The Heart of the Matter: An Essay about the Effects of Managed Care on Family Therapy with Children*

This essay is based on a pilot study that examined the effects of managed care on the treatment of children and families, with special attention to community mental health. We embarked on the pilot study to test the accuracy and generalizability of our impression that family therapy and other systemic practices have been marginalized in ordinary clinics and agencies, and to understand the reasons why. We interviewed managed care providers, researchers, family therapy trainers, and clinicians in the Northeast. Our findings led to seven themes that support our impression that, even though there is a consensus about the need for coordinated family-based services, there is a disconnection between state policies, contractual requirements and what is actually occurring at the implementation level. This study suggests that our knowledge of human systems may be in danger of being disqualified and lost, with damaging consequences for the care of children. Yet, as systemic thinkers and practitioners, it is our belief that ethical and effective treatment need not be at odds with care that is cost-efficient. The direction of our future research will be to study whether the involvement of all stakeholders at all levels of planning and training leads to systemic family-based practices that consistently save costs and provide high-quality care.     

In Vivo Hippocampal Acetylcholine Release During Exposure to Acute Stress

Hippocampal extracellular acetylcholine (ACh) and choline levels were evaluated using in vivo microdialysis in male Fischer 344 rats before, during, and following an 80-min exposure to two different stress conditions. Measurements were taken in rats restrained and immersed in a water bath containing either 37 degreesC (normothermic-restraint) or 20 degreesC (cold-restraint) water. Results were compared to normothermic-freely-moving rats. Cold-restrained rats displayed decreased ACh levels during cold exposure relative to both normothermic-restrained and normothermic-freely-moving rats. By the end of the cold exposure period and following removal from cold, ACh levels had returned to near-baseline values. Normothermic-restrained rats had levels similar to those of normothermic-freely-moving rats, except for a marked increase in ACh following removal from restraint. Cold-restrained rats displayed a gradual elevation in choline levels during cold stress, followed by a gradual decline after stress termination, whereas both normothermic-restrained and normothermic-freely-moving rats displayed gradual decreases during the microdialysis session. These findings demonstrate that central cholinergic neurotransmission can be altered by the application of, and removal from, acute stressors. In addition, the results suggest a possible relationship between the magnitudes of both the stressor and its cholinergic consequences.     

Bullying bystander behaviors: The role of coping effectiveness and the moderating effect of gender

Researchers have suggested that bystander behaviors and victim coping play an important role in counteracting the negative effects of bullying. The current study investigated the relationship between students’ ratings of coping effectiveness when addressing bullying and their behaviors as bystanders when witnessing bullying. Surveys were administered in a Midwestern, suburban school district. Some associations between perceptions of coping effectiveness and bystander behavior supported our hypotheses (e.g., constructive coping associated with defending bystander behaviors, externalizing associated with pro-bullying behaviors). However, some findings did not support hypothesized relationships. For example, higher ratings of effectiveness for cognitive distancing as a coping strategy were associated with increased defending behaviors as a bystander. Gender moderated some of these relationships. Pro-bullying bystander behavior was associated with increased ratings of cognitive distancing and decreased reports of constructive coping effectiveness for girls. Implications for future research and practice are discussed.     

Internalizing Trajectories in Young Boys and Girls: The Whole is Not a Simple Sum of its Parts

There is support for a differentiated model of early internalizing emotions and behaviors, yet researchers have not examined the course of multiple components of an internalizing domain across early childhood. In this paper we present growth models for the Internalizing domain of the Infant-Toddler Social and Emotional Assessment and its component scales (General Anxiety, Separation Distress, Depression/Withdrawal, and Inhibition to Novelty) in a sample of 510 one- to three-year-old children. For all children, Internalizing domain scores decreased over the study, although girls had significantly higher initial levels and boys had steeper declines. General Anxiety increased over the study period and, when modeled individually, girls evidenced higher initial levels and greater increases. For all children, Separation Distress and Inhibition to Novelty decreased significantly over time, while Depression/Withdrawal remained low without change. Findings from our parallel process model, in which all components were modeled simultaneously, revealed that initial levels of internalizing scales were closely associated while rates of change were less closely related. Sex differences in variability around initial levels and rates of change emerged on some scales. Findings suggest that, for one- to three-year-olds, examining scales of the internalizing domain separately rather than as a unitary construct reveals more meaningful developmental and gender variation.     

‘As in a theatre’: scientific spectacle in Bacon's New Atlantis

Essay review of Reclaiming Reality, by Roy Bhaskar, London: Verso, 1989, 218 pages, pb £10.95.     

Sleep disturbance and emotion dysregulation as transdiagnostic processes in a comorbid sample

Sleep disturbance and emotion dysregulation have been identified as etiologic and maintaining factors for a range of psychopathology and separate literatures support their relationships to anxiety, depression, PTSD, and alcohol dependence (AD) symptom severity. Previous studies have examined these relationships in isolation, failing to account for the high rates of comorbidity among disorders. It is not yet known whether these processes uniquely predict symptom severity in each of these domains. Participants were 220 patients in residential substance abuse treatment, who had experienced a potentially traumatic event and exceeded screening cutoffs for probable PTSD and problematic alcohol use. Controlling for emotion dysregulation and the interrelationships among the outcome variables, insomnia was uniquely associated with anxiety (B = .27, p < .001), depression (B = .25, p < .001), PTSD (B = .22, p < .001), and AD (B = .17, p = .01) symptom severity. Similarly, controlling for insomnia, emotion dysregulation was uniquely associated with anxiety (B = .40, p < .001), depression (B = .47, p < .001), PTSD (B = .38, p < .001), and AD (B = .26, p < .001) symptom severity. Insomnia and emotion dysregulation appear to be transdiagnostic processes uniquely associated with symptom severity across a number of different domains and might be important treatment targets for individuals with PTSD and AD.     

A Multi-Study Examination of Well-Being Theory in College and Community Samples

Well-being theory (WBT) proposes five indicators of well-being [i.e., positive emotion, engagement, relationships, meaning, achievement (PERMA)] that are, independently, empirically supported predictors of flourishing (i.e., an optimal level of well-being; Seligman in Flourish: a visionary new understanding of happiness and well-being. Free Press, NY, 2011). However, there is limited empirical support for the multidimensional model suggested by WBT. Two studies sought to test and validate the higher-order factor structure of the five components of PERMA and PERMA’s ability to predict concurrent and prospective flourishing outcomes (e.g., physical health, college success). In Study 1, a longitudinal examination of college students, participants completed measures of well-being (including four of the five PERMA indicators), physical health, and college success at the end of their sophomore, junior, and senior years. In Study 2, a larger, cross-sectional study was conducted online to further validate the PERMA model with a broader sample and all five PERMA indicators. Participants completed measures similar to those administered at Study 1 and other measures used to validate Study 1 measures. Results from Study 2 further validated the PERMA model by comparing Study 1 measures to established measures and by adding meaning to the model. Study 1 and Study 2 PERMA models predicted markers of well-being (e.g., vitality, life satisfaction) and flourishing (e.g., physical health). The two studies reported here provide cross-sectional and longitudinal support that WBT is useful for predicting flourishing.     

Group Cognitive Behavioral Treatment for PTSD: Treatment of Motor Vehicle Accident Survivors

Individual cognitive behavioral therapies (CBT) are now considered the first-line treatment for posttraumatic stress disorder (PTSD; Foa, Keane, & Friedman, 2000). As mental health reimbursement becomes more restricted, it is imperative that we adapt individual-format therapies for use in a small group format. Group therapies have a number of advantages, including provision of a natural support group, the ability to reach more patients, and greater cost efficiency. In this article, we describe the development of a group CBT for PTSD in the aftermath of a serious motor vehicle accident (MVA). Issues unique to the group treatment format are discussed, along with special considerations such as strategies to reduce the potential for triggering reexperiencing symptoms during group sessions. A case example is presented, along with discussion of group process issues. Although still in the early stages, this group CBT may offer promise as an effective treatment of MVA-related PTSD.     

The Vasarhelyi method of child art psychotherapy: an adjunctive treatment in childhood depression

We describe the use of child art psychotherapy (CAP) following the Vasarhelyi method in an 11-year-old female with a history of anxiety and depression which limited her capacity to attend school and in a 15-year-old male who had a history of depressive symptoms with suicidal thinking. In each case, the use of other therapies such as cognitive behaviour therapy was not possible or unsuccessful. Through the creation of images, each young person revealed concerns which had not been previously verbalised, and recovery was linked in time to the revelation of these worries. We propose the use of the Vasarhelyi method of CAP as an adjunctive treatment of depression in young people.     

Does comorbid attention-deficit/hyperactivity disorder impact the clinical expression of pediatric obsessive-compulsive disorder?

What is the impact of attention-deficit/hyperactivity disorder (ADHD) on the phenotypic expression of pediatric obsessive-compulsive disorder (OCD). We examined phenotypic features, and functional and clinical correlates in youths with OCD, with and without comorbid ADHD, from a large sample of consecutively referred pediatric psychiatry patients. Although comorbid ADHD had no meaningful impact on the phenotypic expression or clinical correlates of OCD, it was associated with higher rates of compromised educational functioning compared with other OCD youths. Our findings suggest that the OCD phenotype runs true and is not impacted by comorbid ADHD in youths diagnosed with both OCD and ADHD. In such affected youths, both disorders contribute to morbid dysfunction and require treatment. More work is needed to determine whether OCD plus ADHD represents a developmentally and etiologically distinct form of the OCD syndrome.