to increase reliability and to measure increase reliability and to measure positive/negative affectpositive/negative affect

Better training of Ss using procedures Better training of Ss using procedures worked out in SleepScoreworked out in SleepScore

Patience in the analysis phasePatience in the analysis phase Adolescents are very good participantsAdolescents are very good participants