Contemporary issues with stuttering: The Fourth Croatia Stuttering Symposium

PurposeDuring the 2019 Fourth Croatia Clinical Symposium, speech-language pathologists (SLPs), scholars, and researchers from 29 countries discussed speech-language pathology and psychological practices for the management of early and persistent stuttering. This paper documents what those at the Symposium considered to be the key contemporary clinical issues for early and persistent stuttering.MethodsThe authors prepared a written record of the discussion of Symposium topics, taking care to ensure that the content of the Symposium was faithfully reproduced in written form.ResultsSeven contemporary issues for our field emerged from the Symposium.ConclusionEffective early intervention is fundamental to proper health care for the disorder. However, as yet, there is no consensus about the timing of early intervention and how it should be managed. Currently, clinical translation is a barrier to evidence-based practice with early stuttering, and proactive strategies were suggested for junior SLPs. Apprehension emerged among some discussants that treatment of early stuttering may cause anxiety. For persistent stuttering, assessment procedures were recommended, as were strategies for dealing with childhood bullying. There was agreement that SLPs are the ideal professionals to provide basic cognitive-behavior therapy for clients with persistent stuttering. Questions were raised about our discipline standards for basic professional preparation programs for stuttering management.     

Summer Camp Program for Children With Obsessive–Compulsive Disorder: Description and Preliminary Observations

Summer camp programming has a rich history of promoting childhood development. In the care of children with specific childhood psychiatric disorders, the incorporation of targeted cognitive-behavioral principles provides an opportunity to marry targeted evidence-based practices with broader development, in particular social, emotional, and fine- and gross-motor development. This union is synergistic, providing the practitioner with an opportunity to employ cognitive-behavioral practices in an environment that may overcome common barriers to effective interventions outside the scope of the targeted illness. In this paper, the authors describe the preliminary findings concerning a weeklong, 25-hour summer camp program targeting childhood obsessive–compulsive disorder (OCD). Nine children ages 9–12 years participated in this pilot program. Child and parent feedback alike suggested strong treatment acceptability and efficacy in targeting both core symptoms of OCD as well as associated developmental deficits. The camp’s implementation of exposure and response prevention enables an opportunity to report on the capability of employing these strategies in a summer camp setting. In conjunction with an evidence-based treatment program for childhood OCD, a summer camp program specifically targeted for children with OCD presents a valuable tool for improving child welfare and reducing functional impairments.     

Development of Stepped Care Trauma-Focused Cognitive-Behavioral Therapy for Young Children

Young children who are exposed to traumatic events are at risk for developing posttraumatic stress disorder (PTSD). While effective psychosocial treatments for childhood PTSD exist, novel interventions that are more accessible, efficient, and cost-effective are needed to improve access to evidence-based treatment. Stepped care models currently being developed for mental health conditions are based on a service delivery model designed to address barriers to treatment. This treatment development article describes how trauma-focused cognitive-behavioral therapy (TF-CBT), a well-established evidence-based practice, was developed into a stepped care model for young children exposed to trauma. Considerations for developing the stepped care model for young children exposed to trauma, such as the type and number of steps, training of providers, entry point, inclusion of parents, treatment components, noncompliance, and a self-correcting monitoring system, are discussed. This model of stepped care for young children exposed to trauma, called Stepped Care TF-CBT, may serve as a model for developing and testing stepped care approaches to treating other types of childhood psychiatric disorders. Future research needed on Stepped Care TF-CBT is discussed.     

Impact Challenges in Community Science-with-Practice: Lessons from PROSPER on Transformative Practitioner-Scientist Partnerships and Prevention Infrastructure Development

At present, evidence-based programs (EBPs) to reduce youth violence are failing to translate into widespread community practice, despite their potential for impact on this pervasive public health problem. In this paper we address two types of challenges in the achievement of such impact, drawing upon lessons from the implementation of a partnership model called PROSPER. First, we address five key challenges in the achievement of community-level impact through effective community planning and action: readiness and mobilization of community teams; maintaining EBP implementation quality; sustaining community teams and EBPs; demonstrating community-level impact; and continuous, proactive technical assistance. Second, we consider grand challenges in the large-scale translation of EBPs: (1) building, linking and expanding existing infrastructures to support effective EBP delivery systems, and (2) organizing networks of practitioner-scientist partnerships-networks designed to integrate diffusion of EBPs with research that examines effective strategies to do so. The PROSPER partnership model is an evidence-based delivery system for community-based prevention and has evolved through two decades of NIH-funded research, assisted by land grant universities' Cooperative Extension Systems. Findings and lessons of relevance to each of the challenges are summarized. In this context, we outline how practitioner-scientist partnerships can serve to transform EBP delivery systems, particularly in conjunction with supportive federal policy.     

Childhood Overweight and Obesity: Maternal and Family Factors

Treatment programs for childhood overweight and obesity have highlighted the importance of the family in treatment. Considering this, it is surprising that few studies have examined the role of family factors in the development of childhood overweight and obesity. The objective of this study was to examine which family and maternal factors predict increases in weight in boys and girls during middle to late childhood. This study used longitudinal data from the childhood growth and development (GAD) Study. The GAD Study involved 286 healthy weight, overweight and obese children, aged 6–13 years at baseline, who completed baseline, 1-year follow-up and 2-year follow-up assessments. Overweight/obese children were recruited from clinical and community settings. A broad range of maternal and family factors were assessed. Linear mixed models were used to identify which factors predicted child Body Mass Index (BMI) z-scores over time. For community-based children, maternal BMI and single-parent family structure were significant longitudinal predictors of child BMI z-scores. For the clinical participants, low family income was the only significant multivariate predictor of child BMI z-scores. The strong association between child BMI, maternal BMI and family structure confirms the need to target prevention and intervention efforts for childhood overweight and obesity towards families with overweight parents, particularly single-parent families.     

Are explanatory trials ethical? Shifting the burden of justification in clinical trial design

Most phase III clinical trials today are explanatory. Because explanatory, or efficacy, trials test hypotheses under “ideal” conditions, they are not well suited to providing guidance on decisions made in most clinical care contexts. Pragmatic trials, which test hypotheses under “usual” conditions, are often better suited to this task. Yet, pragmatic, or effectiveness, trials are infrequently carried out. This mismatch between the design of clinical trials and the needs of health care professionals is frustrating for everyone involved, and explains some of the challenges inherent in attempts to enhance knowledge translation and encourage evidence-based practice. The situation is more than simply frustrating, however; it is potentially unethical. Clinical trials must be socially valuable in order to (1) warrant the risks they impose on human research subjects and (2) fairly and efficiently assess new clinical interventions. Most bioethicists would agree that trials that have no social value, for instance, because their results do not have the potential to advance clinical care, should not be performed. What is less widely appreciated is that given limited research resources, trials that are more socially valuable should be preferred to trials that are less socially valuable when all else is equal. With respect to clinical trial design, I argue that while explanatory trials often have some social value, many have less social value than their pragmatic counterparts. On the basis of this general ethical assessment, I provide a preliminary defense of the position that clinical researchers should aim to conduct pragmatic trials, that is, that researchers face a burden of justification related to any idealizing elements added to trial designs.     

Marriage and Family Therapy Students’ Views on Including Weight Bias Training into Their Clinical Programs

Discussions about diversity rarely focus on overweight, obesity, and bias about body size (i.e., weight bias). These discussions allow students to develop self-awareness about how their biases can affect their clinical work, as well as the challenges and subsequent bias clients may face in their everyday lives and from clinical providers. One consequence of the rising prevalence of overweight and obesity in the United States is the increase in the level of weight bias and discrimination towards individuals who are overweight, which has been documented among mental and healthcare professionals. Thus, it is imperative that training programs integrate weight bias as a part of diversity training. The authors will review weight bias in mental and healthcare professions, and describe several trainings focused on self-awareness about weight bias. The purpose of this study was to pilot and evaluate a training program for marriage and family therapy (MFT) students about developing self-awareness around weight bias and working with clients who are overweight. Following the program, focus groups were conducted to explore participants’ experiences, learning, and feedback on the content and delivery method. Focus Group methodology was used to guide the analysis process. Four themes emerged: training program feedback, challenges for the MFT field, self-of-therapist, and etiology of weight loss/gain. Implications for MFT training programs are discussed.     

Training-based interventions in motor rehabilitation after stroke: theoretical and clinical considerations

Basic neuroscience research on brain plasticity, motor learning and recovery has stimulated new concepts in neurological rehabilitation. Combined with the development of set methodological standards in clinical outcome research, these findings have led to a double-paradigm shift in motor rehabilitation: (a) the move towards evidence-based procedures for the assessment of clinical outcome & the employment of disablement models to anchor outcome parameters, and (b) the introduction of practice-based concepts that are derived from testable models that specify treatment mechanisms. In this context, constraint-induced movement therapy (CIT) has played a catalytic role in taking motor rehabilitation forward into the scientific arena. As a theoretically founded and hypothesis-driven intervention, CIT research focuses on two main issues. The first issue is the assessment of long-term clinical benefits in an increasing range of patient groups, and the second issue is the investigation of neuronal and behavioural treatment mechanisms and their interactive contribution to treatment success. These studies are mainly conducted in the research environment and will eventually lead to increased treatment benefits for patients in standard health care. However, gradual but presumably more immediate benefits for patients may be achieved by introducing and testing derivates of the CIT concept that are more compatible with current clinical practice. Here, we summarize the theoretical and empirical issues related to the translation of research-based CIT work into the clinical context of standard health care.     

Joint Consultation for High-Risk Asthmatic Children and Their Families,with Pediatrician and Child Psychiatrist as Co-Therapists: Model and Evaluation

Although a very common disease, childhood asthma can be a life-threatening condition. Psychosocial determinants have been acknowledged to trigger severe asthma. The authors review current knowledge about how psychosocial factors influence childhood asthma, with a special focus on compliance with treatment and family interaction. The authors describe their experience of joint treatment of high-risk asthmatic children and their families. The pediatrician and child psychiatrist work as co-therapists, and the results of this intervention are investigated. Forty-one high-risk asthmatics and their families were followed in the joint-consultation program. Two years after the onset of joint consultation, a significant improvement was found in symptom score, treatment score, and compliance score. The number of hospital admissions and of days spent in hospital decreased significantly. The cost of care was subsequently cut by two-thirds, despite the added cost of psychiatric care. The authors conclude that it is possible for doctors of the body and of the mind to share consultation work, with a positive impact on both the patient's health and the cost of treatment.     

Development of a Multi-Disciplinary Intervention for the Treatment of Childhood Obesity Based on Cognitive Behavioral Therapy

Along the lines of the evidence-based recommendations, we developed a multi-disciplinary intervention for overweight children 7- to 12-years-old, primarily aiming at helping children to adopt healthier eating habits and a physically active lifestyle. The program combined nutrition intervention, based on a non-dieting approach, with physical activity intervention, implemented through the basic principles of Cognitive Behavioral Therapy (CBT), along with parental support. The program was conducted by dieticians with the collaboration of child psychiatrists and pediatricians. Training and regular supervision upon CBT priniciples application was intended to enhance dieticians' efficiency. The intervention is currently being evaluated to determine its effectiveness in treating childhood obesity.     

The treatment of depression in older adults in the primary care setting: an evidence-based review.

The objective of this study was to conduct an evidence-based review of treatments for depression in older adults in the primary care setting. A literature search was conducted using PsycINFO and Medline to identify relevant, English language studies published from January 1994 to April 2004 with samples aged 55 and older. Studies were required to be randomized controlled trials that compared psychosocial interventions conducted within the primary care setting with "usual care" conditions. Eight studies with older adult samples met inclusion criteria and were included in the review. Two treatment models were evident: Geriatric Evaluation Management (GEM) clinics and an approach labeled integrated health care models. Support was found for each model, with improvement in depressive symptoms and better outcomes than usual care; however, findings varied by depression severity, and interventions were difficult to compare. Further efforts to improve research and clinical care of depression in the primary care setting for older adults are needed. The authors recommend the use of interdisciplinary teams and more implementation of psychosocial treatments shown to be effective for older adults.     

Mental health care for Hispanic Americans: a current perspective

In this article, the authors review patterns and challenges in the conceptualization, implementation, and academic support of the mental health services of Hispanic Americans. A critical analysis was conducted on information obtained through manual and computerized searches of published literature and conference reports. New clinical care approaches include the DSM-IV's cultural formulation with its complement of standardized multiaxial diagnosis, integration of services across clinical disorders or conditions and across sources of care, as well as pluralistic criteria and judges for service outcome appraisal. Emerging clinical approaches offer an opportunity to enhance the mental health care of Hispanic Americans within an increasingly multicultural U.S. society.     

Updating the Textbook: A Novel Approach to Training Graduate Students in Evidence-Based Youth Practices

Despite the ever-improving base of evidence-based practices (EBPs) for the treatment of childhood disorders, a gap between EBP research and their use in community settings continues to exist. An exciting opportunity to close this gap exists in the form of graduate student training; however, at present, several roadblocks exist. In this paper, we review the current state of graduate training in delivering EBPs and obstacles involved in training future community clinicians (i.e., graduate students) in EBPs. Next, we describe in detail our initiative to develop a curriculum that addresses these challenges. This innovative course empowered graduate students to receive training in the delivery of youth EBPs in community settings through reviews of the research literature, active learning techniques (e.g., discussions of case conceptualizations, role-playing case studies), and a written, publication-quality review of EBPs. Finally, we offer recommendations for other educators of mental health professionals (e.g., psychologists, social workers, counselors) to improve upon this curriculum in their training of graduate students in the theory and application of EBPs for treating childhood disorders.     

Standards of Care: Potential Implications for the Counseling Profession

The potential implications for development of professionally defined “standards of care” treatment procedures for mental health counseling are presented. The role of xpert witnesses in malpractice cases is examined as one source from which the standards are currently derived. The influence of managed care on the current clinical practices is noted. Finally, the importance of using outcome research as the basis for developing a “best practices” concept of standards of care is discussed. The authors note difficulties and challenges involved in making a commitment to what could be the next major impetus to the mental health movement.     

The Role of Neuropsychological Assessment in the Functional Outcomes of Children with ADHD

The value of evidence-based services is now recognized both within clinical communities and by the public at large. Increasingly, neuropsychologists must justify the necessity of often costly and time-consuming neuropsychological assessments in the diagnosis and treatment of common childhood disorders, such as Attention-deficit/Hyperactivity Disorder (ADHD). Published medical guidelines and prominent researchers, however, have argued against the need for formal neuropsychological assessment of ADHD. The present review examines the literature on developmental outcomes in childhood ADHD, with emphasis on the utility of formal neuropsychological assessment among children diagnosed and treated in primary care settings. The review yields three central findings: 1) adherence to published diagnostic guidelines for ADHD is poor among pediatric and primary care physicians; 2) ADHD most often co-exists with other disorders, thus diagnoses made without formal psychometric assessment can be incomplete or incorrect, ultimately increasing treatment costs; and, 3) untreated children with ADHD, and those who have untreated comorbidities, are at greater risk for poor outcomes in social, academic, vocational, and practical settings. The available literature suggests that neuropsychological assessment provides information that can potentially reduce risks for poor outcomes and improve quality of life among children with ADHD. Controlled studies directly examining the impact of neuropsychological assessments in improving outcomes among children with ADHD are needed.     

Ethical Considerations in the Treatment of Compulsive Hoarding

Although empirically supported treatment for compulsive hoarding is in its preliminary stages, some information has emerged regarding ethical challenges experienced in treating this population. Our aims are twofold: (a) to inform the clinical community of ethical complications when conducting treatment for hoarding clients, and (b) to provide a decision-making model for ensuring quality and ethical care of hoarding clients. The ethical challenges (boundary crossings, dual roles, privacy/confidentiality, record keeping, fees, and cultural competence in treatment) were discovered through multiple roundtable discussions, supervision, and in the course of delivering empirically supported treatment protocols. A literature search was conducted to identify research that addressed ethical concerns. A decision-making model addressing ethical challenges in treatment of compulsive hoarding was developed.