A transactional model of oppositional behavior: underpinnings of the Collaborative Problem Solving approach

Family Partner: study protocol for a pilot randomised study of a home-visitation intervention in Norway

AIM

Every year, about 5% of children in Norway experience severe child maltreatment and need support from the child welfare services. However, research-supported interventions for this group are lacking. The current study piloted an intensive home-visitation intervention, Family Partner, which aims to reduce child maltreatment among at-risk parents by improving parental skills, agency and trust in the welfare services, and children's well-being. The randomised controlled trial piloted in this study examines the acceptability of the Family Partner intervention for staff and families and evaluates its feasibility for a full-scale randomised controlled trial.

METHODS

This protocol outlines a prospective, parallel, pilot randomised trial of the Family Partner intervention in three Norwegian municipal child welfare services. The participants are families with children under 12 years of age, where the parents are identified as having challenges. Families in the treatment group receive the Family Partner intervention, while families in the control group receive ordinary child welfare services. Data are collected at baseline, and at 3, 6, 12 and 18 months after recruitment. The pilot study monitor retention and adherence to inform the feasibility of a future full-scale randomised study. To assess the acceptability of the trial and intervention, a subsample of the participating families, as well as the family partners and representatives of the child welfare services in each municipality, are invited to complete qualitative interviews.

CONCLUSIONS

The results will guide the design of a fully powered randomised controlled trial of the Family Partner intervention compared with ordinary child welfare services.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04957394; Pilot Trial of Family Partner: a Child Maltreatment Prevention Intervention (FAMPART); registered on 12 July 2021.

Mediators and moderators of the effects of the COVID-19 crisis on parent-child conflict in children in tertiary mental health care

This study focused on children treated for mental health problems during the pandemic. The present study examined how parent's difficulties in managing COVID-19 restrictions increased children's behavioral problems (internalizing and externalizing) and parent-child conflict through parental mental health and parental stress. Family functioning, particularly problem-solving ability, was tested as a resilience factor. were collected using online surveys from 337 parents with a child between the ages of 4 and 18 years who was receiving active outpatient mental health treatment at a pediatric tertiary care center. Parents who reported a greater impact of COVID-19 reported more behavioral difficulties in their children. This relationship was significantly mediated by parental mental health (general stress, anxiety, and depression) and parental stress. Similar indirect pathways were observed when examining internalizing and externalizing problems in children, where the most significant pathway had parental stress as the sole mediator. Furthermore, the effect of COVID-19 impact on parent-child conflict through parental stress was significantly moderated by problem-solving skills within the family. Parenting stress mediates the impact of COVID-19 on parent-child conflict. Interventions improving within family problem solving-skills may decrease the effect of parental stress on parent-child conflict.

Conceptualizing the Role of Parent and Child Emotion Regulation in the Treatment of Early-Onset Behavior Disorders: Theory, Research, and Future Directions

Behavior disorders (BDs) are common and costly, making prevention and early-intervention a clinical and public health imperative. Behavioral Parent Training (BPT) is the standard of care for early-onset (3-8 years old) BDs, yet effect sizes vary and wane with time suggesting the role of underlying factors accounting for variability in outcomes. The literature on emotion regulation (ER), which has been proposed as one such underlying factor, is reviewed here, including a brief overview of ER, theory and research linking ER, externalizing symptoms, and/or BDs, and still largely preliminary work exploring the role of parent and child ER in BPT outcomes. Research to date provides clues regarding the interrelationship of ER, BDs, and BPT; yet, determining whether adaptations to BPT targeting ER are necessary or useful, for whom such adaptations would be most important, and how those adaptations would be implemented requires addressing mixed findings and methodological limitations. To guide such work, we propose a conceptual model elucidating how standard BPT may impact ER and processes linked to ER, which we believe will be useful in organizing and advancing both basic and applied research in future work.

Parental and Familial Predictors and Moderators of Parent Management Treatment Programs for Conduct Problems in Youth

Despite the established efficacy of Parent Management Training (PMT) for conduct problems in youth, evidence suggests that up to half of all treated youth still display clinical levels of disruptive behavior post-treatment. The reasons for these unsatisfactory outcomes are poorly understood. The aim of the present review was to provide an updated analysis of studies from the past 15 years that examined parental and familial predictors and moderators of improvement in PMT for conduct problems. A systematic literature review of indicated prevention (children with conduct problem symptoms) and intervention (children with clinical diagnoses) studies published between 2004 and 2019 was conducted. This 15-year time period was examined since the last systematic reviews were reported in 2006 and summarized studies completed through mid-2004 (see Lundahl et al. in Clin Psychol Rev 26(1):86-104, 2006; Reyno and McGrath in J Child Psychol Psychiatry 47(1):99-111, 2006). Risk of bias indices was also computed (see Higgins et al. in Revised Cochrane risk of bias tool for randomized trials (RoB 2.0), University of Bristol, Bristol, 2016) in our review. A total of 21 studies met inclusion criteria. Results indicated that a positive parent-child relationship was most strongly associated with better outcomes; however, little additional consistency in findings was evident. Future PMT research should routinely examine predictors and moderators that are both conceptually and empirically associated with treatment outcomes. This would further our understanding of factors that are associated with poorer treatment outcome and inform the development of treatment components or modes of delivery that might likely enhance evidence-based treatments and our clinical science. Protocol Registration Number: PROSPERO CRD42017058996.

The Role of Irritability in the Treatment of Behavior Disorders: A Review of Theory, Research, and a Proposed Framework

Research provides strong evidence that the symptoms of Oppositional Defiant Disorder (ODD) are comprised of at least two dimensions: irritability and defiance. Given that these two dimensions have distinct etiologies and long-term risk profiles, they may also warrant different treatment approaches. In particular, impaired emotion regulation plays a central role in the irritable dimension of ODD. As such, this subgroup of youth and their families may benefit from greater consideration of and attention to emotion-focused strategies than is standard in traditional Behavioral Parent Training (BPT) approaches. In support of this hypothesis, this review will (1) examine the etiological models guiding the theoretical approach to standard BPT; (2) evaluate theory and research on emotion socialization broadly and its role in the etiology and maintenance of irritability in children with BDs; (3) propose an emotion socialization-based etiological model for the irritable dimension of child oppositionality; and (4) argue for the use of emotion-focused parent training in the treatment of such youth. Clinical implications, gaps in the current state of the literature, and future directions for research will also be discussed.

Individual Therapy on Inpatient Units: Flexibility in the Face of Resistance

The length of stay for inpatient adolescent admissions has decreased significantly over time.¹ This has forced a reframing of the purpose of hospitalization as being focused on the tasks of maintaining safety, clarifying a diagnosis, optimizing medication, and arranging ongoing care. There are thus no standard approaches for the delivery of individual therapy that accommodate the complexity, heterogeneity, acuity, and time limitations of the inpatient setting. That being said, efforts continue to be made to provide some form of therapeutic engagement on inpatient units that goes beyond psychiatric assessment and basic nursing intervention. In this perspective, we describe a targeted approach toward individual therapy during acute hospitalization. This approach is applied successfully on a general inpatient adolescent unit in New England that maintains a low rate of restraints, seclusions, and readmission. Our unit treats verbal adolescents (younger youths and adolescents with significant cognitive or social learning limitations are accommodated in other settings within our community), but aspects of the approach have broader applicability. Guiding principles are drawn from a range of theoretical approaches, including collaborative problem solving,² trauma-informed care,³ and strength-based care⁴ (Table 1). The program involves staff (activity therapists and nurses) being educated around key principles of a range of therapy modalities, which are then modeled by program leadership in multidisciplinary settings, such as walking rounds and group meetings. The approach is then incorporated into how the patient is engaged throughout the milieu. Staff education begins during initial onboarding to the unit, but then occurs in an iterative way as new patients with new therapeutic needs enter the milieu.

What nonpharmacological therapeutic interventions are provided to adolescents admitted to general mental health inpatient units? A descriptive review

Limited research exists regarding the therapeutic operations of adolescent mental health inpatient units, particularly in terms of nonpharmacological therapeutic interventions. This review collates what is known about reported nonpharmacological therapeutic interventions for young people admitted to general or non-disorder-specific adolescent mental health inpatient settings. A descriptive review of this nature was not located in the literature. The aim was to identify what is currently known about reported nonpharmacological therapeutic interventions. The purpose was to consider gaps and contribute to further work being undertaken in describing an exemplary inpatient model of care for adolescents. Sources included CINAHL, MEDLINE, ERIC, EMBASE, and PsycINFO. Studies included were those published in English, between the years 2000 and 2018. Exclusions included residential, community, outpatient, forensic settings, and studies detailing pharmacological interventions. Ten studies were identified. This descriptive review provides an objective foundation to inform an exemplary inpatient model of care currently being investigated. There is a critical need to understand these interventions to identify key components of an inpatient model of care. Such knowledge will provide guidance for future services seeking to create an exemplary model of care. Furthermore, these results can influence current practice by improving quality and delivery of inpatient care.

Assessment of Behavioral Problems in Children With Hearing Loss

OBJECTIVE

To compare the prevalence of disruptive behavior problems between preschool-aged children with hearing loss and normal hearing.

STUDY DESIGN

Cross-sectional study.

SETTING

Tertiary academic center.

PATIENTS

Caregivers of children (2-5 yr old) with normal hearing (NH) (n = 39), hearing loss using hearing aid(s) (HA) (n = 29), or cochlear implant(s) (CI) (n = 21).

INTERVENTION(S)

Demographic information and a mental health history were obtained. Child behavior and language development were assessed.

MAIN OUTCOME MEASURE(S)

The Young Child-Diagnostic Interview Schedule for Children-IV and the MacArthur-Bates Communication Development Inventory III.

RESULTS

Distributions of race, socioeconomic status, insurance status, and parental home situation (single versus two parent family) were similar across all groups. Parents of children with hearing loss were significantly more likely to report behavior problems (HA = 41%, CI = 38%) than parents of NH children (10%; p = 0.002). Children with hearing loss were significantly more likely to meet diagnostic criteria for oppositional defiant disorder (HA = 48%, CI = 48%) than NH children (23%; p = 0.02). More NH children (8%) than hearing impaired children (0%) had accessed mental health services (p = 0.08). NH children were found to have more advanced language development than hearing-impaired children (p < 0.01), but controlling for Communication Development Inventory III percentiles, the observed behavioral differences remained.

CONCLUSION

Controlling for language development, children with hearing loss have higher prevalence of and impairment from disruptive behaviors than their NH peers. These children are less likely to receive appropriate behavioral interventions. Further research is warranted to investigate the impact of disruptive behaviors on speech and hearing rehabilitation. Methods to improve access to effective behavioral interventions in this population are needed.

Mental health of the male adolescent and young man: the Copenhagen statement

BACKGROUND

Male adolescents and young men benefit when their mental health care is specialized to match their unique gendered and developmental needs. Sensitivity to the social circumstances of this population is important; additionally, the emerging ability to tailor care through knowledge gleaned from the intersection of psychiatry, neurology, and endocrinology informs care.

DATA SOURCES

This article summarized the views of six experts in the area of the adolescent and young adult male mental health. These experts were select members of the World Federation of Societies of Biological Psychiatry's Task Force on Men's Mental Health. They convened to present two symposia on the topic of men's mental health at the 13th World Congress of Biological Psychiatry (WCBP) in Copenhagen, Denmark in 2017.

RESULTS

In these works, a special focus is paid to addictive disorders, disruptive behavior disorders, aggression, and brain development. Collectively, the authors present an argument for the merits of a male-specific model of mental health care to advance the overall well-being of this population.

CONCLUSIONS

Men's mental health should be recognized as a social issue as much as a medical issue, with special attention paid to problems such as unemployment, familial disruption, and substance abuse. These problems, and especially those of major societal impact including violence and suicide which are much more frequently the product of male youth and men, should have more male-tailored options for service provision that respond to men's mental health needs.

The Effect of a New Therapy for Children with Tics Targeting Underlying Cognitive, Behavioral, and Physiological Processes

Tourette disorder (TD) is characterized by motor and vocal tics, and children with TD tend to present a lower quality of life than neurotypical children. This study applied a manualized treatment for childhood tics disorder, Facotik, to a consecutive case series of children aged 8-12 years. The Facotik therapy was adapted from the adult cognitive and psychophysiological program validated on a range of subtypes of tics. This approach aims to modify the cognitive-behavioral and physiological processes against which the tic occurs, rather than only addressing the tic behavior. The Facotik therapy lasted 12-14 weeks. Each week 90-min session contained 20 min of parental training. The therapy for children followed 10 stages including: awareness training; improving motor control; modifying style of planning; cognitive and behavioral restructuring; and relapse prevention. Thirteen children were recruited as consecutive referrals from the general population, and seven cases completed therapy and posttreatment measures. Overall results showed a significant decrease in symptom severity as measured by the YGTSS and the TSGS. However, there was a discrepancy between parent and child rating, with some children perceiving an increase in tics, possibly due to improvement of awareness along therapy. They were also individual changes on adaptive aspects of behavior as measured with the BASC-2, and there was variability among children. All children maintained or improved self-esteem posttreatment. The results confirm the conclusion of a previous pilot study, which contributed to the adaptation of the adult therapy. In summary, the Facotik therapy reduced tics in children. These results underline that addressing processes underlying tics may complement approaches that target tics specifically.

Antecedents of the child behavior checklist-dysregulation profile in children born extremely preterm

OBJECTIVE

Extremely preterm newborns are at heightened risk for emotional and behavioral dysregulation later in childhood. Our goal was to systematically evaluate the antenatal and early postnatal antecedents that might mediate the association between extreme preterm birth and emotional and behavioral dysregulation at age 2 years (corrected age).

METHOD

In a multi-site prospective study, the parents of 826 infants born before 28 weeks gestation completed a Child Behavior Checklist (CBCL) when the child was 2 years corrected age. We compared the maternal, pregnancy, placenta, delivery, and newborn characteristics, as well as early postnatal characteristics and exposures of those who satisfied criteria for the CBCL-Dysregulation Profile (CBCL-DP) to those of their peers. We then used time-oriented logistic regression models, starting first with antenatal variables that distinguished children with the CBCL-DP profile from their peers, and then added the distinguishing postnatal variables.

RESULTS

Approximately 9% of the children had a CBCL-DP. In the time-oriented logistic regression model with antenatal variables only, low maternal education achievement, passive smoking, and recovery of Mycoplasma from the placenta were associated with increased risk, whereas histologic chorioamnionitis was associated with reduced risk. None of the postnatal variables added statistically significant discriminating information.

CONCLUSION

Very preterm newborns who later manifest the CBCL-DP at age 2 years differ in multiple ways from their preterm peers who do not develop the CBCL-DP, raising the possibility that potentially modifiable antenatal and early postnatal phenomena contribute to the risk of developing emotional and behavioral dysregulation.

Genome-wide association study of proneness to anger

Background

Community samples suggest that approximately 1 in 20 children and adults exhibit clinically significant anger, hostility, and aggression. Individuals with dysregulated emotional control have a greater lifetime burden of psychiatric morbidity, severe impairment in role functioning, and premature mortality due to cardiovascular disease.

Methods

With publically available data secured from dbGaP, we conducted a genome-wide association study of proneness to anger using the Spielberger State-Trait Anger Scale in the Atherosclerosis Risk in Communities (ARIC) study (n = 8,747).

Results

Subjects were, on average, 54 (range 45–64) years old at baseline enrollment, 47% (n = 4,117) were male, and all were of European descent by self-report. The mean Angry Temperament and Angry Reaction scores were 5.8±1.8 and 7.6±2.2. We observed a nominally significant finding (p = 2.9E-08, λ = 1.027 - corrected p_gc = 2.2E-07, λ = 1.0015) on chromosome 6q21 in the gene coding for the non-receptor protein-tyrosine kinase, Fyn.

Conclusions

Fyn interacts with NDMA receptors and inositol-1,4,5-trisphosphate (IP3)-gated channels to regulate calcium influx and intracellular release in the post-synaptic density. These results suggest that signaling pathways regulating intracellular calcium homeostasis, which are relevant to memory, learning, and neuronal survival, may in part underlie the expression of Angry Temperament.

A review of the nurtured heart approach to parenting: evaluation of its theoretical and empirical foundations

The Nurtured Heart Approach to parenting (NHA; Glasser & Easley, 2008) is summarized and evaluated in terms of its alignment with current theoretical perspectives and empirical evidence in family studies and developmental science. Originally conceived and promoted as a behavior management approach for parents of difficult children (i.e., with behavior disorders), NHA is increasingly offered as a valuable strategy for parents of any children, despite a lack of published empirical support. Parents using NHA are trained to minimize attention to undesired behaviors, provide positive attention and praise for compliance with rules, help children be successful by scaffolding and shaping desired behavior, and establish a set of clear rules and consequences. Many elements of the approach have strong support in the theoretical and empirical literature; however, some of the assumptions are more questionable, such as that negative child behavior can always be attributed to unintentional positive reinforcement by parents responding with negative attention. On balance, NHA appears to promote effective and validated parenting practices, but its effectiveness now needs to be tested empirically.

Factors associated with the use of intrusive measures at a tertiary care facility for children and youth with mental health and developmental disabilities

This study seeks to identify some of the explanatory factors associated with the use of intrusive measures among children with mental health and developmental disabilities in psychiatric facilities. Intrusive intervention data were collected using an organizational database that was developed internally at a tertiary care facility. The sample was composed of 338 children/youth aged between 6 and 18 years (mean = 12.33, standard deviation = 2.70) admitted within a 2-year period. Logistic regression was used to examine the relationship between chemical restraint, physical restraint and secure isolation, and programme type after controlling for demographic and other relevant client characteristics. The study found that the number of chemical restraints and secure isolations was higher for clients with developmental disabilities than for clients with mental health, whereas the number of physical restraints was lower for clients with developmental disabilities than clients with mental health issues. Demographic variables also predicted specific types of intrusive measures. The results of this study outline the differential factors associated with specific types of intrusive measures to control aggressive and self-harm behaviours. The paper also outlines cultural change initiatives, organizational interventions, and policy implications for best practice services for children/youth in psychiatric facilities to further reduce intrusive measures.

The in vivo adherence intervention for at risk adolescents with asthma: report of a randomized pilot trial

OBJECTIVE

Low-income and minority adolescents are at high risk for poor asthma outcomes, due in part to adherence. We tested acceptability, feasibility, and effect sizes of an adherence intervention for low socioeconomic status (SES) minority youth with moderate- and severe-persistent asthma. Design and Methods Single-site randomized pilot trial: intervention (n = 12; asthma education, motivational interviewing, problem-solving skills training, 1 month cell-phone with tailored text messaging) versus control (n = 14; asthma education; cell-phone without tailored messaging). Calculated effect-sizes of relative change from baseline (1 and 3 months).

RESULTS

Intervention was judged acceptable and feasible by participants. Participants (12-18 years, mean = 15.1, SD = 1.67) were 76.9% African-American, 80.7% public/no insurance. At 1 and 3 months, asthma symptoms (Cohen's d's = 0.40, 0.96) and HRQOL (PedsQL™; Cohen's d's = 0.23, 1.25) had clinically meaningful medium to large effect sizes.

CONCLUSIONS

This intervention appears promising for at-risk youth with moderate- and severe-persistent asthma.

Genome-wide association study of the child behavior checklist dysregulation profile

OBJECTIVE

A potentially useful tool for understanding the distribution and determinants of emotional dysregulation in children is a Child Behavior Checklist profile, comprising the Attention Problems, Anxious/Depressed, and Aggressive Behavior clinical subscales (CBCL-DP). The CBCL-DP indexes a heritable trait that increases susceptibility for later psychopathology, including severe mood problems and aggressive behavior. We have conducted a genome-wide association study of the CBCL-DP in children with attention-deficit/hyperactivity disorder (ADHD).

METHOD

Families were ascertained at Massachusetts General Hospital and University of California, Los Angeles. Genotyping was conducted with the Illumina Human1M or Human1M-Duo BeadChip platforms. Genome-wide association analyses were conducted with the MQFAM multivariate extension of PLINK.

RESULTS

CBCL data were available for 341 ADHD offspring from 339 ADHD affected trio families from the UCLA (N = 128) and the MGH (N = 213) sites. We found no genome-wide statistically significant associations but identified several plausible candidate genes among findings at p < 5E-05: TMEM132D, LRRC7, SEMA3A, ALK, and STIP1.

CONCLUSIONS

We found suggestive evidence for developmentally expressed genes operant in hippocampal dependent memory and learning with the CBCL-DP.

Neuroanatomy of childhood disruptive behavior disorders

Our aims were to (1) examine possible neuroanatomical abnormalities associated with the Disruptive Behavior Disorders (DBDs) as a group and (2) assess neuroanatomical anomalies specific to each DBD (i.e., conduct disorder [CD] and oppositional defiant disorder). Cortical thickness analysis and voxel-based morphometry were analyzed in 47 8-year-old boys (22 DBDs with and without CD and/or ODD and 25 healthy controls) from Magnetic Resonance Imaging brain scans. DBD symptoms were assessed using the Dominic-R. In DBD subjects relative to controls, we found (1) a decreased overall mean cortical thickness; (2) thinning of the cingulate, prefrontal and insular cortices; and (3) decreased gray matter density (GMd) in the same brain regions. We also found that scores on the Dominic-R were negatively correlated with GMd in the prefrontal and precuneus/superior temporal regions. There was a subdiagnostic main effect for CD, related to thinning of the middle/medial frontal, and for ODD in the left rectal/orbitofrontal. Findings suggest that thinning and decreased GMd of the insula disorganizes prefrontal circuits, diminishing the inhibitory influence of the prefrontal cortex on anger, aggression, cruelty, and impulsivity, and increasing a person's likelihood of aggressive behavior. These findings have implications for pathophysiologic models of the DBDs, their diagnostic classification system, and for designing more effective intervention programs.

Collaborative problem solving (CPS) as a primary method of addressing acute pediatric pathological aggression along with other modalities

The answer for treating pathologic aggression (PA) in children on inpatient psychiatry units (based on various factors like severity of aggression and co-morbidities) is less likely to be restrictive interventions or sedating the patient. Using seclusion and restraints or medications to calm down the aggression is not free of adverse consequences. A protocol is needed to safely and effectively address aggressive and violent children and adolescents seen very commonly in psychiatry inpatient units.

Problem-solving skills training for vulnerable families of children with persistent asthma: report of a randomized trial on health-related quality of life outcomes

OBJECTIVES

To test the efficacy of problem-solving skill training (PST) in improving health-related quality of life (HRQOL) of children with persistent asthma from predominantly lower socioeconomic status (SES) Spanish-speaking Hispanic families.

METHODS

Randomized controlled trial comparing standard care waitlist (SC) control, home-visiting asthma education/care coordination (CC), and combined intervention (CC + PST) at baseline, after intervention, and 6-month follow-up. The primary outcome was parent proxy-report child HRQOL (PedsQL).

RESULTS

Participants (n = 252) were 83.3% Hispanic and 56.3% monolingual Spanish speakers, and 72.6% of mothers had not graduated high school. We found a significant (P = 0.05) intervention effect for parent proxy-reported child generic (but not asthma-specific) HRQOL, with CC + PST superior to SC [83.8 vs 79.8; adjusted mean difference of 4.05 points (95% confidence interval 0.63-7.4], but no difference between the CC and SC groups.

CONCLUSIONS

In this sample of vulnerable families of children with persistent asthma, a CC + PST intervention was efficacious in improving children's generic HRQOL.

Inattention, hyperactivity, oppositional-defiant symptoms and school failure

BACKGROUND

Attention-deficit hyperactivity disorder (ADHD) is associated with school failure. Inattention has been mainly implicated for this association. Oppositional-defiant disorder's (ODD) impact on academic performance remains controversial, because of the high comorbidity between ODD and ADHD.

OBJECTIVE

To understand the role of inattention (IN), hyperactivity (H/I) and ODD in school failure.

METHOD

Parents and teachers filled out SNAP-IV questionnaires for 241 / 6th grade students. The associations of the scores of oppositional-defiant (OP), H/I and IN symptoms with school year failure were calculated.

RESULTS

IN was strongly correlated with school failure. H/I and OP were not associated with school failure, when controlled for IN.

CONCLUSION

OP and H/I symptoms do not play an important role in school failure, when controlled for IN symptoms. Our study supports the cross-cultural role of IN as a major predictor of school failure.

Randomized double-blind placebo-controlled trial of lithium in youths with severe mood dysregulation

OBJECTIVE

The diagnosis and treatment of youth with severe nonepisodic irritability and hyperarousal, a syndrome defined as severe mood dysregulation (SMD) by Leibenluft, has been the focus of increasing concern. We conducted the first randomized double-blind, placebo-controlled trial in SMD youth, choosing lithium on the basis of its potential in treating irritability and aggression and neuro-metabolic effects.

METHODS

SMD youths 7-17 years were tapered off their medications. Those who continued to meet SMD criteria after a 2-week, single-blind, placebo run-in were randomized to a 6-week double-blind trial of either lithium (n = 14) or placebo (n = 11). Clinical outcome measures were: (1) Clinical Global Impressions-Improvement (CGI-I) score less than 4 at trial's end and (2) the Positive and Negative Syndrome Scale (PANSS) factor 4 score. Magnetic resonance spectroscopy (MRS) outcome measures were myoinositol (mI), N-acetyl-aspartate (NAA), and combined glutamate/glutamine (GLX), all referenced to creatine (Cr).

RESULTS

In all, 45% (n = 20/45) of SMD youths were not randomized due to significant clinical improvement during the placebo run-in. Among randomized patients, there were no significant between-group differences in either clinical or MRS outcome measures.

CONCLUSION

Our study suggests that although lithium may not result in significant clinical or neurometabolic alterations in SMD youths, further SMD treatment trials are warranted given its prevalence.

Perspectives on oppositional defiant disorder, conduct disorder, and psychopathic features

This paper presents a few perspectives on oppositional defiant disorder (ODD), conduct disorder (CD), and early forms of psychopathy. The developmental changes and stability of each, and the interrelationship between the three conditions are reviewed, and correlates and predictors are highlighted. The paper also examines effective interventions for each of the three conditions and makes recommendations for future research.

Beyond point and level systems: moving toward child-centered programming

Many residential treatment facilities and child inpatient units in the United States have been structured by way of motivational programming such as the point and/or level systems. On the surface, they appear to be a straightforward contingency management tool that is based on social learning theory and operant principles. In this article, the authors argue that the assumptions upon which point and level systems are based do not hold up to close empirical scrutiny or theoretical validity, and that point and level system programming is actually counterproductive with some children, and at times can precipitate dangerous clinical situations, such as seclusion and restraint. In this article, the authors critique point and level system programming and assert that continuing such programming is antithetical to individualized, culturally, and developmentally appropriate treatment, and the authors explore the resistance and barriers to changing traditional ways of "doing things." Finally, the authors describe a different approach to providing treatment that is based on a collaborative problem-solving approach and upon which other successful models of treatment have been based.

Reciprocal relationships between parenting behavior and disruptive psychopathology from childhood through adolescence

Theoretical models suggest that child behaviors influence parenting behaviors, and specifically that unpleasant child behaviors coerce parents to discontinue engaging in appropriate discipline. This study examined reciprocal relationships between parenting behaviors (supervision, communication, involvement, timid discipline and harsh punishment) and child disruptive disorder symptoms (ADHD, ODD and CD) in a clinic-referred sample of 177 boys. Annual measures, including structured clinical interviews, were obtained from the beginning of the study (when boys were between the ages of 7 to 12) to age 17. Specific reciprocal influence was observed; only timid discipline predicted worsening behavior, namely ODD symptoms, and ODD symptoms predicted increases in timid discipline. Greater influence from child behaviors to parenting practices was found: ODD also predicted poorer communication and decreased involvement, and CD predicted poorer supervision. ADHD was neither predictive of, nor predicted by, parenting behaviors. The results are specifically supportive of a coercive process between child behaviors and parenting behaviors, and generally suggestive of greater influence of child behaviors on parenting behaviors than of parenting behaviors on child behaviors.

Interventions for reducing the use of seclusion in psychiatric facilities: review of the literature

BACKGROUND

The authors of a recent systematic review concluded that the use of non-pharmacological containment methods, excluding restraint and seclusion, was not supported by evidence. Their focus on randomised, controlled trials, however, does not reflect the research that has been, or could be, conducted.

AIMS

To find empirically supported interventions that allow reduction in the use of seclusion in psychiatric facilities.

METHOD

We reviewed English-language, peer-reviewed literature on interventions that allow reduction in the use of seclusion.

RESULTS

Staff typically used multiple interventions, including state-level support, state policy and regulation changes, leadership, examinations of the practice contexts, staff integration, treatment plan improvement, increased staff to patient ratios, monitoring seclusion episodes, psychiatric emergency response teams, staff education, monitoring of patients, pharmacological interventions, treating patients as active participants in seclusion reduction interventions, changing the therapeutic environment, changing the facility environment, adopting a facility focus, and improving staff safety and welfare.

CONCLUSIONS

Reducing seclusion rates is challenging and generally requires staff to implement several interventions.

Oppositional defiant disorder: information for school nurses

Oppositional defiant disorder, one of the disruptive behavior disorders, has far-reaching consequences for the individual, family, school, community, and society. Early recognition allows interventions geared toward promotion of prosocial behaviors, possibly halting progression to the more deviant conduct disorder. Awareness of this disorder and associated comorbidities is the first step that enables the school nurse to use assessment techniques and to assist in planning of interventions for the child. Children at risk often show tendencies toward oppositional defiant disorder as early as preschool. Interventions should be in place by the elementary school years to interrupt the pathways that may be difficult or impossible to change once adolescence begins. The school nurse can be instrumental in educating staff about risk factors, early associated behaviors, and referrals. Implementation of an individualized healthcare plan targets specific behaviors and provides a means of observing and documenting a child's improvements.

Transtorno desafiador de oposição: uma revisão de correlatos neurobiológicos e ambientais, comorbidades, tratamento e prognóstico

Transtorno desafiador de oposição (TDO) é uma entidade diagnóstica independente, mas é freqüentemente estudada em conjunto com transtorno de déficit de atenção/hiperatividade (TDAH) ou com transtorno de conduta (TC). O objetivo deste artigo é o de fazer uma revisão das evidências existentes, obtidas por meio da base de dados PubMed, sobre achados neurobiológicos no transtorno desafiador de oposição, funcionamento familiar e escolar, comorbidades, prognóstico e opções terapêuticas para transtorno desafiador de oposição. A evidência de correlatos hormonais, genéticos e neurofuncionais de transtorno desafiador de oposição, a conexão com a família, as relações e desempenho escolares, a associação com transtornos do humor, ansiosos e disruptivos, o risco de evolução para transtorno de conduta e de persistência de sintomas de transtorno desafiador de oposição são descritos. Uma revisão do efeito da Terapia Cognitivo-Comportamental e tratamento farmacológico é apresentada. A análise das evidências disponíveis mostra que o impacto de transtorno desafiador de oposição não deve ser ignorado e que o transtorno desafiador de oposição deve ser devidamente abordado. O impacto do tratamento de transtorno desafiador de oposição no prognóstico de longo prazo dos pacientes ainda precisa ser determinado.