Christine E. Cooper-Vince

Internet-Delivered, Family-Based Treatment for Early-Onset OCD: A Preliminary Case Series

Given the burdens of early-onset obsessive-compulsive disorder (OCD), limitations in the broad availability and accessibility of evidence-based care for affected youth present serious public health concerns. The growing potential for technological innovations to transform care for the most traditionally remote and underserved families holds enormous promise. This article presents the rationale, key considerations, and a preliminary case series for a promising behavioral telehealth innovation in the evidence-based treatment of early-onset OCD. We developed an Internet-based format for the delivery of family-based treatment for early-onset OCD directly to families in their homes, regardless of their geographic proximity to a mental health facility. Videoteleconferencing (VTC) methods were used to deliver real-time cognitive-behavioral therapy centering on exposure and response prevention to affected families. Participants in the preliminary case series included 5 children between the ages of 4 and 8 (M Age = 6.5) who received the Internet-delivered treatment format. All youth completed a full treatment course, all showed OCD symptom improvements and global severity improvements from pre- to posttreatment, all showed at least partial diagnostic response, and 60% no longer met diagnostic criteria for OCD at posttreatment. No participants got worse, and all mothers characterized the quality of services received as “excellent.” The present work adds to a growing literature supporting the potential of VTC and related computer technology for meaningfully expanding the reach of supported treatments for OCD and lays the foundation for subsequent controlled evaluations to evaluate matters of efficacy and engagement relative to standard in-office evidence-based care.

Life Impairments in Adults With Medication-Treated ADHD

Objective: In developing psychosocial approaches to augment outcomes for medication-treated adults with ADHD, it is important to understand what types of life-impairments are most affected by continued ADHD symptoms that occur despite medication treatment. This may assist in delineating targets for interventions, as well as assessments of functional outcomes that are sensitive to change in this population. Method: The sample consists of 105 adults with ADHD presenting for entry into clinical trials of CBT for residual ADHD. Life impairments are rated by a clinician using the LIFE-RIFT, which has subscales for work impairment, interpersonal impairment, life-satisfaction, and recreation, ADHD symptoms using the ADHD Rating Scale, overall ADHD severity using the clinical global impression, and associated distress using the Hamilton Depression and Anxiety Rating Scales. Results: The most problematic impairments are in the domain of work, followed by interpersonal. Generally, the subscales of the LIFE-RIFT are associated, at the bivariate level, with all 4 symptom indices. Work and interpersonal impairments are uniquely associated with overall severity of ADHD symptoms using both the CGI and the ADHD Rating Scale. However interpersonal and life-satisfaction impairments are uniquely associated with depression, and life-satisfaction is uniquely associated with anxiety. Conclusion: In medication-treated adults with ADHD, work and interpersonal impairments appear to be the most problematic areas of life-impairment, which are uniquely associated with ADHD severity. Life-satisfaction appears to be uniquely associated with distress as defined by anxiety and depression symptoms, with interpersonal impairments also playing a role. Psychosocial treatments for medication treated adults should target work and interpersonal domains and should include skills for managing associated distress.

Recent developments in the psychosocial treatment of adult ADHD

Adult attention-deficit/hyperactivity disorder (ADHD) is an increasingly recognized Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV psychiatric disorder associated with significant functional impairment in multiple domains. Although stimulant and other pharmacotherapy regimens have the most empirical support as treatments for ADHD in adults, many adults with the disorder continue to experience significant residual symptoms. In the present manuscript, we review the published studies examining group and individual psychosocial treatments for adult ADHD. We include a discussion of coaching interventions and how they differ from cognitive–behavioral therapy. We conclude that the available data support the use of structured, skills-based psychosocial interventions as a viable treatment for adults with residual symptoms of ADHD. Common elements across the various treatment packages include psychoeducation, training in concrete skills (e.g., organization and planning strategies) and emphasis on outside practice and maintenance of these strategies in daily life. These treatments, however, require further study for replication, extension and refinement. Finally, we suggest future directions for the application of psychosocial treatments to the problems of adults with ADHD.

Description and Demonstration of CBT for ADHD in Adults

ADHD in adulthood is a valid, prevalent, distressing, and interfering condition. Although medications help treat this disorder, there are often residual symptoms after medication treatment, and, for some patients, they are contraindicated. Compared to other disorders, such as mood and anxiety disorders, there are few resources available for clinicians wishing to conduct cognitive-behavioral treatment for this problem. The present manuscript provides a description of our cognitive-behavioral approach to treat ADHD in adulthood, which we have developed and tested in our clinic (Safren, Otto, et al., 2005), and for which detailed therapist and client guides exist (Safren, Perlman, Sprich, & Otto, 2005; Safren, Sprich, Perlman, & Otto, 2005). To augment the description of treatment, the present article provides video component demonstrations of several core modules that highlight important aspects of this treatment. This description and the accompanying demonstrations are intended as a practical guide to assist therapists wishing to conduct such a treatment in the outpatient setting.

Patterns and predictors of comorbidity of DSM-IV anxiety disorders in a clinical sample of children and adolescents.

This study examined the comorbidity of anxiety disorders and its predictors in a large, clinically referred sample of children and adolescents. Participants were 608 youth aged 4-18 years presenting at a large anxiety clinic for assessment and treatment of anxiety or mood related problems. The diagnoses were determined using the Anxiety Disorder Interview Schedule, Child/Parent versions. Sixty three percent of the participants had an additional diagnosis of an anxiety or depressive disorder. Comorbidity patterns differed based on the principal diagnostic category. Older children and females with anxiety were more likely to have a comorbid anxiety disorder. The presence of a medical condition increased the odds of having a comorbid anxiety disorder as well. This is the largest clinical sample of children and adolescents in which comorbidity of emotional disorders has been examined. Understanding the common patterns of comorbidity has important implications for future classification and treatment planning of childhood anxiety disorders.

Trajectories of Change Across Outcomes in Intensive Treatment for Adolescent Panic Disorder and Agoraphobia

Much remains to be learned about typical and individual growth trajectories across treatment for adolescent panic disorder with and without agoraphobia and about critical treatment points associated with key changes. The present study examined the rate and shape of change across an 8-day intensive cognitive behavioral therapy for adolescent panic disorder with and without agoraphobia (N = 56). Participants ranged in age from 12 to 17 (M = 15.14, SD = 1.70; 58.9% female, 78.6% Caucasian). Multilevel modeling evaluated within-treatment linear and nonlinear changes across three treatment outcomes: panic severity, fear, and avoidance. Overall panic severity showed linear change, decreasing throughout treatment. In contrast, fear and avoidance ratings both showed cubic change, peaking slightly at the first session of treatment, starting to decrease at the second session of treatment, and with large gains continuing then plateauing at the fourth session. Findings are considered with regard to the extent to which they may elucidate critical treatment components and sessions for adolescents with panic disorder with and without agoraphobia.

Remotely delivering real-time parent training to the home: An initial randomized trial of Internet-delivered parent–child interaction therapy (I-PCIT).

Objective: Remote technologies are increasingly being leveraged to expand the reach of supported care, but applications to early child-behavior problems have been limited. This is the first controlled trial examining video-teleconferencing to remotely deliver behavioral parent training to the home setting with a live therapist. Method: Racially/ethnically diverse children ages 3–5 years with disruptive behavior disorders, and their caregiver(s), using webcams and parent-worn Bluetooth earpieces, participated in a randomized trial comparing Internet-delivered parent–child interaction therapy (I-PCIT) versus standard clinic-based PCIT (N = 40). Major assessments were conducted at baseline, midtreatment, posttreatment, and 6-month follow-up. Linear regressions and hierarchical linear modeling using maximum-likelihood estimation were used to analyze treatment satisfaction, diagnoses, symptoms, functioning, and burden to parents across conditions. Results: Intent-to-treat analyses found 70% and 55% of children treated with I-PCIT and clinic-based PCIT, respectively, showed “treatment response” after treatment, and 55% and 40% of children treated with I-PCIT and clinic-based PCIT, respectively, continued to show “treatment response” at 6-month follow-up. Both treatments had significant effects on children’s symptoms and burden to parents, and many effects were very large in magnitude. Most outcomes were comparable across conditions, except that the rate of posttreatment “excellent response” was significantly higher in I-PCIT than in clinic-based PCIT, and I-PCIT was associated with significantly fewer parent-perceived barriers to treatment than clinic-based PCIT. Both treatments were associated with positive engagement, treatment retention, and very high treatment satisfaction. Conclusion: Findings build on the small but growing literature supporting the promising role of new technologies for expanding the delivery of behavioral parent training.

Internet-delivered, family-based treatment for early-onset OCD: A pilot randomized trial.

Objective: Despite advances in supported treatments for early onset obsessive–compulsive disorder (OCD), progress has been constrained by regionally limited expertise in pediatric OCD. Videoteleconferencing (VTC) methods have proved useful for extending the reach of services for older individuals, but no randomized clinical trials (RCTs) have evaluated VTC for treating early onset OCD. Method: RCT comparing VTC-delivered family based cognitive–behavioral therapy (FB-CBT) versus clinic-based FB-CBT in the treatment of children ages 4–8 with OCD (N = 22). Pretreatment, posttreatment, and 6-month follow-up assessments included mother-/therapist-reports and independent evaluations masked to treatment condition. Primary analyses focused on treatment retention, engagement and satisfaction. Hierarchical linear modeling preliminarily evaluated the effects of time, treatment condition, and their interactions. “Excellent response” was defined as a 1 or 2 on the Clinical Global Impressions-Improvement Scale. Results: Treatment retention, engagement, alliance and satisfaction were high across conditions. Symptom trajectories and family accommodation across both conditions showed outcomes improving from baseline to posttreatment, and continuing through follow-up. At posttreatment, 72.7% of Internet cases and 60% of Clinic cases showed “excellent response,” and at follow-up 80% of Internet cases and 66.7% of Clinic cases showed “excellent response.” Significant condition differences were not found across outcomes. Conclusions: VTC methods may offer solutions to overcoming traditional barriers to care for early onset OCD by extending the reach of real-time expert services regardless of children’s geographic proximity to quality care.

Videoteleconferencing Early Child Anxiety Treatment: A Case Study of the Internet-Delivered PCIT CALM (I-CALM) Program

ABSTRACT Anxiety disorders are one of the most prevalent and impairing classes of mental health difficulties affecting young children. Although the vast majority of supported programs for child anxiety focus on youth 7 years of age and older, preliminary support has emerged for exposure-based adaptations of parent-coaching interventions, that is, the Parent–Child Interaction Therapy (PCIT) CALM Program, to address anxiety disorders in early childhood. Despite these advances, low rates of community service use and accessibility persist. The increased ubiquity of Internet access has positioned videoteleconferencing (VTC) as a powerful tool to overcome traditional barriers to care. The present case study details the VTC delivery of the PCIT CALM Program in the treatment of a 6-year-old boy presenting with generalized anxiety disorder and separation anxiety disorder. This case provides qualitative support for the feasibility of delivering integrated real-time parent coaching and exposure therapy to address early childhood anxiety disorders via VTC. The remission of the patient’s anxiety across treatment sessions suggests that the telehealth format may be a useful modality for the delivery of early childhood anxiety treatment. The technical considerations for the delivery of VTC therapy as well as the implications for treatment are discussed.

Household Water Insecurity, Missed Schooling, and the Mediating role of Caregiver Depression in Rural Uganda

Background School attendance rates in sub-Saharan Africa are among the lowest worldwide, placing children at heightened risk for poor educational and economic outcomes. One understudied risk factor for missed schooling is household water insecurity, which is linked to depression among women and may increase childrens water-fetching burden at the expense of educational activities, particularly among children of depressed caregivers. In this study conducted in rural Uganda, we assessed the association between household water insecurity and child school participation and the mediating pathways behind these associations. Method We conducted a population-based, cross-sectional study of female household heads (N = 257) and their children ages 5–17 (N = 551) in the rural regions surrounding the town of Mbarara, in southwestern Uganda. We used multivariable linear regressions to estimate the association between water insecurity and missed schooling. We then assessed the extent to which the association was mediated by caregiver depression. Results Among children, water insecurity had a statistically significant association with the number of missed school days (a standard deviation increase in water insecurity resulted in 0.30 more missed school days in the last week). The estimated association was partially mediated by caregiver depression. When stratified by sex, this mediating pathway remained significant for boys, but not among girls. Conclusions Water insecurity is a risk factor for missed schooling among children in rural Uganda. Caregiver depression partially mediated this relationship. Also addressing caregiver mental health in water insecure families may more fully address the needs of sub-Saharan African families and promote educational participation among youth.