Erin C. Accurso

Mental Health Care for Children With Disruptive Behavior Problems: A View Inside Therapists' Offices

OBJECTIVES In the United States, more money is spent on treatment for childrens mental health problems than for any other childhood medical condition, yet little is known about usual care treatment for children. Objectives of this study were to characterize usual care outpatient psychotherapy for children with disruptive behavior problems and to identify consistencies and inconsistencies between usual care and common elements of evidence-based practices in order to inform efforts to implement evidence-based practices in usual care. METHODS Participants included 96 psychotherapists and 191 children aged four to 13 who were presenting for treatment for disruptive behavior to one of six usual care clinics. An adapted version of the Therapy Process Observational Coding System for Child Psychotherapy-Strategies scale (TPOCS-S) was used to assess psychotherapy processes in 1,215 randomly selected (out of 3,241 collected) videotaped treatment sessions; treatment sessions were recorded for up to 16 months. RESULTS Most children received a large amount of treatment (mean number of sessions=22, plus children received other auxiliary services), and there was great variability in the amount and type of care received. Therapists employed a wide array of treatment strategies directed toward children and parents within and across sessions, but on average all strategies were delivered at a low intensity. Several strategies that were conceptually consistent with evidence-based practices were observed frequently (for example, affect education and using positive reinforcement); however, others were observed rarely (for example, assigning or reviewing homework and role-playing). CONCLUSIONS Usual care treatment for these youths reflected great breadth but not depth. The results highlight specific discrepancies between evidence-based care and usual care, thus identifying potentially potent targets for improving the effectiveness of usual care.

Early Weight Gain Predicts Outcome in Two Treatments for Adolescent Anorexia Nervosa

OBJECTIVE Determine whether early weight gain predicts full remission at end-of-treatment (EOT) and follow-up in two different treatments for adolescent anorexia nervosa (AN), and to track the rate of weight gain throughout treatment and follow-up. METHOD Participants were 121 adolescents with AN (mean age = 14.4 years, SD = 1.6), from a two-site (Chicago and Stanford) randomized controlled trial. Adolescents were randomly assigned to family-based treatment (FBT) (n = 61) or individual adolescent focused therapy (AFT) (n = 60). Treatment response was assessed using percent of expected body weight (EBW) and the global score on the Eating Disorder Examination (EDE). Full remission was defined as having achieved ≥95% EBW and within one standard deviation of the community norms of the EDE. Full remission was assessed at EOT as well as 12-month follow-up. RESULTS Receiver operating characteristic analyses showed that the earliest predictor of remission at EOT was a gain of 5.8 pounds (2.65 kg) by session 3 in FBT (area under the curve (AUC) = 0.670; p = .043), and a gain of 7.1 pounds (3.20 kg) by session 4 in AFT (AUC = 0.754, p = .014). Early weight gain did not predict remission at follow-up for either treatment. A survival analysis showed that weight was marginally superior in FBT as opposed to AFT (Wald chi-square = 3.692, df = 1, p = .055). DISCUSSION Adolescents with AN who receive either FBT or AFT, and show early weight gain, are likely to remit at EOT. However, FBT is superior to AFT in terms of weight gain throughout treatment and follow-up.

Methodological Challenges of Characterizing Usual Care Psychotherapeutic Practice

There is minimal existing research providing detailed, reliable data characterizing usual community-based psychotherapy practice, and, thus, limited established methods for such research. This article identifies methodological challenges of usual care descriptive research, including, (a) general design considerations, (b) measurement, (c) data analytic, and (d) ethical challenges. Case examples drawn from studies reported in this special issue are used to illustrate the implications, strengths, and weaknesses of different methodological decisions. Central themes include achieving an acceptable balance of scientific rigor, feasibility, and generalizable practice relevance, as well as working collaboratively with practice partners to select and implement study methods.

Psychometric Properties of the Therapeutic Alliance Scale for Caregivers and Parents

This study examined the psychometric properties of the Therapeutic Alliance Scale for Caregivers and Parents (TASCP) in a sample of 209 caregivers whose children (4-13 years of age) presented with disruptive behavior problems to a publicly funded outpatient mental health clinic in San Diego County. Information about therapeutic alliance was collected from caregivers, children, and their therapists across the course of therapy (up to 16 months). Results support the reliability, temporal stability, convergent validity, and discriminant validity of scores on the TASCP. The multilevel factor structure of this new measure was consistent with the parallel child-report version, with 2 within-level factors and 1 between-level factor. Furthermore, predictive validity was strong, with stronger caregiver-reported alliance associated with less treatment dropout, more sessions attended, and greater satisfaction with perceived improvement.

Can Adaptive Treatment Improve Outcomes in Family-Based Therapy for Adolescents with Anorexia Nervosa? Feasibility and Treatment Effects of a Multi-Site Treatment Study

OBJECTIVE Adolescents with Anorexia Nervosa (AN), treated with family-based treatment (FBT) who fail to gain 2.3 kg by the fourth week of treatment have a 40-50% lower chance of recovery than those who do. Because of the high risk of developing enduring AN, improving outcomes in this group of poor responders is essential. This study examines the feasibility and effects of a novel adaptive treatment (i.e., Intensive Parental Coaching-IPC) aimed at enhancing parental self-efficacy related to re-feeding skills in poor early responders to FBT. METHOD 45 adolescents (12-18 years of age) meeting DSM TR IV criteria for AN were randomized in an unbalanced design (10 to standard FBT; 35 to the adaptive arm). Attrition, suitability, expectancy rates, weight change, and psychopathology were compared between groups. OUTCOMES There were no differences in rates of attrition, suitability, expectancy ratings, or most clinical outcomes between randomized groups. However, the group of poor early responders that received IPC achieved full weight restoration (>95% of expected mean BMI) by EOT at similar rates as those who had responded early. CONCLUSIONS The results of this study suggest that it is feasible to use an adaptive design to study the treatment effect of IPC for those who do not gain adequate weight by session 4 of FBT. The results also suggest that using IPC for poor early responders significantly improves weight recovery rates to levels comparable to those who respond early. A sufficiently powered study is needed to confirm these promising findings.

Expressed Emotion, Family Functioning, and Treatment Outcome for Adolescents with Anorexia Nervosa

The current study examined the relation between parental expressed emotion (EE) and treatment outcome among adolescents participating in a treatment study for adolescent anorexia nervosa, as well as its impact on family functioning. One hundred and twenty-one families were assigned to family-based treatment or adolescent-focused therapy. Paternal criticism predicted lesser improvement in eating disorder psychopathology at end of treatment. There was also a significant interaction between maternal hostility and treatment, indicating that adolescents whose mothers displayed hostility had greater increases in percent of expected body weight in adolescent-focused therapy than family-based treatment. In addition, maternal hostility predicted less improvement in general family functioning and family communication at the end of treatment. Findings suggest that maternal and paternal EE may differentially impact treatment outcome and should be directly attended to in clinical settings. Future research is needed to further explore ways in which parental EE can be effectively modified in treatment.

Predictors and moderators of treatment outcome in a randomized clinical trial for adults with symptoms of bulimia nervosa

OBJECTIVE This study examined predictors and moderators of outcome in 2 treatments for bulimia nervosa (BN). METHOD Eighty adults with BN symptoms at 1 of 2 sites were randomized to 21 sessions of integrative cognitive-affective therapy for BN (ICAT-BN) or enhanced cognitive behavior therapy (CBT-E). Generalized linear models examined predictors and moderators of improvements in bulimic behavior and eating disorder psychopathology at end of treatment (EOT) and 4-month follow-up (FU). RESULTS At EOT, individuals with higher dietary restraint had greater reductions in bulimic behavior. At FU, individuals with higher weight and shape concern had greater reductions in bulimic behavior, whereas those with greater baseline depression had less improvement in eating disorder psychopathology. Individuals higher in stimulus seeking had greater reductions in bulimic behavior and eating disorder psychopathology at follow up in ICAT-BN than in CBT-E, whereas individuals lower in stimulus seeking had greater reductions in bulimic behavior in CBT-E than in ICAT-BN. Finally, individuals with higher affective lability had greater reductions in eating disorder psychopathology in ICAT-BN than in CBT-E, whereas improvements were comparable across treatments for individuals with lower affective lability. CONCLUSIONS This study identified 3 nonspecific predictors of outcome (i.e., dietary restraint, weight and shape concern, and depression) and 2 moderators (i.e., affective lability and stimulus seeking). All moderator effects emerged at FU rather than at EOT, suggesting that the moderating effects of treatment were not immediately apparent. These results suggest that individuals with higher affective lability and stimulus seeking may benefit more from treatment with a greater focus on affective states and self-regulation.

Searching for Elements of Evidence-Based Practices in Children's Usual Care and Examining Their Impact

Most of the knowledge generated to bridge the research–practice gap has been derived from experimental studies implementing specific treatment models. Alternatively, this study uses observational methods to generate knowledge about community-based treatment processes and outcomes. Aims are to (a) describe outcome trajectories for children with disruptive behavior problems (DBPs), and (b) test how observed delivery of a benchmark set of practice elements common in evidence-based treatments may be associated with outcome change while accounting for potential confounding variables. Participants included 190 children ages 4 to 13 with DBPs and their caregivers, plus 85 psychotherapists, recruited from six clinics. All treatment sessions were videotaped and a random sample of 4 sessions in the first 4 months of treatment was reliably coded for intensity on 27 practice elements (benchmark set and others). Three outcomes (child symptom severity, parent discipline, and family functioning) were assessed by parent report at intake, 4, and 8 months. Data were collected on several potential covariates including child, parent, therapist, and service use characteristics. Multilevel modeling was used to assess relationships between observed practice and outcome slopes while accounting for covariates. Children and families demonstrated improvements in all 3 outcomes, but few significant associations between treatment processes and outcome change were identified. Families receiving greater intensity on the benchmark practice elements did demonstrate greater improvement in the parental discipline outcome. Observed changes in outcomes for families in community care were generally not strongly associated with the type or amount of treatment received.

An exploratory examination of patient and parental self‐efficacy as predictors of weight gain in adolescents with anorexia nervosa

OBJECTIVE To determine whether increases in adolescent or parental self-efficacy predicted subsequent weight gain in two different therapies for adolescent anorexia nervosa (AN). METHOD Participants were 121 adolescents with AN (M = 14.4 years, SD = 1.6), from a two-site randomized clinical trial for family-based treatment (FBT) and individual adolescent focused therapy (AFT). Both adolescent and parental self-efficacy were assessed at baseline and sessions 2, 4, 6, and 8. Adolescent self-efficacy was assessed using a generic measure of self-efficacy, while parental self-efficacy was assessed using a measure specific to the recovery of an eating disorder. Weight was assessed at baseline, sessions 1 through 8, and end of treatment. Mixed-effects models were used to evaluate the relation between patient and parent self-efficacy and subsequent weight gain, controlling for weight at the previous time point. RESULTS For families who received FBT, greater within-treatment increases in parental self-efficacy predicted greater subsequent adolescent weight gain compared to those who received FBT with lesser change in parental self-efficacy and those who received AFT. Interestingly, adolescent self-efficacy did not significantly predict subsequent weight gain. DISCUSSION Greater increases in parental self-efficacy predicted significantly greater subsequent weight gain for adolescents who received FBT, but the same was not true for adolescents who received AFT. Neither overall level nor change in adolescent self-efficacy significantly predicted subsequent weight gain in either treatment group. These findings emphasize the importance of increasing parental self-efficacy in FBT in order to impact adolescent weight outcomes.

Subjective and objective binge eating in relation to eating disorder symptomatology, depressive symptoms, and self-esteem among treatment-seeking adolescents with bulimia nervosa.

This study investigated the importance of the distinction between objective (OBE) and subjective binge eating (SBE) among 80 treatment-seeking adolescents with bulimia nervosa. We explored relationships among OBEs, SBEs, eating disorder (ED) symptomatology, depression, and self-esteem using two approaches. Group comparisons showed that OBE and SBE groups did not differ on ED symptoms or self-esteem; however, the SBE group had significantly greater depression. Examining continuous variables, OBEs (not SBEs) accounted for significant unique variance in global ED pathology, vomiting, and self-esteem. SBEs (not OBEs) accounted for significant unique variance in restraint and depression. Both OBEs and SBEs accounted for significant unique variance in eating concern; neither accounted for unique variance in weight/shape concern, laxative use, diuretic use, or driven exercise. Loss of control, rather than amount of food, may be most important in defining binge eating. Additionally, OBEs may indicate broader ED pathology, while SBEs may indicate restrictive/depressive symptomatology.