Lawrence A. Vitulano

FAMILY ACCOMMODATION IN PEDIATRIC ANXIETY DISORDERS

Family accommodation has been studied in obsessive compulsive disorder using the Family Accommodation Scale (FAS) and predicts greater symptom severity, more impairment, and poorer treatment outcomes. However, family accommodation has yet to be systematically studied among families of children with other anxiety disorders. We developed the Family Accommodation Scale—Anxiety (FASA) that includes modified questions from the FAS to study accommodation across childhood anxiety disorders. The objectives of this study were to report on the first study of family accommodation across childhood anxiety disorders and to test the utility of the FASA for assessing the phenomenon.

Long-Term Follow-up Studies of Learning-Disabled Persons

From several different perspectives, the question of long-term outcomes for learning-disabled children is an important one. Answers to scientific questions about the nature and developmental course of learning disabilities, as well as the resolution of policy issues concerning the allocation of resources for intervention, may depend on results from follow-up studies of learning-disabled persons. Unfortunately, different follow-up studies have produced a variety of conflicting results. Through a careful analysis of the methodologies employed in existing studies, this months Topical Review not only shows why the research has produced inconsistent results, but also shows how some of these inconsistencies can be resolved. A final contribution of this article is to point out the need for specific methodologies in future follow-up research with learning-disabled children.—J.K.T.

Psychosocial issues for children and adolescents with chronic illness: self-esteem, school functioning and sports participation.

Self-esteem, school functioning, and sports participation are among the most significant psychosocial issues that affect children and adolescents with chronic illness. Although these capacities are essential components of development for all children, they present special concerns for children with limitations of health. Parents, teachers, and coaches play important roles in providing normalizing and gratifying opportunities for children who struggle to be competent and accepted by their peers. Much can be done to provide chronically ill children with experiences and support that will allow them to grow up happier, feel better about themselves, and enjoy more success.

Behavioral treatment of children and adolescents with trichotillomania

Trichotillomania is a behavior disorder with onset generally in childhood, characterized by repetitive, compulsive pulling out of hair from the scalp, eyebrows, or other parts of the body, often leading to disfigurement. Trichotillomania tends to be persistent and is often resistant to counselling and standard psychiatric care. A systematic behavioral treatment program for children and adolescents and pilot findings with three patients are described. Methodological issues in relation to compliance and assessment are discussed. The relative safety and potential effectiveness of behavioral techniques suggest a useful role for this approach, perhaps in conjunction with pharmacological, family, and other treatment modalities.

Biopsychosocial issues and risk factors in the family when the child has a chronic illness.

Between 10 and 20 million American children and adolescents have some type of chronic health condition or impairment. There has been a recent interest in the psychological aspects--emotional and behavioral--of chronic illness in children and adolescents. Major new areas of science, such as behavioral medicine, have emerged to address the research and clinical demands of this field. Several studies already have demonstrated the increased risk for psychiatric problems in children with chronic health conditions to be three to four times greater than their healthy peers. The proposed perspective shifts from a traditional sole reliance on medical diagnosis to a focus more on the dimensions of adjustment, socioeconomic status, visibility of condition, social support, and family functioning.

Randomized Trial of Anger Control Training for Adolescents With Tourette's Syndrome and Disruptive Behavior

OBJECTIVE To evaluate the efficacy of a 10-session individually administered anger control training (ACT) for adolescents with Tourettes syndrome (TS) and disruptive behavior. METHOD Twenty-six subjects (24 boys and 2 girls; mean age 12.7 years, SD 0.88) with TS and high levels of disruptive behavior were randomly assigned to ACT or treatment-as-usual (TAU). The parent-rated Disruptive Behavior Rating Scale and the Clinical Global Impression-Improvement Scale rated by the independent evaluator were used as primary outcome measures. RESULTS All randomized subjects completed end-point evaluation, and all subjects in the ACT group completed 3-month follow-up evaluation. The Disruptive Behavior Rating Scale score decreased by 52% in the ACT group compared with a decrease of 11% in the TAU control group (p <.001). On the Clinical Global Impression-Improvement Scale, the independent evaluator rated 9 (69%) of 13 subjects in the ACT condition as much improved or very much improved compared with 2 (15%) of 13 in the TAU condition (p <.01). This reduction of disruptive behavior in the ACT group was well maintained at 3-month follow-up. CONCLUSIONS Anger control training seems to reduce disruptive behavior in adolescents with TS. Larger trials are needed to confirm these results.Clinical trial registration information-Anger Control Training for Youth With Tourettes Syndrome. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00486551.

Coercive and disruptive behaviors in pediatric obsessive compulsive disorder: a qualitative analysis.

OCD is a common disorder in children and adolescents. Disruptive or coercive behaviors among children with OCD have not been a focus of much research until recently. Family accommodation of OCD is strongly related to symptom severity, level of impairment, and treatment outcomes. The possibility of family accommodation being forcefully imposed on family members against their will has not been investigated systematically, although clinical experience points to the existence of such situations. The present study represents an early, qualitative exploration of such situations. The parents of 10 children and adolescents with OCD, who reported the existence of violent or disruptive behavior on the part of the child, were interviewed and their narratives analyzed using grounded theory methodology. Findings from the interviews point to the existence of a pattern of coercive behaviors in which rules and prohibitions, driven by the child’s OCD, are aggressively imposed on parents and siblings. The emergent themes are analyzed in relation to obsessive compulsive symptom dimensions and in relation to the means and goals they represent for the obsessive compulsive children.

Editorial perspective: when OCD takes over…the family! Coercive and disruptive behaviours in paediatric obsessive compulsive disorder.

Despite the recognized importance of family accommodation (Storch et al., 2007) and of disruptive behaviours (Langley, Lewin, Bergman, Lee, & Piacentini, 2010) for the course of paediatric obsessive compulsive disorder (OCD), little has been published about children using disruptive and coercive behaviours as a means of imposing accommodation on their surroundings (Lebowitz, Omer, & Leckman, 2011; Lebowitz, Vitulano, & Omer, 2011). In an attempt to assess the frequency with which experts encounter such behaviours, and to determine some key aspects of the phenomenon as well as beliefs about how best to formulate and treat it, we conducted a worldwide survey among OCD experts. The survey was distributed via email to 511 corresponding authors of papers on OCD and to the approximately 4500 members of the Association for Behavioral and Cognitive Therapies (ABCT) via that organization’s list-serve. Overall, 110 experts from 27 countries completed the survey. The respondents included primarily psychologists and psychiatrists (52.7% and 40.9%, respectively). The behaviours of interest were described as follows: Coercive/Disruptive behaviours refer to situations in which a child or adolescent with OCD attempts to impose rules and prohibitions on others, particularly family members, because of his or her disorder. Coercion can include accommodation of rituals or forced participation in them, demands to perform actions instead of the child or to refrain from certain behaviours because they cause the child with OCD distress, and compulsive behaviours on the part of the child that negatively impact on others. All but one of the responders (i.e.99%. see Figure 1(a)) reported encountering the coercive and disruptive behaviours described in at least some cases of paediatric OCD and most reported that they characterize at least one quarter of all of their paediatric OCD cases. Most responders reported that physical violence and/or the threat thereof were exhibited in some of the cases. The primary targets of the coercive and disruptive behaviours were reported to be mothers, identified as a target by 95% of all responders (Figure 2). Fathers (57%) and siblings (49%) were also frequent targets. Most responders (58%) endorsed the view that these behaviours were most frequently restricted to the immediate home environment although in some cases the behaviours were seen in extended family settings as well as with peers. Most responders (64%) agreed that coercive behaviours were, more often than not, associated with increased family accommodation and all report that this is true in at least some cases. Parent training was the intervention identified by most responders (86%) as being the most effective intervention strategy for reducing coercive behaviours. Cognitive behavioural therapy (CBT), (53%) and medication (17%) were also commonly endorsed as being effective treatments. Treatment modality notwithstanding, most responders felt that the majority of cases responded to treatment so that the coercive behaviours largely disappeared. The large majority (88%) agreed with the view that these coercive/disruptive behaviours are better seen as secondary to the OCD rather than as representative of a primary disruptive behaviour disorder. In addition, the majority (69%) reported that in only a minority of cases (<25%) did the coercive/disruptive behaviours persist after the OCD showed clear signs of improvement. The OCD symptom dimension most commonly reported by the experts to be associated with coercive behaviours was contamination/washing (67%). Other dimensions commonly identified were symmetry/ordering (42%) and harm/checking (39%). Less commonly indicated were hoarding and sexual and/or religious obsessions and related checking compulsions. Stressful life events were not reported to be a significant factor impacting the coercive behaviours. Journal of Child Psychology and Psychiatry 52:12 (2011), pp 1249–1250 doi:10.1111/j.1469-7610.2011.02480.x

Experiences of patients identifying with chronic Lyme disease in the healthcare system: a qualitative study

BackgroundChronic Lyme disease is a term that describes a constellation of persistent symptoms in patients with or without evidence of previous Borrelia burgdorferi infection. Patients labeled as having chronic Lyme disease have a substantial clinical burden. Little is known about chronic Lyme disease patient experiences in the healthcare system and their relationships with healthcare providers. The purpose of this study was to gather insights about the experiences of patients who carry a diagnosis of chronic Lyme disease in the United States healthcare system.MethodsQualitative, phenomenological study in 12 adult participants who identified themselves as having chronic Lyme disease. Semi-structured face-to-face in-depth interviews were conducted, 60–90 minutes in length, focusing on perceptions of disease burden and of their healthcare providers, using the dimensions of the Health Belief Model. Transcribed interviews were analyzed for emergent topics and themes in the categories of beliefs/understanding, personal history/narrative, consequences/limitations, management, and influences on care.ResultsEnrollment continued until theoretical saturation was obtained. Four major themes emerged from participants’ descriptions of their experiences and perceptions: 1) changes in health status and the social impact of chronic Lyme disease, 2) doubts about recovery and the future, 3) contrasting doctor-patient relationships, 4) and the use of unconventional therapies to treat chronic Lyme disease.ConclusionsParticipants reported a significant decline in health status associated with chronic Lyme disease and were often unsatisfied with care in conventional settings. Negative experiences were associated with reports of dismissive, patronizing, and condescending attitudes. Positive experiences were associated with providers who were reported to be attentive, optimistic, and supportive. Consultations with CAM practitioners and use of CAM therapies were common. Actively engaged and sympathetic clinical encounters may foster greater satisfaction in healthcare settings.

Effects of therapeutic suggestion in children undergoing general anesthesia: a randomized controlled trial

Objectives and aim:  The goal of this randomized controlled trial was to examine the effect of intraoperative positive therapeutic suggestion on postoperative nausea and vomiting (PONV) in children undergoing general anesthesia and otolaryngological surgery.