Bruce J. Masek

Cognitive Behavioral Therapy for 4- to 7-Year-Old Children with Anxiety Disorders: A Randomized Clinical Trial.

OBJECTIVE To examine the efficacy of a developmentally appropriate parent-child cognitive behavioral therapy (CBT) protocol for anxiety disorders in children ages 4-7 years. METHOD DESIGN Randomized wait-list controlled trial. Conduct: Sixty-four children (53% female, mean age 5.4 years, 80% European American) with anxiety disorders were randomized to a parent-child CBT intervention (n = 34) or a 6-month wait-list condition (n = 30). Children were assessed by interviewers blind to treatment assignment, using structured diagnostic interviews with parents, laboratory assessments of behavioral inhibition, and parent questionnaires. ANALYSIS Chi-square analyses of outcome rates and linear and ordinal regression of repeated measures, examining time by intervention interactions. RESULTS The response rate (much or very much improved on the Clinical Global Impression Scale for Anxiety) among 57 completers was 69% versus 32% (CBT vs. controls), p < .01; intent-to-treat: 59% vs. 30%, p = .016. Treated children showed a significantly greater decrease in anxiety disorders (effect size [ES] = .55) and increase in parent-rated coping (ES = .69) than controls, as well as significantly better CGI improvement on social phobia/avoidant disorder (ES = .95), separation anxiety disorder (ES = .82), and specific phobia (ES = .78), but not on generalized anxiety disorder. Results on the Child Behavior Checklist Internalizing scale were not significant and were limited by low return rates. Treatment response was unrelated to age or parental anxiety but was negatively predicted by behavioral inhibition. Gains were maintained at 1-year follow-up. CONCLUSIONS Results suggest that developmentally modified parent-child CBT may show promise in 4- to 7-year-old children.

Improving Access to Mental Health Care for Children: The Massachusetts Child Psychiatry Access Project

BACKGROUND: Inadequate access to care for mentally ill children and their families is a persistent problem in the United States. Although promotion of pediatric primary care clinicians (PCCs) in detection, management, and coordination of child mental health care is a strategy for improving access, limitations in training, time, and specialist availability represent substantial barriers. The Massachusetts Child Psychiatry Access Project (MCPAP), publicly funded with 6 regional consultation teams, provides Massachusetts PCCs with rapid access to child psychiatry expertise, education, and referral assistance. METHODS: Data collected from MCPAP teams measured participation and utilization over 3.5 years from July 1, 2005, to December 31, 2008. Data were analyzed for 35 335 encounters. PCC surveys assessed satisfaction and impact on access to care. RESULTS: The MCPAP enrolled 1341 PCCs in 353 practices covering 95% of the youth in Massachusetts. The MCPAP served 10 114 children. Practices varied in their utilization of the MCPAP, with a mean of 12 encounters per practice per quarter (range: 0–245). PCCs contacted the MCPAP for diagnostic questions (34%), identifying community resources (27%), and consultation regarding medication (27%). Provider surveys revealed improvement in ratings of access to child psychiatry. The rate of PCCs who reported that they are usually able to meet the needs of psychiatric patients increased from 8% to 63%. Consultations were reported to be helpful by 91% of PCCs. CONCLUSIONS: PCCs have used and value a statewide system that provides access to teams of psychiatric consultants. Access to child mental health care may be substantially improved through public health interventions that promote collaboration between PCCs and child mental health specialists.

BIOFEEDBACK AND RELAXATION—RESPONSE TRAINING IN THE TREATMENT OF PEDIATRIC MIGRAINE

To assess the efficacy of electromyographic biofeedback, relaxation‐response training and pain behavior management as a treatment for pediatric migraine, we studied 18 children between the ages of eight and 12 years (mean = 10·1) in a prospective, randomized, controlled investigation. Six patients received all three treatment procedures, six received relaxation‐response training and pain behavior management, and the remaining six constituted a waiting‐list control group. All patients kept a record of their headaches for the 15‐week study period and then for four weeks one year later. Following four weeks of baseline, the treatment groups completed nine one‐hour treatment sessions in 11 weeks. Both treatment groups experienced a significant reduction in headache symptoms and were significantly improved compared to the waiting‐list control group by the end of treatment. The treatment groups did not differ from each other in any of these comparisons. The reduction in headache symptoms in the treatment groups was maintained one year after treatment ended. These results suggest that relaxation‐response training, with or without biofeedback training, combined with pain behavior management, is an effective alternative treatment for pediatric migraine.

Cognitive-Behavioral Intervention with Young Anxious Children

&NA; Despite evidence that preschool and early elementary school‐age children can present with anxiety disorders that may put them at risk for later psychopathology and dysfunction, the cognitive‐behavioral protocols available for treating anxiety in children have been tested almost exclusively in older children. However, there could be benefits to treating children earlier, before anxiety disorders begin to impair their social and academic development. This report discusses the adaptations necessary in providing cognitive‐behavioral therapy to young anxious children and describes a manualized, cognitive‐behavioral intervention, with child and parent components, that was piloted openly in nine families with children aged 4 to 7 years—each of whom had multiple risk factors for developing anxiety disorders, and most of whom had already presented with anxiety disorders. Eight of the nine children were judged “much” or “very much improved” at postintervention on number of anxiety diagnoses, number of DSM‐IV anxiety symptoms, and ability to cope with feared situations. Cases are presented to illustrate the way that cognitive‐behavioral therapy can be conducted with youngsters in this age range. Whereas randomized, controlled trials are needed to confirm the efficacy of this manualized treatment, our experience suggests that cognitive‐behavioral protocols for anxiety can be adapted and successfully implemented with young children.

Behavioral Approaches to the Management of Chronic Pain in Children

This article focuses on the basic premises underlying the behavioral assessment and treatment of chronic pain, particularly as they apply to the less distinct pain disorders of childhood, such as obscure headache and abdominal pain. Pain behavior management procedures, relaxation techniques, and biofeedback training are discussed in detail in reviewing recent research developments in this area.

Psychological, behavioral, and family characteristics of pediatric patients with chronic pain : A 1-year retrospective study and cluster analysis

Objectives:There has been a longstanding recognition that adult patients with chronic pain are not a homogenous population and that there are subgroups of patients who report high levels of distress and interpersonal difficulties as well as subgroups of patients who report little distress and high functioning. The purpose of the present study was to attempt to identify similar subgroups in a pediatric chronic pain population. Methods:The sample consisted of 117 children with chronic pain and their parents who were assessed in a multidisciplinary pain clinic during 2001. Participants completed a set of psychologic self-report questionnaires, as well as demographic and pain characteristic information. A cluster analysis was conducted to identify 3 distinct subgroups of patients to replicate similar studies of adult chronic pain sufferers. Results:Overall, mean scores were within population norms on measures of distress and family functioning, with somatic symptoms at a level of clinical significance. The cluster analysis identified the 3 subgroups that were strikingly similar to those identified in adult chronic pain populations: one with high levels of distress and disability, another with relatively low scores on distress and disability, and a third group that scored in between the other 2 on these measures but with marked low family cohesion. Discussion:The similarity of these subgroups to the adult chronic pain population subgroups as well as implications for future studies are discussed.

Compliance and Medicine

Patient noncompliance with medical regimens has been the subject of considerable research. Several reviews of the literature have reported estimates of noncompliance ranging from 4% to 92% (Davis, 1966; Marston, 1970). The magnitude of the problem has prompted the suggestion that poor medical outcomes resulting from noncompliance might account for much of the current general dissatisfaction with the delivery of health care (Korsch & Negrete, 1972). In particular, noncompliance with medication regimens represents an immediate challenge to behavioral scientists because there now exist a number of highly effective drug therapies for various diseases. Patient noncompliance with prescribed medication regimens seriously undermines the effectiveness of drug therapy in both preventive and curative situations and results in unnecessary morbidity, mortality, and cost.

Behavioral interventions and stress management training for hospitalized adolescents and young adults with cystic fibrosis.

Recent studies have demonstrated that the majority of cystic fibrosis (CF) patients are not at high risk for developing psychological problems. Clinical studies emphasizing the development of adaptive coping mechanisms in these patients have been suggested as a more appropriate line of research. The purpose of the present paper is to describe our experience in teaching various behavioral and stress management strategies to help CF patients. Behavioral counseling, relaxation training, and biofeedback have all been used with these patients to help them manage a number of problems more effectively. The predominant presenting problems have included elevated anxiety levels, sleeping difficulties, pain, and hyperventilation episodes. The typical treatment course with these patients is described and a case example is given to help elucidate the nature of behavioral interventions. Patient satisfaction ratings indicate that most patients view these techniques positively. Clinical observations suggest that the acquisition of behavioral coping skills may enhance the CF patients perceived control of his/her situation, reduce the level of pain and anxiety, and enhance the quality of life.

Measuring outcomes in outpatient child psychiatry: The contribution of electronic technologies and parent report.

The objective of this study was to evaluate the impact of electronic technologies on the completion of a standardized rating form in an outpatient child psychiatry clinic, and the feasibility of adding a parent-report measure to the form. An electronic Outcomes Rating Form (e-ORF) was used in conjunction with a web-based patient tracking system and digital pens which allowed form data to be directly entered into a database. Clinician forms were collected for 87% of the 248 children seen for intake, a significant increase over the rate of 72% obtained in the same clinic with paper forms. Rating forms were also obtained from 85% of parents. Clinician- and parent-completed measures were moderately correlated with each other. This study showed that 1) the use of electronic technologies is associated with improved clinician completion rates; 2) it is possible to obtain rating forms from most parents; 3) clinician and parent measures provide related but distinct information; and 4) improvements in functioning found with clinician-report measures are corroborated by independent parent reports.

A multicomponent behavioral treatment for pediatric migraine

We evaluated the effectiveness of a behavioral program in reducing headache recurrence in children with migraine using a multiple baseline design. Treatment consisted of electromyographic (HMG) biofeedback. relaxation training, and operant pain behavior management. The children studied were randomly assigned to four groups. Each group received the same treatment over nine sessions, but groups differed in the length of baseline assessment of headache occurrence: 3. 6. 9. or 12 weeks. When treatment was introduced, the results indicated statistically significant reductions in dependent measures of headache occurrence across groups. Thirteen of the 17 children who participated in follow-up maintained treatment gains 6 and 12 months after treatment ended. These results are viewed as supporting the usefulness of behavioral treatment as an alternative to medication in the management of pedialric migraine.