Hello and welcome to today's webinar, Unseen Consequences, Research Linking Childhood Trauma and Epigenetics. My name is Vikas Gupta and I serve as the founder and CEO of Wellness Psychiatry. I'm honored to be your moderator for this session. Today, we are thrilled to have Dr. Stacey Durie as our esteemed speaker. Dr. Stacey Durie is a board-certified child and adolescent psychiatrist and the psychiatrist-in-chief at the Boston Children's Hospital. Her transdisciplinary research seeks to define the biological mechanisms through which adversity, including trauma, violence, child abuse, and neglect, racism, and structural inequity drive negative health outcomes and health disparities. She currently directs the NIH-founded Telomere Research Network and has federally funded research projects in multiple states across the United States, as well as in Suriname, Sierra Leone, and Romania. Her clinical work and research focus on the parent-child relationship as a critical buffer against the effects of early life adversity within and across generations. She joined Boston Children's Hospital in 2023, recognizing the urgent need for transformative, community-engaged, and culturally responsive efforts targeting the prevention, treatment, and care of child mental illness. We are very excited, Dr. Durie, for what promises to be an engaging and informative session. Thank you for joining us. And with that, let's begin. Next slide, please. Today's webinar is designated for 1.5 AMA PRA Category 1 credits for physicians. Participation credit will be available for 90 days following today's session. Next slide, please. For today's presentation, captioning is available. To enable, show captions at the bottom of your screen. For a full script, click the arrow and select View Full Script or View Full Transcript to open captions in a side window. Next slide, please. Please feel free to submit questions at the end and during the Q&A session by typing them into the questions area located in the lower portion of your control panel. We'll dedicate the last 10 to 15 minutes of the presentation to answering your questions. Next slide, please. And now, without further ado, let's get started. I'll hand it over to Dr. Stacey Durie. Thank you, Dr. Gupta. It is my pleasure to be here today. And for all of you that are here online, I really appreciate it. I know that there's a lot of things happening in the world this week and last week. And so thank you for taking a break out of all of the other things that are happening to join me today. And just wanted to say to everyone that is involved in the mental health field, our work is even more important now than ever before. And so thank you for everything that you do for the science, for the research, for the clinical care, for the administrative support and for caring about individuals with mental illness, their families and their communities. So just incredibly grateful for all of the people that are working together to solve this mental health care crisis now more than ever. So I do want to just start with disclosures. So I do have funding from the National Institute of Health, NSF. And some of this work was funded by the Center for Disease Control and also had funding from the Kellogg Foundation to do some community-based work. But just those are my disclosures for the last 24 months. In terms of an outline, we're going to really talk about the lasting effects of trauma and to take both a developmental and a very broad spectrum perspective, really define biologic embedding, spend some time talking about the sort of trajectory of epigenetics as a field of science and psychopathology and its relation to trauma. As I have directed the telomere research network for the last four years, have really begun to recognize how important attention to methodologic considerations is. And so we will talk about that both in relation to existing epigenetic studies and really the importance of that consideration for future studies for anyone that's working in epigenetics or is thinking about it. And then, you know, we will go down my favorite rabbit hole, which is thinking about how do we incorporate this pathway of biologic embedding into our understanding of both the neurobiologic basis of developmental psychopathology and most importantly, what are we missing in terms of understanding if our evidence-based treatments that help us feel like our patients are feeling better or reporting that they're better or functioning better and ensuring that we're not missing biologic traces of the first realm of psychopathology when we think that everybody's better and really targeting that as a future direction. So to begin with, I'm a child psychiatrist and I think that that's a really important context for the rest of this talk because for me, the vast majority of things that are important happened early in life. And I would push all of us who are mental health providers and mental health researchers to recognize that an individual when we've diagnosed them with a psychological illness or mental health condition, isn't just that individual in a snapshot of time. And everything that has happened to that individual, both from a biologic basis from their conception and in some cases before conception, as well as the world in which they have grown and developed has influenced that person that we see. And I think that it's important that health or mental health, because I don't think you can actually have physical health without mental health, is determined by the interaction between genetics, biologic pathways, behavioral responses, social factors, and the economic context in which you grow and develop. These interactions are adaptive, meaning that there are some behaviors or some social contexts that we live in that change or we adjust based on the environment or the economic structure or our own genetics. And they're also transactional, meaning that they feed into each other and we adjust based on their interactions. Health trajectories are the results of cumulative risk and protective factors within an individual. I have a very good friend that has this lovely fulcrum slide where you can kind of put a lot of risks on one side and a lot of protective factors on the other side and have a normative trajectory, right? But I think that often we spend a lot of time talking about the risks and as a field, one component that I expect we'll really need to be focusing on is identifying and amplifying protective factors within an individual. And then because I am a child psychiatrist, I absolutely understand that there are differences when an exposure to an adversity happens when you are a two-year-old. And that fact is very different than when you're eight, when you're 18, 68, or 108. And often we are talking about the impact of a traumatic experience driving X. And I think both our understanding of developmental psychopathology as well as the understanding of our biologic stress response systems and our understanding of the impact of any type of adversity varies across the age at which it happens and the sort of social environment around the individual that is exposed. So within that context, when we're talking about the epigenetic sort of embedding of adversity, I think it's also important to talk about that all adversity is not the same. And I really like this model, the dimensional approach to adversity that was proposed by Kate McLaughlin and Margaret Sheridan, because it gets at both the interface between what we think of as the biologic processing of adversity in terms of the neurobiology, right? So how we perceive something that is threatening in our brain is very different than how a lack of exposure or a deprivation such as neglect or living in an institutional care is very different in terms of its impact on the brain and what is happening in a developing brain than if you are hit or physically abused. And I think making sure that we are conceptualizing adversity in these ways is really important when we think about the impact neurobiologically and the risk for psychopathology as well as the risk for different health outcomes. And there's some really lovely data that I'll be presenting from some animal models that really help understand and really talk about that. What is also important in this model is that very seldomly do we have just one type of exposure. So a lot of our exposures to adversity in early child tend to cluster together. So if you are living in a community surrounded by increased rates of community level violence, it's often likely that you might have lower economic resources. And so then you would also have some deprivation in terms of your ability to have stimulation in terms of someone reading a book to you at night or language exposure. You might also be at greater risk of living in a household with domestic violence. And so we see a cumulative amount of risk factors. And unfortunately, that it is the cumulative risk factors that are really, in our case, is driving developmental psychopathology. So for those of you who don't know this study, I joke that this is one of the most impactful, oddly, poorly designed study that was ever done. I hope that Dr. Anda and Folletti don't yell at me for saying that. But if you think about the structure of this study, so this was a study that asked people retrospectively to report on these experiences of abuse, neglect, and household dysfunction. And then you tallied up that retrospective report. And we said, what is the relationship between that retrospective report of these specific kinds of adversity? They didn't integrate any conceptualization of frequency, age at which they happened, just happened at some point in my life before I turned 18. And the perception or the intensity that these very blunt measures of adversity predicted a vast array of health outcomes at a high rate. So obesity, diabetes, cardiovascular disease, in addition to substance use, depression, and other mental illnesses, suggesting that child abuse and exposure to household dysfunction were driving many of the primary predictors of poor health and drivers of healthcare costs across adulthood. And I will also say, and we'll talk more about this later in the presentation, that many of those biologic disorders are actually considered aging disorders, meaning that it's much more frequent to have cardiovascular disease as you get older than when you're younger. And that a lot of these disorders were arising earlier in development, so at a younger age when there is adversity, and that they were somewhat more difficult and challenging to treat. So considering that there might be a relationship between aging and how the biologic processes associated with early adversity were transmitting into health risks. So when we think about the consequences of adversity, this is actually a pretty old slide from the CDC, but if we were to be able to prevent adversity in terms of health outcomes, we could prevent 21 million cases of depression, 1.9 million cases of heart disease, and 2.5 million cases of obesity within the United States. And so these really are a huge public health consequence. What I also want to emphasize is a study done by Ron Kessler and again Kate McLaughlin in 2010 that showed the population of typical risk of childhood adversity and lifetime diagnosis for a DSM disorder. And what they also did, which I think was quite fascinating, was looking at this both in high and middle income countries as well as lower and middle income countries. And what you see across the board is that adversity in early childhood or adversity across the lifespan were all predicting increased rates of all of their main DSM diagnoses so that we could eliminate a huge percentage of our psychiatric illnesses and behavioral disorders if we were able to address childhood adversities, either prevent them or treat the biologic effects when kids were young. So that leads us to the question of what is happening biologically with adversity and how is it driving effects? And I'm going to say that these effects are both within the individual and across generations, and I'll show you some of the intergenerational data as well. This is a slide from the CDC where they really talk about the effects of adverse childhood experiences on risk of injury, psychopathology, pregnancy-related complications, inflammatory processes, risk for chronic disease, elevated risk of behavior, and really even overall functioning and socioeconomic status. Adversity is a huge driver of negative consequences across many platforms and the initial kind of ACEs pyramid really proposed that these were through health risk behaviors. And what we now know is that these are not just through the increased risk of drinking or alcohol or tobacco use, but instead are actually driven by biologic changes within the individual. And these changes I'm going to put out there can be sort of grouped into a couple of different categories. I think that there's probably more changes, but we're going to sort of focus on these because I feel this is where the greatest amount of data is. So changes in epigenetic factors, and we'll talk about what those are. Cellular aging, which I've sort of hinted at, but is a big area of my work. And then recognizing that there are inflammatory changes that are transmitted with adversity and risk for psychopathology and other health outcomes. And one of the other key factors is that there is altered physiologic stress response systems. And when I think about physiologic stress response systems, I think everybody's first thought is the hypothalamic pituitary adrenal axis and the cortisol, both acute response and diurnal patterns, but there are many other physiologic stress response systems. My personal favorite is the autonomic nervous system, but the hypothalamic pituitary gonadal axis is another stress responsive system. So the production of testosterone in social evaluative threats happens as well as the shutdown of our HPG axis with physiologic stressors. And we also see that the immune response is a physiologic stress response system. So for any of you who have ever gotten sick around exam time, that's a great example, or a cold sore right before a big talk. Luckily that didn't happen this time, but I think it's really important to understand that there are these multiple pathways by which adversity is embedding its effects and health risks. And then what we are also seeing is that adversity is a driver of both prenatal stress and preterm birth, potentially influencing later risk for the next generation. And we also see direct relationships between alterations and epigenetic patterns and physiologic responses in the parent and subsequent changes in the offspring that lead to their elevated risk. So when we think about adversity, we need to understand it as a multifaceted way of increasing health and mental health risks, that that is through biologic processes and not through just behavior, and that those biologic processes are leaving traces in the subsequent generations that influence the next generation's risk. So it's really interesting to think about the sort of timeline of genetic and epigenetic studies in psychiatry and relationship to trauma. And I'm going to date myself by saying that early on, I was definitely at this area of family studies and family clustering. So thinking about the genetics of psychopathology in terms of a genetic risk, not necessarily integrating what we now I think are well-established, which is the influence of genetics times the environment times development. But we started really talking about the fact that there was clustering of risk for psychopathology within families. In the early stages of study, there was not as much consideration of development as a part of that pathway. And I think many of, well, depending on how old you are, many people remember sort of the first study of a gene by environment interaction. So the Caspi's serotonin transporter length polymorphism predicting depression and risk for suicide. And the subsequent explosion of G by E studies in psychopathology with not as precise replication as we would like, really challenging the model of a single gene or a single genetic polymorphism driving risk for psychopathology. And part of that came from a recognition that our psychiatric diagnoses are not as closely tied as we would like to neurobiology and certainly not monogenic disorders. And so for a single genetic variant to drive elevated risk within the population sizes that we had been studying in the early 2000s and 2010s would have really required a huge effect size. And we don't really think that any one particular genetic variant drives something like depression or anxiety or PTSD to this magnitude of an effect size that we would see in general sort of 100 to 200 person studies. Because of the advancements in genetics, we were also then able to look across the genome and GWAS studies and complex genomic studies and start to really evaluate genetic risk in terms of complex traits and complex genetic prediction and share genetic variability. So the development of the PGC and really trying to put enough people together within a study group so that we can disentangle genetic risk factors and the complexity of those genetic risk factors. And overlapping with the sort of movement into GWAS, we started to look at epigenetic factors. And I will say that in my PhD years, epigenetics had just kind of come around and it was a very targeted thing that happened and it didn't change and it didn't happen, definitely didn't happen throughout the whole genome. And so recognize that the field of epigenetics continues to evolve, both in our understanding of the complexity of different levels of epigenetic regulation, as well as the static or not static-ness of sort of how epigenetic marks last across development. So this is my most basic slide for epigenetics, because I think every couple of years we'll add more things onto this slide. So the very beginning of epigenetics centered on the placement of a methyl group on the DNA strand. So epigenetics is understood to be changes that occur that are not changes in DNA sequence that influence the tightness or the winding of the DNA and may or presumably can influence the amount of gene expression from a particular gene. So these are signals on the genome that trigger either block or bring in transcription factors or change the confirmation of the DNA such that there's greater access to transcriptional machinery. But the point is that these don't actually change the DNA sequence. And so it started with DNA methylation, so that methyl group, and then we sort of recognize that the DNA is tightly wound around these balls or histones, and that histone acetylation and deacetylation can actually open up those balls and open up the confirmation of the DNA structure. And then there has been some great work out of Kerry Ressler's lab, really looking at intergenerational transmission through the paternal line, through microRNAs in the sperm. And so really thinking about all of these different levels gets you to the point of really thinking about epigenetics as multiple layers, and Shrek is a much better conveyor of that image than I can. And I'll also say that I'm going to consider telomere length as an epigenetic factor for several reasons. So first, telomeres are actually epigenetic regulators, and they can fold over and cause conformational changes and changes in gene expression, and that we really think about telomeres as this sort of edge of the chromosome that is important in sort of preventing DNA degradation. They are considered a biologic marker of aging, and I will suppose that many of the changes across the measurement of all of these epigenetic factors applies equally across all of the different epigenetic factors, and that telomere length is one of those places where we have the same challenges. So one of the very first causal studies that I am aware of that in early environment exposure was driving physiologic and biologic changes in the next generation through causal epigenetic pathways really came out of the elegant work by Michael Meaney's group said this was actually looking at DNA methylation in the hippocampus in animals that were born to a high-licking mom, a mom who did a lot more grooming, versus a low-licking mom who did less grooming, and that this really changed the DNA methylation of a gene that regulated the glucocorticoid response, and that when you change the regulation of the glucocorticoid response, you had increased risk for depression, depression behaviors, obesity, diabetes, and other age-related cognitive impairments in these animals, and because it was an animal model, if we blocked the change in DNA methylation, we could actually prevent the differences between high and low-licking moms. So this was really the first causal pathway that was able to be defined in rodent models because we were able to say, okay, we can see the changes after the event, and if we prevent any differences in methylation, we actually prevent the consequences. So the strength of many of our animal models is the ability to drive causal relationships between epigenetic changes, and because we can give animals things that prevent things like changes in DNA methylation, we can also show that that pathway is causal rather than the inferences where we use in human studies. I give Brian Bogdan lots of credit for this paper from a while ago that I really think is also another component when we think about studying epigenetics and genetics in relationship to adversity, is that we probably underutilize pathways that we are defining neurobiologically. This is a great example of creating a multi-locus genetic profile or the impact of adversity on something like the HPA axis. We have lots of data talking about changes to the regulation of the HPA axis in response to adversity and certainly trauma-related psychopathology like PTSD or depression or anxiety, and what Ryan demonstrated here was that if you think about the actual biologic pathway and the genes involved in the regulation of the HPA axis, and you make clear definitive predictions about how a particular genetic variant will influence that response, you can create a very neurobiologically-based model that becomes much more testable, and you can overlay on this the epigenetic factors as well. If we think that a particular variant of the corticotropin-releasing hormone receptor is a downregulation of it and we overlay increased methylation, we can start to say that there's going to be a greater effect of hypermethylation and this particular T allele on the regulation of the HPA axis. It really helps us define both the places we want to look for epigenetic changes as well as the relationship between genetic variants, recognizing that the influence of an epigenetic change may very much be influenced by another factor, like a genetic polymorphism that is also driving differences in gene expression. When we think about the relationship between childhood adversity, DNA methylation specifically, and psychopathology, what are some of the genes that have been studied? Certainly we have a cluster of genes with various levels of evidence, and I've listed them here, related to the adversity to metabolic consequences. We have a much more, I would say, robust literature around genes regulating the HPA axis and DNA methylation and risk of future psychopathology, in particular NR3C1, so the one that was demonstrated in the rodent model. It's human equivalent. We've actually seen some pretty strong evidence for that in relationship to trauma leading to psychopathology or risk across generations. FKBP5 has some positive and some negative studies. The SLC684A is actually the serotonin transporter, and so there have been both positive and negative studies with that in terms of DNA methylation. Then we also see a cluster of genes focused around what I consider to be the influence of early caregiving as a form of adversity, so either abusive or maltreatment or deprivation in caregiving, driving differences in these genes that are regulating affiliative behavior and our stress response systems as well. When we think of the pathways of transmission of adversity across generations, this was actually made by one of my undergraduate students who's now at Pritzker Medical School, so Renee Tristano drew this diagram, and I love it, and someday I need to get it in a paper so that you can get full credit for it. What I will say about it is it really highlights the complexity of both the epigenetic factors and then the biologic processes as well as the postnatal environment as being modifiable factors, so some of these are unmodifiable and some of these are biologic, and then some of them are really modifiable factors that can influence how transmission happens in the setting of adversity both within and across generations. Just to really think about that, we have all of these biologic pathways by which mom's exposure to preconception and conception adversity can influence both the functioning of the egg, certainly can influence the developing child through the effects on the physiologic maternal fetal placental unit, and dad, so again, I will highlight some of the really impressive work related to microRNA and small nuclear RNA and the transmission of epigenetic effects through the male or paternal side that Kerry Ressler and others have done, but again, recognizing that the shared environmental exposures both for mom and dad and the postnatal environment and postnatal care for this child are going to be influencing how those biologic, physiologic, and environmental risks are transmitted into risk for the next generation. So this is one of the most impressive and fun studies I have seen done by Tracy Bales' group, and I have a huge scientific obsession with Tracy Bales' work because it is super intentional and it really gets at the complexity of how I think about adversity, and so what Tracy Bales' group did was they created a very complex exposure model in terms of stressors, and so what you will see here is our poor little mouse friend. They exposed the mouse to various kind of timings of bright lights, the fox odor marble bedding, which apparently is very disruptive and distressing to mice, intermittent or random loud sounds, and then restraint stress, and this was all in a very unpredictable, unexpected combination, and then they said, what is the effect of this inconsistent type of stressful exposure on gene expression in the brain and gene expression in the placenta of offspring, both of parents, both of moms that are exposed to this and dads that are exposed to this, and so I think that it is such an eloquent way to talk about what I think the typical exposure to adversity is, or I would say the atypical typical exposure of adversity in the human model, which is that it has all of these things, so it has a lack of resources, it has threat, it has unpredictable changes in the environment such as sounds and light, and then said, what does that do to specific pathways in gene expression changes, and what you'll see, and I'll kind of walk you through this, is that in female offspring, maternal stress really increased expression in immune pathways and neuronal pathways, decreased metabolic and cell cycling, increased cell signaling in the female offspring, and very little effect of paternal preconception exposure, and when we stressed both the parent and both parents and created an offspring that we saw sort of a different pattern entirely than just mom, so suggesting that it's both important in terms of the impact of preconception stress on epigenetic pathways that control gene expression to understand which parent had that exposure, and also the sex of the baby themselves, and so when we look at the pattern for male offspring, we still see some increase in immune expression, but instead of a decrease in metabolic, we see an increase. The cell cycling looks pretty similar in terms of that, and cell signaling is a little bit less robust. However, in the dad being stressed transmission to the male offspring, we see much different expression changes in the brain, and I will also say in the placenta, than we see in the relationship between paternal stress and the female offspring, and this is sort of, this is my picture of Tracy Bale because she just does some amazing work in terms of the transmission of adversity and really getting understanding of the biologic pathways, but this is sort of a conceptual model really talking about, so if we stress dad, we see increased metabolic changes in the placenta of the female offspring, but when we stress mom, we see decreased brain expression, decreased immune expression in the male placenta, and decreased immune signaling as well in the male, and then we also see decreased immune signaling in the male placenta from both male and female parental stress. So I put this up here, one, because I think it's a fascinating study, and she's a great person to follow from a research standpoint because I think it's really important research to drive, to use sort of the models that she's built and the pathways that she's identifying to help us drive better questions to be asking and more specific questions to be asking in our human work, and because I think it's really important to understand the unpredictable combination of adversity can have very specific and can have very important effects both on that maternal fetal placental unit and on brain expression changes in the next generation. Another kind of collection of studies that is out there that has really demonstrated persistent epigenetic differences associated with adversity in humans comes from multiple studies of famine exposure in humans. So remember that threat by adversity, by threat by deprivation diagram that Kate McLaughlin and Margaret Sheridan created in terms of adversity, one of the things that was in there, right, was deprivation, and so food deprivation is a very powerful driver of adversity, and what you'll see here is kind of a sort of pictorial diagram of the demonstration of health effects, not just in that exposed generation of the F0, but in subsequent multiple generations actually seeing effects on health span and lifespan. So as I read through these studies and really started to think about it, it highlighted the importance of understanding the generational effects of trauma on the individual that I'm seeing, and that often we will ask what happened in somebody's childhood, but we don't have as much of an understanding of what happened in their parents' life, or in this case when we think about multiple generations of transmission, what was happening in their grandparents' life, and so while that is really challenging to study, I think it's an important concept as we try to understand the generational and individual effects of adversity biologically and its relationship to health and developmental psychopathology. So some other work that has really been able to specifically narrow in on the intergenerational transmission through epigenetic mechanisms of extreme exposures came out of some elegant work by Rachel Yehuda, so these are human studies looking at the effect of a parent who was a survivor of the Holocaust, in this case on FKBP5 methylation in their children, and so what you'll see here is that there are specific methylation patterns to parents who were Holocaust survivors compared to controls, both in terms of the parent and in terms of the offspring methylation, and what you'll see in this study is that the parent actually had increased methylation in this particular region of FKBP5 while the child, who was the offspring, had an inverse pattern, and so I'm going to loop this back to one of the very first slides where I talked about the life course history model and the idea that genetic and biologic factors are both adaptive and transactional, and so in this case we can think about this as an adaptation of the next generation to the parental exposure by saying, okay, we know that there was, because of this trauma exposure, an increased methylation, so if I decrease my methylation and I happen to have another negative exposure, I'm going to have the appropriate level of DNA methylation. Now, I don't want to suggest that the individual spot was having this own internal dialogue about whether I need to demethylate or not methylate, but what I want to suggest is that this is an adaptation in the subsequent generation for the potential of an exposure, like a huge adversity exposure that my mom was exposed to or my dad was exposed to, that I would then be prepared to tolerate that in terms of changes in epigenetics and not have a dysregulated system, so potentially preparing for an environment that I expect because my parents were exposed to it and then when that happens and I happen to get more methylation, I don't have too much methylation and I end up at the right spot. So, we see some other sort of similar data looking at Holocaust survivors and the glucocorticoid receptor promoter methylation, so the glucocorticoid receptor similar to FKBP5 is involved in the regulation of the HPA-access response to stress as well as the diurnal variation over the course of day, and here we see that methylation is influenced not just by the sex of the parent of origin, so mother being M and F being father, so what you'll see is that if mother and father had no exposure to a Holocaust survivor and neither of them had PTSD from another reason, we have one methylation pattern. However, if both parents had both exposure to Holocaust and PTSD, we have a different methylation pattern than if only dad had it and dad had PTSD, so really understanding the interactive effects of both parental exposure to adversity and the development of psychopathology on the child's glucocorticoid receptor methylation. So again, thinking about this transactional, so my parents had this exposure, when my parents both had this exposure and they both have psychopathology, I need to have this level of methylation, and when there is a discrepancy, really having a differential response potentially reflective of not having a clear way to predict what the environment is going to be like. We replicated some of this work with another study looking at moms who were exposed to violence and developed PTSD, and this was work done by Damon Grosso and Margaret Briggs Galwan at the University of Connecticut. So in this case, we're also looking at FKBP5, and here we genotyped the moms and the infants, so these are infants in the newborn period, and we said what is the relationship between mom's genetic risk, so the FKBP5 CT polymorphism is a risk factor for the development of PTSD in the setting of trauma exposure, and so mom's genetic risk coupled with her exposure to threat-based adversity led to decreased methylation in her of FKBP5, so matching what was seen in some of the previous studies in terms of the relationship between exposure and decreased methylation, and was associated with the development of maternal PTSD. Very similar to what we saw in Rachel Yehuda's study of the change in direction of DNA methylation, we actually saw increased FKBP5 methylation in the babies, and particularly babies that were born with the more, I would say, with the opposite genotype from mom, so kind of replicating both the directional shift across generations and also overlaying the importance of genetic variation as well as DNA methylation changes. So I'm betting that many of you have heard a lot about the epigenetic clocks, I will say that this slide here is outdated and there are more epigenetic clocks than even the Denaidon poem from 2020. Really, I think it all kind of started with the Horvath DNA methylation clock, so these are sort of aging-related epigenetic markers that are derived from a collection of different DNA methylation sites across the genome, and you can kind of see like what the platform was and how many tissues and how many CPG sites are embedded in them. These are all very easily calculable, I think the Horvath clock, and actually many of these have actually freely available sort of our programming that can pull the genome-wide DNA methylation data and generate these clocks relatively consistently after you've done appropriate sort of cleaning of the DNA methylation, but we have lots of different DNA methylation clocks that exist and they're being used in many different combinations. I think it's really important to understand where they were created in and trained in, in terms of what the population and the tissue sources that were used to generate them, and recognize that they don't all predict the same health outcomes or mental health outcomes, and so Grim Age is one of the most wonderfully named epigenetic clocks because it was really designed to focus on overall mortality and lifespan, and that's what it is best at predicting, and so when we think about the Dunedin POAM, that was actually trained on a different sort of aging-related marker, and so understanding that these are very powerful tools, but they are not uniformly overlapping, and they are not all as directly relevant to aging-related changes that I care about, which are in younger people. So it's a wonderful and evolving field, and one of the powers of it is that there's a lot of data that exists that can be utilized to generate these clocks in relatively large population studies, and so there's huge potential here to really build out the biologic embedding of adversity and its relationship to health outcomes from existing data. So this is just to remind us that epigenetic aging measures capture different aspects of aging, and so I am talking about aging because I do think this is a primary pathway or sort of a conceptualization of how I think early life adversity leads to risk, and so when I think about understanding epigenetic pathways, I think about what are the epigenetic pathways that are relevant to aging and to psychopathology, and so this is really just to point out that in this collection of studies, what you see is that you'll see that these different clocks are correlated differently with each other as well as with another epigenetic indicator, which is telomere length, and so this is really just to remind us that physiologic age and these biologic predictors of age are different, and that they pick up different factors across the lifespan. So if you look here, telomere length is really focused on molecular and cellular aging. These clocks are capturing a lot of molecular and cellular aging. While we see physiologic age, it's more at sort of the organismal and system level. And then when we talk about functional biologic aging, we think about cognitive decline, things like grip strength, and moving around. And so really thinking about aging across different systems, as well as the epigenetic factors that are tracking it. So this is another study that looks at the association of grim age and gestational age acceleration. So another epigenetic clock with maternal stress, PTSD symptoms, and difficulties in emotion regulation. And so here, what I want you to see is that there is definitely a different relationship between grim age acceleration, pheno age, a different epigenetic mark, and we don't see a relationship with Horvath's measures. And we only see a relationship with the age accelerator, gestational epigenetic age accelerator, and PTSD symptoms. So really understanding that these are picking up different components of aging and different components of both the impact of trauma, so something like PTSD, and the sort of behavioral or emotional consequence of it, which we often think of as one pathway by which this happens and it's influenced to the next generation, is through emotion dysregulation. So we can also see that the DNA methylation clocks are sensitive to the timing and type of early maltreatments. And so this gets back to what I was talking about at the very beginning, which is that the impact of adversity really has to be considered in the sort of relationship between when that adversity happens. And so what you see here is that when we are looking at maltreatment, so physical abuse, emotional abuse, neglect, and assault, or so I guess physical assault, emotional abuse, physical neglect, and emotional neglect, you'll see that the relationship between each other is first strong, right? So that we don't see often kids that are only exposed to one type of adversity. And that if you look across time periods, that often if you are emotionally abused at one age, chances are you're going to have a higher risk of that later. And so similarly with physical abuse. And then when we look at the relationship between these exposures and later epigenetic aging across the different epigenetic clocks that I was talking about, so grim age, pheno age, Dunedin pace, the Horvath clock, and this is the pediatric buccal epithelial clock. Again, you see very, very different relationships between them and also between the influence of epigenetic effects. So we want to be very intentional about recognizing that these epigenetic clocks are not all picking up the same thing and that there is a relationship over time with each other, but that that relationship changes over time. This is another example of really putting an entire model together. So we think about exposures to all of these different types of abuse and neglect, and then looking at epigenetic age acceleration at age nine and how it predicts later psychopathology. And so what I think is important to note, and this is for me a really key parent, because this is one of the things that I study a lot, which is community level threats. So not even necessarily the sort of direct exposure to violence, but this case there was home threat and community threat, but the community threat was a huge predictor of externalizing problems and also epigenetic age acceleration, and that those two pathways were not together. And so I'm going to come back to this, but why that is really important to me is that when I think about treating kids with trauma-related externalizing disorders, I treat the trauma, right? And I do trauma-focused cognitive behavioral therapy, or I treat the associated depression or anxiety, and I'm decreasing the externalizing symptoms. What I'm not measuring is actually whether or not I'm influencing this biologic pathway related to epigenetic age acceleration that is also a result of exposure to community violence or to home threat, right? And so in this case, these pathways are not actually related to each other, and so just fixing externalizing may not influence the epigenetic factor. And why does that become relevant to me? Because if I think that this epigenetic age accelerator is a risk for later health outcomes or later psychopathology, and I only treat the child to eliminate externalizing problems, I'm leaving an unnoticed scar. I'll show you some other data in a little bit that sort of builds upon that model. So one of the important things to think about with these studies is that there are some critical methodologic caveats. So first, epigenetic changes are not static. And one of the things that I would encourage the field to consider and that we seem to have trouble funding in traditional ways is that it is not clear in saliva or peripheral blood or buccal swabs what the expected normative trajectory of epigenetic change is across key developmental windows. So without knowing what is normative, understanding what is a biologic risk factor because of trauma that will lead to later health outcomes is problematic. We are clear that epigenetic changes may be tissue or cell type specific, and in some cases can be global. And I'll show you a very cool tool that can help get at some of that. But often we are measuring epigenetic changes in whatever tissue we can get. So blood if we're lucky, saliva or buccal swab if you're me and don't like to stick kids, and very rarely, if at all, are we getting in human studies the neurobiologic tissue so we can get those post-mortem. But remembering that we are taking a proxy indicator of risk in terms of studying epigenetic changes in tissue that may not be directly in the biologic pathway that we're thinking about. I will also say that we are increasingly aware, and this is the same thing for genetic variants, that not all epigenetic changes actually drive gene expression changes. And so we are making assumptions that these epigenetic changes are important, and if they're important, we think about their importance in terms of how they influence gene functioning. But some of these epigenetic changes that we study don't actually influence gene expression, or at least at a level we can detect. Throughout these studies, despite the fact that I presented a very lovely model of the sort of intersection between deprivation and threat, many of the studies where we have studied trauma do not integrate a model where we define trauma by duration, intensity, or impact. And so when I think about the sort of trauma of famine, or the trauma of being exposed to the Holocaust, I can think of many, many, many, many things that are all kind of brought together within that risk, within that exposure. And so disentangling those may give us more precise information and allow us to map the biologic effects more effectively. I will say that the strength of Tracy Bales' model is reflected here, which is that adversity often travels with other social determinants of health. So it's incredibly hard to sleep well if there's a lot of noise in your neighborhood. If you have community violence, that sometimes means that there is changes in noise and that you don't have the same capacity to sort of relax when you get home, and that influences sleep. A lot of children are exposed to community-level violence and have food insecurity. And so this idea of the complex interface of adversity across social determinants of health is incredibly important. And then we've already sort of touched on the idea that the precision of measurement and the effect size of what we are measuring have to be relatively large if we're looking at typical kind of populations of 100 or 200 individuals. So this was released in translational psychiatry. It's actually a tool that you can go on that looks at the correlation of specific CPG sites and methylation and where they are in different regions in the gene. So some are in the promoter region and what you see, sort of the overall variability across different regions in the brain and the blood, and then the actual correlation across those regions in terms of the percent methylation similarity between these brain regions, and then looking at the cell composition, which can influence the type of or the amount of methylation that's measured between the brain and the blood. And so this is a really great tool to kind of think about and refining the CPGs that you're looking for depending on the cell type that you're thinking about if you want to know where it is happening in terms of the gene and how it might influence gene expression. So heading back to the hallmarks and biomarkers of aging, I think this is actually a really important model when we think about the effect of adversity through biologic pathways and epigenetic mechanisms across the individual and within generations. So this is really talking about sort of the hallmarks of aging at the sort of molecular and cellular level and mitochondrial dysfunction. So I encourage you, Martin Bacard at Columbia has some amazing data and has the best slides I've ever seen, really linking mitochondrial dysfunction in many of these pathways. And so while mitochondria are not directly considered an epigenetic mechanism, what you'll notice is that many of these mitochondrial functions are related to epigenetic changes, cellular senescence, telomere attrition, and a lot of these same biologic sort of downstream pathways that we think are tracking on to how early adversity leads to epigenetic changes and then future health risks. So this is actually looking at the combination of mitochondrial DNA copy numbers. So this is another marker of mitochondrial function. It's more blunt than actually measuring sort of the oxidative phosphorylation capacity of mitochondria, but you can look at the mitochondrial DNA copy number as another indicator. So it's similar to epigenetic age of sort of biologic aging risk and telomere length. And this is a study by Audrey Turco looking at, again, this interface between adversity exposure, the development of psychopathology, and biologic indicators of epigenetic aging. And so what you'll see here is that telomere length gets shorter when you have a psychopathologic disorder. So again, consistent with what we have seen in some other studies already, talking about the bidirectional relationship between telomere shortening and psychopathology, but the cumulative effect of having exposure to adversity and psychopathology really was more impactful on telomere length. And here you can see that individuals with mitochondrial DNA copy number measurement, the loss of appearance, so that is one of the ACEs, as well as being exposed to maltreatment actually were upregulating the mitochondrial DNA content. And so more mitochondrial being produced, more of a cellular response that's actually associated with shorter telomere length. So building, again, these complicated cellular models, but this idea of accelerated sort of cellular aging as a pathway by which early adversity and the interface with psychopathology are really leaving biologic traces. So I'm going to sort of wrap up, but not really wrap up, with a study where we were able to really define causal models in humans in what I think is a really interesting and certainly another approach that people can be using. So I have been lucky enough to be involved in the Bucharest Early Intervention Project for far too long. If I were to actually tell you the number of years, it's worrisome because it's a lot of years. Suffice to say it's over two decades now. And so what the Bucharest Early Intervention Project was, it was started by Nathan Fox, Charles Nelson, and Charlie Zena in the early 2000s. And this was a study where they were invited in by the Romanian government to help understand what to do with the Romanian children that were being left at the, that were orphaned as a function of many of the policies of the Ceausescu regime. And so these children had been dropped off at orphanages at various stages in their life, and it was unclear what the best model was for how to care for them. And so what Charlie Zena, Nathan Fox, and Chuck Nelson were able to do was to design sort of the only randomized controlled trial of institutional care compared to foster care rearing. And the ethics of this have been discussed at length, but there was really no clear evidence to support that it was better to be in foster care than being reared in an institution. And I will say that the foster care that was created here was really designed to be the sort of highest level and, or what I like to call the Alexis level of foster care. So these were foster parents that were paid a full salary to be foster parents. They had a warm line to a developmental psychologist, Dennis Mike, who was able to guide them in understanding how their, the child that they were fostering behavior was related to their early experiences and to really foster a very strong attachment relationship. And the placement in these cases was actually substantially more stable than placement in typical US foster care. I will say that the data at 54 months of age was sufficient to disband the foster care intervention. And many of these children were actually then put into the MacArthur Foundation designed a new foster care system. And so many of these children were placed into that new foster care system. The analysis that I'm going to talk about is actually intent to treat analysis, which allows us to draw causal relationships because this randomization at baseline was actually done randomly. So numbers were picked out and that determined whether the child went into the care as usual or went into the foster care placement. It is hard for me to believe that we are completed the 21 year assessment on these children and are getting, working towards the 23 year assessment. And so several kind of earlier studies with this population. So we collected buccal epithelial samples on these kids when I started my involvement in 2002. And the first analysis that we did was really looking at telomere length between the ages of six and 10 and the relationship between the percent time and institution. And we actually saw significant sex effects such that girls were actually showing a significant decline in telomere length in that six to 10 year old age range as a function of the percent of their life that they had spent in foster care. And then subsequently, Kate Humphreys did an analysis saying, what is the relationship between ever being in an institutionalized setting compared to children who were never institutionalized on the trajectory of telomere length measured repeatedly over the ages six to 16. And what you see is that children who had never been institutionalized had a flatter trajectory of telomere loss. So slower biologic aging than children who had any exposure to institutional caregiving over this time course of a decade. And then subsequent analysis done in collaboration with Mark Wade really said, what is that relationship between this institutional caregiving setting and risk for psychopathology and telomere length? So trying to disentangle is the epigenetic change in telomere length driving psychopathology or is psychopathology driving changes in telomere length? And what we found was that institutional rearing unsurprisingly predicted elevated psychopathology across this time frame, so both at age eight to 10 and age 12 to 14. And that that general psychopathology was associated with decreased telomere length at age 12 to 14. We see a strong correlation between telomere length from ages eight to 12 and 12 to 14. So telomere length at age 12 to 14 was positively, or telomere length at age eight to 10 was associated with telomere at age 12 to 14. And that while we saw a relationship between internalizing and telomere length at age eight to 10, what was really happening was increased internalizing was driving shorter, later telomere length. So really sort of driving a model in a directional way that was actually the opposite of what I would have predicted, but saying that the psychopathology itself was a huge driver of the epigenetic change rather than being the epigenetic change driving psychopathology. And this is actually far more consistent with the data, really looking at the combined effect of PTSD and trauma on epigenetic changes across generations and within individuals. So, as I mentioned, there are some pretty substantial challenges with epigenetics, which led me to be frustrated. And so one of the biggest challenges is that we have this methylation on the DNA that should influence the transcription of DNA into RNA. And then if we see changes in RNA, do we actually see changes in the RNA's conversion into a particular peptide with a translation into a protein, right? And can we build a model where we can look at all of those together in the same biologic sample and draw causal relationships? So this led me to my fascination with saliva and to why saliva, one, kids love to create saliva and give it to you, much more willing to give you saliva than they are to give you blood. Two, within saliva, you actually can measure DNA methylation because there is DNA there. You can actually measure RNA because certain RNA species are expressed there. And saliva is actually where we measure something like cortisol. So in thinking about a lot of the data linking epigenetic changes and physiologic models, clearly changes in the pathway related to the regulation of the HPA axis and cortisol production is one that's been implicated in a variety of different adversity settings. And when we talked about the data earlier in terms of methylation patterns, we saw consistent data of changes in methylation patterns in many of the genes regulating cortisol production. So could we design an analysis that allowed us to measure DNA methylation, RNA expression changes, and the production of cortisol in the same biologic sample? And so within the Bucharest early intervention study at age 12, we did a Trier social stressor test. And for those of you who don't know about the Trier social stressor test, social evaluative threat is actually the best way to activate the acute HPA axis response. And given that we predicted that the impact of early institutional rearing would be to influence the physiologic stress response and particularly social responses, and this is again work done with Margaret Sheridan and Kate McLaughlin and Charlie, Chuck, and Nathan in terms of the leadership of the Bucharest study, was we had the children go through a selection of tasks. So the first task was a peer evaluation task. They then went through the Trier social stressor test. They did a mathematics test and then a frustration task with the expectation that this Trier social stressor test was actually going to be the activator of the HPA axis. And these were other kind of indicators. And so what we did was at the same time we were collecting cortisol, we collected a saliva sample for DNA and a saliva sample for RNA. So really using that same biologic specimen collected at the same time to collect something for DNA methylation at baseline because I wanted to know what the methylation of the genes involved in the production of cortisol might look like at the same time that we collected RNA. And then we collected a second collection of RNA after the Trier social stressor test with the assumption that this change in RNA expression would be capturing the genes that we expect to regulate the change in cortisol because I expect that cortisol is gonna kind of go up in this range. And so study that was published in PNAS with Kate and Margaret really showed the causal relationship between being in continued institutional caregiving leading to a flattened cortisol response. So this is the cortisol response over that pathway that we talked about. This is the never institutionalized children. So really demonstrating the appropriate sort of increase in cortisol that we expect with the social evaluative threat and then a slow decline. And then what you see with the foster care kids is kind of their functioning in the middle. So this was really a causal demonstration that this randomization to institutional rearing was the mechanism by which, the change in caregiving was the mechanism by which children in continued institutional caregiving had a flattened cortisol response. And so remember that we generated, we collected RNA at baseline with DNA and we also collected RNA concurrent with this peak of cortisol. And so the first thing that we did was we said, what is happening in terms of gene expression? And to do this, what we did was we took RNA type 0.1 and we hybridized it with a fluorochrome and we then took RNA type 0.2 and we put them together. And we said, I really only wanna know what genes are left that haven't changed, that have changed significantly in terms of their expression level. Because I wanted to see what changes in gene expression were happening at the same time that I knew cortisol was changing. And so that generated this list of genes here. And what you'll see here is that, if we did the sort of diagram of the care as usual, you'll see that there was a lot of downregulation of these genes and that the NIG kids had a much more increased expression between time 0.1 and time 0.2. So really correlating sort of global changes in expression in at least these genes with the same pattern that we were seeing. So increased cortisol production and sort of increased gene expression. And then we said, what is the correlation between methylation and actually let's see, this should pull up. And so one of the genes that really stood out was CALD1. And so then the next step was to say, what is the relationship between methylation and CALD1 and both gene expression? So these are the transcripts that characterize CALD1 and these are the CPG islands that are located in CALD1. And so really wanted to say, what are the changes in gene expression, right? So this transcript of CALD1 being significantly associated with DNA methylation and these CPG sites in that same gene. And then how does CALD1 expression correlate with cortisol levels? And what you see is that CALD1 expression change actually correlated well with cortisol across all five time points. And when we looked at methylation in this gene, what we saw was a significant decrease in methylation in our care as usual compared to our foster care compared to our foster care and compared to our never institutionalized kids. So within this study, we were able to demonstrate and I'll go back here that changes in gene expression were correlated with methylation in the same gene in the same sample, so the same saliva sample that changes in gene expression from those two different time points of RNA were correlated with the change in cortisol across all individuals across all time points. And then we said, well, what is the known function of CALD1? So this was something we went into sort of blindly and wanted the data to drive the biology. And so what we know about CALD1 is it's involved in active myosin cellular migration. It contains two glucocorticoid response elements and is upregulated and activated by glucocorticoids. So it's upregulated and influenced by cortisol. It is actually involved in tissue specific glucocorticoid responsiveness. And so would actually be relevant to the flattening of the glucocorticoid response that we saw in the care as usual. And that it plays a pivotal role in the regulation of cell migration and organization of the actin cytoskeleton. So the biology of the CALD1 gene that we pulled out through this process actually makes physiologic and biologic sense with the flattening of the glucocorticoid response that was seen in the care as usual children. So why saliva is cool to me is one, we were able to show within saliva the association between changes in DNA methylation and changes when DNA methylation and changes in RNA production. We were able to show that the RNA level actually predicted the protein level and that the protein level was associated with this whole process. So really being able to develop the causal model saying that this early caregiving exposure to institutional rearing drove changes in DNA methylation for this CALD1 gene and subsequently influenced the regulation of CALD1 during a psychosocial stressor and that that pathway was directly related to the flattening of the cortisol response in the care as usual patients. So building that sort of cumulative model together. So where are we now? So we talked about in the past that we have hypothesis-driven candidate gene approaches often too small of the sample sizes, didn't necessarily integrate genetic admixture, didn't really set what an appropriate effect size would be for clinical impact. Where we are now is that we have a lot of affordable technology to run epigenomic-wide and GWAS studies. I will still say we need to be exceptionally cautious about the amount of samples that we have. We need to account for effect size differences in genetic ancestry, just like we have before, which also means we need to ensure that our studies have representative amounts of people from different genetic ancestry. And we need to be really better at harmonizing both our measures of the socioeconomic environments and social determinants, as well as the exposure. I do think we are well-poised or positioned to do impressive and causal and directed research that advances through single-cell approaches, really pushing on the in vitro work to determine how these DNA methylation differences drive changes, and incorporating through big data, large, diverse samples. We need to be better partners with our across different institutions, across different studies, building multi-site collaborations, advancing the integration of biologically meaningful thresholds. When we think about, is this DNA methylation change relevant, right? And then I think also really characterizing it in terms of how it is both driving risk and psychopathology and what's happening when we think about treatment. So I'm going to show you a little bit more data, and this is actually data that I want you to link back to the study a while ago that I talked about the level of home threat and community threat in relationship to epigenetic aging and externalizing. And so in that study, what I pointed out to you was that home threat and community threat were both related to epigenetic age acceleration and externalizing, but the externalizing and the age acceleration were not related, which meant that if I were to treat the externalizing, I might not be getting at the biologic change associated with epigenetic age. Similarly, in a study that we did in the greater New Orleans area, we saw that telomere length was associated not only with domestic violence calls and violent crime within a one mile radius of the house, it was also associated with that same flattening of the cortisol response that I just showed you in the Romanian study, and it was associated with elevated externalizing. Now this wasn't a treatment study, but what was striking was those pathways were completely independent, meaning that the impact of community violence was on the cellular aging measured by telomere length, was on the HPA access measured by an acute cortisol response, and on the rate of behavioral dysregulation exhibited by externalizing. And because none of those pathways were mediated, it raises the question of if I'm only treating psychopathology, am I leaving the accelerated aging measured by telomere length and the physiologic dysregulation measured by altered cortisol response untreated? And so this led to, if the biologic pathways are impacted, what's happening with treatment? And I would suggest that we really need to be measuring the biologic effects. And so this is a lovely study that looked at child parent psychotherapy, so an evidence-based dyadic therapy targeting families with a history of adversity. And what you see is that in the child parent psychotherapy intervention group, baseline, there's no difference between those that have a comparison and those that get CPP. And what we see in the post-intervention is that there's accelerated aging in the untreated, whereas the kids who receive CPP have lower epigenetic age acceleration. So this is kind of the beginning of what I think should be the sort of next stages of research in large enough populations that are appropriately balanced for race, ethnicity, and genetic ancestry. And really saying, if we're really sure that adversity and trauma are leading to biologic effects that place individual at elevated mental and physical health risks, that when we treat with evidence-based treatments, we are treating not just the mental health that we can measure by subjective reports, but the biologic pathways underneath as well. So in conclusion, there are multiple lines of evidence to indicate that early adversity has biologic effects across the lifespan. There are sex effects. The timing of exposure matters. The postnatal environment may alter the relationship between the epigenetic pathways that we need to consider multiple markers together, the tissue and developmental specificity, and the relationship with mental illness. In terms of future directions, I think we need to integrate multiple factors, track normal changes, run, and really use our neurobiology to build the biologic models appropriately. And when patients report that they feel better, we need to get to the point that the biology is matching that. And then lastly, for anybody that is interested in studying the telomeres and wants to integrate it into your work, we have the Telomere Research Network, which is funded by the National Institute of Environmental Health Sciences and NIA. We have webinars, although they haven't been as frequent as I would have liked, but it actually has really important resources in terms of how to calculate your sample size needs. I have the new investigator pack that tells you everything you wanted to know about telomeres and studies, key recommendations, reporting guidelines, and then actually our code for calculating your ICCs. So lots of resources here, and I urge you to go there. And with that, I will stop and take questions. Thank you. Thank you, Dr. Drury, for such an engaging presentation. We have a few questions and I would encourage the attendees to type in their questions in the Q&A section. So talking about your presentation, many attendees and our audience may wonder how their own experiences or those of their loved ones could be influenced by the findings that you showed. Could you share a practical example of how understanding the link between childhood trauma and epigenetics can help individuals or families make sense of their own mental health journeys? So I think what is gonna be really important is that many of these studies are really looking at population effects. So this is not necessarily at the individual level. Our measurements are not that precise. What I think is important for families and for individuals is to understand, so we already know a couple of really key things. So the first is that 50% of children who are born to a parent with severe mental illness will develop severe mental illness. And that is probably one of our biggest predictors that we don't do any preventative work for. And so I think it's really important that just having a parent with mental illness places you at elevated risk. And it is not because a parent with mental illness is not a great parent. They can be amazingly good parents and they are amazingly good parents. And we know that there's risks. And so we need to be really starting to get at this idea that mental health and physical health are entwined and we need to be doing preventative work for people that are at risk, just like we would for cardiovascular disease or diabetes, right? So we have guidance around, based on my history of diabetes, how often we are checking your hemoglobin A1C. We have guidance around how much you should be exercising. We can give you sort of increased advice about diet, nutrition, exercise, and sleep. And because I know that adversity is linked to cardiovascular disease, diabetes, hypertension, part of that same information should be given and integrated into how we think about care for people that are exposed to adversity and trauma. So our kids in foster care, our kids who are in protective custody, we should be amplifying the importance of healthy sleep, healthy nutrition, exercise, mindfulness, meditation, all of those things. I think, so that is a really important part. So just being at risk doesn't mean you are going to have this outcome. And it means that the things that we know that provide protection against mental illness become incredibly important. So nutrition, folate, sleep, sleep, sleep, sleep. That is one of my biggest underappreciated regulators of risk for psychopathology. And if we could get everybody to get the appropriate amount of sleep, and please do not ask me how much I sleep because that's not a good question, but I think that there are a lot of these modifiable behavioral things that are incredibly protective. The other part of this that's important for people that recognize that they have been exposed to trauma is to be aware of the symptoms of depression, anxiety, and psychological illness, and get help quick. Because right now or before the pandemic, the average length of time from first symptom onset to treatment or first contact with a healthcare provider for mental illness was eight to 12 years in kids. And so what I would encourage people with a family history to do is to say, I have a family history, I'm starting to have these feelings. I wanna get cognitive behavioral therapy or mindfulness therapy or psychotherapy of any evidence-based kind before I have had depression for eight years. So being proactive and talking about mental illness and identifying the earliest onset and getting interventions done will be incredibly helpful. Thank you. Any brief comments about what is GrimAge? So GrimAge is actually one of the epigenetic clocks, and again, it's a wonderful name, developed by Steve Horvath that was specifically developed in measuring mortality. Right, so when I talked about the generation of these epigenetic clocks, some of them were generated to pick up physiologic signs of aging. So the Dunedin Phenage was related to like facial appearance, right? So aging, my face is very aged, right? So you can see wrinkles and it's like the skin is tight and my cheeks are flattening out. And so GrimAge was actually trained towards measuring mortality. And so it is a very good predictor of all-cause mortality in population-based studies. Great, thank you. What experiences or interventions are known to reverse trauma-related epigenetic changes? Any brief comments regarding that? Yeah, so I will say that the first study that I have found, there's two studies that have really kind of looked at this, and I will say they're small. So the first study was the one that I presented, so child-parent psychotherapy. And the second is work, some of the work that's come out of Mary Dozier's work. So Mary Dozier has an incredibly powerful intervention called attachment and biobehavioral catch-up, which is a very attachment and dyadic-focused intervention that has been shown in families at risk for involvement with health protective services to not only change the regulation of the HPA access, executive function, language, and many other things out to age 14, it actually showed an effect on epigenetic changes in that as well. It wasn't a randomized controlled trial, so it was small, but I think that those are the only ones that I've really seen the data in terms of childhood trauma. And I think it's a really, really, really important place that we need to be looking. Great, thank you. Any comments about the potential role for psychedelic-associated psychotherapy in favorably modifying epigenetic changes? As long as we focus on adults, I think it'd be great to look. I think we can do the basic science to see if there are demethylation effects or histone acetylation changes. I will say Depakote is a histone deacetylator. So that is probably an underutilized kind of evaluation of are we able to adjust these epigenetic marks using known physiologic medicines or treatments that influence epigenetic changes? So I think there is the potential to take these agents and look at cellular kind of expression and see if we're seeing that within the sort of molecular level because we know that Depakote does that, but I think that that's a very important potential factor there. I will say that my thought process about epigenetic changes as a function of therapy also means that if you're changing or if you're opening up an epigenetic window, you need to have people in a good environment, right? Because it is that transactional model. So I would absolutely say that looking at this in relationship to the use of psychedelics in adult brain, please, let's focus on the adult brain. Kid brains are too unpredictable. And I think using it in adults with the combined therapy because you're providing that sort of using the open plasticity to drive changes would be a really interesting place to look if we have evidence that these psychedelic agents actually drive epigenetic changes at either the level of histone acetylation or DNA methylation. Okay, so last question. What is the approximate cutoff age when epigenetic changes may not make sense? So that is such a wonderful, unanswerable question. I will say that every time we kind of think that there's a cutoff on something, we find new evidence that things change. So as somebody who started her PhD at a time when DNA methylation never changed, and now we know that it is actually can be changing moment to moment. I will say that we, for many of our epigenetic changes, I don't think there's a cutoff age. I think probably if I were to pick the one that might be most static, it would be DNA methylation. But for our small nuclear RNA models or interfering RNA and the histones, I think that that's pretty wide open. Thank you, Dr. Drury. Maybe move on to the next slide, please. Thank you. Thank you for joining today's webinar. And be sure to claim credit for your participation in the APA Learning Center. Be sure to join our next webinar on psychopharmacology and schizophrenia treatment by Dr. Oliver Freitenreich of Massachusetts General Hospital. Mark your calendars. This webinar will take place on Wednesday, February 26th, from 12 to 1.30 p.m. Eastern Time. Registration for this event will open soon. Thank you all, and have a wonderful day. Thank you, Dr. Drury. Thank you. ♪♪

childhood trauma

epigenetics

Dr. Stacey Durie

Boston Children's Hospital

DNA methylation

telomere length

epigenetic clocks

intergenerational changes

stress response systems

psychopathologies

therapeutic interventions

multidisciplinary approaches