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Brown KA, Donise KR, Cancilliere MK, Aluthge DP, Chen ES. Characterizing Autism Spectrum Disorder and Predicting Suicide Risk for Pediatric Psychiatric Emergency Services Encounters. AMIA Annu Symp Proc 2024; 2023:864-873. [PMID: 38222397 PMCID: PMC10785882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
Individuals diagnosed with autism spectrum disorder (ASD) are at a higher risk for mental health concerns including suicidal thoughts and behaviors (STB). Limited studies have focused on suicidal risk factors that are more prevalent or unique to the population with ASD. This study sought to characterize and classify youth presenting to the psychiatric emergency department (ED) for a chief complaint of STB. The results of this study validated that a high number of patients with ASD present to the ED with STB. There were important differences in clinical characteristics to those with ASD versus those without. Clinical features that showed important impact in predicting high suicide risk in the ASD cases include elements of the mental status exam such as affect, trauma symptoms, abuse history, and auditory hallucinations. Focused attention is needed on these unique differences in ASD cases so that suicide risk level can be appropriately and promptly addressed.
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Affiliation(s)
| | - Kathleen R Donise
- Department of Psychiatry and Human Behavior at Alpert Medical School, Brown University, Providence RI
- Department of Child and Adolescent Psychiatry, Hasbro Children's Hospital, Providence RI
| | - Mary Kathryn Cancilliere
- Department of Psychiatry and Human Behavior at Alpert Medical School, Brown University, Providence RI
- Department of Child and Adolescent Psychiatry, Hasbro Children's Hospital, Providence RI
| | - Dilum P Aluthge
- Center for Biomedical Informatics, Brown University, Providence RI
| | - Elizabeth S Chen
- Center for Biomedical Informatics, Brown University, Providence RI
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2
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Moitra E, Brick LA, Cancilliere MK, Elwy AR, Erbe AM, Fenn N, Nunn AS, Salhaney P, Chan PA. A randomized trial of acceptance-based behavioral therapy to improve mental health outcomes for LGBTQ+ persons: Study protocol. Contemp Clin Trials 2023; 130:107211. [PMID: 37146874 PMCID: PMC10155421 DOI: 10.1016/j.cct.2023.107211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/14/2023] [Accepted: 04/27/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND During the COVID-19 pandemic, public health measures limited social interactions as an effective and protective intervention for all. For many, however, this social isolation exacerbated mental health symptoms. People who identify as lesbian, gay, bisexual, transgender, and queer (LGBTQ+) were already at elevated risk of anxiety and depression, relative to cisgender and heterosexual populations, and pandemic-related social isolation likely heightened these disparities. In our prior work with sexual and gender minorities, we developed and established feasibility and acceptability of a novel acceptance-based behavioral therapy (ABBT) intervention for HIV treatment. ABBT showed promise in improving social support and reducing mental health symptoms. In the current study, we investigate the efficacy of ABBT, compared to a treatment-as-usual control condition, in a full-scale randomized controlled trial to improve social support for LGBTQ+ persons living with anxiety and depression. METHODS Two hundred forty LGBTQ+ adults with anxiety and/or depressive symptoms will be recruited and equally randomized to receive: (a) the ABBT intervention, consisting of two 30-40 min sessions plus treatment-as-usual (TAU), or (b) TAU only. Primary outcomes are interviewer-assessed anxiety and depressive symptoms. Secondary outcomes are self-reported anxiety and depressive symptoms. Experiential avoidance and social support are hypothesized mediators and presence of an anxiety and/or depressive disorder is a hypothesized moderator. CONCLUSIONS ABBT represents a novel, identify-affirming real-world approach to promoting social support as a means of improving mental health among individuals who identify as LGBTQ+. This study will contribute actionable data establishing the impact, mediational mechanisms, and effect modifiers of ABBT. CLINICALTRIALS govregistration: NCT05540067.
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Affiliation(s)
- Ethan Moitra
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA.
| | - Leslie A Brick
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
| | - Mary Kathryn Cancilliere
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA; Department of Psychiatry, Rhode Island Hospital, Providence, RI, USA
| | - A Rani Elwy
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA; Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
| | - A Maximillian Erbe
- Open Door Health, Rhode Island Public Health Institute, Providence, RI, USA
| | - Natalie Fenn
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA; Department of Psychiatry, Rhode Island Hospital, Providence, RI, USA
| | - Amy S Nunn
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA; Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA; Open Door Health, Rhode Island Public Health Institute, Providence, RI, USA
| | - Peter Salhaney
- Open Door Health, Rhode Island Public Health Institute, Providence, RI, USA
| | - Philip A Chan
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA; Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA; Open Door Health, Rhode Island Public Health Institute, Providence, RI, USA
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Morgan A, Cancilliere MK, Ramanathan A, Wolff J, Donise K. Reducing access to means for suicidal youth presenting to emergency services: A test of medication lock bag distribution. Gen Hosp Psychiatry 2022; 79:183-184. [PMID: 36114035 DOI: 10.1016/j.genhosppsych.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/01/2022] [Accepted: 09/06/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Emergency departments (ED) provide psychiatric assessments to approximately 4000 youth annually. While most are discharged home, they are not without risk. To improve safety, this study examined the distribution of medication lock bags (MLB) to caregivers of youth discharged following an emergency evaluation. METHOD The objective was to evaluate caregiver attitudes and behaviors related to the bag and perceptions of whether the MLB enhanced their youth's safety. MLB distribution was limited to patients who had presented with recent or current non-suicidal self-injurious behavior, suicidal ideation, or a suicide attempt. RESULTS Caregivers were contacted for a phone survey and asked components of their MLB experience. Of the 119 caregivers offered the MLB, 114 accepted and 5 declined. Results indicate that caregivers found the most positive aspects of the bag to include the "Bag is Secure" (39%) and "Safety of Child and Family" (31%). Parents found the most negative aspects of using the bag to be "Nothing" (30%) and "Size" (21%). CONCLUSION These results suggest most caregivers will accept and use MLBs when it is provided during a psychiatric ED evaluation. Further, data suggests caregivers find the bag to be easy to use and that it provides them with a sense of safety/security.
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Affiliation(s)
| | - Mary Kathryn Cancilliere
- Rhode Island Hospital, Providence, RI, USA; Department of Psychiatry and Human Behavior, Warren Alpert Medical School at Brown University, Providence, RI, USA.
| | | | - Jennifer Wolff
- Rhode Island Hospital, Providence, RI, USA; Department of Psychiatry and Human Behavior, Warren Alpert Medical School at Brown University, Providence, RI, USA; Emma Pendleton Bradley Hospital Providence, RI, USA
| | - Kathleen Donise
- Rhode Island Hospital, Providence, RI, USA; Department of Psychiatry and Human Behavior, Warren Alpert Medical School at Brown University, Providence, RI, USA; Emma Pendleton Bradley Hospital Providence, RI, USA
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Cancilliere MK, Ramanathan A, Hoffman P, Jencks J, Spirito A, Donise K. Characteristics of a Pediatric Emergency Psychiatric Telephone Triage Service. Pediatr Emerg Care 2022; 38:494-501. [PMID: 35981327 DOI: 10.1097/pec.0000000000002831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Caregivers of youth in psychiatric crisis often seek treatment from hospital emergency departments (EDs) as their first point of entry into the mental health system. Emergency departments have struggled over the last decade with growing numbers and now, because of the pandemic, have experienced a deluge of mental health crises. As one approach to divert unnecessary ED admissions, pediatric emergency psychiatric telephone triage services have been created. This study aimed to define the characteristics and utilization of a pediatric triage service and to examine clinician documentation of calls to identify the assessment of risk and disposition. METHODS This study included 517 youth (2-18 years; mean, 12.42 years; SD, 3.40 years) who received triage services in the winter of 2 consecutive years. Triage calls were received from caregivers (>75%), schools (17.0%), and providers (6.6%) regarding concerns, including suicidal ideation (28.6%), school issues (28.6%), and physical aggression (23.4%). RESULTS Dispositions were for acute, same-day evaluation (9.7%), direct care service (28.8%), further evaluation (within 48-72 hours, 40.0%), and resource/service update information (21.5%). Findings revealed that most clinical concerns were referred for further evaluation. Both adolescent females and males were referred for emergency evaluations at high rates. CONCLUSIONS A dearth of information on pediatric crisis telephone triage services exists; thus, developing an evidence base is an important area for future work. This information assists not only in our understanding of which, why, and how many youths are diverted from the ED but allows us to extrapolate significant costs that have been saved because of the utilization of the triage service.
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Affiliation(s)
| | | | | | | | - Anthony Spirito
- From the Department of Psychiatry and Human Behavior, Warren Alpert Medical School at Brown University
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Cancilliere MK, Donise K. A Comparison of Acute Mental Health Presentations to Emergency Services Before and During the COVID-19 Pandemic. R I Med J (2013) 2022; 105:9-15. [PMID: 35476729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVE/BACKGROUND This study aimed to understand how the COVID-19 pandemic affected youth presentations to the Emergency Department's psychiatric service and how many warranted an inpatient and acute residential admission. METHODS This cross-sectional study examined the patients (youth ages 3 to 18 years) evaluated at Hasbro Children's Hospital's Emergency Department by Lifespan's Pediatric Behavioral Health Emergency Service (LPBHES) over four months, March through June, of years 2019, 2020, and 2021. The sample was categorized into two groups: Children ages 3 to 11 years and adolescents ages 12 to 18 years. RESULTS Youth evaluated by LPBHES showed an increase in acuity, where 11% more children and 12% more adolescents met criteria for inpatient and acute residential admission from years 2019 to 2020. This increase was observed despite fewer overall LPBHES evaluations. CONCLUSION Future directions include prospective studies that explore the barriers to youth receiving the appropriate level of outpatient mental health services to prevent acute mental health crises.
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Affiliation(s)
- Mary Kathryn Cancilliere
- Rhode Island Hospital, Department of Psychiatry and Human Behavior; Warren Alpert Medical School of Brown University, Providence, RI
| | - Kathleen Donise
- Rhode Island Hospital, Department of Psychiatry and Human Behavior; Warren Alpert Medical School of Brown University, Providence, RI; Emma Pendleton Bradley Hospital, East Providence, RI
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Kavanaugh BC, Cancilliere MK, Fryc A, Tirrell E, Oliveira J, Oberman LM, Wexler BE, Carpenter LL, Spirito A. Measurement of executive functioning with the National Institute of Health Toolbox and the association to anxiety/depressive symptomatology in childhood/adolescence. Child Neuropsychol 2020; 26:754-769. [PMID: 31876232 PMCID: PMC10629577 DOI: 10.1080/09297049.2019.1708295] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 12/18/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Despite preliminary research, there remain inconsistent findings with regard to the role of executive functioning (EF) deficits in childhood anxiety and depression. This report examined the association of The National Institute of Health (NIH) Toolbox to clinical neuropsychological measures and to childhood, anxiety/depressive symptomatology. Methods: One-hundred eight children and adolescents completed the three EF measures from the NIH Toolbox (List Sorting Working Memory Test [LSWMT], Dimensional Change Card Sorting Test [DCCST], and Flanker Test of Attention and Inhibition [Flanker]) in an outpatient neuropsychology program. These tests were compared to established measures of EF in terms of linear correlations and detection of impairment. Heaton's Global Deficit Score (GDS) was utilized to calculate impairment. The Toolbox-EF measures were paired with parent-reported EF symptoms (Behavior Rating Inventory of Executive Function [BRIEF2]) to identify the role of EF in childhood anxiety/depressive symptomatology. RESULTS Toolbox-EF measures displayed medium sized correlations with their clinically comparable counterparts, and generally did not differ in their detection of impairment. Toolbox-GDS was associated with depression diagnosis and clinically significant child-reported anxiety and depressive symptoms. Together, Toolbox/BRIEF2 accounted for 26.8-30.9% of elevated depressive symptom variance, but only 13.2-14% of elevated anxiety symptom variance. Further, EF impairment was associated with depression across self report, parent report, and clinical diagnosis. DISCUSSION The NIH Toolbox-EF measures display comparable psychometric properties to clinically available EF measures in a pediatric (primarily psychiatric) neuropsychology setting. The Toolbox appears to display an appropriate ability to detect EF deficits secondary to self-reported depression in childhood.
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Affiliation(s)
- Brian C. Kavanaugh
- Department of Psychiatry & Human Behavior, Emma Pendleton Bradley Hospital, Providence, RI, USA
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
| | | | - Alexa Fryc
- Department of Psychology, University of Rhode Island, South Kingstown, RI, USA
| | - Eric Tirrell
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
- Department of Psychiatry & Human Behavior, Butler Hospital Mood Disorders Research Program and Neuromodulation Research Facility, Providence, RI, USA
| | - Jane Oliveira
- Department of Psychiatry & Human Behavior, Emma Pendleton Bradley Hospital, Providence, RI, USA
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
| | - Lindsay M. Oberman
- Center for Neuroscience and Regenerative Medicine, Henry M. Jackson Foundation for the Advancement of Military Medicine, Rockville, MD, USA
| | - Bruce E. Wexler
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Linda L. Carpenter
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
- Department of Psychiatry & Human Behavior, Butler Hospital Mood Disorders Research Program and Neuromodulation Research Facility, Providence, RI, USA
| | - Anthony Spirito
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
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Gervasio M, Beatty A, Kavanaugh B, Cancilliere MK, Holler K. The association between neurocognition and sexual abuse within a children's psychiatric inpatient program. Clin Neuropsychol 2020; 36:189-206. [PMID: 32613898 DOI: 10.1080/13854046.2020.1781932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Objective: The aim of this study was to understand the detrimental effects of sexual abuse on neuropsychological variables including child's intelligence, executive functioning (EF), and learning/memory within a pediatric inpatient population.Method: This study examined the effect of sexual abuse on children's intelligence, EF, and learning/memory by conducting a retrospective chart review for 144 children (aged 7-12) who completed a neuropsychological assessment during a psychiatric inpatient hospitalization. Of the 144 children, participants were matched two to one by gender and age, with one group (n = 52) categorized by reported sexual abuse and the other group (n = 92) categorized by no reported sexual abuse. The neuropsychological measures included the Wechsler Abbreviated Scale of Intelligence (WASI-I/II) or Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV), Wide Range Assessment of Memory and Learning - Second Edition (WRAML-2): Story Memory Immediate/Delayed Recall and Delayed Recognition, Trail Making Test-B, Stroop Interference Test: Color-Word Condition, WRAML-2: Sentence Memory and Conners Continuous Performance Test-Second Edition.Results: Statistical analysis showed that participants with reported sexual abuse had significantly (p< .05) lower intelligence, EF, and learning/memory skills than those without reported sexual abuse. Only working memory and cognitive flexibility differences remained after controlling for clinical variables (e.g., PTSD, amount of total abuse types).Conclusions: These findings contributed to the limited research on the detrimental effects of sexual abuse in a pediatric inpatient population. They demonstrated a relationship between early sexual abuse and neuropsychological deficits, specifically executive function and IQ deficits.
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Affiliation(s)
- Maddi Gervasio
- Department of Psychiatry & Human Behavior, E. P. Bradley Hospital, East Providence, RI, USA
| | - Avery Beatty
- Department of Human Development and Family Studies, University of Rhode Island, Kingston, RI, USA
| | - Brian Kavanaugh
- Department of Psychiatry & Human Behavior, E. P. Bradley Hospital, East Providence, RI, USA.,Department of Psychiatry & Human Behavior, Alpert Medical School of Brown University, East Providence, RI, USA
| | | | - Karen Holler
- Department of Psychiatry & Human Behavior, E. P. Bradley Hospital, East Providence, RI, USA.,Department of Psychiatry & Human Behavior, Alpert Medical School of Brown University, East Providence, RI, USA
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Weber Ku E, Oliveira JS, Cook NE, McCurdy K, Kavanaugh B, Cancilliere MK, Holler KA. Assessing performance validity with the TOMM and automatized sequences task in a pediatric psychiatric inpatient setting. Child Neuropsychol 2020; 26:801-816. [PMID: 31937183 DOI: 10.1080/09297049.2020.1712345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
This study examined the performance of children consecutively admitted to an inpatient psychiatric unit on the Test of Memory Malingering (TOMM) (aged 5-12; n = 96) and Automatized Sequences Task (aged 8-12; n = 67). Eighty-three percent of children passed the TOMM Trial 2 (M raw score = 47.7, SD = 4.7) and 76% of children passed the Automatized Sequences Task total time (M = 23.1 seconds; SD = 8.2). The concordance rate between the TOMM and the total time on the Automatized Sequences Task was 73.1%. Receiver operating characteristic curves indicated that of the Automatized Sequences Task subtests, only Counting 1-20 significantly differentiated children who passed Trial 2 of the TOMM from those who did not pass Trial 2 of the TOMM (area under the curve = .756, p = .006). Performance on both PVTs was unrelated to demographic characteristics and measures of psychological and neuropsychological functioning on both the TOMM and Automatized Sequences Task. Further research is needed to determine whether the nearly 1 in 4 children (23.9%) who performed below recommended cutoffs on Automatized Sequences Task reflects genuine suboptimal effort, cognitive difficulties among these children, and/or other factors.
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Affiliation(s)
- Elyssa Weber Ku
- Clinical Psychology, University of Massachusetts Boston , Boston, MA, USA
| | - Jane S Oliveira
- Clinical Psychology, Antioch University - New England, Keene, NH, USA
| | - Nathan E Cook
- Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital and Harvard Medical School , Boston, USA
| | - Kyle McCurdy
- Department of Counseling, Leadership, & Expressive Arts, Salve Regina , Newport, RI, USA
| | - Brian Kavanaugh
- Department of Psychiatry & Human Behavior E.P. Bradley Hospital/ Alpert Medical School of Brown University , Providence, RI, USA
| | | | - Karen A Holler
- Department of Psychiatry & Human Behavior E.P. Bradley Hospital/ Alpert Medical School of Brown University , Providence, RI, USA
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Kavanaugh B, Studeny J, Cancilliere MK, Holler KA. Neurocognitive predictors of length of stay within a children’s psychiatric inpatient program. Child Neuropsychol 2019; 26:129-136. [DOI: 10.1080/09297049.2019.1617843] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Brian Kavanaugh
- Department of Psychiatry & Human Behavior, E. P. Bradley Hospital/Alpert Medical School of Brown University, East Providence, RI, USA
| | - Jane Studeny
- Department of Clinical Psychology, Antioch University New England, Keene, NH, USA
| | | | - Karen A. Holler
- Department of Psychiatry & Human Behavior, E. P. Bradley Hospital/Alpert Medical School of Brown University, East Providence, RI, USA
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Cancilliere MK, Spirito A, Monti P, Barnett N. Brief Alcohol Interventions for Youth in the Emergency Department: Exploring Proximal and Distal Outcomes. J Child Adolesc Subst Abuse 2019; 27:311-321. [PMID: 31440019 PMCID: PMC6706063 DOI: 10.1080/1067828x.2018.1529645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Brief interventions (BI) for alcohol use in the emergency department (ED) have been shown efficacious among adolescents and young adults; however, whether these interventions extend to other outcomes - proximal and distal - are less explored. This study examined outcomes of ED BIs in four completed trials showing reductions in alcohol use. Limited and inconsistent effects were found on proximal outcomes including parental monitoring, and distal outcomes including tobacco use. Identifying the mechanisms that underlie alcohol-focused BIs as well the intervention processes that may lead to generalized, positive effects on other variables is an important area of future research.
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Affiliation(s)
- Mary Kathryn Cancilliere
- Department of Psychology, College of Health Sciences, University of Rhode Island, Kingston, RI, 02881 USA
| | - Anthony Spirito
- Center for Alcohol and Addiction Studies, Brown University, Box G-S121-5, Providence, RI, 02912 USA
- Department of Psychiatry and Human Behavior, Brown University, Box G-BH, Providence, RI, 02912 USA
| | - Peter Monti
- Center for Alcohol and Addiction Studies, Brown University, Box G-S121-5, Providence, RI, 02912 USA
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Box G-S121-5, Providence, RI, 02912 USA
| | - Nancy Barnett
- Center for Alcohol and Addiction Studies, Brown University, Box G-S121-5, Providence, RI, 02912 USA
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Box G-S121-5, Providence, RI, 02912 USA
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Cancilliere MK, Freeman J, Garcia A, Benito K, Sapyta J, Franklin M. Assessing Acute Secondary Treatment Outcomes in Early-Onset Obsessive-Compulsive Disorder. Child Psychiatry Hum Dev 2018; 49:718-729. [PMID: 29435695 DOI: 10.1007/s10578-018-0786-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Obsessive-compulsive disorder (OCD) in children under 8 years of age, referred to as early-onset OCD, has similar features to OCD in older children, including moderate to severe symptoms, impairment, and significant comorbidity. Family-based cognitive behavioral therapy (FB-CBT) has been found efficacious in reducing OCD symptoms and functional impairment in children ages 5-8 years with OCD; however, its effectiveness on reducing comorbid psychiatric symptoms in this same population has yet to be demonstrated. This study examined the acute effects of FB-CBT vs. family-based relaxation treatment over 14 weeks on measures of secondary treatment outcomes (non-OCD) in children with early-onset OCD. Children in the FB-CBT condition showed significant improvements from pre- to post-treatment on secondary outcomes, with a decrease in overall behavioral and emotional problems, internalizing symptoms, as well as overall anxiety symptom severity. Neither condition yielded significant change in externalizing symptoms. Clinical implications of these findings are considered.
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Affiliation(s)
- Mary Kathryn Cancilliere
- Department of Psychology, University of Rhode Island, 10 Chafee Road, Suite 8, Kingston, RI, 02881, USA.
| | - Jennifer Freeman
- Department of Psychiatry and Human Behavior, Brown University Medical School, Providence, RI, USA.,Bradley-Hasbro Children's Research Center, Emma Pendleton Bradley Hospital, East Providence, RI, USA
| | - Abbe Garcia
- Department of Psychiatry and Human Behavior, Brown University Medical School, Providence, RI, USA.,Bradley-Hasbro Children's Research Center, Emma Pendleton Bradley Hospital, East Providence, RI, USA
| | - Kristen Benito
- Department of Psychiatry and Human Behavior, Brown University Medical School, Providence, RI, USA.,Bradley-Hasbro Children's Research Center, Emma Pendleton Bradley Hospital, East Providence, RI, USA
| | - Jeffrey Sapyta
- Duke Child and Family Study Center, Duke University School of Medicine, Durham, NC, USA
| | - Martin Franklin
- Child and Adolescent OCD, Tic, Trich, and Anxiety Group, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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Cancilliere MK, Yusufov M, Weyandt L. Effects of Co-occurring marijuana use and anxiety on brain structure and functioning: A systematic review of adolescent studies. J Adolesc 2018; 65:177-188. [DOI: 10.1016/j.adolescence.2018.03.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 03/18/2018] [Accepted: 03/23/2018] [Indexed: 01/01/2023]
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13
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Spirito A, Hernandez L, Cancilliere MK, Graves HR, Rodriguez AM, Operario D, Jones R, Barnett NP. Parent and Adolescent Motivational Enhancement Intervention for Substance-Using, Truant Adolescents: A Pilot Randomized Trial. J Clin Child Adolesc Psychol 2017; 47:S467-S479. [PMID: 29252011 DOI: 10.1080/15374416.2017.1399402] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The purpose of this article is to present the results of a treatment development study designed to examine the feasibility, acceptability, and preliminary efficacy of motivational enhancement therapy (MET) for substance using, truant adolescents plus the Family Check-Up (FCU) for parents. A randomized controlled trial was used to test the hypothesis that MET plus the FCU (MET/FCU) would lead to greater reductions in alcohol and marijuana use as well as truant behavior compared to a psychoeducation (PE) condition delivered to both adolescents and parents. Participants (n = 69; M age = 15.8 years) were 39% female, 59% White, and 31% Hispanic/Latino. Adolescents were referred from family court, from school truancy courts, from school counselors, or after presentations in high school health classes. Eligible participants reported using marijuana at least 3 times in the prior 90 days and a history of school truancy in the prior school year. The MET/FCU condition was found to be feasible to implement and was acceptable to both adolescents and parents. The PE condition was also found to be an acceptable and credible comparison condition by participants. Results at the 6-month follow-up favored MET/FCU over PE on days of marijuana use and number of times marijuana was smoked per day (medium effect), high volume drinking days and other drug use (small to medium effects), truancy indicators (small effects), parental monitoring (medium to large effects), and parent-teen problem solving (medium to large effects). A larger study to test the efficacy of the MET/FCU appears warranted based on these promising findings.
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Affiliation(s)
- Anthony Spirito
- a Center for Alcohol and Addiction Studies , Brown University.,b Department of Psychiatry and Human Behavior , The Alpert Medical School of Brown University
| | - Lynn Hernandez
- c Department of Behavioral and Social Sciences , Brown University School of Public Health
| | | | - Hannah R Graves
- a Center for Alcohol and Addiction Studies , Brown University
| | | | - Don Operario
- a Center for Alcohol and Addiction Studies , Brown University.,c Department of Behavioral and Social Sciences , Brown University School of Public Health
| | - Richard Jones
- b Department of Psychiatry and Human Behavior , The Alpert Medical School of Brown University
| | - Nancy P Barnett
- a Center for Alcohol and Addiction Studies , Brown University.,c Department of Behavioral and Social Sciences , Brown University School of Public Health
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Spirito A, Hernandez L, Marceau K, Cancilliere MK, Barnett NP, Graves HR, Rodriguez AM, Knopik VS. Effects of a brief, parent-focused intervention for substance using adolescents and their sibling. J Subst Abuse Treat 2017; 77:156-165. [PMID: 28259500 DOI: 10.1016/j.jsat.2017.02.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 01/30/2017] [Accepted: 02/03/2017] [Indexed: 11/28/2022]
Abstract
The purpose of this study was to evaluate the efficacy of the Family Check-up (FCU), a parent-focused brief motivational intervention, in families where parents were concerned about one adolescent's alcohol or marijuana use and the referred adolescent also had a sibling close in age. The primary goal of the FCU was to provide individualized feedback on specific parenting skills, including monitoring and supervision, limit setting, and alcohol-related communication. A total of 92 adolescents (37 female) between the ages of 12-19years of age along with a sibling (48 female) between the ages of 11-21years old, were randomized to the FCU or a psychoeducation (PE) comparison condition. Findings indicated that the FCU did not produce better effects on alcohol and other drug use outcomes than the PE condition, in either the adolescent or sibling. Brief interventions addressing parenting behaviors may not be sufficient to reduce alcohol use in adolescent drinkers not referred due to an alcohol-related incident. Future research might be conducted to explore whether brief parent interventions, such as those in the present study, could be useful as a preventive intervention for parents whose teens report low levels of substance use.
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Affiliation(s)
- Anthony Spirito
- Center for Alcohol and Addiction Studies, Brown University, Box G-S121-5, Providence, RI 02912, United States; Department of Psychiatry and Human Behavior, The Alpert Medical School of Brown University, Box G-BH, Providence, RI 02912, United States.
| | - Lynn Hernandez
- Center for Alcohol and Addiction Studies, Brown University, Box G-S121-5, Providence, RI 02912, United States; Department of Behavioral and Social Sciences, Brown University School of Public Health, Box G-S121-5, Providence, RI 02912, United States.
| | - Kristine Marceau
- Center for Alcohol and Addiction Studies, Brown University, Box G-S121-5, Providence, RI 02912, United States; Department of Behavioral and Social Sciences, Brown University School of Public Health, Box G-S121-5, Providence, RI 02912, United States; Department of Psychiatry and Human Behavior, The Alpert Medical School of Brown University, Box G-BH, Providence, RI 02912, United States; Division of Behavioral Genetics, Rhode Island Hospital, Coro West, Suite 204, 1 Hoppin Street, Providence, RI 02903, United States.
| | - Mary Kathryn Cancilliere
- Center for Alcohol and Addiction Studies, Brown University, Box G-S121-5, Providence, RI 02912, United States.
| | - Nancy P Barnett
- Center for Alcohol and Addiction Studies, Brown University, Box G-S121-5, Providence, RI 02912, United States; Department of Behavioral and Social Sciences, Brown University School of Public Health, Box G-S121-5, Providence, RI 02912, United States.
| | - Hannah R Graves
- Center for Alcohol and Addiction Studies, Brown University, Box G-S121-5, Providence, RI 02912, United States.
| | - Ana Maria Rodriguez
- Center for Alcohol and Addiction Studies, Brown University, Box G-S121-5, Providence, RI 02912, United States.
| | - Valerie S Knopik
- Center for Alcohol and Addiction Studies, Brown University, Box G-S121-5, Providence, RI 02912, United States; Department of Psychiatry and Human Behavior, The Alpert Medical School of Brown University, Box G-BH, Providence, RI 02912, United States; Division of Behavioral Genetics, Rhode Island Hospital, Coro West, Suite 204, 1 Hoppin Street, Providence, RI 02903, United States.
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15
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Hernandez L, Cancilliere MK, Graves H, Chun TH, Lewander W, Spirito A. Substance Use and Depressive Symptoms among Adolescents Treated in a Pediatric Emergency Department. J Child Adolesc Subst Abuse 2015; 25:124-133. [PMID: 27152065 DOI: 10.1080/1067828x.2014.889633] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The current study examined associations between substance use and depressed mood by gender and type of substance used (no use, alcohol, marijuana or both alcohol and marijuana) in a sample of 713 adolescents (Mage = 15.3) recruited from a Pediatric Emergency Department (PED). Adolescents who reported any marijuana use had higher overall depressed mood scores compared to all other adolescents. When examined by gender, females with both alcohol and marijuana use reported the highest overall depressed mood symptoms. These results suggest the usefulness of screening and identification of depressive symptoms among adolescents presenting to a PED for substance use-related problems.
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Affiliation(s)
- Lynn Hernandez
- Department of Behavioral and Social Sciences, Center for Alcohol and Addiction Studies, The Alpert Medical School of Brown University
| | | | - Hannah Graves
- Center for Alcohol and Addiction Studies, The Alpert Medical School of Brown University
| | - Thomas H Chun
- Departments of Emergency Medicine and Pediatrics, The Alpert Medical School of Brown University
| | - William Lewander
- Departments of Emergency Medicine and Pediatrics, The Alpert Medical School of Brown University
| | - Anthony Spirito
- Department of Psychiatry and Human Behavior, Center for Alcohol and Addiction Studies, The Alpert Medical School of Brown University
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16
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Spirito A, Hernandez L, Cancilliere MK, Graves H, Knopik VS, Barnett N. Improving parenting and parent-teen communication to delay or prevent the onset of alcohol and drug use in young adolescents with emotional/behavioral disorders: A pilot trial. J Child Adolesc Subst Abuse 2015; 24:308-322. [PMID: 26478690 PMCID: PMC4607087 DOI: 10.1080/1067828x.2013.829013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Anthony Spirito
- Center for Alcohol and Addiction Studies, Brown University, Department of Psychiatry and Human Behavior, Brown University, Rhode Island Hospital, Providence, RI
| | - Lynn Hernandez
- Center for Alcohol and Addiction Studies, Brown University, Department of Psychiatry and Human Behavior, Brown University, Rhode Island Hospital, Providence, RI
| | - Mary Kathryn Cancilliere
- Center for Alcohol and Addiction Studies, Brown University, Department of Psychiatry and Human Behavior, Brown University, Rhode Island Hospital, Providence, RI
| | - Hannah Graves
- Center for Alcohol and Addiction Studies, Brown University, Department of Psychiatry and Human Behavior, Brown University, Rhode Island Hospital, Providence, RI
| | - Valerie S Knopik
- Center for Alcohol and Addiction Studies, Brown University, Department of Psychiatry and Human Behavior, Brown University, Rhode Island Hospital, Providence, RI
| | - Nancy Barnett
- Center for Alcohol and Addiction Studies, Brown University, Department of Psychiatry and Human Behavior, Brown University, Rhode Island Hospital, Providence, RI
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17
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Martin RA, Stein LAR, Clair M, Cancilliere MK, Hurlbut W, Rohsenow DJ. Adolescent Substance Treatment Engagement Questionnaire for Incarcerated Teens. J Subst Abuse Treat 2015; 57:49-56. [PMID: 26021405 DOI: 10.1016/j.jsat.2015.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Revised: 04/14/2015] [Accepted: 04/19/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Treatment engagement is often measured in terms of treatment retention and drop out, resource utilization, and missed appointments. Since persons may regularly attend treatment sessions but not pay close attention, actively participate, or comply with the program, attendance may not reflect the level of effort put into treatment. Teens in correctional settings may feel coerced to attend treatment, making it necessary to develop measures of treatment involvement beyond attendance. This study describes the development and validation of the Adolescent Substance Treatment Engagement Questionnaire (ASTEQ), Teen and Counselor versions. METHODS The psychometric properties of the ASTEQ were examined in a sample of incarcerated teens (N = 205) and their counselors. Principal component analysis was conducted on teen and counselor versions of the questionnaire. RESULTS Scales of positive and negative treatment engagement were found, reflecting both overt behaviors (joking around, talking to others) and attitudes (interest in change). Significant correlations with constructs related to treatment attitudes and behaviors, and misbehaviors (including substance use) demonstrate good concurrent and predictive validity. Teen and counselor ratings of engagement produced validity correlations in the medium effect size range. CONCLUSIONS These measures comprise a valid and reliable method for measuring treatment engagement for incarcerated teens.
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Affiliation(s)
- Rosemarie A Martin
- Center for Alcohol and Addiction Studies, Brown University, Providence, RI, 02912.
| | - Lynda A R Stein
- The University of Rhode Island, Kingston, RI, 02881; The Rhode Island Training School, 40 Howard Avenue, Cranston, RI, 02920
| | - Mary Clair
- The University of Rhode Island, Kingston, RI, 02881; The Rhode Island Training School, 40 Howard Avenue, Cranston, RI, 02920
| | | | - Warren Hurlbut
- The Rhode Island Training School, 40 Howard Avenue, Cranston, RI, 02920
| | - Damaris J Rohsenow
- Center for Alcohol and Addiction Studies, Brown University, Providence, RI, 02912; Providence VA Medical Center, 830 Chalkstone Avenue, Providence, RI, 02908
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18
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Stein LAR, Clair M, Rossi JS, Martin RA, Cancilliere MK, Clarke JG. Gender, ethnicity and race in incarcerated and detained youth: services and policy implications for girls. Psychiatr Rehabil J 2015; 38:65-73. [PMID: 25180525 PMCID: PMC4345142 DOI: 10.1037/prj0000089] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE While work has been conducted on gender differences to inform gender-specific programming, relatively little work has been done regarding racial and ethnic differences among incarcerated and detained girls in particular. This is an important gap, considering gender, race, and ethnicity may be important factors in responding to the needs of incarcerated and detained girls within the Risk-Needs-Responsivity (RNR) model. We hypothesize girls will show relatively more pathology than boys, and that White girls will show relatively more pathology as compared to girls of other groups. Implications of findings for services delivery and policy are presented. METHOD Data were collected on N = 657 youth using structured interview and record review. Analyses included χ2 and t tests. RESULTS As compared to boys, girls were older at first arrest yet younger during most lock-up, received poorer grades, experienced more family difficulty, and more were lesbian/bisexual. As compared to minority girls, White girls began hard drugs at a younger age, had more conduct disorder symptoms, and more frequently experienced parental difficulty and abuse. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE Age-appropriate programming that addresses family difficulty and sexuality is needed for girls. As compared to White girls, reentry planning may more readily rely on family support for minority girls. Systems should consider use of actuarial methods in order to reduce bias in making placement decisions. (PsycINFO Database Record
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Affiliation(s)
- L A R Stein
- Social Sciences Research Center and Psychology Depart- ment, University of Rhode Island
| | - Mary Clair
- Social Sciences Research Center and Psychology Depart- ment, University of Rhode Island
| | - Joseph S Rossi
- Social Sciences Research Center and Psychology Depart- ment, University of Rhode Island
| | | | | | - Jennifer G Clarke
- Center for Primary Care & Prevention, Memorial Hospital of Rhode Island, Alpert Medical School, Brown University
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Hernandez L, Salas-Wright CP, Graves H, Cancilliere MK, Spirito A. A confirmatory approach to understanding the four-factor structure of the Adolescent Drinking Index: evidence for a brief version. J Subst Abuse Treat 2014; 47:239-44. [PMID: 25012547 DOI: 10.1016/j.jsat.2014.05.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Revised: 04/02/2014] [Accepted: 05/15/2014] [Indexed: 11/26/2022]
Abstract
The purpose of this study was to examine the psychometric properties of the original version of the Adolescent Drinking Index (ADI), and to examine the fit of a series of confirmatory factor analysis models to arrive at an abbreviated version that can be easily administered in settings with limited time for assessment. These aims were examined in a sample of 740 adolescents (Mage=15.26; 58.5% males) who completed the ADI during an emergency department visit. Results suggested that the four-domain design did not fit the data adequately. Results, however, demonstrated good fit for an 8-item adapted version with a four-factor structure: interpersonal, social, psychological, and physical indicators. This abbreviated version was also associated with outcomes such as hangover, alcohol withdrawal, and substance use. Findings from this study provide support for the use of an abbreviated version of the ADI for screening adolescents and referring them to appropriate interventions.
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Affiliation(s)
- Lynn Hernandez
- Department of Behavioral and Social Sciences, Center for Alcohol and Addiction Studies, The Brown University School of Public Health, Providence, RI 02912.
| | | | - Hannah Graves
- Center for Alcohol and Addiction Studies, The Brown University School of Public Health, Providence, RI 02912
| | - Mary Kathryn Cancilliere
- Center for Alcohol and Addiction Studies, The Brown University School of Public Health, Providence, RI 02912
| | - Anthony Spirito
- Department of Psychiatry and Human Behavior, The Alpert Medical School of Brown University, Providence, RI 02912
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20
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Spirito A, Simon V, Cancilliere MK, Stein R, Norcott C, Loranger K, Prinstein MJ. Outpatient psychotherapy practice with adolescents following psychiatric hospitalization for suicide ideation or a suicide attempt. Clin Child Psychol Psychiatry 2011; 16:53-64. [PMID: 20404070 PMCID: PMC3701940 DOI: 10.1177/1359104509352893] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Outpatient treatment is standard care for adolescents discharged following a psychiatric hospitalization. There is little research, however, on the amount and types of psychotherapy these clients receive in the community. We examined therapy attendance and therapist report of outpatient therapy practice with adolescents discharged from psychiatric hospitalization following either a suicide attempt or severe suicidal ideation in the Northeastern USA. Therapists (n = 84) completed a packet of self-report questionnaires regarding treatment of these adolescents in the first six months after discharge from the hospital. Information on number of sessions attended, primary presenting problem, therapist orientation, therapy techniques, and therapeutic relationship was collected. The findings indicated that therapists met their clients in both private and community outpatient settings. The most common modality of treatment was individual therapy, but almost all types of therapeutic techniques were endorsed. Adolescents attended an average of 8.1 therapy sessions (SD = 4.7), with 18% terminating treatment against therapist advice within the first three months. Psychologists, psychiatrists, and social workers used cognitive-behavioral, psychodynamic, and family system techniques about equally. Social workers used humanistic techniques more than their counterparts. The variability in number of therapy sessions attended suggests that many adolescents discharged after a psychiatric hospitalization will not receive adequate care. Short-term therapy protocols designed for community practice emphasizing cognitive techniques may be useful to test in future community-based research trials based on the high percentage of adolescents attending relatively few sessions.
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Affiliation(s)
- Anthony Spirito
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Center for Alcohol and Addiction Studies, 121 South Main Street, Providence, RI 02912, USA.
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21
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Ievers-Landis CE, Hoff AL, Brez C, Cancilliere MK, McConnell J, Kerr D. Situational analysis of dietary challenges of the treatment regimen for children and adolescents with phenylketonuria and their primary caregivers. J Dev Behav Pediatr 2005; 26:186-93. [PMID: 15956867 DOI: 10.1097/00004703-200506000-00004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
A situational analysis was conducted to evaluate challenges with the treatment regimen (a low protein diet and special supplemental formula) for children and adolescents with phenylketonuria (PKU) and their caregivers. A semistructured interview was administered to 19 caregivers and 11 children with PKU to describe formula and dietary problems and their frequency, difficulty, and affective intensity. Information was also gathered on attempted solutions to problems and their perceived effectiveness. Caregivers who rated dietary problems as less frequent, difficult, and emotionally upsetting and strategies as more effective for solving problems had children with significantly lower phenylalanine (Phe) levels, a biological indicator of adherence (i.e., better adherence; all p values <.05). Caregivers who reported using strategies coded as representing an authoritarian parenting style to solve dietary problems were significantly more likely to have lower household incomes and older children with higher Phe levels than were those who did not report such strategies (all p values <.05).
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Affiliation(s)
- Carolyn E Ievers-Landis
- Division of Behavioral Pediatrics and Psychology, Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio 44106-6038, USA.
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