On the Mic with Mike #5: Dr. Tracie O. Afifi’s quest to change parents’ behaviour and keep kids safe

Dr. Mike Strong: Well welcome again to this episode of On the Mic with Mike. You'll see today that we're inside the CIHR. For those of you who haven't been here, this is sort of the core of everything we do. Normally we do this at a cafe or outside. But today it's a special day. We're going to be interviewing one of the recipients of a Gold Leaf Award - specifically the recipient of the Young Investigator award. It's going to be fascinating to learn about the history of this young woman and how she's managed to move things forward. So come on and join me. We're going to have a bit of a conversation.

Well welcome today. So today joining me for On the Mic with Mike is Dr. Tracie Afifi out of the University of Manitoba. And you've had, first off, a great career so far.

Dr. Tracie Afifi: Thank you.

Dr. Strong: It's going to continue to escalate, that's for sure. But you're actually the recipient today of one of our Gold Leaf awards - particularly for a young investigator. So thanks for joining us. I think we'll have just a little bit of a conversation.

Dr. Afifi: It's been a wonderful day so far.

Dr. Strong: That's great. This is one of our most prestigious awards. It's absolutely amazing - and congratulations on receiving it. Usually we start about talking about some history how you got to where you are. But I think let's start with what you're doing now because it's really important work, and particularly as we think about what the CIHR does in terms of our mandate of trying to prove the health of Canadians. You're getting to a core of a very important problem.

Dr. Afifi: Yeah - it's a very difficult problem to try to solve. But my research focuses on child maltreatment. So it includes physical abuse, sexual abuse, emotional maltreatment, exposure to intimate partner violence, and spanking children. A lot of the earlier work that I did really looked at how those adverse experiences are related to poor mental and physical health outcomes. What we learned now is if you have this type of adversity in childhood, you're going to have reduced mental health and physical health, or you’ll more than likely have problems with your health. So a lot of the work that I do now is try to understand how we can intervene and improve outcomes for individuals who have experienced this adversity because it also continues across the lifespan.

Dr. Strong: How so?

Dr. Afifi: When I first started in this area 20 years ago, I was starting my master’s and a lot of the dialogue at the time was more like when adversity happens in childhood you become an adolescent or an adult and you move on. It’s a distill event that doesn't have an impact. But what we've learned is that when you have these adverse child experiences, it doesn't just stay in childhood but can continue to have an impact on the person's life - right across the lifespan into old age. It can impact their health, their relationships, and their ability to continue their education or be successful in their job. So it really can also have an impact in all areas of their life.

Dr. Strong: You've made a point in a lot of your work about this particularly on the issue of spanking. For there is a continuum that can be initiated by that. I think of a lot of colleagues who are looking at kids who are now having kids. We were all raised in a bit of a different era for all of this. But with this concept that we have a worldwide agreement with regard to the spanking of children, you've made a point of recognizing that there are scenarios in which it could happen. What you're really worried about is to try and anticipate how will that evolve so that it doesn't just become: “yes, there is a spanking.” There’s nothing to justify that so to speak. But then when does it start to become abusive - or is it all abusive?

Dr. Afifi: That's a really interesting question. So you'll note that when I explained child maltreatment I included spanking. And that in of itself is a controversy. Some people would say spanking is legal in Canada, so we're allowed to do it. It's discipline and that's it's not spanking. But what our research has shown is that spanking is actually an adverse childhood experience. We've used data to show that it's similar to experiences of physical abuse and emotional maltreatment. So empirically it looks the same. And then it's also related to similar outcomes of experiencing abuse. The impacts might be lesser. When you think of the continuum, spanking might be on the lesser severe end compared to other more severe types of child physical abuse. But the impacts are still there.

So what we have shown with different data is that it's similar to the experience of physical abuse - and now it’s included. I look at it separately because it is a different thing than some or other types of child maltreatment, but I include it because our data shows that it fits in that category. That's what we need to do as a culture is to really prevent child maltreatment. That's one major thing is to try to help parents understand that spanking their children has risk and it can elevate more severe physical abuse. So we need to do a better job to help Canadians replace their physical discipline with non physical discipline.

Dr. Strong: I was going to go down that pathway a bit. You have two children?

Dr. Afifi: Right.

Dr. Strong: So how have you brought this into your life then in terms of raising your own children?

Dr. Afifi: My husband I have never spanked our children and we knew that that's how we would raise our children from way before having them. You know - being a parent's hard. We have used non-physical means of disciplining our children.

Dr. Strong: Like time outs?

Dr. Afifi: We don’t even uses time outs. We talk a lot to our kids. You know a lot of times you have to sort of navigate the situation as you go along. You don't always have the right answer. There's a lot of dialogue and talking in our in our household. We try to teach our children consequences. So it's almost like you're shifting the language a little bit. You know some people say what's the difference between a consequence and a punishment? What we try to do and you know, while we're not perfect, what we try to do is explain to our children that what they're doing is problematic because... Then it’s a learning experience for them. And then if there is a consequence to it, we make it a natural consequence for them. So it has to be something that is related to whatever problem we’re trying to solve.

Dr. Strong: So we know the brain of a developing child continues to myelinate and inhibitory processes really aren't in place until their late- or mid-20s. In those early formative years children don't have the ability to inhibit raw emotion or behavioral changes. So imagine yourself as a single mom or a single parent who is economically in a very difficult scenario, and your child's in the midst of going through a temper tantrum. How do you handle that?

Dr. Afifi: Well see that's what we're hoping a lot of our research is leading up to. So what we're doing right now is we're trying to understand are protective factors related to poor outcomes. We’re trying to understand why some individuals will use physical discipline and some won't. What we're really trying to do is to understand that parenting is hard. It's really hard.

Dr. Strong: You get to do it once.

Dr. Afifi: Yeah, and even you know even if you have lots of support and you've done lots of reading on child development, parenting is tiring. Sometimes it's hard to navigate the situations when you're tired. When you have less resources, when you have more children, or perhaps as you mentioned you’re a single mother, there's also situations when parents are being told “this is what you should do” by using physical discipline. So they're doing what they think is right and what they think will help. What we're trying to do is really understand how we can replace spanking with things that are easy for parents to do. It would not be some complicated parenting program that's not feasible. We wanted to try to replace it with a daily parenting regime that's sort of easier for parents to implement. I also wish to recognize that I don't think parents who spank their kids are bad parents. I think they are probably really good parents and they have been told that…

Dr. Strong:  … Or they were brought up in that milieu and it was an acceptable practice.

Dr. Afifi: Absolutely. You know it's still quite prevalent. It's decreasing. But when I was a kid I think most kids got spanked if they misbehaved. We didn't know that it was harmful. So you know I always equate it to smoking cigarettes. When people decades ago would smoke cigarettes, it took a little bit of time to realize that maybe this isn't maybe good for us. And then it took a little bit of time to do the science to prove that smoking was bad. So that's sort of where we are now with spanking. We now know that spanking increases the likelihood of poor outcomes. So now we're at the point where we need to try to figure out: how do we decrease that behaviour? Just like smoking, when people find out now or in the past that it’s related to harmful outcomes to their health, it doesn’t mean that their behaviour changes. Even the knowledge of something doesn't mean that behaviour is going to naturally change. So that's where we are with spanking right now. We know that it's harmful, but we need to help parents replace their physical discipline with non-physical discipline. I think that will reduce the likelihood that it will escalate into more severe types of abuse.

Dr. Strong:  Let's explore a bit of a different area. It still relates to your research but you know a lot of what we're doing at CIHR and a lot of our imperatives go back to the CIHR Act. It talks about changing the health of Canadians. The kinds of research that you're doing sound very much to be fundamentally at the core of even our educational systems. How do we get into the schools to teach good parenting early? How do you use your research and specifically the work that you're doing to help influence that? Because that's the holy grail, right?

Dr. Afifi: Yeah, so that to us is on our long term goals. I think about our what's your short term and your long term goals? We're working towards really understanding that. But right now we look at a lot of the education system, we look at how the education system can have a benefit to the child in terms of resilience, and would be related to better outcomes. We've done a lot of work in that area. So we can kind of use education in different ways. We can use it as almost a protective factor for children who are experienced in adversities. We've looked at research that shows that if that child can be engaged with school if they’ve experienced adverse experiences. For instance, if that child has good relationships with a teacher, if they like being at school, if they feel like the teachers like them, and if they value getting good grades, we've found that those are actually protective factors and lead to better outcomes for kids who've experienced adversity. So we're going to do more work in that area, and, once we understand that more, build interventions that have a role with schools. But also what you're mentioning is also understanding how we can sort of teach kids about interactions and relationships and parenting at an earlier age.

Dr. Strong: We see that in inner city schools as a major issue. What are the parenting skills that are going from this generation after another generation and building into all of that? So if we're going to make differences, the kind of research that you're doing in the questions have got to be translated into action.

Dr. Afifi: That's right. So right now what we're trying to do is ask the questions to develop the evidence to build those interventions so that our entry interventions are not just theoretical. We want to have evidence based on our work now to show that the intervention can be theoretical but also rooted in evidence. We’ll then develop interventions which includes schools, and then evaluate them to see if they're working in certain populations. If they are, then how can we expand them to bigger settings? So that's definitely the long term goals that we're working to reach.

Dr. Strong: So let's talk a little bit about your career, and how you got to this because this is one of the most important things we're exploring in these right now. A lot of kids and a lot of students talk to me, and I get letters every now and then from classes where they ask: “How do we have a career like this? How do we move forward?”. So how did that work for you? How did you end up where you are now?

Dr. Afifi: So it's interesting. I never planned to be an academic. I never planned to be a researcher. But the funny part of it is I actually ended up here because I never wanted a real job. I really liked being in school. When I was in high school, I really liked sciences. They were the courses that I did the best in, so when I went into university I thought well - sciences - I'll do that. I did an undergrad in zoology and botany. It’s nothing really related to what I do now. I enjoyed it. When I finished my bachelor’s degree, I decided that I wasn't ready to be done school. I wasn't ready for a job. So I went a master’s degree in science - but I changed my focus to children.

Dr. Strong: Why?

Dr. Afifi: Because I always wanted to work with kids, but it never occurred to me to be a teacher. And I don't know why. But I just love children, and that's where I could find interest and my passion. So it was more mental health and child development at first that I was interested in. Then when I finished my master’s degree I felt like I wasn't sure if I was ready to go get a job. There were some jobs that I was interested in, but they weren't available. So I thought I'd just take a year off and figure it out. But in that year off, the job that was available was a research assistant in psychiatry at the University of Manitoba. So I took that job, and I was a research assistant for Dr. Jitender Sareen - who is one of my closest collaborators now. He was sort of on the earlier end of his research career. He's an MD and a psychiatrist – and he would get excited about a research idea based in his clinical experience. He'd come to me and he'd say: "You know - I have this really great idea." He would then explain the idea to me and then say: "Do we have data to look at that?"

Because this was the early 2000s, you had a lot of data that was just available. It's not like today where data is more protected. You could download the data – at least big national samples from the United States and from the Netherlands - and we had access to it. So I had to figure out how to answer his clinical questions using these population databases. At the same time, I was taking one or two classes to think about whether I should do my PhD. It was a combination of taking those PhD classes and really diving deep into research that I said: “OK - this is this is where I'm going to be.”

So I kept going and I feel like in some senses I never left school, because I just kind of went to the other side of the classroom and stayed there.

Dr. Strong: So that leads to an interesting question that I do run into frequently when I'm talking to students or to graduate trainees. They look at clinical research right and say: “Well that’s the MD's world, or the nursing world, or OT or whatever it might be - it's not really the PhD domain.” And to be fair, I hear the opposite as well too on the fundamental side of things. I'm the first one to look at it and say: "No - this is without boundaries.” But how have you found that? You're a PhD, doing very fundamental transformative clinical research. How's that working?

Dr. Afifi: Well I couldn't do it without collaborating with clinicians. So I work with Dr. Harriet MacMillan - who I think you know.

Dr. Strong: I know Harriet, yes. A shout out to Harriet – hello!

Dr. Afifi: So Harriet's been a wonderful mentor to me. She's a clinician, so she is both a psychiatrist and a pediatrician. Her clinical understanding expertise and insight is very valuable to me, as well as Jitender Sareen who is also a psychiatrist. I wouldn't be able to do clinically relevant work without being a clinician or without being mentored or collaborating with clinicians. It works really well because I have a different skillset than they have. I'm an epidemiologist. I work with the data, and I can take their clinical questions and turn them into answers with the data. That's how my career really started - with this collaboration where I didn't really need to be a clinician in order to understand what are the clinically relevant questions. It's definitely a disadvantage not being the clinician to do work in that area. But I think if you are listening and being collaborative with clinicians and working together you can actually develop a lot of that relevant work.

Dr. Strong: So the pathway that you've taken which is kind of a recurrent theme that I hear – of being open to whatever's coming along - would you do anything differently?

Dr. Afifi: I don't think so. I don't know - it's a good question and I've never been asked it before. I've never really thought about it. But no - I've been very fortunate that the opportunities were there when I was ready for them. I'm really good at listening to other people's advice, such as Jitender or Harriet who are my two greatest mentors. When I don't know what to do, I make sure I ask lots of people and I listen. So far I feel like I haven't gone down a path that has been negative or that I regret.

Dr. Strong: So if - as it's almost certainly going to occur – a young person were to sit down and say: “Well I'm starting to think about where this kind of a career is going…” What would your advice be to them?

Dr. Afifi: Well I think my advice is number one... I love research. It's fantastic. I feel so lucky that this gets to be... that this is my job. I get to do this every day. I love it. But it can also be very stressful to do it just because you need funding to do this work. There are a lot of great researchers and a lot of great ideas. If your idea doesn't get funded then it's difficult. So that part can be really stressful. So my advice is - the first thing you need to do is be really interested and passionate about what it is you're working on because it can be difficult and it can be stressful. I feel like in those times, if you're not really passionate about your work, it's hard to get through it.

So I think that's the first thing is to just make sure that it's just something you're just naturally interested in, and you need to know more about it. And then, as we've already talked about, mentorship is really important because it will help you find those people that have the experience. They can help you out along the way, and give you advice on whether or not you feel this way or this way because it's hard to know.

Dr. Strong: There's a question that I ask everybody. I keep trying to rephrase it in a way so nobody remembers what it is from the last time I did it. If you had the opportunity in your life where you could just go back and be anywhere, anytime, and talk to anybody - who would it be?

Dr. Afifi: I think it would be Murray Straus.

Dr. Strong: Really – why?

Dr. Afifi: Murray Straus was a professor at University of New Hampshire, and he was a trailblazer in family violence, spanking, and corporal punishment research. In the 1970s, he was really started to shed light on the fact that when people experience violence, they're more likely to experience it from someone in the family. Then he started to really do a lot of the fundamental work in spanking and recognize that spanking is a traumatic event for children.

This was also decades ago. So this is at a time in the United States where 90% or more of parents spanked. There was a lot of criticism against his work saying that spanking’s OK and his findings are sort of more in science and data. So he had to do a lot of work in a controversial area.

You know, I think I still face that too as a researcher – but probably not exactly the same and to a lesser degree. When you talk about spanking, there's still resistance around that. And I feel like he was so innovative for his time. He passed away about three years ago. You know - he has such a great legacy. I actually did meet him once at a conference.

Dr. Strong: OK.

Dr. Afifi: You know - he was just the person that everyone loved. He was so lovely and had time for everyone. This was number of years ago, when he would host a conference at University of New Hampshire. Instead of having dinner at a restaurant or in the conference room of a hotel, he would invite the whole conference back to his house.

Dr. Strong: Wow! Did he tell his wife he was doing that?

Dr. Afifi: I don’t know. But buses would come, and take people from the hotel to his house.

Dr. Strong: Yes.

Dr. Afifi: You know lots of those people he would know - but there were lots of people like me. I was a student at the time, and I got to go to Murray Straus's house. So I introduced myself and I said “hi.” But I didn't have the opportunity to collaborate with him or to learn from him. When you listen
to people who did have that opportunity, you can just see this warmth in their eyes. And I'm sure those are really lucky people.

Dr. Strong: Wow. That's a great note to end on. Tracie, I've got to say, it's been wonderful to chat with you and congratulations again. This is a tremendous honour. I wish you nothing but continued success. We'll be watching you anyways.

Dr. Afifi: Thank you, I appreciate it.

Dr. Strong: You're welcome – and take care. Well that's it for another episode of On the Mic with Mike. We'll see you next time.