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  • Journal article
    Nesi J, Burke TA, Caltabiano A, Spirito A, Wolff JCet al., 2022,

    Digital media-related precursors to psychiatric hospitalization among youth

    , Journal of Affective Disorders, Vol: 310, Pages: 235-240, ISSN: 0165-0327

    Digital media, including smartphones and social media, are central in youths' lives. This study aimed to examine the role of digital media in psychiatric hospital admissions among adolescents. 343 psychiatrically-hospitalized youth (Mage = 15.2; 70.3% White, 13.7% Black, 33.9% Hispanic; 48.7% female) completed self-report measures of potential digital media-related reasons for hospitalization, patterns of digital media use, and clinical symptoms (internalizing, externalizing, suicidal ideation and attempts). Digital media-related reasons for hospitalization were common, with over 40% of the sample endorsing at least one such reason; 24.8% endorsed having their phone taken away as a reason for admission. Younger adolescents and youth with addictive patterns of phone use were more likely to endorse digital media-related reasons for hospitalization, including phone restriction and negative social media experiences. In addition, youth endorsing suicide-related social media engagement (e.g., posting or messaging about suicide) as a precursor to admission reported more severe suicidal ideation and greater likelihood of a recent suicide attempt. Limitations of the study include a reliance on self-report measures and cross-sectional design. Findings highlight the need to identify youth who may be especially vulnerable to digital media experiences that contribute to risk for psychiatric hospitalization.

  • Journal article
    Magson NR, Van Zalk N, Mörtberg E, Chard I, Tillfors M, Rapee RMet al., 2022,

    Latent stability and change in subgroups of social anxiety and depressive symptoms in adolescence: a latent profile and transitional analysis

    , Journal of Anxiety Disorders, Vol: 87, Pages: 1-11, ISSN: 0887-6185

    BackgroundSocial anxiety and depressive symptoms increase markedly during adolescence. Most research examining the emergence of these symptoms has used a variable-centered approach providing little information about how these symptoms group together in individuals over time.MethodA person-centered approach utilizing latent profile and latent transitional analyses was applied to a large adolescent sample (N = 2742, Mage=13.65; SD=0.63; 47.9% girls). Subgroups differing in their expressions of social anxiety and depressive symptoms at each of four annual time points were identified and then change in membership of these groups was evaluated.ResultsFour subgroups were identified: 1. Low Distress, 2. Socially Anxious, 3. Dysphoric, and 4. Comorbid. The low distress group was the largest and most stable, followed by the socially anxious group, who most commonly transitioned into the comorbid group. In contrast, the dysphoric group were most likely to remit and move to the low distress group. The comorbid group was the smallest and least stable, although once in this group, three quarters of adolescents remained in this group over time.ConclusionEarly intervention is particularly imperative for socially anxious adolescents with or without comorbid depressive symptoms as they are the least likely to improve across the adolescent years.

  • Journal article
    Tan Y, Rerolle S, Lalitharathne TD, Zalk NV, Jack R, Nanayakkara Tet al., 2022,

    Simulating dynamic facial expressions of pain from visuo-haptic interactions with a robotic patient

    , Scientific Reports, Vol: 12, ISSN: 2045-2322

    Medical training simulators can provide a safe and controlled environment for medical students to practice their physical examination skills. An important source of information for physicians is the visual feedback of involuntary pain facial expressions in response to physical palpation on an affected area of a patient. However, most existing robotic medical training simulators that can capture physical examination behaviours in real-time cannot display facial expressions and comprise a limited range of patient identities in terms of ethnicity and gender. Together, these limitations restrict the utility of medical training simulators because they do not provide medical students with a representative sample of pain facial expressions and face identities, which could result in biased practices. Further, these limitations restrict the utility of such medical simulators to detect and correct early signs of bias in medical training. Here, for the first time, we present a robotic system that can simulate facial expressions of pain in response to palpations, displayed on a range of patient face identities. We use the unique approach of modelling dynamic pain facial expressions using a data-driven perception-based psychophysical method combined with the visuo-haptic inputs of users performing palpations on a robot medical simulator. Specifically, participants performed palpation actions on the abdomen phantom of a simulated patient, which triggered the real-time display of six pain-related facial Action Units (AUs) on a robotic face (MorphFace), each controlled by two pseudo randomly generated transient parameters: rate of change β and activation delay τ. Participants then rated the appropriateness of the facial expression displayed in response to their palpations on a 4-point scale from “strongly disagree” to “strongly agree”. Each participant (n=16, 4 Asian females, 4 Asian males, 4 White females and 4 White males) performed 200 palpation

  • Journal article
    Chard I, Van Zalk N, 2022,

    Virtual Reality Exposure Therapy for treating social anxiety: A scoping review of treatment designs and adaptation to stuttering

    , Frontiers in Digital Health, Vol: 4, ISSN: 2673-253X

    Virtual Reality Exposure Therapy (VRET) has been shown to be an effective technique for reducing social anxiety. People who stutter are at greater risk of developing heightened social anxiety. Cognitive behavior therapy protocols have shown promise in reducing social anxiety in people who stutter, but no studies have investigated VRET targeting social anxiety associated with stuttering. The aim of the current review is to provide an overview of VRET techniques used to treat social anxiety and insights into how these techniques might be adopted in the case of comorbid stuttering and socialanxiety. Twelve studies were reviewed to understand key distinctions in VRET protocols used to treat social anxiety. Distinctions include exercises targeting public speaking vs. general social anxiety, computer-generated virtual environments vs. 360⁰ video, and therapist guided vs. automatedVRET. Based on the review findings, we propose how certain features could be applied in the case of stuttering. Virtual therapists, inhibitory learning techniques and integration into speech therapy may be suitable ways to tailor VRET. Regardless of these different techniques, VRET should consider thesituations and cognitive-behavioral processes that underlie the experience of social anxiety amongst people who stutter.

  • Journal article
    Afifah Ridhuan S, Caltabiano A, Gillis H, Giritlioğlu A, Graff A, Hampikian LE, Jones AK, Luetgerath P, Pierce A, Pomeroy E, Said-Mohamed Ret al., 2021,

    Advocating for a collaborative research approach on transgenerational transmission of trauma

    , Journal of Child and Adolescent Trauma, Vol: 14, Pages: 527-531, ISSN: 1936-1521

    Since Myers (1915) coined the term ‘shell shock’ to define the prolonged suffering of soldiers returning from the Great War, the psychological and physical result of distressing experiences, known as trauma, has been of academic interest. Transgenerational transmission of trauma effects has been recorded, demonstrating that on some level, the exposure to trauma of one generation can impact individuals of a subsequent generation (Yehuda & Lehrner, 2018). Observational studies on children of holocaust survivors formed the basis of this trajectory of research (Rakoff, 1966), and eventually this phenomenon became referred to as the transgenerational transmission of trauma (TTT). Since then, TTT has been observed in several contexts, including within families who have experienced high rates historical trauma (O’Neill et al., 2016), within regions high-frequencies of historical war and terrorism (Yehuda & Lehrner, 2018) and those who have undergone famine (Ahmed, 2010). This report aims to outline several pathways (biological, psychological, and sociological) by which trauma may be transmitted across generations. Moreover, it discusses several methods of trauma assessment and the related challenges and benefits. Lastly, this report advocates a biopsychosocial approach – an interdisciplinary model using the interplay of biological, psychological, and social-environmental factors – to research TTT. By promoting the benefits of such an interdisciplinary approach we attempt to break up silos between disciplines and encourage collaboration between academics from various backgrounds researching this topic to better serve individuals impacted by TTT.

  • Journal article
    Vickers D, Salorio-Corbetto M, Driver S, Rocca C, Levtov Y, Sum K, Parmar B, Dritsakis G, Albanell Flores J, Jiang D, Mahon M, Early F, Van Zalk N, Picinali Let al., 2021,

    Involving children and teenagers with bilateral cochlear implants in the design of the BEARS (Both EARS) virtual reality training suite improves personalization

    , Frontiers in Digital Health, Vol: 3, ISSN: 2673-253X

    Older children and teenagers with bilateral cochlear implants often have poor spatial hearing because they cannot fuse sounds from the two ears. This deficit jeopardizes speech and language development, education, and social well-being. The lack of protocols for fitting bilateral cochlear implants and resources for spatial-hearing training contribute to these difficulties. Spatial hearing develops with bilateral experience. A large body of research demonstrates that sound localisation can improve with training, underpinned by plasticity-driven changes in the auditory pathways. Generalizing training to non-trained auditory skills is best achieved by using a multi-modal (audio-visual) implementation and multi-domain training tasks (localisation, speech-in-noise, and spatial music). The goal of this work was to develop a package of virtual-reality games (BEARS, Both EARS) to train spatial hearing in young people (8–16 years) with bilateral cochlear implants using an action-research protocol. The action research protocol used formalized cycles for participants to trial aspects of the BEARS suite, reflect on their experiences, and in turn inform changes in the game implementations. This participatory design used the stakeholder participants as co-creators. The cycles for each of the three domains (localisation, spatial speech-in-noise, and spatial music) were customized to focus on the elements that the stakeholder participants considered important. The participants agreed that the final games were appropriate and ready to be used by patients. The main areas of modification were: the variety of immersive scenarios to cover age range and interests, the number of levels of complexity to ensure small improvements were measurable, feedback, and reward schemes to ensure positive reinforcement, and an additional implementation on an iPad for those who had difficulties with the headsets due to age or balance issues. The effectiveness of the BEARS training suite will be ev

  • Book chapter
    Furmark T, Van Zalk N, Wurm M, 2021,

    Social ångest som begrepp, diagnos och kulturyttring

    , Social ångest från teori till behandling, Editors: Mörtberg, Tillfors, Publisher: Studentlitteratur, Pages: 25-51
  • Book chapter
    Tillfors M, Mörtberg E, Van Zalk N, 2021,

    Atypisk social ångest

    , Social ångest från teori till behandling, Editors: Mörtberg, Tillfors, Publisher: Studentlitteratur, Pages: 53-68
  • Journal article
    Shaukat-Jali R, Van Zalk N, Boyle DE, 2021,

    Detecting subclinical social anxiety using physiological data from a wrist-worn wearable: a small-scale feasibility study

    , JMIR Formative Research, Vol: 5, ISSN: 2561-326X

    Background: Subclinical (ie, threshold) social anxiety can greatly affect young people’s lives, but existing solutions appear inadequate considering its rising prevalence. Wearable sensors may provide a novel way to detect social anxiety and result in new opportunities for monitoring and treatment, which would be greatly beneficial for persons with social anxiety, society, and health care services. Nevertheless, indicators such as skin temperature measured by wrist-worn sensors have not been used in prior work on physiological social anxiety detection.Objective: This study aimed to investigate whether subclinical social anxiety in young adults can be detected using physiological data obtained from wearable sensors, including heart rate, skin temperature, and electrodermal activity (EDA).Methods: Young adults (N=12) with self-reported subclinical social anxiety (measured using the widely used self-reported version of the Liebowitz Social Anxiety Scale) participated in an impromptu speech task. Physiological data were collected using an E4 Empatica wearable device. Using the preprocessed data and following a supervised machine learning approach, various classification algorithms such as Support Vector Machine, Decision Tree, Random Forest, and K-Nearest Neighbours (KNN) were used to develop models for 3 different contexts. Models were trained to differentiate (1) between baseline and socially anxious states, (2) among baseline, anticipation anxiety, and reactive anxiety states, and (3) social anxiety among individuals with social anxiety of differing severity. The predictive capability of the singular modalities was also explored in each of the 3 supervised learning experiments. The generalizability of the developed models was evaluated using 10-fold cross-validation as a performance index.Results: With modalities combined, the developed models yielded accuracies between 97.54% and 99.48% when differentiating between baseline and socially anxious states. Models

  • Journal article
    Mörtberg E, Jansson Fröjmark M, Van Zalk N, Tillfors Met al., 2021,

    A longitudinal study of prevalence and predictors of incidence and persistence of sub-diagnostic social anxiety among Swedish adolescents

    , Nordic Psychology, Vol: 74, Pages: 152-170, ISSN: 1901-2276

    This longitudinal study aimed to examine the 1-year prevalence, incidence and persistence of sub-diagnostic social anxiety (SSA) as well as general risk factors for the incidence and persistence of SSA during early and mid-adolescence. A Swedish sample of adolescents (N = 2,523) aged 13–14 years at Time 1 and 14–15 years at Time 2 completed measures of anxiety, depressive symptoms, stressors and emotion regulation strategies across the two timepoints. SSA was defined and assessed by the Social Phobia Screening Questionnaire for Children. The prevalence of SSA was 16%, the incidence 12%, and the persistence 53% over time. Symptoms of depression and general anxiety, various stressors and emotion regulation strategies were overall significantly related to SSA. Predictors for the incidence of SSA were lower age, female gender and elevated general anxiety and behavioral avoidance (i.e. being afraid of new activities when there is uncertainty about the outcome). Predictors for persistent SSA were female gender and increased behavioral avoidance. In conclusion, SSA is very common among young individuals, and behavioral avoidance appears particularly important for understanding the development and persistence of SSA in adolescence.

  • Report
    Brophy K, Davies S, Olenik S, Cotur Y, Ming D, Van Zalk N, O'Hare D, Guder F, Yetisen AKet al., 2021,

    The future of wearable technologies

    , Briefing Paper
  • Journal article
    Lalitharatne SWH, Tan Y, He L, Leong F, Van Zalk N, De Lusignan S, Iida F, Nanayakkara Tet al., 2021,

    MorphFace: a hybrid morphable face for a robopatient

    , IEEE Robotics and Automation Letters, Vol: 6, Pages: 643-650, ISSN: 2377-3766

    Physicians use pain expressions shown in a patient’sface to regulate their palpation methods during physical examination.Training to interpret patients’ facial expressions withdifferent genders and ethnicities still remains a challenge, takingnovices a long time to learn through experience. This paperpresents MorphFace: a controllable 3D physical-virtual hybridface to represent pain expressions of patients from differentethnicity-gender backgrounds. It is also an intermediate stepto expose trainee physicians to the gender and ethnic diversityof patients. We extracted four principal components from theChicago Face Database to design a four degrees of freedom(DoF) physical face controlled via tendons to span 85% offacial variations among gender and ethnicity. Details such as skincolour, skin texture, and facial expressions are synthesized by avirtual model and projected onto the 3D physical face via a frontmountedLED projector to obtain a hybrid controllable patientface simulator. A user study revealed that certain differences inethnicity between the observer and the MorphFace lead to differentperceived pain intensity for the same pain level rendered bythe MorphFace. This highlights the value of having MorphFace asa controllable hybrid simulator to quantify perceptual differencesduring physician training.

  • Journal article
    Lalitharatne SWH, Tan Y, Leong F, He L, Van Zalk N, De Lusignan S, Iida F, Nanayakkara Tet al., 2020,

    Facial Expression Rendering in Medical Training Simulators: Current Status and Future Directions

    , IEEE Access, Vol: 8, Pages: 215874-215891, ISSN: 2169-3536

    Recent technological advances in robotic sensing and actuation methods have prompteddevelopment of a range of new medical training simulators with multiple feedback modalities. Learning tointerpret facial expressions of a patient during medical examinations or procedures has been one of the keyfocus areas in medical training. This article reviews facial expression rendering systems in medical trainingsimulators that have been reported to date. Facial expression rendering approaches in other domains are alsosummarized to incorporate the knowledge from those works into developing systems for medical trainingsimulators. Classifications and comparisons of medical training simulators with facial expression renderingare presented, and important design features, merits and limitations are outlined. Medical educators,students and developers are identified as the three key stakeholders involved with these systems and theirconsiderations and needs are presented. Physical-virtual (hybrid) approaches provide multimodal feedback,present accurate facial expression rendering, and can simulate patients of different age, gender and ethnicitygroup; makes it more versatile than virtual and physical systems. The overall findings of this review andproposed future directions are beneficial to researchers interested in initiating or developing such facialexpression rendering systems in medical training simulators.

  • Journal article
    Van Zalk N, 2020,

    The development of internalizing behaviors in early adolescence: introduction to the special issue

    , Journal of Early Adolescence, Vol: 40, ISSN: 0272-4316

    This special issue highlights a number of important processes that help explain the emergence and continuation of internalizing psychopathology (i.e., problem behaviors characterized by inner distress) during early adolescence. The five articles making up the special issue are introduced, each of which represents exciting new work regarding how, why, and for whom internalizing problems develop and are maintained. The introduction to the special issue further elaborates on transdiagnostic and person-oriented approaches, internalizing interpretations and functional effects of internalizing as relatively underused methodological and theoretical perspectives that might help move the field forward and further our understanding regarding the development of internalizing psychopathology early on in life.

  • Journal article
    Van Zalk N, Tillfors M, Mortberg E, 2020,

    Social anxiety-impulsivity subgroups and links to later emotional adjustment in adolescence: a latent transition analysis

    , Journal of Early Adolescence, Vol: 9, Pages: 1397-1426, ISSN: 0272-4316

    A growing body of research has acknowledged the heterogeneity of subclinical social anxiety, identifying a subgroup of individuals who exhibit high levels of impulsivity. In a sample of Swedish early adolescents (N = 2,509, Mage = 13.64; 52.8% girls), we conducted latent transition analyses (LTA) to identify four classes of subclinical social anxiety-impulsivity across three time points. We identified a Low Social Anxiety-Low Impulsivity class, as well as a High Anxiety-High Impulsivity class for girls and boys, which had high levels of Time-4 internalizing problems. The latter class was less stable but larger for boys. There was also a more typical High Anxiety-Low Impulsivity class for both genders. Nevertheless, Low Anxiety-High Impulsivity girls and boys fared the worst in terms of both internalizing and externalizing problems later on. To our knowledge, this is the first study to adopt an LTA framework to investigate trajectories of early adolescent social anxiety-impulsivity over time.

  • Book chapter
    Monks CP, Van Zalk N, 2020,

    Adolescent Relationships in a Digital Age: What Do We Know and Where Does the Future Lie?

    , Online Peer Engagement in Adolescence: Positive and Negative Aspects of Online Social Interaction, Editors: Van Zalk, Monks, Pages: 163-177
  • Book chapter
    Van Zalk N, Lee SH, 2020,

    Links between online communication and compulsive internet use in adolescence: Is there a reason to worry?

    , Online Peer Engagement in Adolescence: Positive and Negative Aspects of Online Social Interaction, Editors: Van Zalk, Monks, Publisher: Routledge, Pages: 85-102
  • Book chapter
    Van Zalk N, 2020,

    Online peer engagement in adolescence: Moving away from “good vs. bad” to brave new frameworks

    , Online Peer Engagement in Adolescence Positive and Negative Aspects of Online Social Interaction, Editors: Van Zalk, Monks, Publisher: Routledge, Pages: 1-17, ISBN: 9780429887406

    peer. engagement. in. adolescence. Moving away from “good vs. bad” to brave new frameworks Nejra Van Zalk Social interaction as we know it is undergoing increasingly rapid changes, perhaps especially so for young people. Everything we ...

  • Book
    Monks CP, Van Zalk N, 2020,

    Online peer engagement in adolescence: Positive and negative aspects of online social interaction

    , ISBN: 9781138604803

    This book provides an in-depth insight into what is currently known and relatively unknown about youths' online peer engagement. It delivers state-of-the-art current reviews of the literature in the field, with a strong coverage of methodological issues in studying online friendships and an emphasis on moving towards a new, less dichotomic, view of online peer interaction in adolescence. With a focus on what spending time with online-exclusive peers entails - in terms of both potential positive as well as negative consequences for friendship quality, intimacy, and well-being - this book offers a more nuanced commentary on youths' online peer engagement. Including coverage of the evolution of online friendships, cyberbullying, cyberdating, sexting, online abuse, smartphones, social networks, as well as their impact on adolescent social interaction online, Van Zalk and Monks consider implications for future research directions and practical applications. Online Peer Engagement in Adolescence is important reading for undergraduate and master students studying social and developmental psychology, education, relationships and health, as well as advanced researchers and academics working in these fields.

  • Journal article
    van Zalk N, van Zalk M, 2020,

    Early adolescent disclosure and parental knowledge regarding online activities: Social anxiety and parental rule-setting as moderators

    , Current Psychology, Vol: 39, Pages: 287-298, ISSN: 1046-1310

    Early adolescents spend a lot of time online, yet little is currently known about the links between parental rule-setting, adolescent disclosure about online activities, and whether social anxiety may interfere with these processes. Using a longitudinal sample of 526 adolescents (269 girls; Mage = 14.00) and their parents (79% mothers, Mage = 43.66), the results from the current study showed low correspondence between parental knowledge, adolescent disclosure, as well as parents’ and adolescents’ ratings of parental legitimacy to set boundaries about online activities. High social anxiety interacted with high adolescent-rated parental rule-setting in predicting the least disclosure about chatting with strangers and posting online content over time. Also, high social anxiety interacted with low parent-rated control to predict more adolescent disclosure about chatting with strangers and money spent online over time. Thus, social anxiety and parental rule-setting moderated the links between disclosure and knowledge for some early adolescent online activities. Our results conflict with the value typically placed on parental rule-setting in online contexts, at least for socially anxious adolescents.

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