Defining Treatment Outcomes in Pediatric Obsessive-Compulsive Disorder Using a Self-Report Scale

This study examined benchmarks of treatment response and clinical remission on the Obsessive Compulsive Inventory–Child Version (OCI-CV) for youth with obsessive-compulsive disorder (OCD). Participants were 91 youth who enrolled in a randomized controlled trial that examined the benefit of augmenting cognitive behavior therapy (CBT) with either d-cycloserine or placebo. Youth completed the OCI-CV at baseline, Week 4 (prior to initiating exposure therapy), and posttreatment. Receiver operator curve (ROC) analyses examined optimal benchmarks for treatment response and clinical remission as identified by independent evaluators at the posttreatment assessment using the Clinical Global Impression (CGI) scales of Improvement (CGI-Improvement), Severity (CGI-Severity), and Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS). Optimal benchmarks for treatment response were a 20%–25% reduction in the OCI-CV total score. Meanwhile, optimal benchmarks for remission were a 55%–65% reduction in the OCI-CV total score and a posttreatment total score ≤ 6-8. OCI-CV benchmarks exhibited moderate agreement with the CY-BOCS for treatment response and clinical remission. Meanwhile, fair agreement was observed for response and remission with CGI scales. A lower pretreatment OCI-CV total score was associated with less agreement between classification approaches. Findings provide benchmarks for classifying treatment response and clinical remission in an efficient manner. Given the moderate agreement between the CY-BOCS and OCI-CV benchmarks, the OCI-CV may serve as a useful alternative when clinician-rated scales cannot be administered due to limited resources (e.g., time, training). Thus, evidence-based measurement can be incorporated to monitor therapeutic response and remission in clinical practice.     

Personality Disorders and Treatment: A Therapeutic Conundrum

Of challenge to developmental psychologists and mental health practitioners is the importance of temperament, the intractable nature of personality, the complex psychodynamics of personality disorders, the fragile features of the therapeutic alliance, and the selection of appropriate therapy techniques. The intent of this article is to provide specific information pertinent to understanding personality disorders and to offer recommendations for effective treatment strategies.     

Non-Suicidal Self-Injury in Pediatric Bipolar Disorder: Clinical Correlates and Impact on Psychosocial Treatment Outcomes

Non-suicidal self-injury (NSSI) in childhood is not well documented, especially among youth with pediatric bipolar disorder (PBD). The current study evaluated prevalence and correlates of NSSI, and its impact on intervention response, in a randomized trial of Child- and Family-Focused Cognitive-Behavioral Therapy (CFF-CBT) versus Treatment As Usual (TAU), adjunctive to pharmacotherapy. This study included 72 children ages 7–13 (58% male) with PBD. NSSI and correlates were assessed at baseline; mood and psychiatric severity were measured longitudinally. NSSI was common: 31% endorsed NSSI behaviors; 10% reported thoughts of NSSI, in the absence of behaviors. Children engaging in NSSI reported higher depression, psychosis, suicidality, and hopelessness; lower self-esteem; and reduced family help-seeking in univariate analyses. In a multivariate logistic regression, high child depression and psychosis, and low family help-seeking, remained significantly associated with baseline NSSI. In mixed-effects regression models, presence of NSSI at baseline did not influence the response of depressive symptoms to treatment. Children who endorsed NSSI experienced steeper response trajectories for psychiatric severity, regardless of treatment group. Youth who denied NSSI showed poorer response to TAU for manic symptoms; mania trajectories in CFF-CBT were similar across youth. Thus, NSSI in PBD is common and associated with impairment. As children might engage in NSSI for different reasons, the function of NSSI should be considered in treatment. Since children without NSSI fared worse in TAU, it may be important to ensure that youth with PBD receive structured, intensive interventions. CFF-CBT was efficacious regardless of NSSI, and thus shows promise for high-risk children with PBD.     

A Psychodynamic Treatment for Severe Personality Disorders: Issues in Treatment Development

We describe a psychodynamic treatment modified for patients with severe personality disorders identified as borderline personality disorder in DSM-IV, Axis II, and understood as borderline personality organization from a psychoanalytic perspective. This treatment is labeled transference-focused psychotherapy (TFP) in order to highlight the centrality of working with these patients in the here-and-now treatment interaction. The empirical development of TFP is described, including the generation of a treatment manual, the utility of various methods to teach the treatment, and preliminary data on efficacy. The latest step in the development of this treatment is an ongoing randomized clinical trial comparing the efficacy of TFP to a cognitive-behavioral and a supportive treatment.     

Outcomes of a Day Treatment Program for Eating Disorders Using Clinical and Statistical Significance

The present study was designed to evaluate the outcomes of a day treatment program for 55 eating disordered (ED) patients using clinical and statistical significance testing. Results indicated a statistically significant reduction on all eating disordered outcomes. With respect to clinical significance testing, analysis of these data indicated that the majority of the individuals in the day treatment program made clinically significant and reliable change by the termination of treatment on all eating disorder measures. However, considerably less patients improved to such a point that they were asymptomatic. The importance of combining clinical significance testing with traditional significance testing is discussed.     

Group CBT for Externalizing Disorders in Urban Schools: Effect of Training Strategy on Treatment Fidelity and Child Outcomes

Public schools are an ideal setting for the delivery of mental health services to children. Unfortunately, services provided in schools, and more so in urban schools, have been found to lead to little or no significant clinical improvements. Studies with urban school children seldom report on the effects of clinician training on treatment fidelity and child outcomes. This study examines the differential effects of two levels of school-based counselor training: training workshop with basic consultation (C) vs. training workshop plus enhanced consultation (C +) on treatment fidelity and child outcomes. Fourteen school staff members (counselors) were randomly assigned to C or C +. Counselors implemented a group cognitive behavioral therapy protocol (Coping Power Program, CPP) for children with or at risk for externalizing behavior disorders. Independent coders coded each CPP session for content and process fidelity. Changes in outcomes from pre to post were assessed via a parent psychiatric interview and interviewer-rated severity of illness and global impairment. Counselors in C + delivered CPP with significantly higher levels of content and process fidelity compared to counselors in C. Both C and C + resulted in significant improvement in interviewer-rated impairment; the conditions did not differ from each other with regard to impairment. Groups did not differ with regard to pre- to- posttreatment changes in diagnostic severity level. School-based behavioral health staff in urban schools are able to implement interventions with fidelity and clinical effectiveness when provided with ongoing consultation. Enhanced consultation resulted in higher fidelity. Enhanced consultation did not result in better student outcomes compared to basic consultation. Implications for resource allocation decisions with staff training in EBP are discussed.     

Enhanced Cognitive Behavior Therapy: A Single Treatment for All Eating Disorders

Eating disorders are serious mental illnesses affecting a significant proportion of women and a smaller number of men. Approximately half of those with an eating disorder (ED) will not meet the criteria for anorexia or bulimia nervosa, and will be diagnosed with an eating disorder not otherwise specified (EDNOS). Until recently, there were no recommended treatments for EDNOS. This article provides an overview of enhanced cognitive behavior therapy, a validated treatment for all forms of EDs.     

Feeding violence: A reply

Genetic Screening: Ethical Issues, Nuffield Council on Bioethics, 1993, 115 pages, pb £6.00 from Nuffield Foundation, 28 Bedford Sq. London W1.

Draft Convention for the Protection of Human Rights and the Dignity of the Human Being with Regard to the Application of Biology and Medicine: Bioethics Convention and Explanatory Report, DIR/JUR (94) 2, Strasbourg: Council of Europe, July 1994.

UNESCO International Bioethics Committee: Report of the subcommittee on genetic screening and testing, Paris; November 1994.     

Clients in Treatment for Alcohol Problems: Treatment Experiencesand Outcomes

This report presents an analysis of National Treatment Improvement Evaluation Study data describing the characteristics and treatment experiences of clients entering treatment for alcohol problems. Three client groups were contrasted—those entering treatment for alcohol only, for alcohol plus other drugs, or for other drugs only. Clients using alcohol only were more often white, male, and currently employed. Alcohol only clients were treated predominantly in outpatient settings. Alcohol only clients were frequently referred to treatment by the criminal justice system, and less often self-referred. In all 3 study groups, employment, general health, and mental health outcomes were improved following treatment. Illicit drug use increased marginally for the alcohol only group following treatment. No significant posttreatment reductions in reports of total abstinencefrom alcohol were found for any of the groups. Findings are discussed as they relate to research, treatment practice, and policyareas.     

Substance Abuse Treatment Outcomes: Treatment Practice and Policy Implications

Treatment professionals, whether clinicians, scientists, or policy makers, are interested in developing methods to improve behavioral health treatment outcomes. Clinicians are interested in knowing what treatment practices to incorporate into the services they offer clients. Policymakers request guidance regarding which decisions are most likely to lead to effective treatment approaches and structures. Scientists are eager to contribute knowledge pertinent to building and evaluating effective treatment practices and policies. The papers in this special series provide information on substance abuse treatment practices andpresent findings relevant to clinical practice, policy decisions, and scientific inquiry. This paper provides a brief overview of the National Treatment Improvement Evaluation Study (NTIES) and briefly summarizes the other research papers included in this issue, all of which exemplify practice and policy issues in the substance abuse treatment field and bolster approaches applied to address these issues.     

Treatment Effects for Common Outcomes of Child Sexual Abuse: A Current Meta-Analysis

The present meta-analysis examined the effects of psychosocial treatments at reducing deleterious outcomes of sexual abuse. The meta-analysis included a total of 35 published and unpublished studies written in English, focusing on youth under the age of 18, and evaluating the effectiveness of treatments for the most common negative outcomes of sexual abuse: PTSD symptoms, externalizing problems, and internalizing problems. Results revealed medium effect sizes for PTSD symptoms, externalizing problems, and internalizing problems following treatment for sexual abuse. This study also examined the potential moderating effects of treatment (e.g., modality, duration, inclusion of caregiver) and participant (e.g., age, gender, ethnicity) characteristics. Results indicated that longer interventions were associated with greater treatment gains while group and individual treatments were equally effective. These findings shed new light on treatment effectiveness and provide useful information regarding the conditions under which treatment may be most effective. Future directions for research in this area are discussed.     

Psychological Outcomes in Fathers of Critically Ill Children in the Pediatric Intensive Care Unit: A Systematic Review

Journal of Clinical Psychology in Medical Settings - Systematically review evidence of psychological distress in fathers of children admitted to the pediatric intensive care unit (PICU). Two...     

Treatment of Anxiety Disorders With Comorbid Depression: A Survey of Expert CBT Clinicians

Cognitive-behavioral therapy (CBT) is an empirically supported psychological treatment for anxiety disorders. These treatments have primarily been developed to target primary anxiety disorders, despite the fact that these disorders frequently co-occur with a diagnosis of depression. Empirical evidence provides guidance regarding how to treat an individual with a primary anxiety disorder with comorbid depression; however, there is limited data regarding how to translate these findings into clinical practice. Improving our understanding of how CBT is currently being used in practice among experts is integral to learning whether modifications to protocols lead to more or less effective treatments. Accordingly, we surveyed expert CBT clinicians about their assessment and treatment approaches and what challenges they face in formulating and treating mood and anxiety comorbidity. Most experts reported that their assessment includes a semistructured interview and self-report measures to determine breadth and hierarchical ordering of comorbidity severity. Symptom severity, client's goals, temporal onset of disorders, presence of suicide risk, and potential for early treatment success were reported as factors to consider when deciding where to begin treatment. Almost three quarters of experts surveyed indicated that they usually take some type of sequential treatment approach when treating primary anxiety disorders with comorbid depression. The top three reported challenges associated with treating comorbid presentations were client's motivation/energy, hopelessness/pessimism, and ongoing need for risk assessment. Implications for the nature and timing of CBT interventions in “real-world” clinical practice are discussed.     

A Review of Self-Management Interventions Targeting Academic Outcomes for Students with Emotional and Behavioral Disorders

The purpose of this review was to report on the effectiveness and focus of academic self-management interventions for children and adolescents with emotional and behavioral disorders. Twenty-two studies published in 20 articles and involving 78 participants met inclusionary criteria. The overall mean effect size (ES) across those studies was 1.80 (range –0.46 to 3.00), indicating effects were generally large in magnitude and educationally meaningful. Self-monitoring interventions were the predominant type of self-management technique used by researchers. The mean ES for intervention types were self-evaluation (1.13), self-monitoring (1.90), strategy instruction techniques (1.75), self-instruction techniques (2.71), and multiple-component interventions (2.11). Interventions targeted improvement in math calculation skills more than any other area. The mean ES by academic area were math interventions (1.97), writing (1.13), reading (2.28), and social studies (2.66). There was evidence to support a claim of the generalization and maintenance of findings. Implications, limitations, and areas for future research are discussed.     

Relapse Prevention Techniques in the Treatment of Childhood Anxiety Disorders: A Case Example

Research has shown that cognitive behavioral therapy (CBT) is an efficacious treatment for children and adolescents with anxiety disorders. CBT incorporates techniques such as cognitive restructuring and exposure, which foster symptom reduction. While these components promote sustained fear reduction, greater attention to relapse prevention (RP) may be warranted, particularly given the comorbidity associated with anxiety disorders. A case example demonstrates a comprehensive relapse prevention (RP) component. Specifically, parental involvement was emphasized as well as the creation of a bound book that consolidated skills and provided a concrete resource for potential future anxious episodes.     

Genetic Disorders of Intellectual Disability: Expanding our Concepts of Phenotypes and of Family Outcomes

Over the past two decades, great strides have been made in our understandings of how genetic conditions influence behavior and how such so-called “behavioral phenotypes” influence parent and family stress and coping. In this paper, we call for expansions in two directions. First, as a field we need to go beyond behavior in our concepts of phenotypes, to also include the many medical, physical, and other “non-behavioral” phenotypes that influence children’s everyday lives. Second, in examining how etiology-related phenotypes affect others, we need to go beyond the outcome of parental stress. In this regard, we focus on parental health, well-being, and various life choices, as well as how parenting children with specific genetic disorders can often lead to positive perceptions and outcomes. We end by discussing remaining research issues and how these two expansions relate to clinical practice.