Behavior therapy with children and adolescents: a twenty-year overview

Discontinuation of enterostomy tube feeding by behavioral treatment in early childhood: a randomized controlled trial

OBJECTIVE

To determine whether behavior therapy was more effective than nutritional therapy in obviating the need for enteral feeding in infants with resistance to feeding.

STUDY DESIGN

Sixty-four children aged 4 to 36 months who were tube fed for at least 1 month and had resistance to feeding were randomly assigned to either behavioral or nutritional interventions (32 per group). For 7 consecutive weeks subjects and their primary feeders attended a weekly clinic with 1 of 2 dietitians followed by 4 follow-up visits. The nutritional intervention provided structured schedules and routines to stimulate the hunger/satiety cycle. The behavioral intervention provided the same schedules and routines plus behavioral therapy (extinction). The primary outcome measure was the proportion of successes, defined as infants no longer requiring tube feeding at the third follow-up visit in each group (4(1/2) months after start of trial). The decision to discontinue tube feeding was made by an independent observer who used criteria defined before the study commencement.

RESULTS

Fifteen (47%) of 32 subjects in the behavioral group versus none in the nutritional group were successes (P <.001).

CONCLUSION

Behavior therapy is more efficacious in eliminating the need for tube feeding than nutritional counseling alone.

Comparative effectiveness of holding therapy with aggressive children

This study was undertaken to assess the effects of holding therapy on children who have a history of aggressive and delinquent behaviors. The study design was a prospective, pre-post, quasi-experimental controlled study. The subjects were recruited through the Attachment Center at Evergreen, Colorado. Eligible subjects were adopted children between the ages of 5-14 years, living in the present adopted home for at least one year. All children had a history of aggressive and delinquent behaviors, which prompted the contact with Evergreen. Findings resulted in significant decrease in the outcome variable for the treatment group within this study.

Methodological strategies in child clinical trials: advancing the efficacy and effectiveness of psychosocial treatments

The present paper reviews issues of treatment efficacy (i.e., potency) and effectiveness (i.e., clinical utility) in applied clinical child research. Threats to treatment evaluation are reviewed in the context of these two dimensions. It is proposed that treatment outcome research faces new challenges stemming from the ever increasing emphasis on generalization of gains and dissemination of interventions outside of clinical research settings. Issues and approaches proposed as warranting further development and attention include development, flexibility, acceptability, and disseminability of psychosocial assessment and treatment methods. A research emphasis is promoted that balances experimental control with the need for treatment generalization and delivery outside of the research setting, in order to maximize the utility of clinical research.

Sleep problems in children of affectively ill mothers

The objective of the study was to determine whether the frequency and severity of sleep problems were greater in children of affectively ill mothers than in children of control mothers. Sleep problems were studied in children of mothers with a diagnosis of unipolar (N = 38) and bipolar (N = 23) affective illness and children of mothers with no current or past psychiatric diagnosis (N = 24). Mothers' reports on the Child Behavior Checklist (CBCL) were obtained three times, 4 years apart, on sibling pairs (ages 1.5-3.5 and 5-8 years, respectively, at first assessment). In addition, on the third assessment, the Diagnostic Interview for Children and Adolescents was filled out by mothers and children. In both siblings, sleep problems, as assessed through the CBCL, were more frequent and severe in children of affectively ill mothers. In younger siblings, the persistence of sleep problems was more frequent in children of affectively ill mothers. Co-occurrence of sleep problems among siblings was more frequent in children of affectively ill mothers than in those of control mothers.

Nonpharmacological response in hospitalized children with conduct disorder

OBJECTIVE

There is a paucity of research regarding the effects of hospitalization and/or the response to placebo in children with conduct disorder who are hospitalized for chronic and severe aggression. However, many children with this problem are hospitalized and immediately begin pharmacotherapy. In this report, the effects of hospitalization and placebo administration were examined.

METHOD

Subjects were forty-four children (37 males, 7 females) with conduct disorder, aged 9.83 to 17.14 years, who were hospitalized for chronic and severe aggression. This was a 4-week double-blind and placebo-controlled study with a 2-week single-blind placebo lead-in period. During the 2-week placebo baseline period, aggression was measured on a 24-hour basis, using the Overt Aggression Scale. Only subjects meeting a specific aggression criterion were randomized to the treatment period of the trial.

RESULTS

Of the 44 subjects enrolled, 23 (52.3%) met the aggression criteria for entering the treatment period (baseline nonresponders), while 21 (47.7%) did not (baseline responders). Thus, almost half of the subjects, while taking no active medication, benefited from the inpatient milieu/structure and/or placebo.

CONCLUSION

This finding has important treatment and research implications. Medication to treat aggression should not be initiated immediately upon hospitalization because improvements associated with hospitalization may be attributed inaccurately to pharmacotherapy, resulting in unnecessarily medicating children. A placebo baseline period is essential to decrease the risk of a type II error in pharmacological research concerning aggression.

Carbamazepine in aggressive children with conduct disorder: a double-blind and placebo-controlled study

OBJECTIVE

To assess critically the short-term efficacy and safety of carbamazepine in the reduction of aggressiveness in children with diagnosed conduct disorder.

METHOD

Subjects were children aged 5 to 12 years who were hospitalized for treatment-resistant aggressiveness and explosiveness and who had diagnosed conduct disorder. The study was double-blind and placebo-controlled, using a parallel-groups design. Following a 2-week placebo baseline period, children who met the aggression criteria were randomly assigned to treatments for 6 weeks; the study ended with a 1-week posttreatment placebo period. Multiple raters rated the children independently, using multiple rating scales under four conditions. The main outcome measures included the Overt Aggression Scale, the Global Clinical Judgments (Consensus) Scale, and the Children's Psychiatric Rating Scale.

RESULTS

Twenty-two children, aged 5.33 to 11.7 years, completed the study. Carbamazepine was not superior to placebo at optimal daily doses ranging from 400 to 800 mg, mean 683 mg, at serum levels of 4.98 to 9.1 micrograms/mL. Untoward effects associated with administration of carbamazepine were common.

CONCLUSIONS

In this modest sample of children, the superiority of carbamazepine over placebo in reducing aggressive behavior was not demonstrated.

Research on psychotherapy with children and adolescents: an overview of evolving trends and current issues

We present a broad overview of research on psychotherapy with children and adolescents, with a focus on dimensions along which progress has been made over the past 35 years. Research in this area has been increasingly characterized by the utilization of a greater variety of and more focused and better specified interventions, with increasingly homogenous samples of clients or patients, using methodologically more stringent approaches. The general consensus in the field is that psychotherapy is effective with younger age groups, as compared to no treatment. However, such a conclusion has to be qualified because of the dearth of studies on clinically referred youths, traditional therapies, and modes of treatment other than individual therapy. Several other issues also require further attention in research, including the need for more comprehensive or novel conceptualizations of juvenile-onset psychopathology to inform treatment efforts. Consideration also should be given to having parents more consistently involved in their children's therapy, integrating the developmental literature and the design of new interventions, and developing and testing therapies for youths with special needs.

Child psychiatric disorders: are they classifiable?

Classification of child (including adolescent) disorders is reviewed within six areas: requirements for a good taxonomy, current systems of classification for children, data-capture methods, reliability and validity, the link between child and adult disorders, and directions for future developments. While substantial progress has been made, there is a continuing need for comparisons of different systems, more systematic yet practicable data capture, proper psychometric analyses of criteria and categories, intensive studies of clinical validity, closer attention to the similarity of, and links between, child and adult categories, and better definition and targeting of those disorders with a serious outcome.

Sleep disorders in early childhood: association with insecure maternal attachment

Psychological, family, and social characteristics relating to attachment relationships were measured in mothers of 20 sleep-disordered toddlers, comparing them with 21 mothers of toddlers without sleep problems. The groups were matched on measures of socioeconomic status, child and maternal age, maternal education, marital status, and family size. Results showed that 100% of mothers of sleep-disordered children were classified as insecure with respect to attachment, as assessed by the Adult Attachment Interview, compared with 57% of control group mothers (p less than 0.002). There were no group differences on measures of maternal defensiveness, self-esteem, marital satisfaction, and social support. These results suggest that maternal current perspectives on their relationship history, rather than general psychosocial adjustment, are crucial contributors to the onset and perpetuation of sleep disorders in early childhood.

Psychopharmacology of the psychiatric disorders of childhood and adolescence

The literature on the psychopharmacology of child and adolescent psychiatric disorders is reviewed. The scanty epidemiological data suggest that psychotherapeutic drugs are utilized more widely than research findings would warrant, especially in preschool-age children. With the exception of hyperactivity, the disorders of childhood and adolescence for which the use of psychopharmacological agents is well-established are rare. This highlights the need for careful prescribing, in which the child's rights, problems with compliance and developmental and behavioural adverse effects are important considerations.