Pia Enebrink

Internet-based parent management training: a randomized controlled study.

OBJECTIVE The current study evaluated the efficacy of an Internet-based parent-training program for children with conduct problems. Dose-response ratio and costs for the program were also considered. METHOD Parents of 104 children (aged 3-12 years) were randomly allocated to either parent training or a waitlist control condition. Diagnostic assessment was conducted at baseline and parent ratings of child externalizing behaviors and parent strategies were completed before and after treatment and at 6-month follow-up. RESULTS At post-treatment assessment, children whose parent(s) had received the intervention showed a greater reduction in conduct problems compared to the waitlist children. Between group intent-to-treat effect sizes (Cohens d) on the Eyberg Intensity and Problem scales were .42 and .72, respectively (study completers .66 and 1.08). In addition, parents in the intervention group reported less use of harsh and inconsistent discipline after the treatment, as well as more positive praise. Effects on behavior problems were maintained at 6-month follow-up. CONCLUSIONS The results support the efficacy of parent training, administered through Internet, with outcomes comparable to many of the group-based parent training programs. The efficacy, low cost, and higher accessibility make this intervention a fitting part in a stepped-care model.

Callous-unemotional traits are associated with clinical severity in referred boys with conduct problems.

Clinical practice with the heterogeneous group of children that present with conduct problems may benefit from improved formats for diagnostic subtyping. We investigated whether high levels of callous–unemotional traits (i.e. lack of empathy, remorselessness and shallow affects) would differentiate clinic-referred conduct-problem boys from those low on such traits. A consecutive series of 41 boys with conduct problems (6–13 years, mean age = 9.60 years) referred to public child psychiatric units in Sweden were studied with data elicited from caregivers. Conduct-problem boys with many callous–unemotional traits had significantly more pervasive, varied and aggressive disruptive behavioural problems than boys low on these traits had. Higher levels of conduct problems in subjects with callous–unemotional traits were not explained by confounding presence of DSM-IV attention-deficit hyperactivity disorder and oppositional defiant disorder/conduct disorder symptoms. Boys with callous–unemotional traits also experienced poorer household circumstances and lived in families under high stress. Interestingly, they less often received help in school from special teachers but were more often diagnosed with dysthymia than boys low on callous–unemotional traits. We conclude that callous–unemotional traits might designate a subgroup of boys with different aetiology to their conduct problems and possibly with specific treatment needs. However, the findings need to be replicated with larger samples.

Preventing sexual abusers of children from reoffending: systematic review of medical and psychological interventions

Objective To evaluate the effectiveness of current medical and psychological interventions for individuals at risk of sexually abusing children, both in known abusers and those at risk of abusing. Design Systematic review of interventions designed to prevent reoffending among known abusers and prevention for individuals at risk of sexually abusing children. Randomised controlled trials and prospective observational studies were eligible. Primary outcomes were arrests, convictions, breaches of conditions, and self reported sexual abuse of children after one year or more. Results After review of 1447 abstracts, we retrieved 167 full text studies, and finally included eight studies with low to moderate risk of bias. We found weak evidence for interventions aimed at reducing reoffending in identified sexual abusers of children. For adults, evidence from five trials was insufficient regarding both benefits and risks with psychological treatment and pharmacotherapy. For adolescents, limited evidence from one trial suggested that multisystemic therapy prevented reoffence (relative risk 0.18, 95% confidence interval 0.04 to 0.73); lack of adequate research prevented conclusions about effects of other treatments. Evidence was also inadequate regarding effectiveness of treatment for children with sexual behavioural problems in the one trial identified. Finally, we found no eligible research on preventive methods for adults and adolescents who had not sexually abused children but were at higher risk of doing so (such as those with paedophilic sexual preference). Conclusion There are major weaknesses in the scientific evidence, particularly regarding adult men, the main category of sexual abusers of children. Better coordinated and funded high quality studies including several countries are urgently needed. Until conclusive evidence is available, realistic clinical strategies might involve reduction of specific risk factors for sex crimes, such as sexual preoccupation, in abusers at risk of reoffending.

Motivational Interviewing in an ordinary clinical setting: A controlled clinical trial at the Swedish National Tobacco Quitline

INTRODUCTION The present study aimed to assess the effect of adding motivational interviewing (MI) to the first session of an effective smoking cessation treatment protocol in an ordinary clinical setting: the Swedish National Tobacco Quitline (SNTQ). METHOD The study was designed as a controlled clinical trial. Between September 2005 and October 2006, 772 clients accepted the invitation to participate in the study and were semi-randomised to either standard treatment (ST) or MI. The primary outcome measures were self-reported 7-day point prevalence abstinence and 6-month continuous abstinence. RESULTS At 12-month follow-up, the 772 clients were included in an intention to treat analysis. Of the clients allocated to MI, 57/296 (19%) reported 6-month continuous abstinence compared to 66/476 (14%) of the clients allocated to ST (OR 1.48, 95% CI 1.00-2.19; P=.047). CONCLUSIONS Integrating MI into a cognitive behavioural therapy-based smoking cessation counselling in an ordinary clinical setting at a tobacco quitline increased client 6-month continuous abstinence rates by 5%.

Predicting aggressive and disruptive behavior in referred 6- to 12-year-old boys: prospective validation of the EARL-20B risk/needs checklist.

The authors investigated the predictive and incremental validity of the Early Assessment Risk List for boys (EARL-20B; Augimeri, Koegl, Webster, & Levene, 2001), a structured clinical checklist designed for the professional judgment of risk for aggressive and disruptive behaviors and risk/needs factor-based management of this risk. Seventy-six boys consecutively referred to child psychiatric outpatient clinics in mid-Sweden were evaluated according to the EARL-20B and with independent (not EARL-20B-based) clinical evaluations. The participants were prospectively followed after 6 and 30 months. EARL- 20B-based assessments were positively and moderately associated with aggressive (reactive and proactive aggression) and disruptive behavior (conduct problems and DSM-IV Conduct Disorder) at both subsequent evaluations. Clinical evaluations made without the instrument were not as consistently associated with outcome. Incremental predictive validity over unstructured clinical evaluations and Conduct Disorder at baseline suggested promising clinical utility. The checklist might be used to support clinical decision making for referred boys at risk for continued antisocial behavior.

Borderline personality disorder: Prevalence and psychiatric comorbidity among male offenders on probation in Sweden

INTRODUCTION Borderline personality disorder (BPD) is a severely disabling condition, associated with substantially increased risk of deliberate self-harm and, particularly in men, also with interpersonal violence and other criminal behavior. Although BPD might be common among prison inmates, little is known about prevalence and psychiatric comorbidity in probationers and parolees. METHOD In 2013, a consecutive sample of 109 newly admitted adult male offenders on probation or parole in all three probation offices of Stockholm, Sweden, completed self-report screening questionnaires for BPD and other psychiatric morbidity. Participants scoring over BPD cut-off participated in a psychiatric diagnostic interview. RESULTS We ascertained a final DSM-5 BPD prevalence rate of 19.8% (95% CI: 12.3-27.3%). The most common current comorbid disorders among subjects with BPD were antisocial personality disorder (91%), major depressive disorder (82%), substance dependence (73%), attention deficit hyperactivity disorder (ADHD) (70%), and alcohol dependence (64%). Individuals diagnosed with BPD had significantly more current psychiatric comorbidity (M=6.2 disorders) than interviewed participants not fulfilling BPD criteria (M=3.6). Participants with BPD also reported substantially more symptoms of ADHD, anxiety and depression compared to all subjects without BPD. CONCLUSIONS BPD affected one fifth of probationers and was related to serious mental ill-health known to affect recidivism risk. The findings suggest further study of possible benefits of improved identification and treatment of BPD in offender populations.

Swedish validation of the Early Assessment Risk List for Boys (EARL-20B), a decision aid for use with children presenting with conduct-disordered behaviour.

Risk and needs assessment of children with conduct-disordered behaviour has been hampered by a lack of validated and easy-to-use decision-support tools. In this study, we investigated reliability and concurrent validity of the Swedish translation of the Early Assessment Risk List for Boys (EARL-20B). Parents to 76 boys aged 6–12 years old, referred to child psychiatric clinics, completed questionnaires about child symptoms and were thereafter administered the EARL-20B. Good to excellent inter-rater agreement and moderate concurrent validity was found. We also investigated possible subgroups of children based on the assessment with the EARL-20B. Cluster analysis yielded a tentative four-cluster solution, where subgroups of boys differed with respect to external measures. Although further study of predictive validity and usefulness for treatment planning is needed, the findings suggest that the EARL-20B is a promising tool for structured assessment of boys presenting with antisocial behaviour in clinical child psychiatry.

The relationship between counselors' technical skills, clients' in-session verbal responses, and outcome in smoking cessation treatment

BACKGROUND The technical component of Motivational Interviewing (MI) posits that client language mediates the relationship between counselor techniques and subsequent client behavioral outcomes. The purpose of this study was to examine this hypothesized technical component of MI in smoking cessation treatment in more depth. METHOD Secondary analysis of 106 first treatment sessions, derived from the Swedish National Tobacco Quitline, and previously rated using the Motivational Interviewing Sequential Code for Observing Process Exchanges (MI-SCOPE) Coders Manual and the Motivational Interviewing Treatment Integrity code (MITI) Manual, version 3.1. The outcome measure was self-reported 6-month continuous abstinence at 12-month follow-up. RESULTS Sequential analyses indicated that clients were significantly more likely than expected by chance to argue for change (change talk) following MI-consistent behaviors and questions and reflections favoring change. Conversely, clients were more likely to argue against change (sustain talk) following questions and reflections favoring status-quo. Parallel mediation analysis revealed that a counselor technique (reflections of client sustain talk) had an indirect effect on smoking outcome at follow-up through client language mediators. CONCLUSIONS The study makes a significant contribution to our understanding of how MI works in smoking cessation treatment and adds further empirical support for the hypothesized technical component in MI. The results emphasize the importance of counselors avoiding unintentional reinforcement of sustain talk and underline the need for a greater emphasis on the direction of questions and reflections in MI trainings and fidelity measures.

The effect of adding Coping Power Program-Sweden to Parent Management Training-effects and moderators in a randomized controlled trial

For children with oppositional defiant disorder (ODD), Parent Management Training (PMT) is a recommended treatment in addition to child Cognitive Behavioral Therapy (child-CBT). There is however a lack of studies investigating the additive effect of group-based child-CBT to PMT for children between 8 and 12 years. The current study investigated the incremental effect of group-based child-CBT, based on the Coping Power Program, when added to the Swedish group-based PMT program KOMET. Outcomes were child behavior problems, child prosocial behavior, parenting skills and the moderating effect of child characteristics. One hundred and twenty children 8-12 years with ODD or Disruptive Behavioral Disorder NOS and their parents were randomized either to combined child-CBT and PMT (n = 63) or to PMT only (n = 57) in Swedish Child- and Adolescent Psychiatric settings. Participants were assessed pre- and post-treatment using semi-structured interviews and child- and parent ratings. After treatment, behavior problems were reduced in both groups. Prosocial behavior were significantly more improved in the combined treatment. Parenting skills were improved in both groups. In moderator analyses, behavior problems and prosocial behavior improved significantly more in the combined treatment compared to PMT only in the group of children with high levels of ODD symptoms.

Randomized Controlled Trial of Acceptance and Commitment Therapy and a Workplace Intervention for Sickness Absence Due to Mental Disorders.

Mental disorders contribute to high rates of sickness absence (SA) and impaired work functioning. The aim of the present study was to evaluate the efficacy of 3 interventions targeting SA of workers. Participants (n = 352; 78.4% females) of working age with current employment, and SA due to depression, anxiety disorders, or exhaustion disorder, were recruited to the study and randomized to (a) acceptance and commitment therapy (ACT), (b) a workplace dialogue intervention (WDI), (c) a combination of ACT and WDI, or (d) treatment as usual (TAU). For SA days, there was a significant interaction effect for the follow-up period, in which ACT + WDI generated more SA compared with TAU. When diagnostic group was included as a moderator, participants with exhaustion disorder had less SA days in the WDI group compared with TAU. For symptoms of depression, anxiety, and stress-related ill health, there were significant interaction effects for ACT and ACT + WDI, when compared with TAU, from pre- to postmeasurement (small to moderate between-groups effect sizes). Within-group effect sizes pre- to postmeasurement (Cohen’s d) ranged from .55 to 1.17 (ACT), .40 to .94 (WDI), .26 to 1.13 (ACT + WI), and −.06 to .70 (TAU). There were no differences between groups during follow-up for symptoms.