Therapist guided, parent-led cognitive behavioural therapy (CBT) for pre-adolescent children with obsessive compulsive disorder (OCD): a non-concurrent multiple baseline case series

BACKGROUND

Cognitive behavioural therapy (CBT) including exposure and response prevention (ERP) is an effective treatment for preadolescent children with obsessive compulsive disorder (OCD); however, there is a need to increase access to this treatment for affected children.

AIMS

This study is a preliminary evaluation of the efficacy and acceptability of a brief therapist-guided, parent-led CBT intervention for pre-adolescent children (5-12 years old) with OCD using a non-concurrent multiple baseline approach.

METHOD

Parents of 10 children with OCD were randomly allocated to no-treatment baselines of 3, 4 or 5 weeks before receiving six to eight individual treatment sessions with a Psychological Wellbeing Practitioner. Diagnostic measures were completed prior to the baseline, 1-week post-treatment, and at a 1-month follow-up, and parents completed weekly measures of children's OCD symptoms/impairment.

RESULTS

Seventy percent of children were 'responders' and/or 'remitters' on diagnostic measures at post-treatment, and 60% at the 1-month follow-up. At least 50% of children showed reliable improvements on parent-reported OCD symptoms/impairment from pre- to post-treatment, and from pre-treatment to 1-month follow-up. Crucially, the intervention was acceptable to parents.

CONCLUSIONS

Brief therapist-guided, parent-led CBT has the potential to be an effective, acceptable and accessible first-line treatment for pre-adolescent children with OCD, subject to the findings of further evaluations.

"Just keep pushing": Parents' experiences of accessing child and adolescent mental health services for child anxiety problems

BACKGROUND

Anxiety disorders are among the most common psychopathologies in childhood; however, a high proportion of children with anxiety disorders do not access effective treatments. The aim of the present qualitative study was to understand families' experiences of seeking help and accessing specialist treatment for difficulties with childhood anxiety.

METHODS

Parents of 16 children (aged 7-12 years) referred to a child mental health service for difficulties with anxiety were interviewed about their experiences of seeking and accessing treatment within Child and Adolescent Mental Health Service (CAMHS). All interviews were transcribed verbatim and thematically analysed for similarities and differences in families' experiences.

RESULTS

Factors that helped and/or hindered families accessing treatment related to (a) parental recognition, (b) contact with professionals, (c) reaching CAMHS, (d) parental effort, and (e) parental knowledge and concerns. High demands on services and parents' uncertainty surrounding the help-seeking process presented key hurdles for families. The critical role of parental persistence and support from general practitioners and school staff was evident across interviews.

CONCLUSIONS

Findings highlighted the need for information and guidance on identifying child anxiety difficulties and professional, peer, and self-help support, and ensuring sufficient provision is available to allow families prompt access to support.

Dissociation in adolescent girls with anorexia: relationship to comorbid psychopathology

This study investigated the relationship between dissociation and psychological symptoms in adolescent girls with anorexia. First, the psychometric properties of the Adolescent Dissociative Experiences Scale (A-DES) were examined using data from 181 nonclinical adolescent boys and girls. Thereafter, A-DES scores and correlations with a range of psychological symptoms were compared across 20 girls with anorexia, 19 mixed clinical girls, and 86 nonclinical girls. The A-DES had a one-factor structure and good psychometric characteristics. Dissociation scores were significantly correlated with level of symptomatology for all groups. Although the group with anorexia did not have significantly higher dissociation scores than the other two groups, dissociation in the anorexic girls was related to psychopathology in a distinct way. Adolescent girls with anorexia appear to use dissociation specifically to avoid processing angry affect with an interpersonal basis, although it is also related to their use of somatization, and obsessive-compulsive features.

The adolescent dissociative experiences scale: psychometric properties and difference in scores across age groups

Adolescence is thought to be a key developmental period for dissociative processes. However, there has been little empirical investigation of dissociation in adolescence. This paper reports the results of a study (N = 768) that investigated the psychometric properties of the Adolescent Dissociative Experiences Scale (A-DES) and compares dissociation scores across the adolescent age range (11 to 16 years). The A-DES had good internal reliability and a one-factor solution. No significant age or gender differences in A-DES scores were found. The implications of these findings for future research and theory are outlined.

User views of a regional secure unit--findings from a patient satisfaction survey

This paper includes key findings of a patient satisfaction survey, conducted within an English Medium Secure Unit, offering care and treatment for 45 male and female mentally disordered offenders. It aims to identify patients' perceptions of the quality of their care and other aspects of their lives within the secure unit. Following permission from the local Ethics Committee, two interviewers collected data within a two week period, using a semi-structured interview schedule. All but three of the respondents agreed to be interviewed. Talking to nurses was perceived as highly satisfying. However, provision for specific cultural and women's needs, facilities for visitors, opportunities to practise religious beliefs and access to care plans were highlighted as unsatisfactory. The study concludes with recommendations for improvement, some of which have already been considered and implemented.

Mental health services--maintaining strategic direction

AIM AND KEY ISSUES: This article reviews the theoretical basis of strategic management in an attempt to provide managers with a better understanding of the underpinning concepts and consequent actions they need to take to avoid loss of control and ultimate failure.

BACKGROUND

The authors argue that community care for the severely mentally ill is failing and that in part the reason for this perceived failure is a closer allegiance to primary care that has shifted the focus away from mental illness. Such a shift, coupled with poor management and a desire by Community Mental Health Nurses (CMHNs) to retain a broad focus and maintain the 'autonomy' they gain when not held in the gravitational grasp of Consultant Psychiatrists, has resulted in strategic drift. The authors suggest 10 possible reasons to explain why CMHNs currently fail to meet the needs of the severely mentally ill. Among these are a lack of explicit strategic implementation plans, professional ambivalence and self-interest, poor management of resources and conflicting demands from key interest groups.

CONCLUSION

It seems that mental health services in this country have reached the point where resistance to change should be crumbling in the face of perceived failure to deliver the required services. Whilst it could be argued that a major and potent source of internal change is performance gaps, few things force change more than sudden and unexpected information about poor organizational performance.

Primary healthcare workers: training needs in mental health

Particular attention is currently being given to the role of primary healthcare workers in supporting people with mental health problems in primary care (McFadyen et al, 1996). The aim of this study was to survey the views of primary healthcare workers regarding their previous mental health training and to identify their current perceived mental health training needs. A sample of 200 primary healthcare workers within Trent Health Region were interviewed using a short semi-structured interview schedule. Forty-six completed questionnaires were also received. An additional 22 respondents participated in exploratory in-depth interviews. Respondents included GPs, health visitors, practice nurses, district nurses, midwives and community psychiatric nurses. The need for further training in communication skills, particularly basic counselling skills, was highlighted. Respondents also perceived a need for additional training in coping with their own personal stress, the assessment and treatment of depression and stress/anxiety management in clients. Several themes which developed from the research were explored, including communication skills training, problems with collaborative working, coping with personal stress, the prevention of burnout and depression training. The reason why some respondents had no mental health training needs whatsoever was also addressed.

Creating a new brand of mental health nurse

Mental health nurse training provision has been criticized for failing to develop practitioners with the appropriate skills to care for clients with severe mental illness (Owen and Sweeney, 1995), However, a tide of change is about to wash over the initial and ongoing education of mental health nurses.

Strategies for reducing stress and burnout in nursing

Three models of stress-the stimulus model, the response model and the cognitive-phenomenological-transactional (CPT) model-have been described in detail elsewhere (Farrington, 1995), and the notion of accepting occupational stress as an industrial disease has been suggested (Nursing Times, 1995). This article focuses on the nursing experience of stress and describes strategies for reducing stress and burnout on a personal and organizational level. It concludes by presenting a small-scale research study which examined the nature and impact of events perceived by postregistration nurses to cause personal psychological distress. The findings of the research show that certain stimuli are consistently perceived as being psychologically traumatizing in the daily working life of the student nurse. Nursing clearly remains an emotionally demanding occupation and more work is needed to examine the way in which events and microstressors are cognitively processed by nurses.

The failure of community care for the severely mentally ill

For the past 10 years or more there has been an ongoing debate about community mental health (CMH) nursing. It is clearly important in any discourse about CMH nursing to begin by examining where this branch of nursing is at present, i.e. what route it has taken, as well as considering where it is destined to travel. The views expressed in this article are supported by a literature review undertaken as part of a research study into CMH nursing. The first and quantitative stage, which was completed in late 1995, and the second qualitative part of the study has now reached the data analysis stage. The preliminary findings from this study are discussed in this article.

Developing a research culture for nursing in higher education

For colleges of nursing that have moved into higher education over the last 12-18 months, the forthcoming Research Assessment Exercise 1996, conducted by the Higher Education Funding Council, is unlikely to be very meaningful or impact on research activities. While the mission of colleges of nursing, before integration, was to provide good quality teaching, underpinned by innovative curriculum design, the future of nursing in higher education, after integration, is likely to be quite different.

Models of clinical supervision

This article describes several schools of practice in relation to clinical supervision and discusses models of supervision, particularly an integrative approach to clinical supervision in mental health practice. While it is recognised that clinical supervision is more likely to occur in mental health nursing, the article concludes by suggesting a broader application of the underlying principles described.

Shared governance: developing a British model

This article will examine the concept of shared governance and describe the development of a model for a British NHS trust. The philosophy of shared governance will be related to a decentralised style of management and the consequences that this will have for managers and staff nurses. The introduction of shared governance in the USA has realised many benefits. However, limitations have also been illustrated and these will be discussed in relation to the proposed model for Leicester General Hospital.

Stress and nursing

This article looks at definitions and models of stress and examines sources of stress in nursing and the assessment and measurement of stress factors.

Suicide and psychological debriefing

The death of a patient by suicide is one of many upsetting experiences that nurses face. However, psychological debriefing after such an event is not commonly available.

Cancer, emotional responses and cognitive behavioural psychotherapy

Cancer and its treatment is known to have a substantial psychological morbidity and, while adjuvant psychological therapy (APT) is well established, relatively little work has been done to investigate the effectiveness of psychotherapy, particularly cognitive behaviour therapy (CBT), for patients with cancer. This article focuses initially on emotional responses to the diagnosis of cancer, individual vulnerability and the prevalence of psychological problems in patients with cancer. The use of cognitive behaviour therapy is then described, together with key issues in its application and specific problems. The work concludes by considering differences in applying CBT to patients with cancer compared to patients with other physical illnesses and the notion of 'relapse inoculation'.

The fourth paradigm: a new model of leadership for managing nurse education

Over 20 years ago Toffler suggested that 'tomorrow's individual will have to cope with even more hectic change than we do today' and that for education the lesson is clear, 'its prime objective must be to increase the individuals 'copeability'--the speed and economy with which he/she can adapt to continual change and the faster the rate of change, the more attention must be devoted to discerning the pattern of future events' (Toffler 1970). Knowledge and understanding about what produces change in education is often unclear, however, many theories exist to account for change, which has been described as 'the most recalcitrant subject in the social sciences' (Clark 1983). This work considers change and process and includes types of change, the process and management of change, and models of organization. The integration of colleges of nursing into higher education and university departments is then discussed before the article concludes, by putting forward a new model of leadership for nurse education--the fourth paradigm.

Change, revolt and the student nurse

Nurse education is facing great changes which challenge traditional methods of training and educating student nurses. Project 2000, college amalgamation and links with universities have coincided with a drive towards increasing opportunities for nurses to achieve graduate status and generally raise the academic status of nursing as a profession. The student nurses caught up in these changes must be more than passive recipients of information, or dissatisfaction will occur. The author considers the unsettling effect of change on students and, through examination of factors such as teachers' attitudes and adult education, concludes that student participation in programme planning and policy-making must become more widespread of educators are to avoid dissatisfaction turning to revolt.

Transcultural psychiatry, ethnic minorities and marginalization

Cultural and racial bias has been woven into the fabric of Western psychiatry in its historic development. Western psychiatry emphasizes the medical model as being fundamental to the discipline. Many communities in large cities and industrial areas have become multicultural and multiracial. Culture-bound syndromes are not specific to non-Western ethnic minorities. Black people are overrepresented among psychiatric patients in institutions. Mental health services for ethnic minorities have been haphazard and inconsistent. Cultural experiences and the practical realities of racism are overdue their recognition.

Intuition and expert clinical practice in nursing

The quest for the essence of nursing in the UK continues unabated. Similarly, the concept of what constitutes expert clinical practice and the problem of how it can be achieved are topical issues. This article considers the notion of a developmental process in nursing and the concept of reflective practice, and examines the idea of intuition as a key component in the functioning of the expert nurse.

Mental health nursing: now you see it, now you don't

As we enter the closing decade of this century, mental health nursing has reached a crisis point and is on the road to invisibility. If the marginalization of mental health nursing continues it will reach the end of that road before the year 2000.

Caring for people with learning difficulties in Czechoslovakia

In June 1992 a massive step forward was made in Czechoslovakia when the first school for people with learning difficulties was opened. This article examines the problems facing this school and the background to its creation.