Addressing co-occurring conditions in behavioural therapy for tic disorders: a review and guideline

Co-occurring psychiatric conditions are very common in tic disorders and Tourette syndrome. These additional symptoms are often detrimental to quality of life and may impact upon the implementation and efficacy of evidence-based behavioural therapies (BT) for tics. Combining a review of the available literature, relevant theory, and expert clinical practice, we present a guideline for implementing behavioural and psychosocial interventions when common comorbidities are present. These include attention-deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), anxiety, disruptive behaviour, autism spectrum disorder (ASD) and depression. Practical recommendations are provided for assessment, formulation and management of specific and multiple comorbidities in BT for both children and adults. Despite comorbidities being common in tic disorders, few studies have comprehensively addressed how they may influence the efficacy or implementation of existing therapies or how such treatments may need to be modified or sequenced. We outline recommendations for future research, including randomised control trials of BT for those with specific or multiple comorbidities, as well as adequately powered sub-group analyses within larger scale trials or naturalistic study designs. Transdiagnostic models of psychiatric disorders and treatment, including modular cross-diagnostic therapies, which recognise the dimensionality of psychiatric disorders are also highlighted as an important focus in treatment development in tic disorders.

Understanding stress factors for scrub nurses in the perioperative period: A cross-sectional survey

PURPOSE OF THE STUDY

To assess the stress factors affecting operating theater nurses during the perioperative period.

PATIENTS AND METHODS

The study was conducted as a cross-sectional survey by means of a specifically drawn-up questionnaire based on the data available in the literature. Stress was measured on a 0/100 visual analogue scale (VAS).

RESULTS

Six hundred and twelve (612) persons responded. Stress associated with an operation amounted to 31.8; it was higher at the time of the procedure (49.6) and immediately beforehand (39.4), particularly among the least experienced nurses. The most widely represented stress factors were associated with the surgical team (perceived incompetence, lack of confidence), relational problems with regard to the surgeon, and team members' disruptive behavior. By contrast, familiarity with the team or the procedure seemed to shield the nurses from stress. Feelings of stress had a relatively frequent impact on quality of life (33%), family and personal life (26%), with chronic (recurrent or constant) stress symptoms reported among 20% of respondents.

CONCLUSION

Among operating theater nurses, stress associated with an operation was particularly strong among the least experienced professionals, when the type of procedure or the other team members were unfamiliar, and in the event of disruptive behavior. Stress factor improvement should be a priority, the objective being to enhance professional and personal quality of life, while better ensuring patient safety.

Surgery and Radiosurgery in Autism: A Retrospective Study in 10 Patients

INTRODUCTION

A subgroup of patients with autism spectrum disorder (ASD) show self or heteroaggression, dyscontrol episodes, and others are of obsessive-compulsive disorder (OCD) profile; some of them are resistant to medical and behavioural treatment. We describe the long-term outcome in a group of these patients, treated with radiofrequency brain lesions or combined stereotactic surgery and Gamma Knife (GK) radiosurgery.

METHODS

We reviewed the medical records of 10 ASD patients with pathological aggressiveness and OCD, who had undergone radiofrequency lesions and/or radiosurgery with GK in our institution.

RESULTS

The 10 patients had a significant reduction of their symptoms (PCQ 39.9 and 33, OAS 11.8 and 5, CYBOCS-ASD 30.4 and 20), preoperatively and in the last follow-up, respectively; p < 0.005 (in all cases), although all but 2 needed more than 1 treatment to maintain this improvement.

CONCLUSIONS

We observed a marked improvement in behaviour, quality of life, and relationship with the environment in all our 10 patients after the lesioning treatments, without long-lasting side effects.

M.I.C.E-Mental Health Intervention for Children with Epilepsy: a randomised controlled, multi-centre clinical trial evaluating the clinical and cost-effectiveness of MATCH-ADTC in addition to usual care compared to usual care alone for children and young people with common mental health disorders and epilepsy-study protocol

BACKGROUND

Mental health disorders in the context of long-term conditions in children and young people are currently overlooked and undertreated. Evidence-based psychological treatments for common childhood mental health disorders (anxiety, depression and disruptive behaviour disorders) have not been systematically evaluated in young people with epilepsy despite their high prevalence in this population. The aim of this multi-site randomised controlled trial is to determine the clinical and cost-effectiveness of adding a modular psychological intervention to usual care for the mental health disorders in comparison to assessment-enhanced usual care alone.

METHODS

In total, 334 participants aged 3-18 years attending epilepsy services will be screened for mental health disorders with the Strengths and Difficulties Questionnaire (SDQ) and the diagnostic Development and Wellbeing Assessment (DAWBA). Those identified as having a mental health disorder and consenting to the trial will be randomised to either receive up to 22 sessions of the modular psychological intervention (MATCH-ADTC) delivered over the telephone over 6 months by non-mental health professionals in addition to usual care or to assessment-enhanced usual care alone. Outcomes will be measured at baseline, 6 months and 12 months post-randomisation. It is hypothesised that MATCH-ADTC plus usual care will be superior to assessment-enhanced usual care in improving emotional and behavioural symptoms. The primary outcome is the SDQ reported by parents at 6 months. Secondary outcomes include parent-reported mental health measures such as the Revised Children's Anxiety and Depression Scale, quality of life measures such as the Paediatric Quality of Life Inventory and physical health measures such as the Hague Seizure Severity Scale. Outcome assessors will be blinded to group assignment. Qualitative process evaluations and a health economic evaluation will also be completed.

DISCUSSION

This trial aims to determine whether a systematic and integrated approach to the identification and treatment of mental health disorders in children and young people with epilepsy is clinically and cost-effective. The findings will contribute to policies and practice with regard to addressing mental health needs in children and young people with other long-term conditions.

TRIAL REGISTRATION

ISRCTN ISRCTN57823197 . Registered on 25 February 2019.

Inhibitory Control Deficits in Children with Oppositional Defiant Disorder and Conduct Disorder Compared to Attention Deficit/Hyperactivity Disorder: A Systematic Review and Meta-analysis

Inhibitory control deficits are known to be characteristic of Oppositional Defiant Disorder (ODD), Conduct Disorder (CD), and Attention-Deficit/Hyperactivity Disorder (ADHD); but it is unclear whether children with ODD/CD have inhibitory control problems independent of ADHD comorbidity. Previous reviews of inhibitory control and ODD/CD have only focused on one type of measure of inhibitory control or used non-clinical samples. The current meta-analysis explored inhibitory control problems of children with ODD/CD by systematically reviewing studies where children have a diagnosis of ODD and/or CD. Comparisons were made across 25 studies between children with ODD/CD, ODD/CD + ADHD, ADHD, and healthy controls (HC) on various measures of inhibitory control and ADHD symptomatology to explore impacts of ADHD comorbidity. A small significant effect (g = -0.58, p < .001) suggested children with ODD/CD are likely to have more difficulties with inhibitory control than healthy children. However, comparisons between clinical groups suggested this effect may be due to ADHD symptomatology present in each group. As difficulties with inhibitory control are similar, across clinical groups, a dimensional approach to understanding ODD/CD and ADHD may be more useful to consider in future diagnostic criteria. Similarities across clinical groups highlight that therapeutic approaches that assist children with disruptive behaviours could benefit from teaching children and their families how to cope with inhibitory control deficits.

The nature and extent of emotion recognition and empathy impairments in children showing disruptive behaviour referred into a crime prevention programme

Childhood disruptive behaviour has been linked to later antisocial and criminal behaviour. Emotion recognition and empathy impairments, thought to be caused by inattention to the eye region, are hypothesised to contribute to antisocial and criminal behaviour. This is the first study to simultaneously examine emotion recognition and empathy impairments, their relationship, and the mechanism behind these impairments, in children with disruptive behaviour. We hypothesised that children with disruptive behaviour would exhibit negative emotion recognition and cognitive and affective empathy impairments, but that these impairments would not be due to reduced attention to the eye region. We expected these emotion impairments to be driven by disruptive behaviour. We also expected a relationship between emotion recognition and cognitive empathy only. Ninety-two children with disruptive behaviour, who were participating in a police crime prevention programme and rated by their schoolteacher using the Strengths and Difficulties Questionnaire (DB; mean age 8.8 years, 80% male), took part. There was a comparison group of 58 typically developing children (TD; mean age 9.7 years, 78% male). All children completed emotion recognition and empathy tasks, both with concurrent eye tracking to assess social attention. Not only were DB children significantly impaired in negative emotion and neutral emotion recognition, and in cognitive and affective empathy compared to the TD children, but severity of disruptive behaviour also predicted intensity of emotion impairments. There were no differences in social attention to the eye region. Negative emotion recognition and empathy impairments are already present in an identifiable group of children displaying disruptive behaviour. These findings provide evidence to encourage the use of targeted interventions.

Guided self-help for mental health disorders in children and young people with chronic neurological conditions: A qualitative evaluation

OBJECTIVE

Children with neurological conditions such as epilepsy are at high risk of developing mental health disorders. Guided self-help can be used to increase access to psychological therapies. When developing and evaluating interventions, it is important to obtain the views of service-users about their acceptability. A telephone-guided self-help intervention was used to treat common mental health difficulties in children and young people with neurological conditions. The intervention was not adapted in content to account for chronic illness. This study therefore reports on qualitative interviews with participants to determine the acceptability of the intervention.

METHODS

Semi-structured interviews were conducted with 27 participants (25 parents and 2 young people) who had undertaken a telephone-delivered guided self-help intervention for common mental health difficulties in the context of a paediatric neurological condition. Transcripts were analysed thematically using the framework approach.

RESULTS

Thirteen themes were extracted, organised into three main domains, which covered: the practicalities of telephone guided self-help treatment; the outcomes of the intervention; and the extent to which adaptation was needed for chronic illness. Most families found the intervention helpful in working towards their specific goals and noticed changes for the child and/or parents and family.

CONCLUSIONS

Participants had a positive experience of the intervention and the majority of parents found the standard intervention with individualised goals sufficient to meet the young person's mental health needs.

Parental and child factors associated with participation in a randomised control trial of an Internet-assisted parent training programme

BACKGROUND

Parental training is an effective way to treat and prevent children's conduct problems, but knowledge of who participates in such initiatives is limited.

METHOD

This study examined child and family factors associated with participation in an Internet-assisted parent training programme. The parents of 4-year-old children with high levels of disruptive behaviour in a region of Finland were offered the opportunity to participate in a randomised controlled trial of the Strongest Families Smart Website intervention (SFSW). The participants and nonparticipants were compared using the Strengths and Difficulties Questionnaire (SDQ), duration of child problems and information about family demographics, which were routinely collected prior to randomisation to the SFSW and control group.

RESULTS

We found that 464 (64.5%) of the 709 parents of children fulfilling the screening criteria, participated. In the multivariable analysis, nonparticipation was most strongly associated with a child only having minor difficulties [odds ratio (OR): 2.1; 95% confidence interval (CI): 1.5-3.0] and a shorter duration of problems, for less than 12 months (OR: 1.7, 95% CI: 1.2-2.5), after controlling for other child factors. Nonparticipation was significantly associated with mothers spending a shorter time in the education system (OR: 1.6, 95% CI: 1.2-2.3) after controlling for other parental factors.

CONCLUSIONS

A larger percentage of parents of children with longer lasting and more severe problems seemed to be motivated to participate in this remote parent training programme. Future studies on how to encourage parents with shorter duration of education to participate in early intervention programmes are warranted.

Many, more, most: four risk profiles of adolescents in residential care with major psychiatric problems

BACKGROUND

The development of delinquent behaviour is largely determined by the presence of (multiple) risk factors. It is essential to focus on the patterns of co-occurring risk factors in different subgroups in order to better understand disruptive behaviour.

AIMS AND HYPOTHESIS

The aim of this study was to examine whether subgroups could be identified to obtain more insight into the patterns of co-occurring risk factors in a population of adolescents in residential care. Based on the results of prior studies, at least one subgroup with many risk factors in multiple domains and one subgroup with primarily risk factors in a single domain were expected.

METHODS

The structured assessment of violence risk in youth and the juvenile forensic profile were used to operationalize eleven risk factors in four domains: individual, family, peer and school. Data from 270 male adolescents admitted to a hospital for youth forensic psychiatry and orthopsychiatry in the Netherlands were available. Latent class analysis was used to identify subgroups and significant differences between the subgroups were examined in more detail.

RESULTS

Based on the fit statistics and the clinical interpretability, the four-class model was chosen. The four classes had different patterns of co-occurring risk factors, and differed in the included external variables such as psychopathology and criminal behaviour.

CONCLUSIONS

Two groups were found with many risk factors in multiple domains and two groups with fewer (but still several) risk factors in single domains. This study shed light on the complexity of disruptive behaviour, providing a better insight into the patterns of co-occurring risk factors in a heterogeneous population of adolescents with major psychiatric problems admitted to residential care.