1. Use of EMA Methods in Adolescents: Case of Project Pressure

2. SES & Ethnicity Stress Exposure- Conflict Dispositions Hostility Vigilance Anxiety CV Reactivity CV Markers: Total BP Burden Aortic Stiffness LVM Old Model of Development of CV Risk Factors in Adolescents

3. Overall BP Burden Overall exposure to high BP in day and night, not estimated by clinic pressure Overall exposure to high BP in day and night, not estimated by clinic pressure Masked hypertension: high AMBY BP in presence of normal clinic BP Masked hypertension: high AMBY BP in presence of normal clinic BP Allows studies of disruption of circadian rhythm and nondipping Allows studies of disruption of circadian rhythm and nondipping Allows measure of reactivity to stress by examining covariation of stress and BP/HR increases Allows measure of reactivity to stress by examining covariation of stress and BP/HR increases

4. Types of hypotheses addressed in relation to BP burden: role of Neighborhood and family SES Neighborhood and family SES Accumulation of uncontrollable chronic negative life events Accumulation of uncontrollable chronic negative life events Unfair treatment and discrimination Unfair treatment and discrimination Personal characteristics, e.g. pessimism, tendency to attribute malintent to others, and attachment style Personal characteristics, e.g. pessimism, tendency to attribute malintent to others, and attachment style

5. Rationale for Use of EMA Measures types of experiences of adolescents throughout several days Measures types of experiences of adolescents throughout several days Focuses on role of interpersonal experiences that cannot be easily reported retrospectively Focuses on role of interpersonal experiences that cannot be easily reported retrospectively Aids understanding of BP and HR measured concurrent with EMA measures Aids understanding of BP and HR measured concurrent with EMA measures

6. Method: Participants Participants Participants 207 adolescents 207 adolescents Recruited from 2 Pittsburgh area high schools Recruited from 2 Pittsburgh area high schools 14-16 years old 14-16 years old 50% Female 50% Female 50% Black; 50% White 50% Black; 50% White Good health Good health

7. Self-report data Sampling in relation to BP measurement (every 30 min. day) Sampling in relation to BP measurement (every 30 min. day) Fixed interval because of BP assessment target time Fixed interval because of BP assessment target time Because of sampling during school, could only use few items Because of sampling during school, could only use few items

8. Assessment Content: Concurrent Time, hour, min, date Time, hour, min, date Location: school, home, car/bus, other Location: school, home, car/bus, other Posture: lying down, sitting down, on feet Posture: lying down, sitting down, on feet Physical activity (1 to 4) Physical activity (1 to 4) Calm/relaxed; angry/upset; interested involved Calm/relaxed; angry/upset; interested involved Mood based on data reduction from adult study of amby BP Mood based on data reduction from adult study of amby BP

9. YES/NO SCALE Example: At time of BP – are you calm/relaxed? YES! YESyes no NO NO!

10. Assessment Content: 10 Min. Physical activity (none to heavy) Physical activity (none to heavy) Consumption (none, food, caffeine, smoking) Consumption (none, food, caffeine, smoking) Talking with school personnel, friend, parent, other relative, other, no one (yes/no). Talking with school personnel, friend, parent, other relative, other, no one (yes/no). Conflict/disagreement (6 point) Conflict/disagreement (6 point) Pleasant interaction (6 point) Pleasant interaction (6 point)

11. YES/NO SCALE Example: In the last 10 minutes, did you have a conflict or disagreement? YES! YESyes no NO NO!

12. Assessment Methods Electronic diary with no auditory prompt Electronic diary with no auditory prompt BP cuff inflation served as prompt BP cuff inflation served as prompt Accepted first diary record if BP was valid on the next try within 5 min. Accepted first diary record if BP was valid on the next try within 5 min. BP and diary time stamped allowed for time linkage BP and diary time stamped allowed for time linkage Training conducted first morning of assessment by staff Training conducted first morning of assessment by staff Compliance: 24.6 out of 29 possible diary entries; 34.4 of 37 possible AMBY Compliance: 24.6 out of 29 possible diary entries; 34.4 of 37 possible AMBY

13. Data Analysis Use of hierarchical linear modeling using HLM or PROC MIXED Use of hierarchical linear modeling using HLM or PROC MIXED Required that BP data have accompanying diary data for analysis (80% both data points) Required that BP data have accompanying diary data for analysis (80% both data points) Reviewers have a hard time understanding HLM Reviewers have a hard time understanding HLM

14. Background: Attachment Theory Attachment style predicts satisfaction, and behavior, emotion, and cognition in adult and adolescent social relationships. Attachment style predicts satisfaction, and behavior, emotion, and cognition in adult and adolescent social relationships. Attachment style may have health implications (Maunder & Hunter, 2001). Attachment style may have health implications (Maunder & Hunter, 2001). Attachment insecurity predicts elevated and prolonged physiological responses to social stressors in laboratory (e.g., Carpenter & Kirkpatrick, 1996; Nachmias et al., 1996). Attachment insecurity predicts elevated and prolonged physiological responses to social stressors in laboratory (e.g., Carpenter & Kirkpatrick, 1996; Nachmias et al., 1996).

15. Dimensional model of adult attachment High Anxiety Low Anxiety High Avoidance Low Avoidance Security Preoccupation Dismissive- Avoidance Fearful- Avoidance Fraley & Shaver, 2000

16. Examine effects of attachment on adolescents responses to naturalistic social interactions with attachment figures (parents and friends). Examine effects of attachment on adolescents responses to naturalistic social interactions with attachment figures (parents and friends). Anxious Attachment: Exaggerated physiological and emotional stress reactivity to social interaction. Anxious Attachment: Exaggerated physiological and emotional stress reactivity to social interaction. Avoidant Attachment: Reduced social interaction with others. Avoidant Attachment: Reduced social interaction with others. Current Study: Purpose and Hypotheses

17. Method: Procedure Attachment Style Attachment Style Measurement of Attachment Qualities (Carver et al., 1997) Measurement of Attachment Qualities (Carver et al., 1997) Anxious Attachment (I often worry that someone I care about doesnt really love me), =.75 Anxious Attachment (I often worry that someone I care about doesnt really love me), =.75 Avoidant Attachment (I prefer not to be close with others), =.70 Avoidant Attachment (I prefer not to be close with others), =.70

18. Methods: Analytic Approach Hierarchical Linear Modeling (HLM 5.0), accounts for nesting of measures within participants. Hierarchical Linear Modeling (HLM 5.0), accounts for nesting of measures within participants. Level 1: Average outcomes (intercepts) and effect of interactions with attachment figures (slopes) estimated for each individual. Level 1: Average outcomes (intercepts) and effect of interactions with attachment figures (slopes) estimated for each individual. Level 2: Intercepts and slopes estimated at Level 1 predicted by attachment variables. Level 2: Intercepts and slopes estimated at Level 1 predicted by attachment variables.

19. Adolescents reported talking to friend(s) at 79% of readings at school and 35% after school; to parents 32% after school. Adolescents reported talking to friend(s) at 79% of readings at school and 35% after school; to parents 32% after school. Higher Avoidant Attachment less likely to be talking with friends at school, p <.01. Higher Avoidant Attachment less likely to be talking with friends at school, p <.01. Higher Anxious Attachment less likely to report talking with parents after school and less pleasant interactions, ps <.01. Higher Anxious Attachment less likely to report talking with parents after school and less pleasant interactions, ps <.01. Results: Interaction Quantity

20. Attachment Quality and BP/HR Higher Anxious Attachment the higher Amby SBP and DBP when interacting with friends Higher Anxious Attachment the higher Amby SBP and DBP when interacting with friends Higher Anxious Attachment trend toward higher Amby HR when interacting with friends Higher Anxious Attachment trend toward higher Amby HR when interacting with friends Higher avoidant attachment higher Amby DBP during conflict Higher avoidant attachment higher Amby DBP during conflict

21. Effect of Anxious Attachment by Talking with Friend(s) on SBP R 2 =.08, p <.05

22. Implications Anxious Attachment could influence adolescent health risks by altering daily BP regulation, as related to interactions with attachment figures. Anxious Attachment could influence adolescent health risks by altering daily BP regulation, as related to interactions with attachment figures. Avoidant Attachment could contribute to adolescent health and well-being by influencing the quantity of peer interactions and, possibly, friendship development and continuity. Avoidant Attachment could contribute to adolescent health and well-being by influencing the quantity of peer interactions and, possibly, friendship development and continuity.

23. Lessons Learned More items to measure mood to increase reliability and to measure positive/negative affect More items to measure mood to increase reliability and to measure positive/negative affect Better training of Ss using procedures worked out in SleepScore Better training of Ss using procedures worked out in SleepScore Patience in the analysis phase Patience in the analysis phase Adolescents are very good participants Adolescents are very good participants