Implementing Cognitive Behavioral Therapy in Specialty Medical Settings

This article is an introduction to the second issue of a two-part special series on integrating cognitive behavioral therapy (CBT) into medical settings. The first issue focused on integrating CBT into primary care, and this issue focuses on implementing CBT in other specialty medical settings, including cancer treatment, HIV care, and specialized pediatric medical clinics. Models for treatment delivery to improve ease of implementation are also discussed, including telehealth and home-delivered treatment. The six articles in this series provide examples of how to transport CBT techniques that are largely designed for implementation in outpatient mental health settings to specialized medical settings, and discuss unique considerations and recommendations for implementation.     

Helping Children and Caregivers Cope with Repeated Invasive Procedures: How Are We Doing?

This paper discusses recent developments in the medical and psychological management of child behavioral distress during invasive (i.e., needle stick) procedures for diagnosis and treatment of chronic pediatric disorders. Along with a review of relevant studies from the medical, pediatric psychology and behavior analysis literatures, representative data are presented from recent research on pediatric procedural pain management. The impact of increasing use of implanted subcutaneous intravenous catheters (ports) and decreased reliance on intravenous cannulation is discussed. Similarly, the effects (and limitations) of more frequent use of topical anesthesia to prepare needle sites also are presented. The continuing need for adjunctive, nonpharmacological (i.e., cognitive and behavioral) interventions for procedural pain is emphasized, and recent studies on distraction and counter-conditioning-based treatments are described. Future research is encouraged on (1) behavioral interventions in relation to day-to-day contextual variables that modulate treatment effects and (2) the development of efficient screening measures to identify children and families who are least likely to cope effectively with repeated procedures, allowing them to be given greater priority for allocation of limited resources for psychosocial intervention.     

Editorial: Applications of Cognitive and Behavioral Therapy in Response to COVID-19

The corona virus (COVID-19) continues to have a devastating health, economic, and social impact on our local and international communities. Cognitive and Behavioral Therapies (CBTs), as a family of therapies that posit cognitive, behavioral, emotional, and interpersonal change processes in the understanding and successful treatment of mental health disorders, have risen to the challenge. This special issue represents contributions from CBT experts on the impact on psychopathology, new assessment methods, adaptations of integrated behavioral health, telehealth, psychology training, and discusses a public health framework. The issue includes a series of articles offering guidance for the clinician on interventions for those impacted by trauma, CBT for youth and families, and telehealth for psychotic spectrum disorders and group therapy for social anxiety.     

Acceptability and cost-effectiveness of military telehealth mental health screening

Telehealth has been touted as one solution to the shortage of mental health providers within the military. Despite developing evidence for the equivalence of telehealth mental health care, there is no research that covers the use of telehealth for population mental health screening, a standard component of postdeployment medical screening. This paper summarizes soldier perceptions of three separate screening events in which telehealth was used and the cost-effectiveness of telehealth versus in-person implementations of the same screening. Soldiers who have not been through telehealth screening report a strong preference for in-person screening. Soldiers who have been through telehealth screening still report preference for in-person screening, but they express more ambivalence about the screening method. Using telehealth-only mental health screening for large numbers of soldiers within a compressed time frame is more expensive than in-person screening. Telehealth resulted in higher referral rates than in-person screening. Government and military leaders should use care when making decisions about telehealth implementation. Although telehealth for small numbers may be sufficiently equivalent and economical, there is no evidence of cost savings or improved acceptability for telehealth mental health post-deployment screening.     

Collaborating With Pediatric Gastroenterologists to Treat Co-Occurring Inflammatory Bowel Disease and Anxiety in Pediatric Medical Settings

Children and adolescents with inflammatory bowel disease (IBD) have distinct physical and emotional challenges that may place them at risk for developing anxiety and that may impede their receipt of mental health treatment. Only a handful of studies have applied empirically validated cognitive behavioral therapy (CBT) to IBD-related issues and no studies have examined the benefit of CBT for anxiety disorders in pediatric IBD. The aim of this paper is to describe a newly adapted cognitive behavioral treatment protocol, Treatment of Anxiety and Physical Symptoms related to IBD (TAPS + IBD), that has been tailored to concurrently address anxiety, including IBD-specific anxiety, and disease management in children and adolescents with IBD in pediatric medical offices. Two case studies are presented to demonstrate treatment implementation and preliminary assessment data. General considerations for health providers working with youth with comorbid anxiety and IBD from a multidisciplinary perspective and future research directions are provided.     

Comprehensive community-based education and neurorehabilitation for children and adolescents with traumatic brain injury

Children and adolescents who experience a traumatic brain injury (TBI) typically have sensory, cognitive, behavioral, and functional skill challenges that must be addressed in acute and post-acute rehabilitation settings. This article describes a community-based school that combines educational, medical, nursing, family, residential-living, and psychological services in a comprehensive program of pediatric neurorehabilitation. The operational, administrative, and clinical features of these service components are presented. A critical aspect of the program is an emphasis on applied behavior analysis procedures for purposes of assessment, treatment formulation, and evaluation. Data are reviewed to demonstrate demographics, patterns of service delivery, and outcome. The school program represents an educational alternative for students with TBI who are discharged from acute-care settings and require comprehensive support services to facilitate their transition and re-entry to public school and community living. © 1998 John Wiley & Sons, Ltd.     

Conducting Exposure-Based Groups via Telehealth for Adolescents and Young Adults With Social Anxiety Disorder

The rapid spread of COVID-19 and subsequent social distancing measures posed unprecedented challenges in providing mental health care and a swift transition of services to telehealth platforms. Social distancing measures create unique concerns for young people with social anxiety disorder who already struggle with social connection and isolation; therefore, the continuation of care via telehealth platforms is especially important for this population. To date, there is little literature regarding use of telehealth groups for this population and the current commentary aims to fill in this gap in the literature while also providing general guidelines for telehealth groups. The commentary discusses the delivery of an exposure-based cognitive behavioral therapy group for adolescents and young adults via telehealth and provides considerations, challenges, and benefits of conducting a group through a telehealth platform. In conjunction with clinically relevant examples and in-depth exposure discussions, we aim to provide guidance for youth-focused practitioners who are considering conducting groups in a telehealth format for a range of presentations.     

Training Pediatric Psychologists for Perinatal Behavioral Health Services in a Pediatric Hospital

Although pediatric hospitals specialize in providing care to children and adolescents, at The Children’s Hospital of Philadelphia (CHOP), our team has been providing behavioral health services for two unique parent populations—parents with a child in the Newborn Infant Intensive Care Unit and pregnant women carrying fetuses with specific birth defects and receiving prenatal care in the Center for Fetal Diagnosis and Treatment. A new training program was developed to expand the scope of pediatric psychologists’ practice to include perinatal behavioral health services, specifically for these two unique parent populations served at CHOP. The program includes direct service provision for adult mental health concerns, as well as education and support to help families cope with the existing medical conditions. This article describes the training program and its implementation as a model of training for other pediatric hospitals. The roles of psychologists embedded in these units and hospital privileges are discussed.     

Publishing in Journals Outside the Box: Attaining Mainstream Prominence Requires Demonstrations of Mainstream Relevance

Primary pediatric medical care is as mainstream as any major cultural practice in the USA. Thus, publishing behavior analytic papers that pertain to problems that present in pediatric settings in pediatric medical journals is one route to mainstream relevance. With sufficient numbers of such papers, it could even lead to prominence. This article describes examples of publishing in pediatric journals and some lessons I learned from the experience. For example, (1) all child behavior problems that present in pediatric settings are of social importance but most are high-frequency, low-intensity problems that are not necessarily exotic or representative of serious pathology, and they usually respond to straightforward behavioral applications; (2) it is usually best to use a “colloquialized version of learning theory” when writing for and speaking to pediatric providers (and the families for whom they provide care); (3) pediatricians often have limited knowledge about behavior analytic research designs; and (4) when submissions are rejected by pediatric journals, the rejection can be exploited as an opportunity to educate pediatric editors and reviewers.     

Wrapping community-based mental health services around children with a severe behavioral disorder: An evaluation of project wraparound

During the past two decades there has been a significant increase in community-based mental health and educational services for children and youth with serious emotional and behavioral problems and their families. However, in the vast majority of programs there are no reliable longitudinal data on the adjustment of the children that are served. Project Wraparound was a community-based individualized treatment program which served children and youth with severely maladjusted behavior and their families by providing intensive home and school-based services. The purpose of this paper is to provide a longitudinal analysis of client and family adjustment data. Data on client adjustment within the home and characteristics of the home environment were obtained at intervals of 3 months, 6 months, and 1 year. Data on client adjustment in school was obtained at four points over a period of 2 years. The results from 19 cases indicate that substantial change occurred on measures of the home environment and client adjustment in the home with no significant change in adjustment in the school. Implications of the findings are discussed.     

Cognitive‐Behavioral Tasks Accomplished in a Person‐Centered Relational Framework

The authors propose a person‐centered relational framework in which C. R. Rogers's (1957) core conditions remain the primary catalyst of therapeutic change and cognitive‐behavioral work is accomplished while adhering to person‐centered principles. Important ideas asserted include the following: Cognitive‐behavioral tasks occur naturally within the person‐centered approach, knowledge of cognitive‐behavioral theory can increase counselor empathy, and cognitive‐behavioral techniques can be carefully applied within a person‐centered relational framework. Finally, the person‐centered relational framework with other theories is addressed.     

Family-based obesity treatment, then and now: twenty-five years of pediatric obesity treatment.

OBJECTIVE: Family-based treatments for pediatric obesity were developed over 25 years ago. Over that time, youth have become more obese and the environment more obesiogenic, which may influence efficacy of pediatric weight control. Mixed-effects regression models were used to compare the efficacy of programs initiated 20 to 25 years ago to current programs through 24-month follow-up, as well as to reanalyze 10-year outcomes of previous research using contemporary measures and analytic strategies. MAIN OUTCOME MEASURES: z-BMI and percent overweight. RESULTS: Results showed significant reductions over time, with no differences in z-BMI change for older versus contemporary studies. Age was a predictor of z-BMI up to 24 months, with younger children showing larger change. Mixed-effects regression models replicated previous long-term effects of family-based interventions. Gender was a predictor of long-term z-BMI change, with girls benefiting more over time than did boys. CONCLUSION: The efficacy of the family-based behavioral approach to treating pediatric obesity replicates over a 25-year period. Challenges in evaluating treatment effects over time are discussed. Ideas for studying choice of treatments that vary in effect size and for strengthening family-based behavioral treatments are noted.     

Training Individuals to Implement Applied Behavior Analytic Procedures via Telehealth: A Systematic Review of the Literature

The purpose of this article is to summarize literature relating to training individuals to implement applied behavior analytic procedures via telehealth and identify any gaps in the evidence base for this type of support. A systematic literature search revealed 20 articles focusing on training individuals to implement specific ABA techniques via telehealth. The Evaluative Method (Reichow et al. in J Austism Dev Disord 38:1311–1319, 2008; Reichow, in: Reichow, Doehring, Cicchetti, Volkmar (eds) Evidence-based practices and treatments for children with autism, Springer, New York, Reichow 2011) was used to assess the methodological quality of included articles. Results indicated that individuals were trained to implement a range of techniques, including assessments, targeted interventions, and specific teaching techniques. Socially significant outcomes were reported for clients in the form of reduced challenging behavior and increased skills. Trainee fidelity following training via telehealth was variable, and barriers related to the use of telehealth were highlighted. Where evaluated, cost and travel burdens were considerably lower than support provided in-person. The emerging literature is promising and suggests that telehealth may be an effective means of training individuals in ABA techniques; however, wider issues and practical implications related to the use of telehealth should be considered and are discussed as it relates to ABA providers.     

Exploring the effect of therapists' treatment practices on client attendance in community-based care for children

Sustained treatment attendance has been reported to be poor in publicly funded community-based clinic settings serving children and families. Several child and family characteristics have been shown to predict attendance in community-based care, but virtually no research has been conducted to examine how experiences in care, including psychotherapists' within-session practices, influence client attendance. The goal of this exploratory study was to examine how observed practice within sessions, in particular the extent to which therapists delivered elements consistent with evidence-based practices, impacts total number of sessions attended, while accounting for an array of other potential predictors. Participants include 181 children ages 4-13 and their parents entering a new episode of care for disruptive behavior problems in publicly funded clinics. Data sources include administrative billing records on treatment attendance; coded videotaped treatment sessions; and self-reports from children, parents, and therapists. Results indicate that parent education, service funding source, parent alliance with therapist, and therapist experience predicted number of sessions attended; intensity of evidence-based treatment techniques delivered to children was marginally associated with attendance (p = .059). Implications for improving engagement in community-based care are discussed.     

The Effects of Cognitive Development on the Use of Cognitive Behavioral Techniques with Children

The present paper hypothesizes that, for children, cognitive behavior therapy techniques cannot be applied without first determining the cognitive developmental level of information processing that is being used by the client. Demand requirements of various cognitive behavioral techniques are compared with information processing limitations described by developmental theorists to hypothesize a continuum of cognitive behavioral interventions for children.     

肥胖和/或NAFLD患者的药物性肝损伤

与药物有关的肝毒性是一个严重的健康问题,广泛影响着患者、医疗机构和政府监管机构.另外,由于久坐的生活方式和热量过度摄取,我们还面临着肥胖和非酒精性脂肪性肝病（NAFLD）的流行和困扰,因为肥胖和/或NAFLD提高各种疾病的风险,成为影响公众健康的又一个主要问题,这些患者平均使用药物的量远高于非肥胖患者.越来越多的证据表明,某些药物能够增加肥胖和NAFLD患者药物诱发肝损伤（DILI）的风险.因此,我们应该重视和防治肥胖和NAFLD患者DILI的发生.     

Cognitive Behavioral Therapy for Late-Life Depression: Evidence,Issues, and Recommendations

This paper discusses relevant research on structured therapy techniques used in the course of cognitive behavioral therapy (CBT) that are helpful in treating older adults with depressive disorders. These findings are compared and contrasted with clinical observations pertinent to the identification of moderator/mediator and other contextual factors critical to the efficacy of CBT for the treatment of this population. While some of these techniques may be viewed as a specific type of intervention in their own right (e.g., Behavioral Activation and Lifeskills Approach), their underlying theory and specific operations are consistent with the underpinnings of other cognitive and behavioral strategies and may be frequently juxtaposed within a CBT framework, depending on the nature of the problem and the specific available resources. Several common issues identified as being problematic for clinicians new to clinical work with older adults are highlighted, and useful information on how to adapt/modify traditional CBT approaches to augment treatment outcome with older adults is provided. Clinicians who use CBT will be familiar with most components discussed, but one novel augmentation towards the development of an age-appropriate format of CBT, termed Lifeskills Approach, is included. In this approach, clinicians are encouraged to identify and incorporate evidence of prior successful coping strategies to challenges that occur across the lifespan. This approach values and respects how clients have overcome aversive life experiences to facilitate attentional deployment away from a narrative of failure to one of resilience and self-acceptance, thereby down-regulating emotional distress. An important consideration discussed is how to use behavioral activation effectively, particularly with persons who have mild cognitive impairment (MCI) or are in the early stages of dementia.     

Delivering Transdiagnostic Treatment Over Telehealth During the COVID-19 Pandemic: Application of the Unified Protocol

The COVID-19 pandemic has necessitated an abrupt transition to remote delivery of psychology services at a time when patients and practicing clinicians are experiencing an increase in life stressors (e.g., job loss, social isolation, need to adapt to telehealth practice), which can exacerbate mental health concerns and contribute to clinician burnout. Because the COVID-19 pandemic is affecting diverse individuals in myriad ways, these circumstances can elicit a wide range of emotions and emotional responses. Thus, treatment during this time must be able to address heterogeneous presenting problems while placing minimal burden on clinicians who are adjusting to continuously changing circumstances. Transdiagnostic, emotion-focused, cognitive behavioral treatments (CBT), such as the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP), may be particularly well suited to address the challenges faced by practicing psychologists, and their patients, in the current COVID-19 pandemic. This paper discusses the applicability and adaptability of transdiagnostic treatments to telehealth, focusing primarily on the UP in the context of the COVID-19 pandemic. Further, while many CBT skills (e.g., mindfulness) can be easily translated to tele-delivery, other skills, such as exposure, can be more difficult to implement remotely, especially in the midst of a pandemic. Thus, this paper also provides practical suggestions for clinicians with regard to implementing the UP remotely.