The Promise of Prevention for Conduct Problems in At-Risk Youth, Part 2

Courtesy of the Research Channel: (get Part 1 here)

“Dr. Robert McMahon, professor of psychology at the University of Washington, and Patrick Tolan, director of the Institute for Juvenile Research and professor of psychiatry and public health at the University of Illinois at Chicago, outline intervention methods and limitations in scientific knowledge that could one day identify and prevent conduct problems at an early age.”


The Promise of Prevention for Conduct Problems in At-Risk Youth, Part 1

Courtesy of the Research Channel:

Dr. Robert McMahon, professor of psychology at the University of Washington, and Patrick Tolan, director of the Institute for Juvenile Research and professor of psychiatry and public health at the University of Illinois at Chicago, outline intervention methods and limitations in scientific knowledge that could one day identify and prevent conduct problems at an early age.”


Evidence Based Treatments for Child and Adolescent Mental Health Disorders #2 – Eating Problems and Eating Disorders

In a previous post, I explored an article by Sally J. Rogers and Laurie A. Vismara on the state of early interventions for autism. The Rogers and Vismara article was one of a series of articles in a special issue of the Journal of Clinical Child and Adolescent Psychology exploring the evidence base for current child and adolescent mental health treatments. In this post, I explore an article by Pamela K. Keel and Alissa Haedt on the current status of psychosocial treatments for Eating Problems and Eating Disorders.

Details of the studies they reviewed

Keel & Haedt reviewed a total of 12 studies, of which the majority (8) focused on Anorexia Nervosa (AN), with the remaining 4 including a mix of Bulimia Nervosa (BN) and Eating Disorder Not Otherwise Specified (EDNOS). All of the studies were treatment control studies, meaning the therapy of interest was pitted against another type of therapy or control condition. Common practice for a long time was to pit the therapy of interest against waiting list controls (control participants go on a waiting list to receive therapy after the main group) or no-treatment controls (control participants do not receive a therapy). Interestingly with eating disorder studies, the tendency is to compare the treatment of interest to another potentially viable treatment. This is good for a couple of reasons; a) control group participants receive a potentially helpful intervention (better ethically) and b) the therapy of interest is required to prove itself against other treatment options, rather than just against a no-treatment condition (more rigorous methodologically).  In terms of methodological quality, 10 of the 12 studies were classified “Type 2″ meaning they were good quality clinical trials with only 1 or 2 components missing denying them “Type 1″ status as achieved by the other 2 studies. The quality of trials is important for multiple reasons, but simply put – the better the methodological quality of studies in an area (i.e., plenty of Type 1 and Type 2), the more confident we can be that the effects observed reflect real changes that could be achieved in clinical practice.

Study participants reflected a wide age range from 11.5 to 21 reflecting a child/adolescent/youth perspective and were mostly female (80-100% across the studies). Study sizes ranged from 13 to 86 participants and were generally two treatment comparisons (i.e., treatment vs treatment) with the exception of 1 study which had three treatment conditions. Given the child and adolescent focus the predominant therapy style was Family Therapy, with a few cognitive/behavioural type therapies and a couple of idiosyncratic therapies. Outcome measures were used routinely in all studies but there was significant variation across studies. BMI (Body Mass Index) and quantitative symptom measures were common outcomes along with varied mood and family functioning measures. There were a mix of therapists delivering the treatments. 7 of the 12 studies had psychologists, 5 had social workers followed by a mix of professionals from nursing, psychiatry and occupational therapy, similar to what you would expect in a modern multi-disciplinary CAMHS team.

Keel & Haedt also briefly reviewed 50 studies of treatments in adult populations, given the high proportion of adolescents in these studies, as this was informative on what approaches might are suggested for clients on the cusp of adulthood. In contrast to the 12 child/adolescent studies, the therapy focus in adult studies was cognitive/behavioural treatments with  1/2 of the 50 studies examining some kind of CBT (cognitive behavioural therapy) for BN.

What is suggested in the treatment of Anorexia in adolescents?

Anorexia, defined in the DSM-IV involves a refusal to maintain a minimally normal weight (e.g., weight below 85% of what would be expected), fear of gaining weight or becomming fat, cognitive distortions regarding weight (e.g., experiencing part or all of the body as fat despite emaciation) and loss of menstrual cycles (in menstrual teens). Although it affects less than 1% of the population, it can be severely debilitating and my understanding is the mortality rate from anorexia is the highest of any of the psychiatric illnesses.

Keel & Haedt’s review identified, for adolescents the most studied form of therapy is Family Therapy. There are many “schools” of Family Therapy and I will not pretend to be knowledgable about the distinctions between them. In simple terms though, Family Therapy views the family unit as the client, and through various strategies seeks to alter family dynamics hypothesized to have given rise to the individual’s symptoms. Typical strategies or processes might include: psychoeducation for family around the dangers faced by the client, minimizing blame and fault finding, altering family interactions around eating and the client’s symptoms, sustaining the cooperation of all family members and working with individuals in the family to change how they respond to the eating disorder. In anorexia, the most widely known and reported model of Family Therapy is the Maudsley Model, an intensive outpatient treatment that involves parents/caregivers heavily in the process of re-feeding the adolescent (weight restoration), re-establishing healthy family dynamics around eating and promoting the development of the adolescent’s non-eating-disorder identity. Common to Family Therapy models in eating disorders is the use of hospitalization in order to obtain a minimally health weight prior to commencing therapy. Often the therapy commences during hospitalization so the transition from hospital to home is easier.

Success-wise, for younger adolescents (17 below) the studies suggest 60-90% of patients will achieve good to intermediate outcomes, good being weight maintenance and return of menses, intermediate being weight maintenance only. This appears predicated on successful minimal weight restoration during hospitalization, that is, hospitalization is a critical part of the treatment. As for variation between different Family Therapy models, the literature is still quite young so these kinds of questions are difficult to answer. For example it is not clear whether there is a difference between separated or combined models (referring to whether or not the family are seen at the same time as the adolescent) or short versus long-term therapy models. What is promising is that family interventions following on from successful hospitalization leads to strong effects in the areas of weight gain in particularly.

In older adolescents (17-21), the picture is more varied and a variety of treatment modalities have shown some positive impact on anorexia symptoms. These include cognitive therapy, self psychology, body image therapy and a form of refeeding therapy. In cognitive therapy the focus is on behaviour change – setting goals for weight gain, challenging of core beliefs – particularly beliefs around control, achievement and approval, and relapse prevention – planning for future contingencies. In self psychology, a psychoanalytically driven therapy, eating disordered behaviour is viewed as a consequence of the patient substituting food for people to meet the needs of regulating self-esteem, self-nurturance & vitalization. In body image therapy, techniques such as virtual reality are used to help patients perceive their physical form more accurately. Finally in the refeeding therapy reviewed by Keel & Haedt called KPT (Kyoto Prefectural University of Medicine Behaviour Therapy), therapists use psychoeducation on the physical and metal consequences of starvation as well as the benefits of weight restoration through liquid meals.

As adolescents move into adulthood, current evidence suggests a movement towards as Keel & Haedt call it “nonspecific therapy”. I was a tad confused by this term, so I consulted a colleague of mine who has her finger on the eating disorder pulse. She described to me a model of therapy in which therapists with significant experience and knowledge of AN personalize therapy to the needs of the client. In her words “they did discuss at every appointment issues related to AN such as intake, BMI, etc.  But then they picked up on issues that were of priority to the patient”.

In summary, it appears that early presentations of anorexia (late childhood and adolescence) are best addressed through family therapy models, but as the adolescent moves into adulthood, individualized therapy protocols appear more effiacacious.

What is suggested in the treatment of Bulimia Nervosa in adolescents?

Bulimia Nervosa (BN), as defined by the DSM-IV involves the presence of both binge episodes (loss of control over eating and consuming an unusually large amount of food in a short-period) and innappropriate compensatory behaviours such as vomiting, laxative use, fasting, excessive exercise. In BN self-evaluation is unduly influenced by weight. More common than AN, with lifetime prevalence rates between 1.1 and 4.2% in USA, only a small proportion of sufferers actually receive mental health care.

For younger adolescents, similar to AN, Family Therapy (i.e, a version of the Maudsley Model) appears to be a promising treatment, when compared to non-directive supportive psychotherapy. However remission rates associated with the treatment were only in the 29-39% range over 6-months suggesting a large proportion remain symptomatic.

For older adolescents, guided self-help CBT appears to be promising with rates of abstinence from binge eating and compensatory behaviours on par with Family Therapy approaches. Interestingly, in my early training I gained a lot of experience providing guided self-help interventions for women with BN and found it to be a very potent form of intervention, mixing specific strategies (from the self-help book) with interpersonal contact and support.

In early adulthood, the emphasis in the research has definitely been on CBT, such that CBT is recognized as a well-established treatment for Bulimia. In CBT, therapists use a combination of behavioural (e.g., goal setting, behavioural experiements) and cognitive (e.g., thought challenging, cognitive defusion) strategies to reduce identification with eating disorder thoughts/feelings and promote healthy eating habits. It is hypothesized that given the success of CBT in adult samples, the same CBT protocols are probably appropriate for older adolescents (17-21).

In summary, it appears a similar trend exists in the treatment of Bulimia, in that early presentations in late childhood or early adolescence will respond to family interventions, whereas later presentations are more likely to respond to individualized cognitive-behavioural input.

Limitations

I hate throwing out this limitation when talking about reviews, but currently the number of studies in the area of treatment for child and adolescent eating disorder limits firm conclusions. Of the 12 studies found by Keel & Haedt, only 2 studies met full “Type 1″ criteria. The field is in need of big high quality controlled trials. There appears to be no child studies in this area and the authors of the review suggest we may need to expand our diagnostic profiles beyond anorexia and bulimia if we hope to capture the syndromes seen in childhood such as food avoidance, selective eating, functional dysphagia (difficulty swallowing) and food refusal. Given that symptoms of eating disorders are appearing in progressively younger populations, this is an important early intervention priority. A long-standing criticism of the eating disorder literature is the fact males are under-represented in the reported studies. Males make up 10-15% of those with eating disorders in the population yet generally constitute less than 5% of participants in treatment control studies.

My thoughts

The over-arching theme emerging from this review in my opinion is the developmental stance therapists should take in choosing treatment options for child and adolescent eating disorder presentations. Early presentations of both BN and AN appear to respond to family interventions, ensuring the family environment is conducive to re-establishing healthy eating habits and normal emotional development. As adolescents draw closer to adulthood, therapists should consider employing structured individualized programs focusing specifically on the thoughts, feelings and behaviours of the adolescent.

It is interesting that these findings parallel how I see the transition of mental health interventions through developmental stages. Interventions with infants, toddlers and young children are typically more family focused. The underlying philosphy here is that if you alter the context in which the behaviour occurs, you alter the function of the behaviour. As a child moves towards adolescence and developmentally towards independence and self-direction, therapeutic interventions are more likely to focus on the adolescent themselves, namely their thoughts, feelings and choices.

ResearchBlogging.org

Pamela Keel, Alissa Haedt (2008). Evidence-Based Psychosocial Treatments for Eating Problems and Eating Disorders Journal of Clinical Child & Adolescent Psychology, 37 (1), 39-61 DOI: 10.1080/15374410701817832

Special Issue Spotter: Attachment-related mental representations

attachmenthumanThe Journal “Attachment & Human Development” has a special issue focused on attachment representations, giving readers a taste of what modern researchers are doing with the concepts of John Bowlby.

Evidence Based Treatments for Child and Adolescent Mental Health Disorders #1 – Early Intervention In Autism

In a previous “Special Issue Spotter”, I linked to the January edition of the Journal of Clinical Child and Adolescent Psychology which published a 10-year review on evidence-based psychosocial treatments for children and adolescents. The edition is made up of a series of 10 review articles in which experts sift through the last 10 years of research in specific areas to identify best practice programs/ interventions. Over the next few months, I’d like to visit each of these 10 articles and draw out some of the key findings. In this post, I tackle the article by Sally J. Rogers and Laurie A. Vismara entitled “Evidence-Based Comprehensive Treatments for Early Autism”.

It seems the last 10 years have been much better for the early autism literature than the previous. As the authors note, when the original review was conducted in 1998, there were no randomized controlled trials of early autism interventions. In the current paper, 5 trials are included. In total, Rogers & Vismara review a total of 22 early autism interventions studies ranging in quality, scope, method, target group, intervention type and not surprisingly outcome. Whilst there is considerable variation between the studies, it is possible to summarize some of the characteristics of the studies.

Study Characteristics

Age of children: the age of the children involved in the studies ranges from 18 months to 72 months (6 years) with the majority falling in the 24 to 40 month age bracket (2 and 3 year old kids).

Diagnosis: Not surprisingly, the majority of the children meet criteria for Autism, Autism Spectrum Disorder or Pervasive Developmental Disorder Not Otherwise Specified.

Intervention Type: The range of interventions is probably the hardest to summarize, given a) the number of points of difference and b) that review articles are unable to provide extensive detail on the specific interventions. 16 of the 22 studies had manualized treatments, with only 2 studies looking specifically at “eclectic” treatments. Thus most interventions were based on a specific set of procedures. All interventions had behavioural components, focused specifically on shaping behaviours typically deficient in children with Autism (think language, social reciprocity, play, joint attention, self-help, recreational & academic skills). The length of interventions ranged from 12 weeks to 3 years, with intensity ranging from a couple hours per week to 40 hours per week direct intervention. Interventions were delivered by a mix of trained parents, trained workers, specialist early intervention consultants and trainee early intervention workers and delivered across a range of settings (childcare, home, clinic). Some interventions focused on the children themselves (e.g., direct training) whilst others others focused on upskilling the various agents in the child’s life (e.g., parent, childcare worker).

What treament(s) stand out?

Getting recognition as a “well established” treatment in the research literature is a complex task. Without going into extensive detail (Chambless & Hollon, 1998; Nathan & Gorman, 2002 are good starting points), a treatment must be well manualized and defined, so others can replicate the therapy in a different setting; the studies that have evaluated the treatment need to be of high quality; and the outcomes of the studies must show the treatment to be superior to no treatment (or best available treatment if going up against already well established treatments). In the early intervention for Autism field, only one treatment currently meets these criteria (Lovaas). That being said, many of the treatment programs for early intervention in Autism are based on similar theory (i.e., Applied Behaviour Analysis – ABA) and it may simply be a matter of time before they have been sufficiently well evaluated and we have a larger range of established treatment programs. In terms of treatment characteristics, Rogers & Vismara’s review does suggest that programmatic treatments with specific methods built on core theory are better than “eclectic” treatments drawing upon multiple factors. There is also the suggestion (as I read it) that clinic-based, focused daily interventions over long time periods (> 1 year) lead to greater effects thans shorter interventions, although shorter trials do show effects and it may point to a common finding in psychotherapeutic interventions that early response to treatment is a predictor of overall response.

Lovaas Method: The Lovaas method (described on their website), is an time-intensive (5-7 days per week, 2-8 hours per day for up to 3 years), individualized behaviour program for children aged 2-8 that focuses on shaping specific behaviours, particularly around language, social interaction, ability to learn as well as the reduction of inappropriate or destructive behaviours. Delivered by trained professionals, typically in a clinic-based environment, the treatment is intensive, gradual (shaping behaviours through successive approximations) and involves parents in addition to the instructor. It is a type of Discrete Trial Training (DTT) program in which the instructor leads the way in shaping specific behaviours in the child.  Results from the original Lovaas study (1987) showed a 47% “recovery” rate, namely these children attained a normal IQ and tested within the normal range on adaptive and social skills. Subsequent replication studies (Smith, Groen, and Wynn, 2000; Sallows and Graupner, 2005) have demonstrated positive outcomes also. Whilst both studies demonstrated significant improvements in IQ as a result of the intervention, with Sallows & Graupner showing a similar “recovery rate” to the original Lovaas study, there are multiple disclaimers. First, Smith, Groen & Wynn’s subjects did not show the same degree of IQ change, did not improve on measures of adaptive or social functioning and the gains were limited to those subjects with a PDDNOS diagnosis (i.e., not full autism). Sallows & Graupner’s subjects were provided with a augmented version of Lovaas program (involving components of Pivotal Response Training) and a significant portion (12 of 23) showed no improvement even after 4 years of therapy.

Pivotal Response Training: Whilst not getting a “well established” treatment guernsey, Pivotal Response Training (PRT) does get a special mention as a “probably efficacious” treatment. Information from the PRT website (http://psy3.ucsd.edu/~autism/prttraining.html) describes PRT as a naturalistic treatment approach, built upon the same applied behaviour analysis (ABA) theory as Lovaas but employing a different method of learning.  Unlike DTT where the instructor shapes skills according to a specific curriculum, PRT reinforces naturally occuring behaviours demonstrating “motivation” and “responsivity to cues”, particularly those around language, social interaction and play.

What improvements can parents expect for their children from these types of treatments?

Current evidence suggests children involved in these types of programs may demonstrate accelerated intelligence & developmental gains (i.e., age appropriate performance), improvements in use of language/communication and adaptive behaviour (i.e., behaviours that make up our daily life – toileting, dressing, feeding etc) and significant reductions in problematic behaviours (e.g., aggression). In best case scenarios, current evidence does suggest the possibility of “recovery” whereby the child is able to return to standard school placements and demonstrate adaptive behaviour at the level of a “normal” child. This should be interpreted with extreme caution though, as Rogers & Vismara point out, the “best” studies in the area have not demonstrated this “recovery” effect and hope for recovery comes from earlier, less rigorous trials and the recovery rate appears, at this stage, to be capped at 50% (i.e., 1 in 2 children may show this level of improvement). Aside from the direct effects on the child, it should also be noted that parents and childcare workers involved in many of these studies reported considerably improved knowledge about autism and how to respond to behaviours more appropriately.

Caveats on these improvements – what you should also know

When a body of research gets sufficiently large enough, researchers can start looking at what are called “predictors of treatment outcome”. These are characteristics of the treatment or the clients that predict how well the clients will respond to the treatment. Whilst still a relatively young research field, Rogers & Vismara’s article does suggest a number of potential predictors that professionals and parents should be aware of. Specifically, children who are likely to do better in treatment are those:

  • Who have a less severe initial presentation – for example, better response to treatment is often found in those children not meeting full autism criteria (pervasive developmental disorder not otherwise specified PDDNOS)
  • Whose autism is identified earlier – the earlier the intervention the better
  • Whose initial IQ (intelligence) is higher
  • Who receive longer treatments – although interestingly this does not yet seem to be related to actual therapy time, but the period of time over which therapy is conducted
  • Whose treatment also includes specific efforts to integrate it into the family’s life
  • Who show less dysmorphology (unusual physical features)
  • Who are more socially initially (i.e., show more spontaneous social initiation) – although it has also been found that those children with greater social avoidance initially show the greatest improvement over time, so this one is a little contradictory.

Primarily, it appears as though the more functional the child is pre-treatment, the better they respond to treatment overall. From reading the review, it appears as a sad fact that many of the children with severe initial presentations (low IQ, communication and social interaction particularly) do not respond as favourably to the treatments currently available.

Evaluating Programs (advice for professionals and parents)

Rogers & Vismara provide an excellent set of suggestions for parents and professionals looking to access programs for children. Specifically, they suggest that professionals and parents should look for programs that:

a) use positive behaviour management & functional behaviour analysis to address unwanted or challenging behaviours

b) provide regular daily opportunities for spontanous communication

c) capitalize on naturalistic teaching methods involving child’s preferences to increase motivation, and generalization

d) seek to provide intervention across multiple settings, specifically home, special classrooms & inclusive settings

e) provide opportunities for peer interactions

f) push to generalize gains

g) involve parents and family members

h) regularly monitor progress

i) co-ordinate care across different settings

j) address other factors, not just the progress of the child (e.g., family health)

Final Thought

Rogers & Vismara’s article is fundamentally a snapshot of the current state of affairs with regards to early intervention treatments in Autism. As such it does not enter into the debate/discussion that I have seen on the web around attitudes towards autism and whether we have become too focused on identifying the problems associated with autism and not recognizing the unique world view that people with autism and autism spectrum disorders bring to our society. In doing this blog post, I have purposefully come from the angle of simply trying to extract from Rogers and Vismara’s article, some of the key findings relating to treatment, so that those searching for this kind of information are aware that these reviews are being written. I am happy to take comments from anyone though who wants to address the issue of treating autism as I am particularly open minded on the issue myself.

ResearchBlogging.org

Sally Rogers, Laurie Vismara (2008). Evidence-Based Comprehensive Treatments for Early Autism Journal of Clinical Child & Adolescent Psychology, 37 (1), 8-38 DOI: 10.1080/15374410701817808

Special Issue Spotter: Using Technology to Address Child Maltreatment

The Journal “Child Maltreatment” has a special issue on using technology to address child maltreatment. If child welfare is your area, you might find one of the topics covered interesting

- Use of mobile phones for assessment and as an adjunct to therapy

- Internet-based therapeutic interventions

- Media and television interventions

- Web conferencing for case management

- Tele-medicine dissemination of Parent Child Interaction Therapy

- Database and data mining technologies for welfare agencies

Use of technology in child maltreatment prevention

Special Issue Spotter: Evidence-based Assessment in Pediatric Psychology

The Journal of Pediatric Psychology has just published a special issue on assessment practices in pediatric psychology. Articles cover best practice on assessment across a range of domains; medical, psychosocial, quality of life, cognitive functioning, coping, stress and family functioning. Accessible to those with individual or institutional subscriptions.

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