Heather D. Lehmkuhl

Impact of Comorbidity on Cognitive-Behavioral Therapy Response in Pediatric Obsessive-Compulsive Disorder.

OBJECTIVE To examine the impact of psychiatric comorbidity on cognitive-behavioral therapy response in children and adolescents with obsessive-compulsive disorder. METHOD Ninety-six youths with obsessive-compulsive disorder (range 7-19 years) received 14 sessions of weekly or intensive family-based cognitive-behavioral therapy. Assessments were conducted before and after treatment. Primary outcomes included scores on the Childrens Yale-Brown Obsessive-Compulsive Scale, response rates, and remission status. RESULTS Seventy-four percent of participants met criteria for at least one comorbid diagnosis. In general, participants with one or more comorbid diagnoses had lower treatment response and remission rates relative to those without a comorbid diagnosis. The number of comorbid conditions was negatively related to outcome. The presence of attention-deficit/hyperactivity disorder and disruptive behavior disorders was related to lower treatment response rates, and the presence of disruptive behavior disorders and major depressive disorder were related to lower remission rates. CONCLUSIONS The presence of a comorbid disorder, particularly disruptive behavior, major depressive, and attention-deficit/hyperactivity disorders, has a negative impact on treatment response. Assessing for psychiatric disorders before treatment entry and treating these comorbid conditions before or during cognitive-behavioral therapy may improve final outcome. Comorbid anxiety or tic disorders do not seem to negatively affect response.

Decreased Family Accommodation Associated with Improved Therapy Outcome in Pediatric Obsessive-Compulsive Disorder

Pediatric obsessive-compulsive disorder (OCD) is a chronic, disabling condition that affects both patients and their families. Despite the identification of efficacious treatments (e.g., cognitive-behavioral therapy and selective serotonin reuptake inhibitor medications), not all patients respond fully. The purpose of the present study was to examine whether the amount of family accommodation provided to pediatric patients with OCD is associated with treatment outcome, and whether decreases in accommodation are associated with improved outcome. The sample consisted of 49 youths (6-18 years of age), who participated in 14 sessions of family-based cognitive-behavioral therapy for OCD, and their parents. Participants completed measures at pretreatment and posttreatment. Results indicate that family accommodation was prevalent among families of pediatric patients with OCD and that such accommodation was associated with symptom severity at pretreatment. In addition, decreases in family accommodation during treatment predicted treatment outcome, even when controlling for pretreatment OCD severity-impairment. Results suggest that the level of accommodation provided by the family may indicate an important obstacle to, or predictor of, treatment outcome in pediatric OCD. Directions for future research are discussed.

Cognitive behavioral therapy plus motivational interviewing improves outcome for pediatric obsessive-compulsive disorder: a preliminary study.

Abstract Lack of motivation may negatively impact cognitive behavioral therapy (CBT) response for pediatric patients with obsessive–compulsive disorder (OCD). Motivational interviewing is a method for interacting with patients in order to decrease their ambivalence and support their self-efficacy in their efforts at behavior change. The authors present a preliminary randomized trial (N = 16) to evaluate the effectiveness of adding motivational interviewing (MI) as an adjunct to CBT. Patients aged 6 to 17 years who were participating in intensive family-based CBT for OCD were randomized to receive either CBT plus MI or CBT plus extra psychoeducation (PE) sessions. After four sessions, the mean Childrens Yale-Brown Obsessive Compulsive Scale (CY-BOCS) score for the CBT plus MI group was significantly lower than for the CBT plus psychoeducation group, t(14) = 2.51, p < .03, Cohens d = 1.34. In addition, the degree of reduction in CY-BOCS scores was significantly greater, t(14) = 2.14, p = .05, Cohens d = 1.02, for the CBT plus MI group (mean Δ = 16.75, SD = 9.66) than for the CBT plus psychoeducation group (mean Δ = 8.13, SD = 6.01). This effect decreased over time, and scores at posttreatment were not significantly different. However, participants in the MI group completed treatment on average three sessions earlier than those in the psychoeducation group, providing support for the utility of MI in facilitating rapid improvement and minimizing the burden of treatment for families.

An Open Trial of Intensive Family Based Cognitive-Behavioral Therapy in Youth With Obsessive-Compulsive Disorder Who Are Medication Partial Responders or Nonresponders

This study reports an open-trial of family-based cognitive-behavioral therapy (CBT) in children and adolescents with obsessive-compulsive disorder (OCD). Thirty primarily Caucasian youth with OCD (range = 7–19 years; 15 girls) who were partial responders or nonresponders to two or more medication trials that were delivered either serially or concomitantly received 14 sessions of intensive family-based CBT. Eighty percent of participants were considered improved at posttreatment and at 3-month follow-up, and symptom severity was reduced by 54% at both posttreatment and follow-up. Seventeen (56.6%) and 16 (53.3%) participants were classified as being in remission at posttreatment and follow-up, respectively. Significant reductions in OCD-related impairment, depressive symptoms, behavioral problems, and family accommodation were noted. No significant difference in youth-reported anxiety was found.

Cognitive-behavioral therapy for obsessive–compulsive disorder: A non-randomized comparison of intensive and weekly approaches

This study examined the relative efficacy of intensive versus weekly cognitive-behavioral therapy (CBT) for adults with obsessive-compulsive disorder (OCD). Sixty-two adults with OCD received either 14 sessions of weekly (n=30) or intensive CBT (n=32; daily psychotherapy sessions) in a non-randomized format. Assessments were conducted at Pre-treatment, Post-treatment, and 3-month Follow-up by raters who were blind to treatment group at the Pre-treatment assessment. Intensive and weekly CBT were similar in efficacy at Post-treatment and Follow-up and associated with large treatment effect sizes. Since many people with OCD do not have access to trained CBT providers, intensive treatment may be a viable option in such cases.

Telehealth Behavior Therapy for the Management of Type 1 Diabetes in Adolescents

Background: Poor management of type 1 diabetes mellitus (T1DM) may result in serious medical complications. Psychological intervention may improve adherence to medical regimens; however, access to trained professionals is limited, particularly in rural communities. Telehealth interventions may address this by allowing families to access services at home; however, little is known about the efficacy of such services. Method: This study presents results from a pilot trial of a randomized waitlist controlled trial of Telehealth Behavioral Therapy (TBT) for youths with T1DM. Primary outcome measures were adherence to the diabetes regimen, glycemic control, and level of family discord. Thirty-two youths (23 female) with T1DM (aged 9 to 17 years) and one parent or caregiver participated. Telehealth Behavioral Therapy sessions were conducted thrice weekly for 12 weeks by phone and lasted an average of 15 min each. Results: Results indicated that youths in treatment decreased their hemoglobin A1c by 0.74 compared to 0.09 in the waitlist, though this was not statistically significant. Youths in treatment reported increased unsupportive and decreased caring parental behaviors. Conclusion: Telehealth Behavioral Therapy improves access to knowledgeable providers and results in a clinically significant improvement in glycemic control. Despite some youths experiencing an increase in unsupportive parental behaviors, TBT is a promising method of service delivery that warrants further investigation.

Perceptions of Type 1 Diabetes among Affected Youth and their Peers

Management of type 1 diabetes (T1D) involves balancing several components including diet, exercise, and medication. Peer involvement in management tasks is an important, but understudied, issue in T1D. This study presents results of a preliminary examination of perceptions of disease management in youth with T1D and their peers. Data were collected using a mixed methods (qualitative and quantitative data) approach during medical education time at a camp for youth with T1D and their peers. Results suggest that both youth with T1D and their peers believe that peers need more information about medical consequences of having diabetes. Further, youth with T1D and their peers would like coaching on how peers may help the child with T1D manage their illness better. Results provide preliminary ideas for intervention (i.e., including peers, assessing social support) in the medical setting as well as ideas for future research (i.e., examining relationships among perceptions and gender, time since diagnosis).

Just Say No: Sequential Parent Management Training and Cognitive-Behavioral Therapy for a Child With Comorbid Disruptive Behavior and Obsessive Compulsive Disorder

Psychiatric comorbidity is common in pediatric patients with obsessive-compulsive disorder (OCD) and may negatively affect treatment outcome. In particular, comorbid disruptive behavior disorders have been associated with attenuated treatment response in youth undergoing cognitive-behavioral therapy (CBT) for OCD. This article presents the case of a 10-year-old female with a primary diagnosis of OCD and secondary diagnosis of oppositional defiant disorder who was successfully treated with parent management training (PMT) prior to initiation of CBT. PMT was effective in reducing oppositional behaviors and resulted in improved adherence to the treatment protocol. The current report provides preliminary evidence for the effectiveness of PMT in youth with OCD and comorbid disruptive behavior. Clinical recommendations are provided to foster improved outcomes in this population.

Reevaluation of the Effect of Phenylephrine on Resolution of Nephrosplenic Entrapment by the Rolling Procedure in 87 Horses

OBJECTIVE To evaluate the outcome in horses treated with a rolling technique or surgically for nephrosplenic entrapment of the large colon (NSE) and to examine the benefit of phenylephrine (PE) HCl on the efficacy of nonsurgical (rolling) management of NSE. STUDY DESIGN Case series. ANIMALS Horses (n = 211) diagnosed with NSE by rectal palpation with or without ultrasonography, or at the time of exploratory celiotomy or necropsy. METHODS Medical records (January 1, 2001-September 1, 2008) were collected from horses diagnosed with NSE at 2 referral centers. Records were used to obtain signalment, physical exam findings, laboratory results, ultrasonographic findings, the use of PE HCl, the specific treatment used, and outcome. Rectal findings indicative of NSE were: (1) palpation of large colon within the nephrosplenic space or (2) palpation of colonic bands coursing dorsally toward the nephrosplenic space in association with ultrasonographic findings suggestive of NSE. RESULTS Rolling was successful in 50 of 87 (58%) horses, 85 horses (98%) survived to discharge. Horses (n = 155) that were treated surgically (42 of which had previously undergone the rolling procedure) had a 94% short-term survival rate. Premedication with PE resulted in no significant difference (P = .91) in resolution of NSE by rolling. CONCLUSIONS Resolution of NSE by rolling was not significantly affected by premedication with PE in the population studied.

Psychometric Properties of a Self-Report Measure of Adherence to the Diabetes Regimen

Management of type 1 diabetes (T1D) involves a complex regimen. Adherence may improve glycemic control and health outcomes. Accurately assessing adherence is critical. A parent and child self-report measure of regimen adherence was developed: Assessment of Diabetes Adherence, Parent and Child (ADA–P/–C). One hundred sixty-five youth with T1D and parents completed the Diabetes Self-Management Profile (DSMP), psychosocial measures, and the ADA–P/–C. Results revealed good psychometric properties. Parent and child agreement was adequate. Although not intended to replace the DSMP, the ADA–P/–C may be used for multiple adherence measurements, as part of a larger assessment battery, and when a trained clinician is not available.