Multiple Intervention Points Research Articles

Evidence for a vicious socioemotional cycle of negative emotions and interpersonal conflict.

Four samples of adults (Sample 1, N = 145; Sample 2, N = 160; Sample 3, N = 297; Sample 4 = 89 dyads, 178 individuals) completed ecological momentary assessment protocols focused on a variety of interpersonal and emotional experiences. Samples were enriched for aggressive and self-harming behavior (Sample 1), trait hostility (Sample 2), interpersonal problems (Sample 3), and personality disorder features (Sample 4). Using multilevel dynamic structural equation modeling, we investigated how emotions and interpersonal functioning operate over brief timescales in daily life. We found evidence for a vicious socioemotional cycle across all four samples, whereby negative emotions related to interpersonal conflict (i.e., perceptions of and enacting cold, antagonistic, or quarrelsome behavior; components that contribute to the interpersonal situation from the perspective of CIIT) which in turn related to increased negative emotions. Although individuals differed in the strength of this process, it was unrelated to trait negative affectivity. Viewing these results through the lens of CIIT, we discuss multiple intervention points highlighted by these dynamic results whereby the vicious cycle might be changed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Understanding and optimising helmet-related and other health and social effects of the first North American university campus skatepark

ABSTRACT Skateboarding has growing societal uptake, as seen through its inclusion in 2021’s Summer Olympics. To promote positive health and social outcomes, skateparks are being developed around the world. A challenge in optimising skateparks’ benefits lies in reducing injury risk, particularly head trauma. This study occurred at the University of British Columbia Skatepark (July–September 2019) with the goal of identifying and theoretically contextualising facilitators and barriers to helmet use. Participants (total n = 54, 92.6% male) were interviewed (n = 54) and surveyed (n = 27). We performed thematic analysis on the transcripts, finding that barriers to helmet use included helmet discomfort, low perceived risk of injury, cultural norms, and style, and facilitators included a belief that helmets promote safety, higher-risk skating activities, older and younger ages, and role modelling. We propose a conceptual model showing multiple points of intervention to promote skatepark safety beyond helmet use alone, integrating theories of sociology, social psychology, and public health.

Surfacing Values Created by Incentive Policies in Support of Sustainable Urban Development: A Theoretical Evaluation Framework

The development of sustainable cities involves improving the performance of the built environment and its effects on its context as one of the multiple intervention points. Indeed, outlining and implementing building artefacts does not constitute a simple act of generating a physical place, but represents a process that cannot ignore the positive and/or negative impacts that these transformations can have on the environment and societies in which it is embedded. Since in a profit-driven logic, a private investor’s interest in environmental and social values may be limited in favour of economic value, a positive push towards urban sustainability can be found in government-promoted fiscal building incentives. Indeed, these tools offer direct actions for more favourable urban conditions, supporting private entities in meeting the intervention costs. This paper aims to define a theoretical evaluation framework through which the “sustainable” value creation potential of building incentives can be assessed. Through this framework, the research analysed the main Italian building incentives, observing how they support the creation of economic, environmental, and social values for the benefit of society, the environment, and urban areas. This paper discusses the usefulness of the framework in supporting public actors in the potential revision, definition, and communication of such incentive policies.

Neurobiology and the Treatment of Alcohol Use Disorder: A Review of the Evidence Base.

Alcohol use disorder (AUD) is a significant public health concern, accounting for a majority of substance use disorder cases in the United States. Treatment for AUD is complex, with multiple intervention points that may be further complicated by genotype and phenotype, resulting in diverse outcomes. In order to better understand the current landscape of AUD treatment, the present review considers different etiological models of AUD and assesses the evidence base of current treatment options. The first section of this review summarizes various etiological models of AUD and presents different approaches to classifying the disorder. Various theories, including neurobiological models, are discussed. The second section presents a comprehensive analysis of available treatment options for AUD, encompassing behavioral and pharmacological interventions and their current evidence base. Finally, this review discusses the ongoing treatment gap and significant factors contributing to low treatment utilization. Together, this review provides an overview of different etiological processes and mechanisms of AUD, as well as summarizes the literature on key treatment approaches. By integrating historical, theoretical, and empirical data, this review aims to inform both researchers and providers with valuable insights to advance AUD treatment approaches and narrow the treatment gap.

Advancing Sustainability in the Future of Work through the Design of Post-Pandemic Work-from-Home Systems

The COVID-19 pandemic accelerated and solidified the adoption of work-from-home systems (WFHSs) across all economic sectors, and finding ways to incorporate sustainability into these systems is a fundamental aspect of a sustainable future of work. Designing sustainable WFHSs requires an innovative approach capable of understanding complex interrelationships between multiple systems. This paper applies the sustainable system-of-systems (SSoSs) framework to find innovative design solutions for post-pandemic/endemic WFHSs. First, the SSoSs framework is depicted using examples of applications in systems to clarify its main ideas and concepts. Then, the literature on WFHSs is considered to discuss the impacts of COVID-19 on work from a systemic perspective. This provides inputs for the factors to be considered at each level of the SSoSs analysis. Finally, the SSoSs framework is applied to analyze the WFHSs’ requirements in the context of COVID-19. The nature of the application of this framework is theoretical, facilitating the provision of a multi-layered perspective on sustainability in work systems that are increasingly prevalent across various economic sectors. This study contributes to research and practice by characterizing the various relevant systems and their impact on the design of sustainable WFHSs and identifies multiple intervention points to make predictions about how they might influence other systems.

Exploring the relationships between Industry 4.0 implementation factors through systems thinking and network analysis

AbstractIndustry 4.0 provides companies with the technological and theoretical means to enhance data‐driven decision‐making procedures. To facilitate the transformation process, several studies have identified factors that need to be considered when implementing Industry 4.0 on a broader level. However, the dynamic relationship between these factors has yet to be understood to provide companies with the in‐depth knowledge needed to effectively manage the transition. The principal aim of our research is therefore to map out the complex relationships between the identified factors, by adapting a novel approach that combines network analysis and causal loop diagrams. Results show that the roles of implementation factors are not static, and what role they play depends on their position in the network, complementing the findings of previous investigations about the drivers of change. Furthermore, our findings indicate that multiple intervention points exist, shedding more light on how to develop effective implementation strategies.

SWITCH-ing Quality Physical Education to Multicomponent Comprehensive School Physical Activity Programs

Comprehensive School Physical Activity Programs (CSPAP) coordinate physical activity opportunities for school-age children through physical education, programs offered before/after school and during the school day, and those facilitated through staff involvement and community engagement. An active school is considered to implement quality physical education and one additional CSPAP component. This paper aims to describe evidence-based school initiatives that have used a multicomponent approach to integrating CSPAP in schools. Common themes will be summarized to provide strategies and suggestions on creating, implementing, and sustaining a CSPAP in schools. The Let’s Get Fit to Learn partnered with local underserved elementary schools to increase physical activity at school designed to improve or increase health and on-task behaviors. The Whole Communities-Whole Health is an equity-centered, community-engaged research project one outcome is to deeply integrate physical activity into the school curriculum. SWITCH (School Wellness Integration Targeting Child Health) is an evidence-based CSPAP designed to build capacity through a partnership with 4-H Youth Development. In Ireland, Active School Flag is a national initiative focused on self-reflection, action planning and collaboration at the school level and provides options for schools to achieve the “Flag.” Multicomponent CSPAP purposefully links multiple points of intervention to maximize physical activity opportunities for children. Given the implementation of culturally relevant and contextually grounded learning opportunities in and around schools, the potential for impact and sustainability is high.

Dynamic Control Balancing Cell Proliferation and Inflammation is Crucial for an Effective Immune Response to Malaria.

Malaria has a complex pathology with varying manifestations and symptoms, effects on host tissues, and different degrees of severity and ultimate outcome, depending on the causative Plasmodium pathogen and host species. Previously, we compared the peripheral blood transcriptomes of two macaque species (Macaca mulatta and Macaca fascicularis) in response to acute primary infection by Plasmodium knowlesi. Although these two species are very closely related, the infection in M. mulatta is fatal, unless aggressively treated, whereas M. fascicularis develops a chronic, but tolerable infection in the blood. As a reason for this stark difference, our analysis suggests delayed pathogen detection in M. mulatta followed by extended inflammation that eventually overwhelms this monkey’s immune response. By contrast, the natural host M. fascicularis detects the pathogen earlier and controls the inflammation. Additionally, M. fascicularis limits cell proliferation pathways during the log phase of infection, presumably in an attempt to control inflammation. Subsequent cell proliferation suggests a cell-mediated adaptive immune response. Here, we focus on molecular mechanisms underlying the key differences in the host and parasite responses and their coordination. SICAvar Type 1 surface antigens are highly correlated with pattern recognition receptor signaling and important inflammatory genes for both hosts. Analysis of pathogen detection pathways reveals a similar signaling mechanism, but with important differences in the glutamate G-protein coupled receptor (GPCR) signaling pathway. Furthermore, differences in inflammasome assembly processes suggests an important role of S100 proteins in balancing inflammation and cell proliferation. Both differences point to the importance of Ca2+ homeostasis in inflammation. Additionally, the kynurenine-to-tryptophan ratio, a known inflammatory biomarker, emphasizes higher inflammation in M. mulatta during log phase. Transcriptomics-aided metabolic modeling provides a functional method for evaluating these changes and understanding downstream changes in NAD metabolism and aryl hydrocarbon receptor (AhR) signaling, with enhanced NAD metabolism in M. fascicularis and stronger AhR signaling in M. mulatta. AhR signaling controls important immune genes like IL6, IFNγ and IDO1. However, direct changes due to AhR signaling could not be established due to complicated regulatory feedback mechanisms associated with the AhR repressor (AhRR). A complete understanding of the exact dynamics of the immune response is difficult to achieve. Nonetheless, our comparative analysis provides clear suggestions of processes that underlie an effective immune response. Thus, our study identifies multiple points of intervention that are apparently responsible for a balanced and effective immune response and thereby paves the way toward future immune strategies for treating malaria.

Standardization of fertility preservation discussion amongst pediatric oncology and bone marrow transplant patients.

10051 Background: As treatment for pediatric malignancies improves long term survival, physicians are shifting focus to late effects of therapy such as infertility. Currently, options for fertility preservation include cryopreservation of mature oocytes, sperm, and gonadal tissue, although barriers remain present. Within our division, we lacked a standard approach to discussing fertility preservation options. Methods: Records from 474 pediatric patients with new oncologic diagnoses at CMH from 2014-2020 were retrospectively reviewed. We evaluated the frequency that reproductive health discussions were documented in pubertal males and females requiring chemotherapy or radiation treatment. We implemented a standard fertility preservation note and patient handouts, then surveyed our department to identify diagnoses that place patients at risk for infertility and barriers to formalized fertility consultations. We then provided educational sessions to address these barriers with pre- and post-evaluation to measure efficacy. Our longitudinal assessment, encompassing multiple points of intervention, was compared to results from previous chart review (2010-2013). Results: Of 474 patients diagnosed between 2014-2020, 175 (90 females, 85 males) warranted a fertility discussion per inclusion criteria. 61 (67.8%) females received a fertility discussion and of those 8 (8.9%) completed oocyte or gonadal tissue preservation, all between 2017-2020. 52 (61.2%) males received a fertility discussion and 20 (23.5%) completed sperm cryopreservation, with even distribution pattern between 2014-2020. Following implementation of an electronic fertility consult process and standardized fertility preservation documentation, there was an increase in documented fertility discussions from 30% in 2014 to 63.6% in 2020. Internal department survey responses identified a lack of comfort with knowing fertility preservation options available and diagnoses that should prompt this conversation. Education sessions with pre- and post-provider assessment demonstrated more comfort discussing fertility preservation (average score increase from 3.44 to 4.33) and knowledge regarding diagnoses at higher risk of infertility (average score increase from 3.67 to 4.33). Conclusions: Integration of a standardized fertility preservation process and addressing barriers identified within our division have led to a 33.6% increase in fertility discussions over the last 6 years. While the data shows a promising increase in oocyte and ovarian tissue preservation, sperm banking completion rates remained unchanged. Further steps include incorporation of an automated fertility consultation order into electronic chemotherapy orders, hospital-wide identification of other high-risk patient populations, and continued education of patient, families, and the health care team.

Complementary feeding in Kongwa, Tanzania: Findings to inform a mycotoxin mitigation trial.

Complementary feeding of 6‐ to 24‐month‐old infants and young children with adequate, safe and developmentally appropriate food is essential to child health. Inappropriate complementary foods and feeding practices are linked to the high incidences of undernutrition among infant and young children in most developing countries, including Tanzania. Mycotoxin risk is an additional concern, given the documented presence of aflatoxin and fumonisin in food systems of Africa, especially maize and groundnut. In preparation for a trial of mycotoxin mitigation, we conducted focus group discussions and recipe trials to explore complementary foods and feeding practices in Kongwa, a rural district of central Tanzania. Sixty mothers of infants from 6 to 18 months of age in five villages across the district were purposefully sampled. During focus group discussions, mothers reported to mostly feed their children with cereal and groundnut‐based foods as thin or thick porridges. The most common porridge preparations contained cereal (mostly, maize) ranging from 66.7% to 80.0% by weight and groundnuts from 7.7% to 33.3%. The ratio of cereal to groundnut ranged from 3:1 to 4:1. For the recipe trial sessions, mothers chose similar ingredients reported during discussions to prepare complementary foods. The reliance on maize and groundnuts in complementary foods predisposes the children to undernutrition and exposure to aflatoxins and fumonisins. These formative research results suggest multiple intervention points to improve complementary feeding and reduce mycotoxin exposure in this population, including education messages package on feeding practices, mycotoxin control practices and complementary food formulation.

Sensory Health and Social Well-Being

Scientific inquiry into the psychological and social issues surrounding age-related sensory impairments has focused on ways in which the conditions are a catalyst for negative outcomes. However, investigating the patterns associated with negative life events can offer guidance on ways to circumvent or mitigate negative outcomes, and even to foster and facilitate the positive outcomes of growth and thriving. This symposium will present findings from individual studies that describe how social well-being among older adults with sensory impairments can be protected, by assessing social isolation as a point of intervention to maintain cognitive function and to promote post-traumatic growth, and by understanding the unique social considerations relevant to Hispanic older adults, and to improve the physical safety of older drivers with sensory and cognitive impairment by reducing exposure-adjusted motor vehicle crash risk. Authors will present both cross sectional and longitudinal, population based data, and will explore patterns and relationships between known variables associated with sensory impairments including depression, cognitive processing, cognitive functioning, social network, social isolation, driving patterns, and posttraumatic growth. Findings from the Longitudinal Research on Aging Drivers (LongROAD) study, the National Health and Aging Trends Study (NHATS), and data from a mixed methods study, underscore the reality that the negative outcomes associated with age related sensory impairments are not necessarily imminent and that there may be multiple intervention points to optimize the social well-being of older adults with sensory impairments.

Early Social Origins of Biological Risks for Men and Women in Later Life.

We investigate whether childhood exposures influence adult chronic inflammation and mortality risk via adult health characteristics and socioeconomic status (SES) and whether gender moderates these relationships. Analyzing a longitudinal national sample of 9,310 men and women over age 50, we found that childhood SES, parental behaviors, and adolescent behaviors were associated with adult chronic inflammation via health characteristics and SES in adulthood. The process of disadvantage initiated by low childhood SES (i.e., adult health risk factors, socioeconomic disadvantage, and chronic inflammation) subsequently raised mortality risk. In addition, gender moderated the mediating influence of childhood SES via unhealthy behaviors and parental behaviors via adult SES. Demonstrating how social forces shape biological health through multiple mechanisms informs health policies by identifying multiple points of intervention in an effort to reduce the lasting consequences of childhood disadvantage.

Travel behavior as a driver of attitude: Car use and car pride in U.S. cities

Individuals attribute social status and personal image to owning and using a car (‘car pride’), which may interact with their travel behavior in complex ways. This study explores the multi-directional relations among car pride, car ownership, and car use for a sample of 1236 adult commuters in New York City, NY and Houston, TX. Applying multivariate structural equation modeling and incorporating instrumental variables, we find evidence of a feedback loop among car pride, car ownership, and car use. Our results suggest that an individual with higher car pride is more likely to own a vehicle, and, enabled with this ownership, use it more frequently. And individuals who use their car more frequently are likely to feel more pride in owning and using their vehicle.This exploration of causal multi-directionality in transportation attitude-behavior relations has important implications for behavioral research, model development, and policy interventions. For researchers, potential bidirectionality must be anticipated from the outset of research design and accounted for appropriately in modeling to address underlying endogeneity. For policymakers, our results suggest that there are multiple intervention points within the reinforcing cycle of attitudes and car consumption. Policies could directly target car ownership and use or could consider influencing behavior through attitude change.

Abstract 2220: Non-clinical tumor models reveal broad combination potential of ICOS agonist antibodies

Abstract Unprecedented rates of durable clinical responses have been observed for antibody-based therapeutics targeting immune checkpoint proteins such as cytotoxic T lymphocyte antigen-4 (CTLA-4) or programmed death receptor-1 (PD-1). Nonetheless, a significant number of patients fail to respond, highlighting the need for alternative and complementary immunotherapeutic interventions for cancer. Inducible T-cell costimulator (ICOS/CD278) is a CD28 superfamily receptor that is predominantly expressed on effector and cytotoxic T cells shortly after T cell receptor (TCR) activation. In addition to promotion of T cell and B cell collaboration, ICOS signaling (via ICOS ligand [ICOSL] or antibody-based crosslinking) has been shown to improve T cell antitumor activity, survival, durable tumor rejection. To support the clinical development of GSK3359609 (a hIgG4 ICOS agonist antibody) several in vivo combination studies were conducted using a tool anti-mouse ICOS agonist antibody (clone 7E.17G9). Analogous with the Fc-based characteristics of a human IgG4 antibody, the anti-mouse ICOS tool antibody exhibited significant antitumor activity when grafted on a murine IgG1 (or Fc-reduced) backbone. Using an in vivo models of breast cancer (EMT6, BALB/c), the murinized ICOS tool antibody demonstrated potent antitumor activity alone (tumor growth inhibition [TGI] of 40-60%) in combination with immune checkpoint inhibitors (ICI) targeting PD-1 and CTLA-4 (TGI of 100% and 90%, respectively). Antitumor activity was associated with increased total T cell infiltration into the tumor, a higher tumor CD8/Treg cell ratio, and broad increases in T cell activation markers (e.g. CD25, CD69, Granzyme B, perforin, and PD-1). The cancer immunity cycle posits that multiple points of intervention exist for cancer immunotherapy, many of which should be considered in order to identify complementary therapeutic strategies. With this in mind, and consistent with ICI, antitumor activity was observed in combination with innate immune modulators (e.g. TLR4 agonist) and chemo/cytotoxic (e.g. carboplatin and paclitaxel) therapies in different syngeneic tumor models. Altogether these data underscore the broad utility of ICOS agonist antibodies as a reliable combination partner for cancer immunotherapy. Citation Format: Jeremy D. Waight, Meixia Bi, David Kilian, Christopher Hopson, Shu-Yun Zhang, Sara Brett, Sapna Yadavilli, Tianqian Zhang, Hong Shi, Kenneth W. Hance, Marc Ballas, Axel Hoos. Non-clinical tumor models reveal broad combination potential of ICOS agonist antibodies [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 2220.

Developmental Pathways to BPD-Related Features in Adolescence: Infancy to Age 15.

The self-damaging behaviors central to borderline personality disorder (BPD) become prominent in adolescence. Current developmental theories cite both early family processes and childhood dysregulation as contributors to BPD, but longitudinal data from infancy are rare. Using the National Institute of Child Health and Human Development (NICHD) Study of Early Child Care and Youth Development database (SECCYD; N = 1,364), we examined path models to evaluate parent and child contributors from infancy/preschool, middle childhood, and adolescence to adolescent BPD-related features. In addition, person-centered latent class analyses (LCA) investigated whether adolescent BPD-related features were more strongly predicted by particular patterns of maladaptive parenting. Path modeling identified unique influences of maternal insensitivity and maternal depression on BPD-related features, first, through social-emotional dysregulation in middle childhood, and second, through continuity from infancy in maternal insensitivity and depression. LCA results indicated that early withdrawn parenting was particularly predictive of BPD-related features in adolescence. Results suggest multiple points of intervention to alter pathways toward adolescent borderline psychopathology.

Techno-economic analysis of a plant-based platform for manufacturing antimicrobial proteins for food safety.

Continuous reports of foodborne illnesses worldwide and the prevalence of antibiotic‐resistant bacteria mandate novel interventions to assure the safety of our food. Treatment of a variety of foods with bacteriophage‐derived lysins and bacteriocin‐class antimicrobial proteins has been shown to protect against high‐risk pathogens at multiple intervention points along the food supply chain. The most significant barrier to the adoption of antimicrobial proteins as a food safety intervention by the food industry is the high production cost using current fermentation‐based approaches. Recently, plants have been shown to produce antimicrobial proteins with accumulation as high as 3 g/kg fresh weight and with demonstrated activity against major foodborne pathogens. To investigate potential economic advantages and scalability of this novel platform, we evaluated a highly efficient transgenic plant‐based production process. A detailed process simulation model was developed to help identify economic “hot spots” for research and development focus including process operating parameters, unit operations, consumables, and/or raw materials that have the most significant impact on production costs. Our analyses indicate that the unit production cost of antimicrobial proteins in plants at commercial scale for three scenarios is $3.00–6.88/g, which can support a competitive selling price to traditional food safety treatments.

Aging With Vision Loss: A Framework for Assessing the Impact of Visual Impairment on Older Adults.

There is limited research examining the impact of visual impairment (VI) on older adults while considering the complexities of aging, leaving gaps in our understanding of how health consequences of VI might be averted. We created a framework integrating concepts from disability, geriatrics, and ophthalmology that conceptualizes how VI challenges successful aging. Here, VI influences multiple functional domains, and increases the risk of negative health outcomes. This model acknowledges that common causes, such as risk factors that affect eyes and other systems simultaneously, may also drive the relationship between VI and health outcomes. Finally, the model highlights how the impact of VI on aging outcomes can be addressed at multiple intervention points.

Contributing factors predicting nightmares in children: Trauma, anxiety, dissociation, and emotion regulation.

There is little research in the current literature regarding contributing factors to nightmares in children. This study aimed to test potentially overlapping predictors of nightmare distress and severity, including anxiety, dissociation, trauma history, vagal tone, and parental processing of emotions. Sixty parent-child dyads (children ages 6-11) filled out a variety of child-report and parent-observation inventories on nightmare frequency and distress, dissociation, anxiety, and trauma history of the child. Children were monitored on heart rate variability and vagal tone. Both parent and child participated in a discussion of positive and negative life events that were later coded for degree of parent processing of emotional information. Anxiety, trauma history, dissociation, and baseline vagal tone accounted for 39% of the variance in nightmare distress. Anxiety and dissociation were positive predictors of nightmare distress in the multiple regression. Parent processing variables were weak predictors in the current analysis. The predictive power of anxiety, dissociation, vagal tone, and trauma history was not entirely due to their overlap, as shown by uniquely significant beta weights in the prediction of distress. Treatment procedures with multiple intervention points targeting physiological and psychological sources of nightmare distress may be warranted. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

DNA methylation dynamics during embryonic development and postnatal maturation of the mouse auditory sensory epithelium

The inner ear is a complex structure responsible for hearing and balance, and organ pathology is associated with deafness and balance disorders. To evaluate the role of epigenomic dynamics, we performed whole genome bisulfite sequencing at key time points during the development and maturation of the mouse inner ear sensory epithelium (SE). Our single-nucleotide resolution maps revealed variations in both general characteristics and dynamics of DNA methylation over time. This allowed us to predict the location of non-coding regulatory regions and to identify several novel candidate regulatory factors, such as Bach2, that connect stage-specific regulatory elements to molecular features that drive the development and maturation of the SE. Constructing in silico regulatory networks around sites of differential methylation enabled us to link key inner ear regulators, such as Atoh1 and Stat3, to pathways responsible for cell lineage determination and maturation, such as the Notch pathway. We also discovered that a putative enhancer, defined as a low methylated region (LMR), can upregulate the GJB6 gene and a neighboring non-coding RNA. The study of inner ear SE methylomes revealed novel regulatory regions in the hearing organ, which may improve diagnostic capabilities, and has the potential to guide the development of therapeutics for hearing loss by providing multiple intervention points for manipulation of the auditory system.

Multiple Points of Intervention as an Approach in Child Psychotherapy

ABSTRACTThis article develops an integrated model that emphasizes multiple points of intervention in therapeutic work with children. It draws on nonlinear dynamic systems theory, Winnicott's theory of play and transitional space, elements of contemporary relational theory, client-centered therapy, Gestalt therapy, family systems, behavior therapy, selected aspects of cognitive behavior therapy, psychological education, and school consultations.