Enhancements to the Behavioral Parent Training Paradigm for Families of Children with ADHD: Review and Future Directions

Behavioral parent training (BPT) is one of the empirically supported psychosocial treatments for ADHD. Over many years and in many studies, BPT has been documented to improve both child ADHD behavior and maladaptive parenting behavior. In some studies, BPT has also been found to result in benefits in additional domains, such as parenting stress and child classroom behavior. However, the BPT literature on children selected as having ADHD lags behind research conducted on BPT for children selected as having oppositional defiant and conduct disorders (ODD and CD, respectively) with regard to examination of factors that may limit treatment attainment, compliance, and outcomes, such as single parenthood, parental psychopathology, and child comorbidity. Because of the high degree of comorbidity between ADHD and ODD/CD, it is difficult to separate the two BPT literatures. The parameters of BPT (e.g.. format and setting), parent factors, and child factors that may contribute to treatment outcomes for families of children with ADHD are reviewed here and recommendations for future BPT research in the area of ADHD are made.     

Idiographic outcome analyses of the clinical significance of two interventions for patients with musculoskeletal pain

This study adopted a perspective of the individual to define domains of everyday life for the analysis of clinically meaningful change. The purpose was to compare the clinical significance of two interventions for patients with musculoskeletal pain, applying an idiographic outcome measure, The Patient Goal Priority Questionnaire, in combination with the Jacobson and Truax methodology [(1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 67 (3), 300-307] for determination of clinical significance. The concurrent validity of the outcome variables behavioral performance, satisfaction with behavioral performance, and fulfilled pre-treatment expectations was also studied. Eighty-two patients, randomized to either individually tailored behavioral medicine treatment (experimental group) or physical exercise therapy (control group) were evaluated at baseline and 3 months post-treatment regarding behavioral treatment goals. The experimental intervention had high impact on participants' performance of their highest ranked everyday life activities, and resulted in larger proportions of clinically significant outcomes compared with controls. The concurrent validity of the outcomes was high for those reporting clinically significant changes, but more generally, there was a moderate agreement across outcome categories. The individual should be the unit for analyses of clinical significance to enhance the ecological validity of the construct. Further development of idiographic outcome measures is necessary, as is the inclusion in pain intervention research.     

Stimulus equivalence: testing Sidman's (2000) theory

Sidman's (2000) theory regarding the origin of equivalence relations predicts that a reinforcing stimulus common to distinct equivalence classes must drop out of the equivalence relations. This prediction was tested in the present study by arranging class-specific reinforcers, R1 and R2, following correct responding on the prerequisite conditional discriminations (Ax-Bx, Cx-Bx) for two stimulus classes, A1B1C1 and A2B2C2. A class-common reinforcer, R3, was presented following correct responding on the prerequisite conditional discriminations for a further two stimulus classes, A3B3C3 and A4B4C4. Sidman's theory predicts reinforcer inclusion within Classes 1 and 2 only, given this training arrangement. Experiment 1 tested for the emergence of four equivalence classes and of stimulus-reinforcer and reinforcer-stimulus relations in each class. Four of the 6 subjects demonstrated the reinforcer-based relations in all four equivalence classes, rather than in only those classes with a class-specific reinforcer, as Sidman's theory predicts. One of the remaining 2 subjects showed the reinforcer-based relations in three of the four classes. Experiment 2 extended these findings to document the emergence of interclass matching relations based on the common reinforcer R3, in 5 of 6 subjects, such that a Class 3 sample occasioned the selection of a Class 4 sample when the Class 3 comparison was absent, and similarly, a Class 4 sample occasioned the selection of a Class 3 comparison when the Class 4 comparison was absent. These interclass relations emerged despite the simultaneous maintenance of Class 3 and 4 baseline conditional discriminations, so that the Class 3 and 4 stimuli and reinforcer simultaneously were, and were not, part of a single larger equivalence class. These data are irreconcilable with Sidman's theory, and question the utility of the application of the equivalence relation in describing derived stimulus relations.     

A cross-cultural, long-term outcome evaluation of the ISTAR Comprehensive Stuttering Program across Dutch and Canadian adults who stutter

There is a need to evaluate the effectiveness of stuttering treatment programs delivered in domestic and international contexts and to determine if treatment delivered internationally is culturally sensitive. Evaluation of the effectiveness of the ISTAR Comprehensive Stuttering Program (CSP) within and across client groups from the Netherlands and Canada revealed generally positive results. At 2 years post-treatment both groups were maintaining statistically significant reductions in stuttering frequency and improvements in attitudes, confidence, and perceptions as measured by the Revised Communication Attitude Inventory (S24), Perceptions of Stuttering Inventory (PSI), and the approach scale of the Self-Efficacy Scaling by Adult Stutterers (SESAS). Data pooled across the groups on these measures gave evidence of a global treatment effect with standardized effect sizes ranging from typical to larger than typical in the behavioural sciences. Only two differences between the groups emerged: differences in speech rate and perception of self. Given that these groups represent two distinct cultures, differences were discussed in terms of whether they could be due to cultural, methodological, or other variables. Overall, results suggest that, the CSP appears to be similarly effective in both cultures and thus, sufficiently sensitive to the culture of Dutch adults who stutter.

Educational objectives: The reader will be able to (a) describe a methodology that can be used in a clinical setting to evaluate the long-term effectiveness of stuttering treatment with adults, (b) describe some of the challenges in developing a model of clinically meaningful outcome, (c) explain the rationale for the need for cross-cultural investigations of treatment outcome, and (d) summarize speech and self-report results of the cross-cultural evaluation of an integrated stuttering treatment program.     

Accuracy of a Rationally Derived Method for Identifying Treatment Failure in Children and Adolescents

Psychotherapy outcome can be enhanced by early identification of potential treatment failures before they leave treatment. In adults, compelling data are emerging that provide evidence that an early warning system that identifies potential treatment failures can be developed and applied to enhance outcome. The present study reports an analysis of early warning algorithms to identify treatment failures among child/adolescent patients (ages 3–18). The progress of 300 patients who had completed treatment was analyzed to see if algorithms could identify those children who ultimately had a negative outcome. Results indicated that the rationally derived method had a 77% success rate for identifying child/adolescent patients who were reliably worse or had deteriorated by the time that therapy was terminated.     

The clinical effectiveness of cognitive behaviour therapy: outcome for a large sample of adults treated in routine practice

There is increasing interest in questions about how far the demonstrated efficacy of psychological therapies in research trials can be translated into clinical effectiveness in routine practice. This paper summarises outcome data from several hundred patients treated with CBT in routine clinical practice in a National Health Service psychology service, and compares their outcomes with some of the published research. Although the data have flaws common in ordinary clinical practice (no untreated controls, missing data, uncontrolled pharmacotherapy, etc.), the analyses suggest that CBT in this context is an effective treatment, albeit with probably not quite such good results as it achieves in research trials. Using clinical significance statistics on standardised measures, about half of the sample reliably improved over a course of therapy, including about a third who recovered to normal range.     

Cognitive therapy versus interoceptive exposure as treatment of panic disorder without agoraphobia

Cognitive therapy (CT) and interoceptive exposure (IE) as treatments of panic disorder without agoraphobia were compared in a sample of 69 patients, randomly allocated to condition. There were no significant differences between treatments as to reductions in panic frequency, daily anxiety levels and a composite questionnaire score, at posttest after the 12-session treatment, and at both follow-ups (4 weeks, 6 months). In both conditions, high percentages of patients were panic free at post and follow-up tests (range 75-92%). Although the reduction in idiosyncratic beliefs about the catastrophic nature of bodily sensations was equally strong in both conditions, post-treatment beliefs correlated strongly with symptoms at post and follow-up tests in the CT condition, but not in the IE condition. Reduction of beliefs may be essential in CT, but not in IE. This suggests that the two treatments utilize different change mechanisms.     

Virtual reality treatment versus exposure in vivo: a comparative evaluation in acrophobia

The aim of the present study was to evaluate the effectiveness of low-budget virtual reality (VR) exposure versus exposure in vivo in a between-group design in 33 patients suffering from acrophobia. The virtual environments used in treatment were exactly copied from the real environments used in the exposure in vivo program. VR exposure was found to be as effective as exposure in vivo on anxiety and avoidance as measured with the Acrophobia Questionnaire (AQ), the Attitude Towards Heights Questionnaire (ATHQ) and the Behavioral Avoidance Test (BAT). Results were maintained up to six months follow-up. The present study shows that VR exposure can be effective with relatively cheap hardware and software on stand-alone computers currently on the market. Further studies into the effectiveness of VR exposure are recommended in other clinical groups as agoraphobics and social phobics and studies in which VR exposure is compared with more emerging virtual worlds as presented in CAVE-type systems.     

Supervisees' perspectives on the contribution of supervision to psychotherapy outcomes

Objective

The aim of this study was to examine supervisees' perspectives about the contribution of two predefined aspects of supervision, supervisory bond (SB) and didactic input of supervisor (DI), to their ascribed outcome of therapy.

Method

Supervisees anonymously assessed the SB, supervisors' DI and their contribution to therapy outcome. Assessment was quantitative and qualitative. The supervisory aspects were assessed using a questionnaire constructed for this study. Perceived contribution was evaluated by two scaled questions, and themes generated by an open question. Supervisees (n = 111) evaluated 16 supervisors and supervision’s contribution to psychotherapy outcomes of 111 clients.

Findings

Hierarchical regression showed that supervisees' age, supervisors' status and frequency of supervision accounted for 24% of the variance ascribed to outcome. SB and DI accounted for 51% of the variance. These values, which are higher than reported in the literature, may be attributed to the assessment of predefined aspects of supervision by the same assessor. Thematic analysis of the didactic input produced more themes than for the supervisory bond.

Conclusion

Sociodemographic variables and supervisory relationship variables determine supervisees' evaluations of supervision’s contribution to outcome.

Implications for practice

Training and supervision may benefit from information obtained from quantitative and qualitative measures regarding these and other predefined variables related to supervision. The in-depth look at views and experiences shared by supervisees may advance training, practice and research.