J. Stuart Ablon

Mania-like symptoms suggestive of childhood-onset bipolar disorder in clinically referred children

OBJECTIVE To examine the prevalence, characteristics, and correlates of mania among referred children aged 12 or younger. Many case reports challenge the widely accepted belief that childhood-onset mania is rare. Sources of diagnostic confusion include the variable developmental expression of mania and its symptomatic overlap with attention-deficit hyperactivity disorder (ADHD). METHOD The authors compared 43 children aged 12 years or younger who satisfied criteria for mania, 164 ADHD children without mania, and 84 non-ADHD control children. RESULTS The clinical picture was fully compatible with the DSM-III-R diagnosis of mania in 16% (n = 43) of referred children. All but one of the children meeting criteria for mania also met criteria for ADHD. Compared with ADHD children without mania, manic children had significantly higher rates of major depression, psychosis, multiple anxiety disorders, conduct disorder, and oppositional defiant disorder as well as evidence of significantly more impaired psychosocial functioning. In addition, 21% (n = 9) of manic children had had at least one previous psychiatric hospitalization. CONCLUSIONS Mania may be relatively common among psychiatrically referred children. The clinical picture of childhood-onset mania is very severe and frequently comorbid with ADHD and other psychiatric disorders. Because of the high comorbidity with ADHD, more work is needed to clarify whether these children have ADHD, bipolar disorder, or both.

Impact of Adversity on Functioning and Comorbidity in Children with Attention-Deficit Hyperactivity Disorder

OBJECTIVE Prior research on risk factors for attention-deficit hyperactivity disorder (ADHD) has shown that familial risk factors play a role in the disorders etiology. This study investigated whether features of the family environment were associated with ADHD. METHOD One hundred forty children with ADHD and 120 normal control probands were studied. Subjects were Caucasian, non-Hispanic males between the ages of 6 and 17 years. Exposure to parental psychopathology and exposure to parental conflict were used as indicators of adversity, and their impact on ADHD and ADHD-related psychopathology and dysfunction in children was assessed. RESULTS Increased levels of environmental adversity were found among ADHD compared with control probands. The analyses showed significant associations between the index of parental conflict and several of the measures of psychopathology and psychosocial functioning in the children. In contrast, the index of exposure to parental psychopathology had a much narrower impact, affecting primarily the childs use of leisure time and externalizing symptoms. CONCLUSIONS A relationship appears to exist between adversity indicators and the risk for ADHD as well as for its associated impairments in multiple domains. These findings confirm previous work and stress the importance of adverse family-environment variables as risk factors for children who have ADHD.

Psychotherapy Process in the National Institute of Mental Health Treatment of Depression Collaborative Research Program

This study examined psychotherapy process in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Transcripts of brief interpersonal and cognitive-behavioral therapies were rated using the Psychotherapy Process Q Set (PQS), an instrument designed to provide a standard language for describing therapy process. Results demonstrated that there were important areas of overlap and key differences in the process of the treatments. There were important differences in therapist stance, activity, and technique that were consistent with theoretical prescription, but patient characteristics within sessions were quite similar. Patient in-session characteristics as measured by the PQS were related to outcome across the treatment samples. These findings are linked to theoretical models, which may help explain the role of nonspecific factors associated with nondifferential treatment outcome in brief therapy.

Birth outcomes following prenatal exposure to fluoxetine

BACKGROUND Although pregnancy has frequently been described as a time of emotional well-being, some women experience significant antenatal depression that may require treatment with antidepressants. The purpose of this investigation was to examine the relative effects of early and late trimester exposure to fluoxetine and perinatal outcome. METHODS Obstetric and neonatal records were reviewed for 64 mother-infant pairs where there was documented use of fluoxetine at some point during pregnancy. Differences in several measures of obstetrical outcome and neonatal well-being were examined in early trimester- and late trimester-exposed infants. RESULTS No differences in birth weight and acute neonatal outcome were evident across the two groups, though there was a higher frequency of special care nursery admissions for infants with exposure to fluoxetine late in pregnancy. Special care nursery admissions could not be attributed to any specific factor. CONCLUSIONS Given the growing numbers of women who are treated with antidepressants, including fluoxetine, during pregnancy, and the strong association between depression during pregnancy and risk for postpartum depression, patients may be best advised to continue treatment with antidepressants through labor and delivery versus making any change in intensity of treatment during the acute peripartum period.

Beyond brand names of psychotherapy: Identifying empirically supported change processes.

There is considerable debate about which empirical research methods best advance clinical outcomes in psychotherapy. The prevailing tendency has been to test treatment packages using randomized, controlled clinical trials. Recently, focus has shifted to considering how studying the process of change in naturalistic treatments can be a useful complement to controlled trials. Clinicians self-identifying as psychodynamic treated 17 panic disorder patients in naturalistic psychotherapy for an average of 21 sessions. Patients achieved statistically significant reductions in symptoms across all domains. Rates of remission and clinically significant change as well as effect sizes were commensurate with those of empirically supported therapies for panic disorder. Treatment gains were maintained at 6-month follow-up. Intensive analysis of the process of the treatments revealed that integrative elements characterized the treatments: Adherence to cognitive-behavioral process was most characteristic, adherence to interpersonal and psychodynamic process, however, was most predictive of positive outcome. Specific process predictors of outcome were identified using the Psychotherapy Process Q-Set. These findings demonstrate how process research can be used to empirically validate change processes in naturalistic treatments as opposed to treatment packages in controlled trials. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Effectiveness of collaborative problem solving in affectively dysregulated children with oppositional-defiant disorder: initial findings.

Oppositional-defiant disorder (ODD) refers to a recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures. Research has shown that children with ODD and comorbid mood disorders may be at particular risk for long-term adverse outcomes, including conduct disorder. In this study, the authors examined the effectiveness of a cognitive-behavioral model of intervention--called collaborative problem solving (CPS)--in comparison with parent training (PT) in 47 affectively dysregulated children with ODD. Results indicate that CPS produced significant improvements across multiple domains of functioning at posttreatment and at 4-month follow-up. These improvements were in all instances equivalent, and in many instances superior, to the improvements produced by PT. Implications of these findings for further research on and treatment selection in children with ODD are discussed.

On analytic process.

An innovative methodology is presented for identifying and assessing change process in psychoanalytic treatments. Using the Psychotherapy Process Q-set (PQS), a panel of experienced psychoanalysts developed a prototype of an ideal psychoanalytic hour. This prototype was then applied to verbatim transcripts of three archived treatment samples: psychoanalyses, long-term analytic therapies, and brief psychodynamic therapies. The degree to which these treatments fostered an analytic process as represented by the prototype was measured quantitatively. Analytic process was significantly more present in psychoanalyses than in the long-term analytic therapies, which, in turn fostered significantly more analytic process than did brief psychodynamic therapies. The study demonstrates that, given descriptive language that does not represent a particular theoretical perspective, analysts can agree on a definition of analytic process, and that analytic process can be operationalized and quantitatively assessed. A second study demonstrates that despite consensus on its definition, there is not just one proper analytic process; rather, there are change processes unique to each dyad. Two quantitative case studies illustrate how each analytic pair has a unique interaction pattern linked to treatment progress. These dyad-unique “interaction structures” are recurrent, mutually influencing patterns of interaction, the experience, recognition, and comprehension of which appear to be a fundamental component of therapeutic action. A bipersonal model is described that attempts to bridge theories of therapeutic action that focus on insight and self-understanding and those that emphasize the patients experience of the therapist.

A transactional model of oppositional behavior: Underpinnings of the Collaborative Problem Solving approach

Oppositional defiant disorder (ODD) refers to a recurrent pattern of developmentally inappropriate levels of negativistic, defiant, disobedient, and hostile behavior toward authority figures. ODD is one of the most common (and debilitating) comorbid disorders within Tourettes disorder (TD). Diverse psychosocial treatment approaches have been applied to childrens ODD-related behaviors. In this paper, the authors articulate a transactional developmental conceptualization of oppositional behavior and describe a cognitive-behavioral model of intervention-called collaborative problem solving (CPS)-emanating from this conceptualization. The specific goals of the CPS approach are to help adults (1). understand the specific adult and child characteristics contributing to the development of a childs oppositional behavior; (2). become cognizant of three basic strategies for handling unmet expectations, including (a). imposition of adult will, (b). CPS, and (c). removing the expectation; (3). recognize the impact of each of these three approaches on parent-child interactions; and (4). become proficient, along with their children, at CPS as a means of resolving disagreements and defusing potentially conflictual situations so as to reduce oppositional episodes and improve parent-child compatibility. Summary data from an initial study documenting the effectiveness of the CPS approach (in comparison to the standard of care) are also presented.

Psychotherapy process: the missing link: comment on Westen, Novotny, and Thompson-Brenner (2004).

In this comment, J. S. Ablon and C. Marci argue that focusing on the empirical validation of manualized treatment packages misses important information about what is efficacious about a given treatment. Psychotherapy process has demonstrated that treatments may promote change in ways other than their underlying theories claim. Manualized therapies may appear distinct despite important similarities in dyadic interaction. These functional similarities in the emergent transactional process between therapist and patient may help explain the difficulty demonstrating differential outcomes across brands of brief therapy. Rather than focus on treatment packages targeting patient symptomatology, the authors recommend a shift in focus to the empirical validation of change processes coconstructed by therapist and patient in naturalistic settings.

The relationship among patient contemplation, early alliance, and continuation in psychotherapy.

The present study examined the relationship among contemplation stage of readiness to change, formation of an early therapeutic alliance, and psychological distress following the first session of psychotherapy. Significant correlations between the contemplation scores and the therapeutic alliance were found for patients in the contemplation stage. Although contemplation scores were not a factor in return for a second session of psychotherapy, the bond subscale of the alliance inventory did significantly contribute to whether patients returned for therapy. Patient psychological distress was not a significant factor in predicting the early alliance. Results indicate a need for further focus on contemplation with its inherent ambivalence, its relationship to alliance, and continuation in early psychotherapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved).