Cognitive and behavioural treatment of hypochondriasis

BACKGROUND

This study investigates the feasibility and effectiveness of time-limited treatment protocols based upon cognitive and behavioural interventions.

METHOD

Seventeen patients with DSM-IV diagnoses of hypochondriasis were offered 12 1-hour sessions of either 'pure' cognitive or 'pure' behavioural (i.e. exposure in vivo and response prevention) treatment. Patients were used as their own controls by observing a 4-week period without interventions before and after treatment.

RESULTS

Patients in both treatment conditions improved on specific measures of hypochondriasis (Kellner's Illness Attitude Scales) and depression. These changes took place during the active treatment period, whereas in the control periods scores remained unchanged. Furthermore, no differential treatment effectiveness could be demonstrated.

CONCLUSIONS

Cognitive and behavioural interventions seem to be active ingredients in the treatment of hypochondriasis, although the contribution of nonspecific factors (e.g. patient motivation, therapist attitudes, and the therapeutic relationship) requires further study.

Trichotillomania: current issues in conceptualization and treatment

Trichotillomania is a little-known disorder with wider prevalence and more significant consequences than previously believed. While sharing similarities with obsessive-compulsive disorder, compelling differences from it have also been noted. This fact, coupled with recognized overlap with other obsessive-compulsive spectrum disorders, has resulted in the ongoing evolution of our conceptualization of this illness. While empirical evidence supports the use of behavioral treatment and pharmacotherapy, considerable research is still needed before we can promise highly effective interventions tailored to the individual hairpuller. This review will summarize the evidence supporting, as well as challenging, a hypothesized link with obsessive-compulsive disorder. Current treatment approaches will be reviewed, as well as evidence for their efficacy. Suggestions will be made for future directions in this field.

The real and imagined harmful effects of rewards: implications for clinical practice

In recent years, a number of researchers and social critics have cautioned against the widespread application of behavioral interventions on the grounds that the philosophy of behaviorism is fundamentally manipulative and damaging to creative and intrinsically motivated behavior. Most central to their arguments are concerns about the harmful effects of "extrinsic" rewards. Though concerns about the allegedly harmful effects of "rewards" on intrinsically motivated actions may have been partially allayed by a recent meta-analysis, proponents of the view that intrinsic interest is eroded by the delivery of contingent rewards will likely continue to attest to the dangers of operant conditioning and its application to human behavior. The present manuscript addresses the content of claims about the harmful effects of extrinsic rewards. While consideration is given to the existing behavior therapy literature and its treatment of "natural" versus "arbitrary" rewards, some surprising convergences between the views of self-determination theorists and behavioral practitioners are noted.

Empirically supported psychosocial treatments for attention deficit hyperactivity disorder

Reviews and evaluates psychosocial treatments for attention deficit hyperactivity disorder (ADHD) in children and adolescents according to Task Force Criteria (Lonigan, Elbert, & Johnson, this issue). It is concluded that behavioral parent training and behavioral interventions in the classroom meet criteria for well-established treatments. Cognitive interventions do not meet criteria for well-established or probably efficacious treatments. Issues regarding the evaluative process are discussed and future directions for psychosocial treatment for ADHD are outlined.

A review of behavioral and pharmacological treatments for habit disorders in individuals with mental retardation

This paper reviews the prevalence and behavioral and pharmacological treatment-outcome studies for habit disorders exhibited by individuals with mental retardation. The treatment-outcome studies target the habit disorders identified previously by researchers including nervous habits (nail biting, bruxism, and trichotillomania), motor and vocal tics, and Tourette's disorder. The paucity of behavioral treatments and the lack of controlled pharmacological research warrants further experimental evaluation of treatments for habit disorders affecting individuals with mental retardation. Conclusions and recommendations for future research are made.

Applying the criteria for empirically supported treatments to studies of psychosocial interventions for child and adolescent depression

Reviews the psychosocial treatment outcome studies for depressed children and adolescents and concludes that psychosocial interventions are effective at posttreatment and follow-up in reducing depressive symptoms/disorders in clinical and nonclinical samples of youth, regardless of treatment modality or extent of parental involvement. The article then examines the extent to which each study conforms to the guidelines set forth by the Task Force on Promotion and Dissemination of Psychological Procedures (1996) for well-established and probably efficacious interventions. Results of this analysis indicate only 2 series of studies that meet criteria for probably efficacious interventions and no studies that meet criteria for well-established treatments. Finally, the advantages and disadvantages of applying criteria for empirically supported treatments to identify good treatments for depressed youth are discussed, the importance of devising developmentally and culturally sensitive interventions targeted to the unique needs of each child is highlighted, and recommendations for future research that is informed by clinical practice and empirical findings are offered.

Empirically supported treatments for children with phobic and anxiety disorders: current status

Reviews the empirically supported status of behavioral and cognitive-behavioral interventions in the treatment of childhood phobias and anxiety disorders. For childhood phobias, it is concluded that imaginal desensitization, in vivo desensitization, filmed modeling, live modeling, and cognitive-behavioral interventions that use self-instruction training are probably efficacious and that participant modeling and reinforced practice are well established. For anxiety disorders, only cognitive-behavioral procedures with and without family anxiety management (FAM) were found to be probably efficacious. However, much of the support for these procedures comes from analogue studies conducted in research laboratory or school settings, delivered in small-group format and, not infrequently, with nonclinically referred children. Additional research that examines high-strength interventions with clinic-referred children is recommended. Furthermore, research that examines the pathological processes involved in the onset and maintenance of phobic and anxiety disorders as well as the change processes used to treat these disorders is called for.

Training schizophrenic patients to manage their symptoms: predictors of treatment response to the German version of the Symptom Management Module

This study examined whether patient demographic and clinical characteristics were predictors of differential treatment response in a sample of 57 schizophrenic patients who received the German version of the Symptom Management Module. Psychopathology, global functioning and knowledge about schizophrenia were assessed as dependent variables. Overall, patients improved over the treatment period on most dimensions of psychopathology as well as knowledge about psychosis. There was little evidence of differential treatment response as a function of either sociodemographic or clinical variables. However, gender was related to changes in psychopathology from pre- to posttreatment, with females improving less than males. Possible implications of these findings were discussed.

Sexual adjustment of male alcoholics: changes from before to after receiving alcoholism counseling with and without marital therapy

Married male alcoholics (N = 36), who had recently begun individual outpatient alcoholism counseling, were randomly assigned to a no-marital-treatment control group or to 10 weekly sessions of either a behavioral marital therapy (BMT) or an interactional couples therapy group. Impotence decreased from before to after counseling irrespective of whether the alcoholic patients received additional marital therapy. Husbands who received BMT reported increased frequency of wives' orgasm during intercourse and greater increases in satisfaction with the privacy and context of their sexual activities than did couples in the other two treatment groups. These findings support a biopsychosocial formulation of alcoholics' sexual problems that implicates the physical effects of acute and chronic alcohol intake as most relevant to the elevated rates of impotence and marital conflict as a major contributing factor to most sexual problems of alcoholics. The improvement observed in sexual adjustment was rather limited. Despite the improvements in impotence, the alcoholics still experienced over twice the rate of impotence reported by demographically similar nonalcoholics. In terms of sexual satisfaction, BMT produced only modest gains as viewed by husbands and no gains from the wives' perspective. Perhaps sexual adjustment is one of the last areas of the alcoholic's marriage to improve after treatment. The limited time frame of the present study may have precluded observing further improvements in sexual adjustment that would emerge later after a longer period of recovery.

Using "stages of behavioral change" constructs to measure the short-term effects of a worksite-based intervention to increase moderate physical activity

We evaluated a three-level incentive program to promote regular, moderate physical activity among employees working in a federal agency. The objective was to assess the short-term effects of the intervention by examining the stages people go through as they attempt to make permanent changes in physical activity. Indicators of the process by which changes in physical activity take place were based on a modified version of the Transtheoretical Model of Behavior. A one-group pretest/posttest design was used to ascertain which of the stages the 1,192 participants were in both before and after the intervention. Analysis indicated that, of the 1,192 participants, 6.5% regressed one or more stages, 30.3% did not regress or progress from one stage to another, 27.7% remained in the maintenance stage, and 35.4% progressed one (21.1%) or more (14.3%) stages during the 50-day intervention. Among those who progressed, the most common change was from preparation to late preparation (20.8%) and from late preparation to action (19.4%). Findings reinforce the notion that the stages of change concept can serve as indicators of the change process which in turn, can be used as evidence of the short-term effectiveness of interventions. Findings also indicate this type of intervention holds promise for increasing physical activity among willing participants of a worksite population.

Increasing employment of opioid dependent outpatients: an intensive behavioral intervention

The impact of a new, mandatory employment requirement in a community-based methadone treatment program was evaluated. All patients who had been in the methadone substitution program for at least 1 year but who were not currently employed (n = 36) were required to enhance their treatment with 20 h of employment (paid or volunteer). Patients with significant psychiatric or medical disabilities were excluded from the routine treatment requirement. Patients were informed by counseling staff that they had 2 months to secure employment. Those who did not accomplish the goal within that time period were transferred to more intensive weekly counseling (i.e. up to 8 h/week) for 10 weeks, with the enhanced counseling focusing primarily on resistance to the employment goal. Patients who remained resistant to the treatment plan were eventually started on a 21 day methadone taper until employment was verified. Seventy-five percent of the patients secured employment and maintained the position for at least 1 month. Positions were found in an average of 60 days. Most patients (78%) continued working throughout the 6-month follow-up. Those who failed to find work or maintain employment engaged in more illicit drug use. These results demonstrate that behavioral contingencies can motivate many methadone maintenance patients to obtain verified employment in the community.

Behavioural effects of long-term multi-sensory stimulation

OBJECTIVES

Regular access to a multi-sensory environment (MSE or Snoezelen room) was compared with a non-complex sensory environment for individuals with learning disabilities. We also tested the prediction that those individuals whose challenging behaviour was maintained by sensory consequences would benefit most from exposure to the MSE.

DESIGN

The conditions were compared over 16-week periods using a double crossover design, and were matched for social contact and attention from the enabler. Participants were randomly assigned to orders of treatments.

METHODS

Participants were 27 adults with severe/profound learning disabilities who exhibited challenging behaviour. Behaviour was assessed before and after each treatment phase using both direct observation and standardized assessments (the Functional Performance Record and the Problem Behaviour Inventory). The behavioural observations formed the basis of a functional analysis of each individual's challenging behaviour.

RESULTS

Some participants became more calm and relaxed while in the MSE, however, the objective measures of behaviour outside the treatment settings revealed no difference between the MSE and control conditions. Challenging behaviour maintained by sensory consequences showed no greater responsivity to the MSE than to the control condition.

CONCLUSIONS

The multi-sensory environment had no effects beyond those that could be ascribed to the social interaction between participant and enabler. Anecdotal evidence of favourable responses within the MSE itself could not be confirmed outside the environment.

The course of relapse across 36 months for smokers from a smoking-cessation program

The aim of this study is to examine relapse of 72 smokers who stopped smoking with a behavioral smoking cessation program and relapse in the period from the end-of-treatment to the 36-mo. follow-up. The relapse occurred fundamentally between the end-of-treatment and the 6- (53.7% relapse) and the 12-mo. follow-up (61.1% relapse), and more slowly beyond 12-mo. follow-ups with 72.2% and 70.4% relapse at the 24- and 36-mo. follow-up.

Preliminary evidence of good treatment response in antisocial drug abusers

Antisocial personality disorder (APD) is a chronic debilitating condition strongly associated with the development and maintenance of severe drug and alcohol use disorder. The overlap of these problems is associated with high rates of personal and social suffering. Available literature consistently point to this as a population in need of effective clinical services. The present study reports preliminary data from a controlled clinical trial aimed at improving the treatment outcomes of antisocial drug abusers using an intensive behavioral approach relying upon a highly structured contingency management intervention. Drug abusers in methadone substitution therapy (n = 40) were assessed for APD and other psychiatric and substance use problems. Patients were randomly assigned to an experimental (n = 20) or control (n = 20) condition following stratification on demographic and selected clinical variables (baseline drug use, evidence of other non-substance use psychiatric diagnoses). Treatment outcome data are presented for the first 17 weeks of participation in the study (4 weeks baseline and 13 weeks randomized treatment), including results of weekly urine drug testing and monthly self-reports of drug use and other psychosocial problems. Patients in both study conditions attained generally good outcomes. These early results suggest that antisocial drug abusers can respond positively to drug abuse treatments with a behavioral focus, but fail to support superior effectiveness for the more intensive intervention used in the experimental condition.

Evaluating therapist competency and adherence to behavioral family management with bipolar patients

The present study assessed fidelity to the behavioral family management (BFM) model for treating bipolar disorder patients and their families. The BFM Therapist Competency/Adherence Scale (BFM-TCAS) was developed to evaluate clinicians' competency and adherence to BFM, as outlined by Miklowitz' (1989) BFM Manual for use with bipolar patients. Therapist competency and treatment adherence was also evaluated with regard to two family characteristics: overall level of family difficulty and family expressed emotion (EE) status. The BFM-TCAS was used to code 78 videotaped sessions of 26 families with a bipolar member, selected from a larger treatment study of bipolar disorder patients. The findings suggest that, overall, clinicians adhered closely to the BFM manual. Specific areas in which there was high competency and treatment adherence were (a) skill in conveying factual information about bipolar illness, (b) establishment of a therapeutic environment, and (c) ability to take command of therapy sessions. The one area in which there was less competency and relatively weak adherence to the manual was the use of between-session homework assignments to assist families in mastering the BFM exercises. Results of this study also suggest that, for the most part, therapist competency and adherence ratings were not related to overall level of difficulty or to family EE status.

Behaviour therapy for obsessive-compulsive disorder: a decade of progress

OBJECTIVE

To review the last decade of behaviour therapy research in obsessive-compulsive disorder (OCD).

METHOD

The most salient research was analyzed.

RESULTS

Many studies confirmed that exposure and ritual prevention (ERP) effectively reduced compulsive rituals and obsessive thoughts in most patients in all age groups, although a minority of the patients did not complete treatment. Gains persisted to follow-up 2 to 6 years later in several countries. Improvement after ERP generalized to obsessive-compulsive beliefs, mood, work, and social adjustment, and was accompanied by reduction in cerebral blood flow in the right caudate nucleus. Teaching patients how to prevent relapse seems to reduce the risk of recurrence. ERP yields slightly more improvement than does appropriate antidepressant medication and is followed by far less relapse after treatment has stopped, so ERP may be more cost-effective in the long term. Antidepressant medication is a useful adjunct to ERP when OCD is accompanied by comorbid depression. The therapist now tends to teach patients how to carry out self-exposure and self-imposed ritual prevention, rather than to impose ERP on them. Self-help manuals help patients to do this, and computer aids to allow patients to learn how to do ERP at home have been valuable in pilot studies. Cognitive therapy without ERP was as useful as ERP.

CONCLUSION

ERP is of lasting value for OCD. Long-term cost-effectiveness comparisons are needed of self-administered ERP versus cognitive therapy and versus medication. Studies are also needed of brief psychological treatment for depression comorbid with OCD.

Efficacy of psychosocial treatments for noisemaking in severe dementia

Noisemaking is one of the most disturbing behavior disorders associated with dementia. Standard management practices, including pharmacological interventions, are not very successful in treating the behavior. Very little research has been carried out to evaluate innovative treatments or to determine the etiology of noisemaking. In this article, we report on a series of 12 case studies in which we tested the efficacy of some psychosocial interventions in reducing the frequency of noisemaking in long-term-care residents with severe dementia. Interventions were contingent reinforcement of quiet behavior and environmental stimulation tailored to individual preferences. Of the 12 patients recruited into the study, 2 died during the course of observations, 3 were not observed to be as noisy as reported by staff, and 3 showed a clear reduction in noise during the intervention period. Four patients did not show any overall reduction in noisemaking during psychosocial interventions. Future research could differentiate between types of interventions in successful cases and attempt to control further for the consistent application of interventions by long-term-care staff.

Extinction of panicogenic effects of a 35% CO2 challenge in patients with panic disorder

Inhalations of high concentrations of carbon dioxide (CO2) reliably produce panic attacks in patients with panic disorder. The present study evaluated whether cognitive-behavioral treatment (CBT) for panic disorder would extinguish CO2-induced panic and whether changes in panic and arousal-related cognitions were associated with the induction of panic. Patients with panic disorder (N = 54) were assigned to 1 of 3 experimental conditions: CBT with respiratory training (CBT-R), CBT without respiratory training (CBT), or delayed treatment. Participants received 5 repeated vital-capacity inhalations of 35% CO2/65% O2 prior to and following either 12 treatment sessions or a 12-week waiting period. During pretreatment assessments, 74% of patients experienced a panic attack during at least 1 inhalation. At posttreatment, only 20% of treated participants (CBT-R = 19%, CBT = 22%), compared with 64% of untreated participants, panicked. Forty-four percent of treated participants, compared with 0% of untreated participants, reported no anxiety during all posttreatment inhalations. Anxiety sensitivity as well as panic appraisals regarding the likelihood of panic and self-efficacy with coping with panic were significantly related to fearful responding to the CO2 challenge.

Smoking cessation in military personnel

Tobacco use is the single most important preventable cause of death in military personnel. The purpose of this randomized clinical trial was to evaluate the effectiveness of two behavioral interventions when added to nicotine-replacement therapy on smoking cessation. The sample of 512 included 52% active duty military, 29% family, 11% retirees, and 8% Department of Defense civilians. There was a main effect of compliance at the end of the program (EOP); 69% of those who attended 75% of the classes were abstinent from tobacco; regression analysis found the more intensive program to be twice as effective at EOP and at 3 months, an outcome not continued at 6 months. The longer, more intensive Vanderbilt University Medical Center program was significantly more effective at helping the civilian portion of the population (85% versus 60% in the American Cancer Society program) but not the active duty participants.

Does short-term group therapy affect unexplained medical symptoms?

This paper describes an intensive time-limited group-therapy program conducted in a busy surgical clinic by two nursing staff with the support of a consultant psychiatrist. Nineteen patients with chronic idiopathic facial pain were recruited to the study and underwent weekly group therapy over 8 weeks. At the end of the study period, results showed decreases in pain, anxiety and depression scores, along with an improvement in the patients coping skills. The findings support the use of group psychological interventions undertaken by appropriately trained nursing staff in reducing symptoms associated with chronic idiopathic facial pain.

Structured habituation training for movement provoked vertigo after severe traumatic brain injury: a single-case experiment

The purpose of this study was to evaluate the effect of structured habituation training (HT) for movement provoked vertigo (PV) secondary to unilateral peripheral hypofunction in a 16 year old patient who had sustained a severe TBI. Treatment of PV with severe TBI patients can be quite different from other patients with vestibular deficits because of the physiological, behavioural and cognitive sequelae of brain trauma. A single-subject experimental paradigm using an ABA protocol was used to assess efficacy of HT. The data were submitted to C statistic analysis. The transformed data were submitted to combined visual and statistical analysis by the celeration line with a directional one-tailed test and the two-standard deviation band method. Significant change in duration from sitting to supine without triggering vertigo was found between baseline phase (A) and structured HT phase (B) and was maintained for 1 month after the end of treatment. This single-case experiment demonstrates successful structured HT for PV for a 16 year old severe TBI patient. Important clinical decisions (time of introduction of treatment, type of activity, pacing, frequency, intensity, repetition, support and education) necessary to achieve optimal resolution of PV with HT in severe TBI patients are discussed.

Collegial support and barriers to behavioral programs for severe mental illness

Previous investigations have identified staff beliefs about barriers to implementing behavioral interventions in programs for persons with severe mental illness. One of these barriers, institutional constraints, was found to be associated with collegial support; i.e., staff who report more collegial support were less likely to endorse institutional constraints. The purpose of this study was to determine how the components of collegial support were associated with beliefs about institutional constraints. Fifty-six staff members completed measures of staff opinions about barriers to implementing behavior therapy, satisfaction with collegial support, source of support, and functions of support. Results suggested that collegial support is significantly associated with co-worker and supervisor support, but not the support of family and friends. Endorsing institutional constraints was inversely associated with the support of co-workers and supervisors; institutional constraints were positively associated with the support of family and friends. Endorsing institutional constraints was also inversely associated with the sense that others rely upon the individual for their well-being. Implications of these findings for diminishing barriers to behavioral interventions are discussed.

Treatment choice for agoraphobic women: exposure or cognitive-behaviour therapy?

OBJECTIVES

The paper describes a treatment trial where exposure was compared with cognitive-behaviour therapy in the treatment of 39 female participants with a diagnosis of agoraphobia (DSM-111-R). The primary objective of the study was to see if cognitive therapy enhanced the effectiveness of exposure in the treatment of agoraphobia.

DESIGN

Participants were randomly assigned to either exposure or cognitive-behaviour therapy. The two treatment groups were balanced for severity and duration of agoraphobia, presence of panic disorder, and age.

METHODS

The exposure and the cognitive-behaviour therapy groups received the same amount of therapist-assisted exposure to feared situations but the participants in the cognitive-behaviour therapy group were, additionally, taught to identify and challenge negative automatic thoughts and dysfunctional assumptions. In the cognitive-behaviour therapy condition exposure was presented as an opportunity to identify and challenge negative thoughts. In the exposure condition, participants were given a behavioural rationale for doing exposure. Participants were seen individually for 10 sessions. Assessments were carried out before and after the treatment programme and, also, six months later. Assessments included self-reports of fear and avoidance, a behavioural test and questionnaire measures of relevant cognitions. Thirteen participants dropped out of treatment leaving 14 in the exposure condition and 12 in the cognitive-behaviour condition. Therapy sessions were taped and a sample of tapes was given to a judge who rated the quality of the cognitive-behaviour therapy.

RESULTS

Substantial improvement was seen on virtually all measures irrespective of treatment condition both at the end of treatment and six months later. The cognitive-behaviour therapy group and the exposure group did not differ significantly at post-treatment or at six-month follow-up.

Parent-assisted transfer of children's social skills training: effects on children with and without attention-deficit hyperactivity disorder

OBJECTIVE

Previous research has demonstrated that peer rejection is a significant part of the clinical presentation of many children with attention-deficit hyperactivity disorder (ADHD). Outcome studies of treatment interventions have typically failed to show generalization of treatment gains to the home and classroom. This has been especially true for children who have comorbid oppositional defiant disorder (ODD). The present study was intended to demonstrate generalization of an outpatient social skills training program when parents were trained in skills relevant to their child's social adjustment.

METHOD

Thirty-five children with ADHD and 14 children without ADHD were given 12 sessions of treatment (treatment group). Outcome was compared with 12 children with ADHD and 12 children without ADHD who were on a waitlist for treatment (waitlist group). Nineteen children with ODD were in the treatment group and five in the waitlist. Stimulant medication was prescribed for all children with ADHD.

RESULTS

Subjects with ADHD showed improvement comparable with that of subjects without ADHD on all teacher- and parent-reported measures of peer adjustment and social skills, except teacher-reported withdrawal. Children with ODD had outcome comparable with that of children without ODD. Effect sized ranged from 0.93 to 1.34 indicating that the average treatment group subject was better off than 83.4% of waitlist subjects on outcome measures.

CONCLUSIONS

The present results suggest that children with ADHD are best heiped by a combination of social skills training for themselves, collateral training for their parents and stimulant medication.

One-session group therapy of spider phobia: direct versus indirect treatments

Forty-six patients with spider phobia, fulfilling the DSM-IV criteria for specific phobia, were assessed with behavioral, physiological and self-report measures. They were randomly assigned to three group treatment conditions: (1) direct treatment; (2) direct observation; and (3) indirect observation. All treatments were carried out in large groups of eight patients, and consisted of one 3 hr session of massed exposure and modelling. The results showed that on the behavioral test, measures and the specific self-report measures of spider phobia the direct treatment was significantly better than direct observation and indirect observation, which did not differ. On the physiological measures and the psychopathology self-report measures there were significant pre-post improvements, but no differences between the groups. The effects were maintained or furthered at the one year follow-up assessment. The proportion of clinically significantly improved patients were, at post-treatment, 75% in the direct treatment, 7% in the direct observation, and 31% in the indirect observation group. At follow-up, the corresponding figures were 75, 14, and 44%, respectively. The conclusion that can be drawn is that direct treatment is the treatment of choice.

Nurse coaching and cartoon distraction: an effective and practical intervention to reduce child, parent, and nurse distress during immunizations

Evaluated a low cost and practical intervention designed to decrease children's, parents', and nurses' distress during children's immunizations. The intervention consisted of children viewing a popular cartoon movie and being coached by nurses and parents to attend to the movie. Ninety-two children, 4-6 years of age, and their parents were alternatively assigned to either a nurse coach intervention, a nurse coach plus train parent and child intervention, or a standard medical care condition. Based on previous findings of generalization of adult behaviors during medical procedures, it was hypothesized that training only the nurses to coach the children would cost-effectively reduce all participants levels of distress. Observational measures and subjective ratings were used to assess the following dependent variables: children's coping, distress, pain, and need for restraint; nurses' and parents' coaching behavior; and parents' and nurses' distress. Results indicate that, in the two intervention conditions, children coped more and were less distressed, nurses and parents exhibited more coping promoting behavior and less distress promoting behavior, and parents and nurses were less distressed than in the control condition. Although neither intervention was superior on any of the variables assessed in the study, nurse coach was markedly more practical and cost-effective. Therefore, nurses' coaching of children to watch cartoon movies has great potential for dissemination in pediatric settings.

The use of scheduled awakenings to eliminate childhood sleepwalking

Evaluated the use of scheduled awakenings to eliminate sleepwalking using a noncurrent multiple baseline design across three subjects with persistent sleep-walking. Treatment procedure involves having parents awaken children several hours after they go to sleep and just before the typical time of the sleepwalking episode. This intervention proved immediately successful in eliminating sleep-walking in all three children. Treatment effects were maintained at 3 and 6 months posttreatment. Implications for intervention and future research are discussed.

Social implications of behavioral interventions for persons with mental retardation

The influence of type of behavioral program and program outcome on university students' perceptions of a hypothetical 17-year-old boy with mental retardation who exhibited severe self-injury was examined. A positive program was viewed as more acceptable and effective than were other programs (extremely aversive, mildly aversive, positive combined with extremely aversive, and control). Successful programs were also judged more acceptable and effective than were unsuccessful ones. When a program succeeded the individual was also seen as more likable, competent, adjusted, capable of learning, responsible, and problem-free. These preliminary findings point to the merits of considering the individual's social image in evaluating treatment acceptability.

Behaviour therapy for obsessive compulsive disorder in a 78-year-old woman

OBJECTIVE

To describe a case of late onset obsessive compulsive disorder (OCD) and determine the impact of a behavioural intervention on OCD symptoms.

DESIGN

A single case design was undertaken in which the severity of the patient's OCD symptoms was measured before and after treatment.

SETTING

The intervention was undertaken in the patient's home.

PATIENT

A 78-year-old woman with a history of depression who experienced sudden onset and rapid escalation of OCD following a domestic accident.

INTERVENTION

A behavioural procedure involving continuous in vivo exposure and response prevention over an 8-hour period.

MEASURES

The Y-BOCS self-rating scale (Yale Brown Obsessive Compulsive Scale) and clinical observation.

RESULTS

Y-BOCS score improved from 35 prior to treatment to 12 post treatment (mean for OCD population = 25.1; SD = 6, Goodman et al., 1989). Improvement was maintained at 2 months follow-up (Y-BOCS = 11). Improvements in confusion and agitation were also observed.

CONCLUSIONS

This case study supports the use of behavioural interventions for elderly patients suffering from OCD. Risk factors and treatment designs are discussed in view of the literature.

The effects of child behavior problems on the maintenance of intervention fidelity

Maintenance of behavior change has been considered a crucial, through largely unrealized, goal of behavioral interventions. One often overlooked factor is that before interventions can be successful and durable, the intervention protocol must be implemented as planned. This study investigated the effects of child behavior problems on the maintenance of intervention fidelity by teachers across two intervention protocols: escape extinction and functional communication training. A high rate of behavior problems during escape extinction appeared to punish teachers' efforts, and fidelity deteriorated. In contrast, there was a low rate of behavior problems during functional communication training. Teachers maintained high protocol fidelity and those sessions were less stressful and more productive. We propose that intervention protocols can be differentiated by the costs associated with implementing them faithfully. Protocols designed to be user friendly will be more likely to produce high fidelity, and therefore, durable intervention gains.

A maintenance program for obsessive-compulsive disorder using exposure with response prevention: 2-year follow-up

Recent literature has emphasized the importance of instituting procedures for preventing relapse in obsessive-compulsive disorder (OCD). This study presents data documenting the effect of a maintenance program on the long term (2-year) adjustment of a group of patients with OCD treated with exposure and response prevention. Results indicate that patients maintained their gains for the 2-year follow-up period on measures of anxiety associated with avoidance (Behavioral Avoidance Tests), obsessions, compulsions, and anxiety. Further, patients were able to effectively manage situations defined as lapses (limited symptom return) effectively without additional therapist intervention. However, as in a previous report, treatment gains for depression were not well established. It is concluded that sessions prior to treatment termination which focus on relapse prevention methods focus on additional psychological symptoms aside from the acute disturbance of OCD.

The efficacy of a response cost-based treatment package for managing aggressive behavior in preschoolers

The present study examined the effectiveness of a response cost treatment package for improving the classroom behavior of four aggressive preschoolers. Using a multiple baseline design, teachers implemented the response cost system during the treatment phases of the study. The system required teachers to remove smiley faces contingent on aggressive behavior. Each face loss was accompanied by a reprimand. If the child retained at least one smiley face at the end of the observation period, he was allowed to choose from a list of rewards. Rewards were easily administered at school. The results indicated that the response cost treatment package substantially decreased aggressive behavior and was a highly acceptable classroom treatment to teachers and parents.

Cognition in behavior therapy: agreements and differences

The issue of cognition has often been divisive among behavior therapists. Typically the debate has centered around the causal status of cognition. Cognitive psychologists have argued for the causal efficacy of cognition, while behavior analysts have argued against it. These disputes are not entirely empirical matters. In part, they reflect irreconcilable differences at the level of theory and philosophy. Such differences may make theoretical integration impossible. However, in this paper we examine the potential for reconciliation of the cognitive and behavioral wings of behavior therapy when the issue of cognition is approached as a shared content area, rather than at the level of theory and philosophy. Behavior therapy has always been comprised of very diverse theoretical positions. Historically they found common ground around a set of shared values centered on an empirical science of clinical work. We will argue that this core of shared values still exists, and that even controversial topics can provide an arena for reconciliation when we focus on the core values that initially brought us together.

Effects of decreasing sedentary behaviors on activity choice in obese children

In this study, methods of decreasing highly preferred sedentary behaviors were compared and the consequent effects on activity choice were examined. Following free choice of sedentary and physical activities, 34 obese children either were positively reinforced for decreases in high-preference sedentary activity, were punished for high-preference sedentary activity, had access to high-preference sedentary activity restricted, or had no contingencies on activity (control group). Children randomized to reinforcement and punishment were more physically active on intervention days than the control group. Liking for targeted sedentary activity decreased in the reinforcement group, but increased in the restriction and control groups. Results suggest that reinforcing decreases in high-preference sedentary activity can increase physical activity and decrease liking for targeted sedentary activities.

Prospective evaluation of three smoking interventions in 205 recovering alcoholics: one-year results of Project SCRAP-Tobacco

A total of 205 (113 male, 92 female) nonhospitalized recovering alcoholics with > 3 months of continuous abstinence from alcohol and drugs and relatively heavy tobacco dependence (Fagerstrom Tolerance Questionnaire score = 7.7; mean number of cigarettes per day, 26.8; mean number of years smoked, 24.4) were randomized to standard treatment (ST) American Lung Association quit program plus nicotine anonymous meetings (n = 70), behavioral counseling plus physical exercise (BEX; n = 72), or behavioral counseling plus nicotine gum (BNIC; n = 63). A 3 x 4 repeated measures design was used to evaluate the effectiveness of the interventions on smoking outcome at baseline, posttreatment, and 6- and 12-month follow-ups. Self-reported smoking status was verified with biochemical and informant report. Verified self-report indicated that significantly more smokers in BEX quit by posttreatment (60%) than in either BNIC (52%) or ST (31%), chi 2 (2, N = 205) = 17.85, p < .01, but not at the 6-month (29%, 27%, and 21%, respectively) or 12-month (27%, 27%, and 26%, respectively) follow-up. Only 4% (7 of 188) relapsed to alcohol or drugs. Alcohol relapse did not differ by treatment group or smoking status. Length of alcohol abstinence was not associated with smoking cessation outcome.

Effectiveness of psychological and pharmacological treatments for obsessive-compulsive disorder: a quantitative review

Quantitative review of the controlled treatment outcome literature for obsessive-compulsive disorder (OCD) showed that exposure with response prevention was highly effective in reducing OCD symptoms. Cognitive approaches were also found to be at least as effective as exposure procedures. It appears that both cognitive and exposure interventions involve some overlapping procedures and capitalize on similar mechanisms of change. Serotonergic medication, particularly clomipramine, also substantially reduced OCD symptoms. However, clomipramine may not be particularly superior to other serotonergic medication. The relationship between side effects and effect size in medication trials was explored.

Treating children with early-onset conduct problems: a comparison of child and parent training interventions

Families of 97 children with early-onset conduct problems, 4 to 8 years old, were randomly assigned to 1 of 4 conditions: a parent training treatment group (PT), a child training group (CT), a combined child and parent training group (CT + PT), or a waiting-list control group (CON). Posttreatment assessments indicated that all 3 treatment conditions had resulted in significant improvements in comparison with controls. Comparisons of the 3 treatment conditions indicated that CT and CT + PT children showed significant improvements in problem solving as well as conflict management skills, as measured by observations of their interactions with a best friend; differences among treatment conditions on these measures consistently favored the CT condition over the PT condition. As for parent and child behavior at home, PT and CT + PT parents and children had significantly more positive interactions, compared with CT parents and children. One-year follow-up assessments indicated that all the significant changes noted immediately posttreatment had been maintained over time. Moreover, child conduct problems at home had significantly lessened over time. Analyses of the clinical significance of the results suggested that the combined CT + PT condition produced the most significant improvements in child behavior at 1-year follow-up.

Comparison of palmtop-computer-assisted brief cognitive-behavioral treatment to cognitive-behavioral treatment for panic disorder

In the present study, the authors sought to determine whether the efficiency and cost-effectiveness of cognitive-behavioral treatment (CBT) for panic disorder could be improved by adjunctive computer-assisted therapy. Eighteen participants who met Diagnostic and Statistical Manual of Mental Disorders (3rd ed., revised; American Psychiatric Association, 1987) criteria for panic disorder were randomly assigned to a 12-session CBT (CBT 12) condition (D. H. Barlow & M. G. Craske, 1989) or to a 4-session computer-assisted CBT (CBT4-CA) condition. Palmtop computers, with a program developed to incorporate basic principles of CBT, were used by CBT4-CA clients whenever they felt anxious or wanted to practice the therapy techniques and were used by all participants as a momentary assessment tool. CBT4-CA clients carried the computer at all times and continued to use it for 8 weeks after termination of therapy. Analyses of clinically significant changes showed superiority of CBT12 at posttest on some measures; however, there were no differences at follow-up.

Nondirective prompting and noncontingent reinforcement in the treatment of destructive behavior during hygiene routines

The escape-maintained destructive behavior of a girl with mental retardation persisted during hygiene routines with directive prompting, differential reinforcement for compliance, and extinction as treatment. Using nondirective prompting and noncontingent reinforcement, destructive behavior was reduced to near-zero levels during the hygiene routine.

Programming generalization of social skills in preschool children with hearing impairments

The efficacy of a social skills training package in producing stimulus generalization, both with and without the systematic application of generalization programming techniques, was evaluated with 5 preschool children with hearing impairments. The evaluation was conducted within a multiple baseline design. Generalization probes were conducted daily. The social skills training package was implemented in a training setting and produced high, stable rates of social interaction in that setting. However, generalization of the social skills to new teachers, peers, and play activities did not occur until generalization programming strategies were applied in the original training setting. Using sufficient stimulus exemplars and contacting natural consequences appeared to be the key strategies for promoting generalization of social interaction. In addition, the use of supplementary procedures (e.g., a fluency criterion and treatment integrity checks) may have contributed to stimulus generalization.

Using pretreatment and posttreatment assessments to enhance and evaluate existing treatment packages

Pretreatment assessment data were used to enhance an existing treatment package to reduce aggression and to increase positive social interactions between a young boy and his peers. Based on the results of pretreatment assessments, additional reinforcement (differential reinforcement of alternative behavior with adult attention) and punishment (performing a nonpreferred task during time-out) components were added to an existing nonresetting differential reinforcement of other behavior (access to peers unless aggression occurred) plus time-out procedure. A posttreatment component analysis of the additional treatment components indicated that the reinforcement component facilitated positive social interactions and the punishment component suppressed aggression towards peers.

Body dysmorphic disorder: a preliminary evaluation of treatment and maintenance using exposure with response prevention

In recent investigations, body dysmorphic disorder (BDD) has been shown to share common etiological and symptom presentation to obsessive-compulsive disorder (OCD). When treating BDD, there have been some investigations suggesting that exposure with response prevention is effective in alleviating symptoms. Ten patients diagnosed with BDD participated in a study examining the effects of treatment and maintenance using exposure with response prevention. They received a standard behavior therapy protocol which consisted of exposure in vivo and in imagery, with response prevention. Symptom severity, depression, anxiety, and avoidance were assessed weekly during treatment. Following treatment, a 6-month maintenance program was instituted for five patients, with the other five serving as controls. Patients in the maintenance program were assessed bi-weekly with all measures and a 6-month follow-up was conducted. Patients improved for measures of avoidance, BDD symptoms, depression and anxiety when using exposure with response prevention. Although all patients remained symptom free at follow-up, those in the maintenance program continued to improve. Based on these results, BDD appears to be amenable to exposure with response prevention treatment. Additional treatment gains can be obtained when structured maintenance programs are implemented.

Assessment-based intervention for severe behavior problems in a natural family context

Functional assessments and assessment-based interventions were conducted with a boy with disabilities and severe problem behavior in the context of two family routines: using the bathroom in the family home and dining in a fast-food restaurant. A multiple baseline design demonstrated the effectiveness of the intervention package as implemented by the boy's mother in the two routines. The results provide a systematic replication and extension of behavior-analytic interventions in natural family contexts.

The concept of outcome

The Enuresis Resource and Information Centre in the UK has recently launched a second edition of Guidelines on Minimum Standards of Practice in the Treatment of Enuresis. The purpose of the Guidelines is to provide a blueprint for service delivery in the UK, leading to enuresis services that offer effective, accessible and dependable treatment. In particular, these Guidelines propose minimum and target standards that enuresis services should aim to achieve, relating to referral, assessment and treatment, as well as catchment area appointments, research and referral. In addition, the Guidelines may be used to provide a framework within which enuresis services can be audited and evaluated. Successive cycles of observation, appraisal and action should encourage a continual improvement process in each clinic, resulting in a progressive development of the service offered.

Using neutralizing routines to reduce problem behaviors

Establishing operations can alter problem behaviors by changing the momentary value of reinforcers associated with those problem behaviors. If establishing operations (EOs) precede the presentation of discriminative stimuli (SDs) for problem behaviors, it may be possible to introduce neutralizing routines that both reduce the value of reinforcers associated with problem behaviors and decrease the occurrence of problem behaviors. The present study examined this logic with 3 adolescents with severe intellectual disabilities. Initial functional analyses indicated that problem behaviors were motivated by either escape or tangible items. Functional assessment interviews identified possible establishing operations that were associated with the occurrence of problem behavior and indicated that these establishing operations occurred over 1 hr before presentation of the SD for problem behaviors. We used an alternating treatments design to examine problem behaviors during instruction under four conditions: EO + SD, SD only, EO only, and neither SD nor EO. For all 3 participants, problem behaviors occurred almost exclusively during the EO + SD condition. A further analysis compared the EO + SD condition when neutralizing routines were embedded between the EO and the SD. Results from an ABAB reversal design supported the effectiveness of neutralizing routines to reduce these problem behaviors. Applied and theoretical implications are discussed.

An evaluation of methylphenidate as a potential establishing operation for some common classroom reinforcers

We conducted reinforcer assessments for 3 boys with a diagnosis of attention deficit hyperactivity disorder who alternately received either placebo or previously prescribed methylphenidate. Our purpose was to evaluate whether methylphenidate altered the relative reinforcing effectiveness of various stimuli that are often used in classroom-based behavioral treatment programs (e.g., activities, tangible items). Results showed clear differences for some stimuli between reinforcer assessments conducted when participants had received methylphenidate compared to placebo. Results suggest that methylphenidate might act as an establishing operation for some common classroom reinforcers. Implications for the development and evaluation of behavioral treatments are discussed.

Functional analysis and treatment of elopement

Elopement is a dangerous behavior because children who run away may encounter life-threatening situations (e.g., traffic). We conducted functional analyses of the elopement of 3 children who had been diagnosed with developmental disabilities. The results identified a maintaining reinforcer for the elopement of 1 child, but the data were difficult to interpret for 2 of the children. Subsequent reinforcer assessments were used to help to clarify the reinforcers for elopement for these 2 children. Results of the functional analyses and reinforcer assessments then were used to develop successful treatments to reduce elopement. The findings are discussed in terms of (a) the application of functional analysis methodology to elopement, (b) the use of reinforcer assessments to identify potential reinforcers when standard functional analyses are undifferentiated, and (c) the utility of assessment-based treatments for elopement.

Improving adherence to medication regimens for children with asthma and its effect on clinical outcome

We examined the effects of a combined education and token system intervention to improve adherence to inhaled corticosteroids for an 8-year-old girl and a 10-year-old boy with asthma. Adherence was measured by an electronic chronolog monitor, and disease outcome was assessed by repeated pulmonary function testing. A withdrawal design demonstrated improved adherence and, for 1 child, an associated improvement in pulmonary function occurred. Methodological and clinical implications are discussed, including variables other than adherence that may affect disease outcome.

Functional analysis and treatment of social-communicative behavior of adolescents with developmental disabilities

This investigation used functional analyses to identify the social variables that maintained the inappropriate social-communicative behaviors of 2 adolescent students with mental retardation. Analyses were performed in the students' classrooms with the assistance of peers and teachers. The results of these assessments were used to identify appropriate, functionally equivalent behaviors that the students were taught to self-monitor. Findings showed substantial decreases in inappropriate social responding and increases in the use of appropriate social skills.