Reductions in Alexithymia and Emotion Dysregulation After Training Emotional Self-Awareness Following Traumatic Brain Injury: A Phase I Trial

OBJECTIVES

To examine the acceptability and initial efficacy of an emotional self-awareness treatment at reducing alexithymia and emotion dysregulation in participants with traumatic brain injury (TBI).

SETTING

An outpatient rehabilitation hospital.

PARTICIPANTS

Seventeen adults with moderate to severe TBI and alexithymia. Time postinjury ranged 1 to 33 years.

DESIGN

Within subject design, with 3 assessment times: baseline, posttest, and 2-month follow-up.

INTERVENTION

Eight lessons incorporated psychoeducational information and skill-building exercises teaching emotional vocabulary, labeling, and differentiating self-emotions; interoceptive awareness; and distinguishing emotions from thoughts, actions, and sensations.

MEASURES

Toronto Alexithymia Scale-20 (TAS-20); Levels of Emotional Awareness Scale (LEAS); Trait Anxiety Inventory (TAI); Patient Health Questionnaire-9 (PHQ-9); State-Trait Anger Expression Inventory (STAXI); Difficulty With Emotion Regulation Scale (DERS); and Positive and Negative Affect Scale (PANAS).

RESULTS

Thirteen participants completed the treatment. Repeated-measures analysis of variance revealed changes on the TAS-20 (P = .003), LEAS (P < .001), TAI (P = .014), STAXI (P = .015), DERS (P = .020), and positive affect (P < .005). Paired t tests indicated significant baseline to posttest improvements on these measures. Gains were maintained at follow-up for the TAS, LEAS, and positive affect. Treatment satisfaction was high.

CONCLUSION

This is the first study published on treating alexithymia post-TBI. Positive changes were identified for emotional self-awareness and emotion regulation; some changes were maintained several months posttreatment. Findings justify advancing to the next investigational phase for this novel intervention.

[Disability after stroke: a longitudinal study in moderate and severe stroke patients included in a multidisciplinary rehabilitation program]

INTRODUCTION

Stroke is a recognized cause of disability among adults. However the impact that the deficits that occur after a moderate/severe stroke have on long-term disability, as well as the response of the resultant deficits to rehabilitation, are not completely understood.

PATIENTS AND METHODS

A total of 396 patients with a modified Rankin score >= 3 after an ischemic (n = 221) or hemorrhagic (n = 175) stroke were included in this study. All patients were assessed with cognitive, behavior, emotional, motor and functional domains. All patients were assessed at baseline and six months after inclusion in a multidisciplinary rehabilitation program.

RESULTS

Risk of falling (Berg Balance Scale < 45 in 83.1% of the sample at baseline and 49.5% at follow-up) and functional problems (82.8% with a Barthel Index < 75 at baseline and 53% at follow-up) were the most prevalent deficits. Emotional disturbances were those that most improved while behavioral problems were those that did less. Although global disability improved during treatment among most patients, only 11% of our patients, especially those with preserved cognitive function at baseline, could be classified as patients with mild disability at follow-up.

CONCLUSIONS

Stroke consequences are multidimensional. The symptoms that the stroke can cause in multiple domains, as well as the pattern of recovery are widely diverse, with prevalence of behavioral long-term disturbances.

[Neuropsychotherapy in brain injury rehabilitation]

INTRODUCTION

Persons who have suffered brain damage can experience a wide range of cognitive, behavioural and emotional disorders. However, neuropsychological rehabilitation usually focuses, almost exclusively, on the cognitive deficits and pays very little attention to the emotional challenges associated with the psychological impact of the lesion. It is in this more personal side of brain damage where neuropsychotherapy can be of great aid to facilitate the process of acceptance and adaptation following a neurological lesion.

DEVELOPMENT

In this article, we describe the theoretical and conceptual aspects of psychotherapy oriented towards persons with brain damage, the implications of cognitive deficits in the practice of neuropsychotherapy and the evidence regarding its effectiveness.

CONCLUSIONS

In the past, neuropsychotherapy was considered to be of little use in the rehabilitation of brain damage. Today, however, a growing number of professionals are acknowledging its importance in the management of the psychological/emotional suffering associated with brain damage. The aim of neuropsychological rehabilitation is not just to promote the recovery of the altered brain functions, but also to improve the individual's functional capacity, deal with his or her experiences of loss and help him or her to again find a meaning to life.

[The clinical and functional rationale for the application of the baths containing the Siberian Stag velvet antler extracts in the rehabilitative treatment of the patients presenting with arterial hypertension and concomitant chronic psychoemothional overtension]

We have developed the method for the treatment of the patients presenting with arterial hypertension and concomitant chronic psychoemothional overtension. The method consists of the application of the baths containing the Siberian Stag velvet antler extracts in combination with exercise therapy and massage. A total of 35 patients with arterial hypertension and concomitant chronic psychoemothional overtension were enrolled in the study. It was shown that inclusion of the baths containing the Siberian Stag velvet antler extracts in the combined treatment of arterial hypertension and concomitant chronic psychoemothional overtension has positive effect on the parameters of the main homeostatic systems, enhances the working capacity of the patients, promotes their psychological stability, and increases the adaptive potential of the organism.

Postsecondary employment experiences among young adults with an autism spectrum disorder

OBJECTIVE

We examined postsecondary employment experiences of young adults with an autism spectrum disorder (ASD) and compared these outcomes with those of young adults with different disabilities.

METHOD

Data were from Wave 5 of the National Longitudinal Transition Study-2 (NLTS2), a nationally representative survey of young adults who had received special education services during high school. We examined the prevalence of ever having had, and currently having, a paid job at 21 to 25 years of age. We analyzed rates of full-time employment, wages earned, number of jobs held since high school, and job types.

RESULTS

Approximately one-half (53.4%) of young adults with an ASD had ever worked for pay outside the home since leaving high school, the lowest rate among disability groups. Young adults with an ASD earned an average of $8.10 per hour, significantly lower than average wages for young adults in the comparison groups, and held jobs that clustered within fewer occupational types. Odds of ever having had a paid job were higher for those who were older, from higher-income households, and with better conversational abilities or functional skills.

CONCLUSIONS

Findings of worse employment outcomes for young adults with an ASD suggest that this population is experiencing particular difficulty in successfully transitioning into employment. Research is needed to determine strategies for improving outcomes as these young adults transition into adulthood.

Factors associated with admission to a day school treatment program

In this study the authors examine the individual and family characteristics of youth (N = 105) admitted over a five year period to a day school treatment program in a western New York community. All had exhausted alternative school placements within their home school districts and had a history of severe emotional or behavioral problems. Consistent with national patterns, more males (78%) than females were admitted, but in contrast to national trends, more Caucasians (63.8%) than students of color (36.2%) were admitted. Most lived in female headed single-parent households (51.4%). A few were foster children living with relatives or in non-relative foster homes (14.3%). Poverty was common with 45.7% of these youth eligible for free lunches. Most were on psychotropic medications (57.1%) and had histories of outpatient (62.9%) and inpatient hospitalizations (23.6%) at admission. Involvement in the juvenile justice system was common with nearly a quarter involved in the juvenile justice system (n = 25; 23.8%).

The role of acceptance in rehabilitation in life-threatening illness

CONTEXT

Palliative care rehabilitation aims to maximize physical and psychological functioning, but negative thoughts can hinder patients from attempting this approach. Acceptance and commitment therapy (ACT), a modified form of cognitive behavioral therapy, encourages individuals to experience and manage negative emotions by focusing on changing individual behavior and so improve functioning. ACT has been used in many health-related behavioral interventions but not in palliative care rehabilitation.

OBJECTIVES

To investigate the relationship between acceptance (often called experiential acceptance in ACT) and psychological and physical status.

METHODS

Cross-sectional study in which a consecutive sample of patients attending a specialist palliative care day therapy unit for rehabilitation completed the Acceptance and Action Questionnaire-II to measure acceptance and the Kessler-10 questionnaire to measure psychological morbidity. Physical function was assessed by a timed two-minute walking test and one-minute sit-to-stand test. Correlation statistics and multivariable regression analyses were used to explore the strength of relationships between acceptance and psychological morbidity and physical function.

RESULTS

One hundred one patients were recruited, mainly white women with a mean age of 64 years. Correlation analysis showed a negative association between acceptance and psychological morbidity (r=-0.59) and a positive association between acceptance and sit to stand (r=0.27) and distance walked (r=0.21). All three of these relationships were statistically significant after adjustment.

CONCLUSION

These associations suggest that it may be possible to reduce psychological morbidity and improve physical mobility by increasing patients' acceptance using an ACT-based intervention. Future work is now needed to develop an ACT-based intervention in palliative care rehabilitation and test its acceptability and feasibility.

Defining a target population at high risk of long-term foster care: barriers to permanency for families of children with serious emotional disturbances

Long-term foster care (LTFC) is an enduring problem that lacks evidence of effective strategies for practice or policy. This article describes initial activities of a statewide project of the national Permanency Innovations Initiative. The authors sought to: (1) verify the relevance of children's mental health as a predictor of LTFC, (2) describe critical barriers encountered by parents of children with serious emotional disturbances, and (3) identify systems barriers that hinder permanency for this target population.

Individual, life events, family and socio-economic factors associated with young people with intellectual disability and with and without behavioural/emotional problems

The aim of this study was to compare a range of individual, life events, family and socio-economic factors associated with young people with intellectual disabilities and with and without behavioural/emotional problems. Teachers in 16 schools in one region of the UK completed a postal questionnaire on 249 young people with intellectual disabilities aged between 11 and 19 years. There were two groups: 155 young people with behavioural/emotional issues, and 94 without. Using a binary logistic regression analysis, a number of individual, life events, family and socio-economic risk factors were found to be significantly associated with emotional/behavioural problems. The results are discussed alongside findings from other studies. The importance of a multidimensional assessment is highlighted, as well as the interdependent nature of the risk factors.

Staying in the here-and-now: a pilot study on the use of dialectical behaviour therapy group skills training for forensic clients with intellectual disability

BACKGROUND

Dialectic behaviour therapy (DBT) has been widely used with individuals diagnosed with borderline personality disorder who exhibit severe emotional and behavioural dysregulation. There is a paucity of research in assessing the effectiveness of DBT with forensic clients with intellectual disability (ID).

METHODS

This pilot study aims to evaluate the effectiveness of the DBT group skills training programme adapted particularly for offenders with ID. Six participants completed the 13-week adapted DBT group skills training programme. All participants exhibited challenging behaviours and have a history of prior charges or convictions for violent crimes. The study conducted pre- and post-tests using instruments that measured dynamic risks, relative strengths, coping skills and global functioning.

RESULTS

The study result showed improvement across all measures. A decrease in the level of risks, increase in relative strengths and general improvement in overall functioning were found significant. The results were promising particularly as a stand-alone adapted DBT group skills training programme for this client group.

Negative symptoms in schizophrenia: avolition and Occam's razor

The identification of schizophrenia's negative symptoms dates back to the earliest descriptions of Kraepelin and Bleuler, who each highlighted the central role of avolition in the phenomenology and course of this illness. Since, there have been numerous advances in our understanding of schizophrenia, and the present review tracks the changes that have taken place in our understanding of negative symptoms, their description and measurement. That these symptoms represent a distinct domain of the illness is discussed in the context of their ties to other symptoms and functional outcome. The underlying structure of the negative symptom construct is explored, including several lines of investigation that point towards diminished expression and amotivation as key underlying subdomains. We also discuss findings of intact emotional experience and consummatory pleasure in individuals with schizophrenia, calling into question the presence of anhedonia in this illness. We conclude with a reconceptualization of the negative symptoms, suggesting amotivation (ie, avolition) represents the critical component, particularly in regard to functional outcome. Further exploration and clarification of this core deficit will ultimately enhance our neurobiological understanding of schizophrenia, as well as strategies that may improve outcome.

Suicidality and veterans with a history of traumatic brain injury: precipitants events, protective factors, and prevention strategies

OBJECTIVES

To increase understanding regarding precipitating and preventative factors of suicidal behavior and to highlight past experiences and recommendations regarding services aimed at suicide prevention among Veterans with a history of traumatic brain injury (TBI).

STUDY DESIGN

Qualitative.

PARTICIPANTS

Sample of 13 Veterans with a history of TBI, and a history of clinically significant suicidal ideation or behavior.

METHOD

In-person interviews were conducted and data were analyzed using a hermeneutic approach.

RESULTS

Shared precipitants noted included loss-of-self post-TBI, cognitive sequelae, and psychiatric and emotional disturbances. Common protective factors noted included social supports, a sense of purpose regarding the future, religion and spirituality, and mental health care. Means of improving care were also identified (e.g., increasing the availability of services and mental health professionals' knowledge regarding TBI, providing more structured treatment).

CONCLUSIONS

Findings highlight potential areas of importance in the assessment and treatment of suicidal Veterans with a history of TBI. Recommendations regarding means of improving care are also presented.

Developing a new system to measure outcomes in a service coordination program for youth with severe emotional disturbance

This paper presents information on re-developing an outcome evaluation for a state-funded program providing service coordination utilizing wraparound to youth with severe emotional disturbance (SED) and their families. Originally funded by the Robert Wood Johnson Foundation, the Kentucky IMPACT program has existed statewide since 1990. Changing data needs and limitations of the original evaluation required revamping the program's data collection system. The new evaluation uses the extant knowledge base to improve: (1) design, (2) measures, and (3) utility. A pre-post design with multiple follow-ups provides the framework for data collection. An ecological framework provides a conceptual structure for selecting measures focusing on both the service recipients and their environment. Data collection via a personal digital assistant (PDA) ensures utility of the data for both consumers and researchers. Issues ranging from conceptualization to implementation of the project as well as lessons learned are discussed.

Delayed emotional recovery after taxane-based chemotherapy

BACKGROUND

There are few patient-reported data regarding quality of life after taxane-based adjuvant chemotherapy and none regarding mental health outcomes.

METHODS

This was a naturalistic, longitudinal study that used a case-control design. Data were derived from a randomized clinical trial in patients who had stage II/III breast cancer (N = 227). Paclitaxel (Taxol) was approved for use midway during the accrual period (1994-1999). Patients who received taxanes as part of their adjuvant chemotherapy (the taxane group; n = 55) were matched with patients receiving regimens without taxanes (the no-taxane group; n = 83) on trial arm, lymph node status, surgery type, menopausal status, and partner status. Mixed-effects models tested for group differences in nurse evaluations of patients' symptoms and Karnofsky performance status and in patient-reported quality of life (the 36-item Medical Outcomes Study Short Form) and emotional distress (Profile of Mood States; Center for Epidemiological Studies Depression scale).

RESULTS

As expected, patients in the taxane group experienced significantly higher rates of selected toxicities, including arthralgia/myalgia (45% vs 26%) and ataxia (20% vs 5%). Patients in the taxane group also had significantly worse emotional distress and mental quality of life throughout adjuvant treatment. Rates of probable clinical depression also were high. In contrast, these outcomes were improving for patients in the no-taxane group (all P < .023). Emotional recovery for patients in the taxane group required 2 years on average versus 6 to 12 months for patients in the no-taxane group. During Years 3 through 5, the groups had similar outcomes.

CONCLUSIONS

These data suggested that taxane-based chemotherapies confer risk for significant psychological symptoms. Depression, in particular, should be monitored.

Absence of iatrogenic or contagion effects in adolescent group therapy: findings from the Cannabis Youth Treatment (CYT) study

Though widely used and presumed effective in practice, some scholars (Dishion et al., 1999) have raised the concern that group therapy for adolescents with substance use disorder and a range of deviancy has the potential for causing iatrogenic effects (e.g., increased substance use, behavior and legal problems) for those with low deviancy. Using data from 400 youth in the largest adolescent treatment experiment conducted to date (Dennis et al., 2004), this study shows that group composition in terms of conduct disorder symptoms is not associated with worse substance use, psychological, environmental or legal treatment outcomes. The results actually indicated that there was a slight advantage for youth with high conduct disorder to be included in the groups with less symptoms. The results appear consistent with recent meta-analyses of delinquency studies (Lipsey, 2006) which have found no evidence of iatrogenic effects. These results support the common clinical belief that group therapy for youths with substance use disorders is a safe and effective treatment modality.

Cost-effectiveness of an activating intervention by social workers for patients with minor mental disorders on sick leave: a randomized controlled trial

BACKGROUND

Sickness absence often occurs in patients with emotional distress or minor mental disorders. In several European countries, these patients are over-represented among those receiving illness benefits, and interventions are needed. The aim of this study was to evaluate the cost-effectiveness of an intervention conducted by social workers, designed to reduce sick leave duration in patients absent from work owing to emotional distress or minor mental disorders.

METHODS

In this Randomized Controlled Trial, patients were recruited by GPs. The intervention group (N = 98) received an activating, structured treatment by social workers, the control group (N = 96) received routine GP care. Sick leave duration, clinical symptoms, and medical consumption (consumption of medical staffs' time as well as consumption of drugs) were measured at baseline and 3, 6, and 18 months later.

RESULTS

Neither for sick leave duration nor for clinical improvement over time were significant differences found between the groups. Also the associated costs were not significantly lower in the intervention group.

CONCLUSIONS

Compared with usual GP care, the activating social work intervention was not superior in reducing sick leave duration, improving clinical symptoms, and decreasing medical consumption. It was also not cost-effective compared with GP routine care in the treatment of minor mental disorders. Therefore, further implementation of the intervention is not justified. Potentially, programmes aimed at reducing sick leave duration in patients with minor mental disorders carried out closer to the workplace (e.g. by occupational physicians) are more successful than programmes in primary care.

[Alexithymia in women after myocardial infarction: the role of neurophysiological correction method in complex sanatorium rehabilitation]

The article is dedicated to analysis of psychological features of 152 women with coronary artery disease (CAD), who had had acute myocardial infarction and had begun sanatorium rehabilitation in Belokurikha sanatorium. The role of the neurophysiological method of bioadaptive regulation in improvement of the efficacy of early post-infarction rehabilitation and secondary CAD prophylaxis in women with alexithymia was evaluated. The authors make their conclusion on the basis of clinico-functional and psychological studies and statistical evaluation of the data received in the course of the study. The study demonstrated full reestablishment of functional reserve, the presence of psychoemotional relaxation, compensation of complications, and mobilization of psychological resourse in patients with alexithymia whose sanatorium rehabilitation program included psychotherapy with biological feedback trainings.

Intervention effects of supplying homeless individuals with permanent housing: a 3-year prospective study

OBJECTIVE

To describe the intervention effects of supplying homeless individuals with permanent housing.

METHOD

In a prospective study, 109 male and 20 female homeless individuals were assessed at baseline and at 1- and 3-year follow-up concerning mental illness (SCID-I), psychopathology, global assessment of functioning, emotional lability and alcohol consumption.

RESULTS

A high proportion (86%) of the individuals was able to maintain or improve stability of housing. Only minor changes were observed concerning mental illness and global functioning. Extensive alcohol consumption and high psychopathology increased the risk of losing the stable housing.

CONCLUSION

The placement of homeless individuals in board and care homes or community housing after social counselling seems to be a necessary measure to remedy homelessness. However, supplying more permanent housing is not sufficient to decisively improve mental health status.

Hope as an outcome variable among youths in a residential care setting

This study investigated changes in hope among 155 youths (ages 10 to 17 years) placed in a residential treatment facility over a 6-month period. The child and adolescent participants met criteria for a range of emotional and behavioral disorders and received interventions hypothesized to improve hopeful thinking. Hope scores significantly improved over 6 months of treatment. The positive changes in hope were not moderated by ethnicity or sex. For Agency hope scores (i.e., willpower), those with higher levels of psychopathology at admission demonstrated significantly more improvement in agency thinking over the course of 6 months.

Attachment representations of institutionalized adolescents and their professional caregivers: predicting the development of therapeutic relationships

This study prospectively examined the effects of adolescent (N=81) and professional caregiver (N=33) attachment representations, measured using the Adult Attachment Interview, on therapeutic relationships in a youth treatment institution. After the first 3 months of the clients' stay in the institution, no effects of adolescents' or mentors' (i.e., the professional caregiver assigned) security and type of attachment representations were found. In a subgroup of 28 clients staying for a longer period, more secure adolescents were perceived by their mentors as increasing their secure base use and decreasing avoidance of contact, whereas more secure mentors were increasingly perceived as available as a secure base. Moreover, specific combinations of attachment representations of mentor and adolescent had different effects on adolescent hostility.

Psychiatric disturbances after traumatic brain injury: neurobehavioral and personality changes

Traumatic brain injuries (TBI) are frequently accompanied by psychiatric disturbances, which can include striking to relatively minor alterations in personality, behavior, and emotional regulation. The persistence of these neurobehavioral syndromes often leads to deleterious effects on recovery and rehabilitation outcomes. A recent surge of studies has emerged in the past several years to quantify the extent of psychiatric disorders in TBI and to describe differential clinical presentations. Various pre- and post-injury factors also have been hypothesized to contribute to the development and maintenance of psychiatric symptoms in survivors of brain injuries. The identification of high-risk individuals with distinct neuropathophysiological and psychosocial features permits the development of multidisciplinary and tailored approaches to the assessment, prevention, and management of the negative effects of personality and behavioral changes in TBI. This article summarizes the most recent research in these areas and highlights the gaps that need to be filled in subsequent future.

Cognitive and emotional consequences of TBI: intervention strategies for vocational rehabilitation

The effects of a traumatic brain injury on vocational outcome can be predicted on the basis of several factors. Environmental factors such as a supportive work environment, and person specific factors, including the client's age, premorbid occupation, injury variables, level of awareness, psychosocial adjustment, coping skills, and cognitive deficits have all been found to predict return to work following a traumatic brain injury. Some of these factors are amenable to treatment, and clinicians can impact clients' likelihood of returning to work by intervening in various ways. Through case studies and a literature review on the effectiveness of cognitive rehabilitation interventions, we have outlined specific strategies and recommendations for interventions. Cognitive rehabilitation strategies that address attention, memory and executive deficits can improve clients' abilities to manage workplace tasks and demands. Many clients continue to experience problems with social and emotional adjustment following a brain injury that impact return to work. Cognitive behavioural therapy is well suited for improving coping skills, helping clients to manage cognitive difficulties, and addressing more generalized anxiety and depression in the context of a brain injury.

Psychological distress in alcohol-dependent patients. Evaluating inpatient treatment with the symptom checklist (SCL-90-R)

The aim of this study was to evaluate the change of psychological distress measured by the symptom checklist in alcohol dependent inpatients during treatment and at follow-up. In addition, psychological distress as a predictive variable for abstinence or relapse during a 1-year follow-up was investigated. In a sample of 314 alcohol-dependent inpatients, we found a statistically significant reduction of psychological distress during therapy. Comparison of patients within 1-year follow-up showed a significant reduction of psychological distress only for the later abstinent subgroup. Later abstinent patients were significantly less distressed at the end of therapy and at follow-up. Logistic regression indicated that a higher Global Severity Index (GSI) of psychological distress at the end of therapy increases the relapse risk.

Optimizing treatment of schizophrenia. Enhancing affective/cognitive and depressive functioning

Recognition and treatment of schizophrenia has largely focused on positive symptoms of the disorder, such as delusions, hallucinations, and disorganization. However, other important symptoms, such as depression, cognition, and social functioning, have not received comparable attention. Fifty percent of schizophrenic patients suffer from comorbid depression, which is a major risk factor for suicide in this population, while 10% to 25% suffer from comorbid obsessive-compulsive disorder. Cognitive deficits commonly observed in patients with schizophrenia include problems with concentration, attention, and memory, as well as problem-solving and verbal skills. These deficits are observed at early stages of the illness and can predict deficits in functional capabilities, such as occupational and social skills, educational attainment, and the ability to live independently. The severity of such impairments affects all patient in this population, including up to 10% of patients working full time and up to one third of those working part time. In light of the debilitating effects of depression, cognitive impairment, and other aspects of affective functioning on the quality of life of patients with schizophrenia, physicians need to partner with their patients to address these concerns and determine an appropriate treatment regimen. This can be done with simple functional-based cognitive questioning, the use of evidence-based psychosocial practices, and psychoeducation on the many pharmacotherapeutic options. It is recommended that depressive or suicidal symptoms of schizophrenia be treated with an antidepressant or mood stabilizer only if the symptoms have not subsided after treatment of the psychosis with an atypical antipsychotic. Additionally, relative to older medications, atypicals have demonstrated benefit in improving some of the cognitive impairments.

Using music as a therapy tool to motivate troubled adolescents

Children and adolescents with emotional disorders may often be characterized by having problems in peer and adult relations and in display of inappropriate behaviours. These include suicide attempts, anger, withdrawal from family, social isolation from peers, aggression, school failure, running away, and alcohol and/or drug abuse. A lack of self-concept and self-esteem is often central to these difficulties. Traditional treatment methods with young people usually includes cognitive- behavioural approaches with psychotherapy. Unfortunately these children often lack a solid communication base, creating a block to successful treatment. In my private clinical practice, I have endeavoured to break through these communication barriers by using music as a therapy tool. This paper describes and discusses my use of music as a therapy tool with troubled adolescents. Pre- and post-testing of the effectiveness of this intervention technique by using the Psychosocial Functioning Inventory for Primary School Children (PFI-PSC) has yielded positive initial results, lending support to its continued use. Music has often been successful in helping these adolescents engage in the therapeutic process with minimised resistance as they relate to the music and the therapist becomes a safe and trusted adult. Various techniques such as song discussion, listening, writing lyrics, composing music, and performing music.

Krankheitsprofile und Therapieeffekte von Patientinnen in Mutter-Kind-Einrichtungen

Within the setting of external quality management of mother-child rehabilitation centres the short-term and medium-term therapy effects as well as the disease profiles of patients were analysed. This paper is focused on the changing of the main symptoms among the mothers. The patients' state of health is essentially characterized by physical and psychological exhaustion as well as by multimorbidity. It is strongly associated with the mothers' current situation of living. Before intervention the patients' health status was significantly impaired. Directly after the treatment high or very high therapy effects were found. All indicators are still higher after 6 months than they were at the beginning of the treatment. The results of a quasi-control population give evidence that these effects are caused by the treatment. First trends about the children treated show that behaviour problems can be reduced and the quality of life enhanced.

Perceptions regarding school-based occupational therapy for children with emotional disturbances

The purpose of this study was to identify the perceived appropriateness, extent, and types of services provided by occupational therapists to children with emotional disturbances in public schools. A nationally mailed survey was conducted of randomly selected school occupational therapists derived from the American Occupational Therapy Association School System Special Interest Section list. The sampling frame was 982 with a response rate of 48% (n = 476). Eighty-seven percent of all respondents were supportive of school occupational therapy for students with emotional disturbances, although these students made up only a small proportion of their caseload. The therapists indicated that a variety of intervention approaches were used with most targeting educational areas, especially handwriting. The most commonly reported intervention was sensory integration. Many respondents perceived that they could not provide effective interventions because they were not appropriately trained. Perceived lack of knowledge and confusion about occupational therapy's role may lead to underutilization of occupational therapy for addressing the complex needs of children with emotional disturbances. Further research and discussion are needed in the profession to arrive at consensus regarding what approaches are most appropriate and effective in schools.

Predicting length of service provision in school-based occupational therapy

Parents and school administrators commonly ask how long a child is likely to need school-based occupational therapy services. In an effort to provide a statistically supported answer, a record review of 464 cases of students discharged from school-based occupational therapy services in the past 7 years was performed. This review demonstrated that some general statements about service patterns could be determined for this particular caseload. Of note was the significant variability in length of services for students with multiple disabilities as compared to the more discrete length of service provision for students with speech impairments, learning disabilities and those students without a specific classification. The applicability to other practice settings is limited, but this study serves as a beginning point for discussion on the topic.

What does getting better mean? Child improvement and measure of outcome in residential treatment

A single-sample, within-subject descriptive study was completed to ascertain individual subject characteristics associated with outcome for 87 youths discharged from a residential treatment facility. Two different methods of assessing outcome were also compared. Variables assessing a history of abuse and internalizing psychopathology at admission to residential care were associated with outcome. Low levels of staff agreement were found on the 2 outcome measures. Implications for acute residential care are discussed.

Psychosocial functioning during the year following severe traumatic brain injury

The psychosocial functioning of a group of 65 adults with severe traumatic brain injury was assessed at 6 months and 1 year post-injury. Aspects of emotional, behavioural, and social functioning were investigated. The prevalence of depression remained constant (24%) over time, although there was some individual variation in the reporting of symptoms. Impatience was the most frequently reported behavioural problem at both assessments. Whilst there was a slight increase in the number of behavioural problems and level of distress reported over time, the most obvious change was in the type of behavioural problems that caused distress. At 1 year post-injury, problems with emotional control were found to be most distressing for the patients. A comparison with pre-morbid social functioning showed the loss of employment to be 70%, 30% returned to live with their parents, and relationship breakdown occurred for 38%. There was also a significant and ongoing decrease in all five aspects of social and leisure activities.

Psychotherapy with "mild" brain-injured patients

A review of neuropsychological studies reveals that patients with mild brain injuries suffer from a wide range of cognitive, physical, and emotional problems. Yet, their symptoms may be overlooked because of inadequate assessment. Family involvement and group work are described as beneficial for these patients. Individual psychotherapy is indicated for those who have a more realistic perception of their skill level, can adjust to a new self, and are able to manage emotional reactions.

Teachers' causal attributions, cognitive, emotional and behavioural responses to students with emotional and behavioural difficulties

BACKGROUND

The vast majority of children with emotional and behavioural difficulties are educated in their usual classes in ordinary schools across the countries. The study, therefore, of teachers' responses to these children is important for both teachers' and students' well-being in schools. Research provides evidence that teachers attribute students' difficulties to factors external to themselves, that is family or child factors and although they experience feelings of irritation and indifference with disruptive students they feel responsible and committed to help them. As far as their coping strategies are concerned, teachers seem to mostly favour positive interventions.

AIMS

This study aimed to examine Greek teachers' causal attributions, emotional and cognitive responses, coping strategies and suggestions for effective coping strategies with students with emotional and behavioural difficulties.

SAMPLE

This comprised 391 elementary teachers teaching in 60 public schools in the area of Athens.

METHOD

Teachers completed an inventory presenting six short scenarios of students with emotional and behavioural difficulties, varying in the type of difficulty (conduct or emotional) and the degree of severity for teachers to handle them (mild or severe).

RESULTS

Repeated-measures ANOVA revealed that teachers perceived school and teacher factors as causal of emotional and behavioural difficulties. Teachers expressed feelings of sympathy for these children, and perceived themselves as responsible, self-efficacious and inclined to help them. Finally, they reported using supportive techniques to handle emotional and behavioural difficulties, which they also considered as effective.

CONCLUSIONS

Teacher training becomes crucial as a process of adopting patterns of thought and strategies for responding to students with emotional and behavioural difficulties.

[Therapy motivation of young prisoners]

OBJECTIVES

Therapy adherence was examined within a sample of 145 imprisoned male juveniles with regard to factors of influence, structure and predictability.

METHODS

Predictors included biographic data, expectations with regard to therapy, personality traits (measured with the FPI-R) and psychological impairment (investigated by means of the Symptom Checklist). Therapy adherence as a criterion can be divided into the following dimensions: affliction, dissatisfaction, requests for change and help, and expectations of success.

RESULTS

Within the sample a clear impairment of biographical and psychological data, as well as of personality traits was found. Values were average for expectations regarding therapy and therapy adherence, while two thirds of the sample were willing to undergo treatment during imprisonment.

CONCLUSIONS

Therapy adherence proved to be a one-dimensional construct, best predicted by emotional instability, followed by the symptom score, expectations regarding therapy and inhibition. Dividing the entire sample into subgroups, significant differences were found mainly for psychological test data and less so for the construct of therapy adherence.

Reduced mortality after severe head injury will increase the demands for rehabilitation services

PRIMARY OBJECTIVE

In 1989, a new therapy to reduce intracranial pressure in severely head-injured patients was introduced in Lund. The new treatment reduced mortality significantly. The present study describes the quality of life for the survivors.

METHODS AND PROCEDURES

The study includes 53 patients treated during 1989-1994, according to a new treatment protocol for increased intracranial pressure ('Lund concept' group). During 1982-1986, 38 patients were managed according to a protocol including high dose thiopentone ('Thiopentone' group). The two groups are compared regarding neurophysical and psychiatric symptoms as well as aspects regarding the patient's role, performance, interpersonal relationship, frictions, feelings and satisfaction in work, areas of social and leisure activities, and extended family.

RESULTS

Mortality was reduced from 47% to 8%, but the number of patients with a persistent vegetative state and/or remaining severe disability did not increase. However, the number of patients with persisting emotional and intellectual deficits increased significantly.

CONCLUSION

The new treatment regime has dramatically increased the number of survivors after severe head trauma. Although most patients have a favourable outcome, there are more patients with remaining sequelae and disabilities, and the demand for qualified rehabilitation has increased.

[Emotional disorders in railway workers and their rehabilitation]

The paper discusses whether industrial factors can influence the emotional sphere of railway workers. It outlines the basic trends of recreative measures and the principle of their use in emotional disorders.

Emotional and behavioral adjustment after traumatic brain injury

OBJECTIVES

To examine emotional and behavioral adjustment and recovery over 1 year after traumatic brain injury (TBI), and to determine whether the difficulties, if present, are due to neurologic insult.

DESIGN

Longitudinal evaluation of adjustment from 1 month to 1 year after injury.

SETTING

Level I trauma center at a university hospital.

PATIENTS

One hundred fifty-seven consecutively hospitalized adults with TBI and 125 trauma controls with other system injuries evaluated at 1 and 12 months after injury.

MAIN OUTCOME MEASURES

Katz Adjustment Scale (KAS).

RESULTS

The TBI group at 1 year follow-up demonstrated significant emotional and behavioral maladjustment, but such difficulties did not appear to be mediated by the brain injury, since the KAS scores for the TBI and trauma control groups were not significantly different. Those with moderate TBI reported greater difficulties than those with mild or severe injuries. Changes in adjustment over 1 year were common for both groups. Within the TBI group there was differential recovery: improvement in cognitive clarity, dysphoric mood, and emotional stability, but increased difficulties with anger management, antisocial behaviors, and self-monitoring.

CONCLUSIONS

These results raise questions about commonly held beliefs that those with mild TBI report greater distress, and clarify some misconceptions regarding change in emotional and behavioral functioning over time.

Prognostic factors and treatment-related changes associated with return to work in the multimodal treatment of chronic back pain

The goals of the current study were to determine those preprogram (= prognostic) variables and treatment-related changes that predict return to work in the multimodal management of chronic back pain. The outcome measures for 143 patients at 6-month follow-up were analyzed. The program had a duration of 4 weeks, was based largely on the functional restoration approach (Mayer and Gatchel, 1998), and occurred within a workers' compensation framework. Some 87% of the patients successfully returned to work. Three sets of predictor variables were considered: demographic/socioeconomic data, physical measures, and psychological measures. Three prognostic variables proved to be significant negative predictors of return to work: time off work, previous spinal surgery, and a clinically elevated (preprogram) score on the MMPI-2 scale Lassitude-Malaise (Hy3). A repeated-measures MANOVA showed an incomplete return to work to be associated with only limited improvement in self-reported disability and pain report. However, patients who failed to return to work did not differ with regard to improvement in objective physical functioning or psychological distress. It is therefore hypothesized that a change in the perceived disability status is the key element necessary to return patients with chronic back pain to work, although ongoing reinforcement schemes operative in the home/work environment may lead to a relapse in the posttreatment phase.

Evaluation of state efforts to improve systems of care for children and adolescents with severe emotional disturbances: the CASSP (Child and Adolescent Service System Program) initial cohort study

In 1984, the National Institute of Mental Health (NIMH) began funding its Child and Adolescent Service System Program (CASSP). In this paper, we present findings from a descriptive study of the experiences of the initial cohort of states to receive CASSP grants, conceived and conducted when the projects were approaching the end of their fifth and final year of NIMH funding. Detailed case studies were conducted of each of the 10 initial cohort projects, and the findings analyzed across projects. Data were collected from three major sources: (1) existing documentation about the projects, (2) site visits to each of the projects, and (3) information from relevant secondary sources. Findings suggest that the initial cohort projects utilized a variety of strategies and encountered a variety of barriers and facilitating factors. The projects generally implemented the intended CASSP program and did so by using a variety of strategies. The projects were judged by stakeholders in their states to have influenced the service systems in their states in the intended directions: toward a more comprehensive system of care that emphasizes community-based treatment; toward better integrated, more collaborative efforts among the state agencies involved; toward a more detailed understanding on the part of system stakeholders of the mental health problems of children and adolescents who have severe emotional disturbances, and of the influence of those problems on the lives of the children and their families; and toward increased involvement by parents and other family members in the care of these children and adolescents.

Barriers and facilitators to use of services following intensive family preservation services

The primary caregivers of 101 families that used short-term, intensive home-based services were interviewed 2 months after the services to ascertain use of the recommended aftercare services, perceived barriers to service use, and perceived facilitators of service use. While 88% of the families accessed at least some of the recommended services, more than 50% failed to access all of the recommended aftercare services. The most often noted barriers to service use were enabling factors at the agency or community level. Yet, many of the services were used, and the respondents indicated that professionals played a role in helping them link to services. Researchers should continue to study the use of recommended aftercare services and the relationship between aftercare service use and clinical outcomes.

Treatment of emotionalism with fluoxetine during rehabilitation

Emotionalism (emotional lability) is a common but distressing phenomenon that occurs frequently in individuals suffering cerebral vascular accidents and other brain diseases. Patients with emotionalism sometimes embarrass their families and themselves, becoming socially disabled despite normal physical function. At its worst, emotionalism interferes with rehabilitation programs, delays progress and sometimes makes these programs impossible. This paper reports the effect of fluoxetine in treating three patients with persistent emotionalism (2 cases following cerebrovascular accidents, 1 case following encephalitis). All 3 patients demonstrated dramatic improvement in emotionalism within 6 days of treatment. The severity, frequency and duration of each episode were reduced greatly. The treatment improved the effectiveness of the rehabilitation program, relieved patient and family embarrassment, and enabled patients to resume rapidly their previous lifestyle patterns. All patients reached the functional goals planned prior to the onset of rehabilitation. We conclude that fluoxetine is highly effective in treating the symptoms of emotionalism in all patients, and allows for recovery of both physical and social function.

Adolescents with borderline intellectual functioning: psychopathological risk

This paper presents a qualitative analysis of cognitive and emotional functioning in intellectually borderline adolescents (IQ ranging from 71 to 84) and the consequences for personality and social development. Psychopathological risk, particularly in terms of mood disorders, conduct disorders, and intellectual deterioration, is analyzed, with the distinction made between "excited" and "inhibited" forms. Conceptualizations intellectually borderline adolescents have of their own mental functioning are described in light of the notion of cognitive self--the ability to understand and control internal and external reality. The implications for psychotherapy and rehabilitation are discussed.

Utilization management analysis for children's mental health services

Efficient identification of high-cost child and adolescent consumers of public mental health services using existing utilization and cost data is illustrated, along with analyses that profile these high-cost consumers and demonstrate the effect on total service cost per client of providing case management. The results indicate that providing high levels of case management services is not correlated with reductions in total service costs and that there is a need in the service system for using high-cost case management review techniques to control service utilization and lower costs.

The transition to adulthood for youth who have serious emotional disturbance: developmental transition and young adult outcomes

This article reviews studies that depict the developmental transition from adolescence to young adulthood of persons who have experienced serious emotional disturbance (SED) as children or adolescents. The literature demonstrates that their plight in young adulthood is grave. Youth with SED enter the transition phase delayed in their developmental maturation and face additional challenges relative to their nondisabled peers. As a group, they are undereducated, underemployed, and have limited social supports. Homelessness, criminal activity, and drug use are prevalent. This article defines the transitional youth population, describes the developmental tasks of transition, and summarizes the results of longitudinal studies that have tracked functional outcomes of transitional youth into young adulthood. The discussion focuses on the relevance of these findings to service provision.

Promoting the full inclusion of emotionally disturbed students through "no fault" interactions between parents and professionals

The essential focus and topics covered in “no fault” parental training which promotes the full inclusion of emotionally disturbed children in regular school settings are presented.

A pilot HIV prevention program for adolescents in a psychiatric hospital

In a pilot HIV prevention program for 35 adolescents in a psychiatric hospital, patients completed assessments of their HIV-related knowledge, attitudes, and behaviors before entering the program, at discharge, and three months after discharge. At discharge they showed significant increases in knowledge, tolerance of people with AIDS, and self-efficacy (or perceived ability to engage in safe-sex behaviors), although those who had been sexually abused showed significantly less change in self-efficacy than others. At three-month follow-up, scores had returned to baseline, but there was a trend toward increased condom use. Findings confirm the need for HIV-AIDS interventions for adolescents in psychiatric settings despite barriers to implementation.

Screening for drug abuse among adolescents in clinical and correctional settings using the Problem-Oriented Screening Instrument for Teenagers

Recent research has indicated high rates of substance abuse among adolescents with emotional and behavioral disorders. Moreover, adolescents in clinical and correctional settings found to have comorbid disorders involving substance abuse experience higher morbidity and mortality rates when compared to adolescents having one or no condition. The present study examines the ability of the Problem-Oriented Screening Instrument for Teenagers (POSIT) to identify DSM-III-R-defined psychoactive substance use disorders among 342 adolescents aged 12-19 years. Participants were sampled from school, clinical, and correctional settings. Optimal-scale cut scores for drug abuse diagnosis classification were derived by a minimum loss function method that minimized false classifications. When using the optimal cut score of two for the total sample, the standard POSIT substance use/abuse scale obtained a drug abuse diagnosis classification accuracy of 84% with sensitivity and specificity ratios of 95% and 79%, respectively. The internal validity of the standard 17-item substance use/abuse scale was subsequently examined by principle component analysis, item analysis, and coefficient alpha. The internal validity analyses were conducted to determine if a shortened scale could be developed and yet retain acceptable classification accuracy. When using the optimal cut score of two for the total sample, the revised 11-item scale obtained a drug abuse diagnosis classification accuracy of 85% with sensitivity and specificity ratios of 91% and 82%, respectively. The results suggest that the POSIT can serve as a useful first-gate instrument to identify adolescents in need of further drug abuse assessment.