Might Relationship “Techniques” Extend the Reach, Efficacy, and Efficiency of the Psychotherapies? The Challenge of Treatment-Resistant Outpatients

Study-based clinical observations and two premises are presented as indications for a need to identify therapeutic relationship techniques or the like that can extend the reach and efficiency of the psychotherapies. The premises are: (1) advances in psychotherapy practice and research now highlight one of the field's most longstanding challenges, signified by terms like treatment resistance; and (2) some proportion of outpatients whose problems are resistant to the psychotherapies (and medications) have marked limitations in the capacity to relate positively and productively to others, including therapists. Thus, ironically, they cannot optimally utilize a treatment modality that largely has developed to ameliorate problems relating to others.     

Psychosocial Treatment Strategies in the MTA Study: Rationale, Methods, and Critical Issues in Design and Implementation

The Collaborative Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder (ADHD), the MTA, is the first multisite, cooperative agreement treatment study of children, and the largest psychiatric/psychological treatment trial ever conducted by the National Institute of Mental Health. It examines the effectiveness of Medication vs. Psychosocial treatment vs. their combination for treatment of ADHD and compares these experimental arms to each other and to routine community care. In a parallel group design, 579 (male and female) ADHD children, aged 7–9 years, 11 months, were randomly assigned to one of the four experimental arms, and then received 14 months of prescribed treatment (or community care) with periodic reassessments. After delineating the theoretical and empirical rationales for Psychosocial treatment of ADHD, we describe the MTA's Psychosocial Treatment strategy applied to all children in two of the four experimental arms (Psychosocial treatment alone; Combined treatment). Psychosocial treatment consisted of three major components: a Parent Training component, a two-part School Intervention component, and a child treatment component anchored in an intensive Summer Treatment Program. Components were selected based on evidence of treatment efficacy and because they address comprehensive symptom targets, settings, comorbidities, and functional domains. We delineate key conceptual and logistical issues faced by clinical researchers in design and implementation of Psychosocial research with examples of how these issues were addressed in the MTA study.Deceased     

The Parents Matter! Program Interventions: Content and the Facilitation Process

The Parents Matter! Program (PMP) has developed three interventions for parents of 4th and 5th grade African-American children (9–12 years old). The overarching goal of all three interventions is to provide parents with knowledge, skills, and support for enhancing their efforts to raise healthy children. The interventions are: (1) Enhanced Communication and Parenting (five 2 -hour sessions), (2) Brief Communication and Parenting (single 2 -hour session), and (3) General Health (single 2 -hour session). This article discusses the development of these interventions, presents an overview of the content of each intervention, and discusses issues related to the facilitation/presentation of these interventions.     

Training parents to implement pediatric feeding protocols

Four different multicomponent training packages were evaluated to increase the treatment integrity of parents implementing pediatric feeding protocols. In Study 1 we exposed 3 parents to a training package that consisted of written protocols (baseline), verbal instructions, therapist modeling, and rehearsal training. Results suggested that the package was successful in increasing treatment integrity of the feeding protocols to high levels. Study 2 investigated three different parent-training packages comprised of components used in Study 1. Two parents were exposed to written protocols, verbal instructions, and modeling; 2 parents were exposed to written protocols, verbal instructions, and rehearsal; and 2 parents were exposed to written protocols and verbal instructions. Results of Study 2 showed that each parent-training package produced very high treatment integrity. Follow-up data in the clinic and home for 5 participants suggested that the results were durable for up to 3 months. These results demonstrate a first step in the transfer and application of research findings into routine clinical practice because we evaluated several methods for training parents to implement behavioral feeding protocols, and we demonstrated that these methods resulted in high levels of treatment integrity in a controlled clinical setting.     

Corporal Punishment by American Parents: National Data on Prevalence, Chronicity, Severity, and Duration, in Relation to Child and Family Characteristics

We present data on corporal punishment (CP) by a nationally representative sample of 991 American parents interviewed in 1995. Six types of CP were examined: slaps on the hand or leg, spanking on the buttocks, pinching, shaking, hitting on the buttocks with a belt or paddle, and slapping in the face. The overall prevalence rate (the percentage of parents using any of these types of CP during the previous year) was 35% for infants and reached a peak of 94% at ages 3 and 4. Despite rapid decline after age 5, just over half of American parents hit children at age 12, a third at age 14, and 13% at age 17. Analysis of chronicity found that parents who hit teenage children did so an average of about six times during the year. Severity, as measured by hitting the child with a belt or paddle, was greatest for children age 5–12 (28% of such children). CP was more prevalent among African American and low socioeconomic status parents, in the South, for boys, and by mothers. The pervasiveness of CP reported in this article, and the harmful side effects of CP shown by recent longitudinal research, indicates a need for psychology and sociology textbooks to reverse the current tendency to almost ignore CP and instead treat it as a major aspect of the socialization experience of American children; and for developmental psychologists to be cognizant of the likelihood that parents are using CP far more often than even advocates of CP recommend, and to inform parents about the risks involved.     

Sequenced neurocognitive and behavioral parent training for the treatment of ADHD in school-age children

The present study examines the potential of sequencing a neurocognitive intervention with behavioral parent training (BPT) to improve executive functions (EFs), psychiatric symptoms, and multiple indices of functional impairment in school-age children aged 7 to 11 years who have been diagnosed with attention-deficit/hyperactivity disorder (ADHD). Specifically, in a randomized controlled trial design, 85 children were assigned to either Cogmed Working Memory Training (CWMT) followed by an empirically supported, manualized BPT intervention, or to a placebo version of CWMT followed by the same BPT intervention. Working memory maintenance (i.e., attention control/short-term memory), working memory processing and manipulation, ADHD and oppositional defiant disorder (ODD) symptoms, impairment in parent–child dynamics, familial impairment, and overall functional compromise were evaluated as outcomes. The results suggest specific effects of the combined CWMT and BPT program on verbal and nonverbal working memory storage and nonverbal working memory processing and manipulation but no incremental benefits in regard to ADHD symptoms, ODD symptoms, and functional outcomes. The present findings do not support the hypothesis regarding the complementary and augmentative benefits of sequenced neurocognitive and BPT interventions for the treatment of ADHD. These results, the study’s limitations, and future directions for research are further discussed.     

Evaluation of "the incredible years" in Sweden: the transferability of an American parent-training program to Sweden

Structured parent training has been proven to be effective in reducing disruptive behavior problems (DBP) in children. Most of the programs that are used in Sweden have their origin in North America, and there is an ongoing debate over the transferability to Sweden of manual-based programs developed in other contexts. The goal of the present study was to study effectiveness of the Incredible Years parent-training program (IY), developed in the US, in regular clinical work in Sweden, using a randomized controlled design. Parents of 62 four to eight-year-old children diagnosed with Oppositional Defiant Disorder participated in the study. Parents of 38 children were assigned to parent training (PT) and 24 to a waiting list (WL). The results indicate that the IYS retains the positive effects on children's disruptive behavior problems when translated and transferred to Swedish. There was a statistically significant difference in reduction of DBP in children between the groups in favor of the PT. The improvement in the PT group was sustained at the one-year follow-up. The improvement also, at least to some extent, generalized over time to the school context. There was also a statistically significant difference in mothers' report of pre to post change in parenting alliance between the PT and WL groups. The IYS program was appreciated and well received by the participating mothers.     

Children's human figure drawings do not measure intellectual ability

Children typically follow a well-defined series of stages as they learn to draw, but the rate at which they progress through these stages varies from child to child. Some experts have argued that these individual differences in drawing development reflect individual differences in intelligence. Here we assessed the validity of a drawing test that is commonly used to assess children’s intellectual abilities. In a single study, 125 5- and 6-year-olds completed the Draw-A-Person: A Quantitative Scoring System (DAP:QSS) and the Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-R) or the Wechsler Abbreviated Scale of Intelligence (WASI). Although there was a statistically significant correlation between scores on the DAP:QSS and scores on the Wechsler tests, when the scores of individual children were examined, the DAP:QSS yielded a high number of false positives and false negatives for low intellectual functioning. We conclude that the DAP:QSS is not a valid measure of intellectual ability and should not be used as a screening tool.