Process Mechanisms in Behavioral Versus Nondirective Guided Self-help for Parents of Children with Externalizing Behavior

The study examined potential mediating effects of therapist behaviors in the per-protocol sample (n = 108) of a randomized controlled trial comparing a behavioral and a nondirective guided self-help intervention for parents of children with externalizing disorders (4-11 years). Additionally, from an exploratory perspective, we analyzed a sequential model with parental adherence as second mediator following therapist behavior. Outcomes were child symptom severity of attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder rated by blinded clinicians, and parent-rated child functional impairment. We found a significant indirect effect on the reduction of ADHD and functional impairment through emotion- and relationship-focused therapist behavior in the nondirective intervention. Additionally, we found limited support for an extended sequential mediation effect through therapist behavior and parental adherence in the models for these outcomes. The study proposes potential mediating mechanisms unique to the nondirective intervention and complements previous findings on mediator processes in favor of the behavioral group. Trial registration ClinicalTrials.gov NCT01350986.

Behavioural and nondirective parent training for children with externalising disorders: First steps towards personalised treatment recommendations

For children with externalising disorders, parent training programmes with different theoretical foundations are available. Currently, there is little knowledge concerning which programme should be recommended to a family based on their individual needs (e.g., single parenthood). The personalised advantage index (PAI) indicates the predicted treatment advantage of one treatment over another. The aim of the present study was to examine the usefulness of this score in providing individualised treatment recommendations. The analysis considered 110 parents (per-protocol sample) of children (4-11 years) with attention-deficit/hyperactivity (ADHD) or oppositional defiant disorder (ODD), randomised to either a behavioural or a nondirective telephone-assisted self-help parent training. In multiple moderator analyses with four different regression algorithms (linear, ridge, k-nearest neighbors, and tree), the linear model was preferred for computing the PAI. For ODD, families randomised to their PAI-predicted optimal intervention showed a treatment advantage of d = 0.54, 95% CI [0.17, 0.97]; for ADHD, the advantage was negligible at d = 0.35, 95% CI [-0.01, 0.78]. For children with conduct problems, it may be helpful if the PAI includes the treatment moderators single parent status and ODD baseline symptoms when providing personalised treatment recommendations for the selection of behavioural versus nondirective parent training. TRIAL REGISTRATION: The study was registered prospectively with ClinicalTrials.gov (Identifier NCT01350986).

Effects of Computer-Assisted Social Skills Training in Children With Disruptive Behavior Disorders: A Randomized Controlled Trial

OBJECTIVE

Computer-assisted child-focused interventions are expected to improve efficiency and personalization of therapist-led treatments for children and adolescents. However, therapist-led, outpatient interventions using computer assistance are lacking for children with oppositional defiant disorder (ODD) or conduct disorder (CD). The present randomized controlled trial examined the efficacy of individualized computer-assisted social skills training for children with aggressive behavior compared to a resource activation intervention.

METHOD

A total of 100 children aged 6-12 years with a diagnosis of ODD/CD and peer-related aggression were randomly (1:1) assigned to either individually delivered computer-assisted social skills training (ScouT) or an individually delivered supportive resource activation treatment (STARK). The primary outcome was parent-rated peer-related aggression, assessed with the respective scale of the Questionnaire for Aggressive Behavior of Children (FAVK) and measured at pre-assessment and after the 16-week intervention (post-assessment). Further parent-, self-, teacher- and/or clinician-rated outcomes included ODD and CD symptoms, a wide range of behavioral and emotional symptoms, callous-unemotional traits, functional impairment, and quality of life.

RESULTS

After correcting for multiple testing, analyses of covariance comparing the efficacy of ScouT to the efficacy of STARK yielded small to moderate treatment effects in favor of the ScouT condition regarding parent-rated peer-related aggression (primary outcome; d = -0.64, 95% CI = -1.05, -0.24), parent-rated callous and uncaring traits, and parent-rated quality of life. However, the analyses did not reveal any significant effects for self- or teacher-rated peer-related aggression assessed with the respective scale of the FAVK (self-report: d = -0.21, 95% CI = -0.69, 0.29; teacher rating: d = -0.17, 95% CI = -0.56, 0.22). Moreover, after controlling for multiple comparisons, no significant effects emerged for the following: parent-, self-, and teacher-rated adult-related aggression; parent-, self-, teacher-, and clinician-rated ODD and CD symptoms; parent-, self-, and teacher-rated emotional and behavioral symptoms; and parent-rated functional impairment.

CONCLUSION

According to parent ratings, school-age children with disruptive behavior disorders and peer-related aggression seem to benefit more from individualized, computer-assisted social skills training than from resource activation treatment. However, this conclusion is limited by the missing effects on the clinician-, self-, and teacher-rated measures.

CLINICAL TRIAL REGISTRATION INFORMATION

Treatment of Children With Peer Related Aggressive Behavior (ScouT); https://clinicaltrials.gov/; NCT02143427.

Simulation study on LDL cholesterol target attainment, ASCVD events, and treatment cost of bempedoic acid in a representative German cohort of high- and very-high-CV risk patients

Background

The LDL cholesterol (LDL-C) treatment goals recommended by the 2019 ESC/EAS guidelines are only achieved in a minority of patients. For patients above goal despite statins and ezetimibe, additional LDL-C lowering can be achieved by treatment with bempedoic acid (BA) or PCSK9 inhibitors (PCSK9i).

Purpose

Simulation of LDL-C target attainment with BA as additional lipid-lowering medication in a representative cohort of German outpatients at high or very-high cardiovascular (CV) risk, calculation of the number of prevented atherosclerotic cardiovascular disease (ASCVD) events and budget impact.

Methods

Data were obtained from IQVIA™ Disease Analyzer database containing a representative sample of German outpatients. We selected patients with high or very-high CV risk (based on ESC/EAS guidelines), diagnosed hypercholesterolaemia and treatment with lipid-lowering medication. In patients with uncontrolled LDL-C, sequentially adding ezetimibe and BA was simulated using a Monte Carlo approach. Drug costs to control LDL-C by adding BA vs. PCSK9i were calculated based on current pricing in Germany. Considered were a scenario without BA and one with BA, in which BA was replaced by PCSK9i if LDL-C was still not controlled. The number of prevented events was calculated based on simulated LDL-C reduction.

Results

105,577 patients met the inclusion criteria and entered the simulation model. 76,900 patients had very-high and 28,677 high CV risk. The baseline characteristics are depicted in Table 1. Only a minority of total patients (11.2%) achieved their risk-based LDL-C goal. Simulation of the sequential addition of ezetimibe to statins resulted in controlled LDL-C in 33.1% of total patients. Simulated addition of BA in patients with uncontrolled LDL-C despite statin and ezetimibe increased the percentage of controlled patients to 61.9% of total. The proportion of patients achieving LDL-C goals was higher in high- compared to very-high risk patients (Figure 1). Treatment with BA reduced the need for PCSK9i in patients on statin and ezetimibe from 66.6% to 37.8%. The considered scenario resulted in an anticipated reduction of drug costs by 35.9% per year on stable lipid-lowering medication. This effect was more pronounced in high-risk compared to very-high-risk patients (cost reductions of 40.6% and 34.4%, respectively). In this simulation model, the BA/PCSK9i strategy is projected to prevent 6,148 ASCVD events annually per 1 million patients on top of statin+ezetimibe, whereas LDL-C target achievement with PCSK9i alone would prevent 7,939 events.

Conclusions

A considerable larger proportion of high- and very-high-risk patients can achieve guideline-recommended LDL-C targets with escalated lipid-lowering medication. BA is projected to substantially decrease the need for PCSK9i treatment to achieve LDL-C targets which reduces drug costs compared to PCSK9i. LDL-C target attainment is projected to markedly reduce ASCVD events.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Deutschland GmbH

Treatment components in behavioral versus nondirective telephone-assisted self-help interventions for parents of children with externalizing behavior problems

BACKGROUND

The aim of this study was to analyze treatment differentiation in a behavioral and a nondirective telephone-assisted self-help intervention for parents of children with externalizing behavior problems, including the development and evaluation of a rating scale.

METHODS

In a randomized controlled trial, 149 parents of children aged 4-11 years with externalizing behavior problems were allocated to a behavioral or a nondirective guided self-help intervention. Parents in both conditions received eight self-help booklets and ten telephone consultations. To analyze the content of the interventions, we developed the Therapist Intervention Scale (TIS). In order to evaluate the scale and analyze treatment differentiation, parent booklets and recorded telephone consultations were rated.

RESULTS

Item selection and scale development were based on predefined psychometric criteria. The subscales Guidance & Structures and Relationship & Emotions were developed based on exploratory factor analyses. Interrater reliability and internal consistency were found to be acceptable to excellent. Analyses of construct validity demonstrated positive correlations for corresponding and negative correlations for non-corresponding subscales of therapist ratings. Therapists and booklets in the behavioral intervention showed higher scores on the subscale Guidance & Structures, while therapists and booklets in the nondirective intervention showed higher scores on the subscale Relationship & Emotions.

CONCLUSION

The analyses of the TIS support its reliability and validity. The subscale Guidance & Structures contains mainly cognitive-behavioral treatment components, while the subscale Relationship & Emotions contains mainly nondirective treatment components. The implemented telephone-assisted self-help interventions demonstrated distinct treatment profiles which match their intended therapeutic approaches.

Affective dysregulation in childhood - optimizing prevention and treatment: protocol of three randomized controlled trials in the ADOPT study

BACKGROUND

The terms affective dysregulation (AD) and irritability describe transdiagnostic dimensions and are characterized by an excessive reactivity to negative emotional stimuli with an affective (anger) and a behavioral component (aggression). Due to early onset, high prevalence and persistence, as well as developmental comorbidity, AD in childhood is one of the most psychosocially impairing and cost-intensive mental health conditions. AD is especially prevalent in children in the youth welfare service. Despite continuous research, there remains a substantial need for diagnostic approaches and optimization of individualized treatment strategies in order to improve outcomes and reduce the subjective and economic burden.

METHODS

The ADOPT (Affective Dysregulation - Optimizing Prevention and Treatment) Consortium integrates internationally established, highly experienced and interdisciplinary research groups. The work program encompasses (a) epidemiology, including prevalence of symptoms and disorders, (b) development and evaluation of screening and assessment tools, (c) stepped care approaches for clinically useful personalized medicine, (d) evaluation of an easily accessible and cost-effective online intervention as indicated prevention (treatment effects, moderation/mediation analysis), and (e) evaluation of an intensive personalized modular outpatient treatment in a cohort of children with AD who live with their parents and in a cohort of children with AD who live in out-of-home care (treatment effects, moderation/mediation analysis).

DISCUSSION

The results will lead to significant recommendations for improving treatment within routine clinical care in two cohorts of children with AD and coexisting conditions, especially oppositional-defiant disorder, conduct disorder and disruptive mood dysregulation disorder.

TRIAL REGISTRATION

Trial registration ADOPT Online: German Clinical Trials Register (DRKS) DRKS00014963 . Registered 27 June 2018. Trial registration ADOPT Treatment: German Clinical Trials Register (DRKS) DRKS00013317 . Registered 27 September 2018. Trial registration ADOPT Institution: German Clinical Trials Register (DRKS) DRKS00014581 . Registered 04 July 2018.

Sequential treatment of ADHD in mother and child (AIMAC study): importance of the treatment phases for intervention success in a randomized trial

BACKGROUND

The efficacy of parent-child training (PCT) regarding child symptoms may be reduced if the mother has attention-deficit/hyperactivity disorder (ADHD). The AIMAC study (ADHD in Mothers and Children) aimed to compensate for the deteriorating effect of parental psychopathology by treating the mother (Step 1) before the beginning of PCT (Step 2). This secondary analysis was particularly concerned with the additional effect of the Step 2 PCT on child symptoms after the Step 1 treatment.

METHODS

The analysis included 143 mothers and children (aged 6-12 years) both diagnosed with ADHD. The study design was a two-stage, two-arm parallel group trial (Step 1 treatment group [TG]: intensive treatment of the mother including psychotherapy and pharmacotherapy; Step 1 control group [CG]: supportive counseling only for mother; Step 2 TG and CG: PCT). Single- and multi-group analyses with piecewise linear latent growth curve models were applied to test for the effects of group and phase. Child symptoms (e.g., ADHD symptoms, disruptive behavior) were rated by three informants (blinded clinician, mother, teacher).

RESULTS

Children in the TG showed a stronger improvement of their disruptive behavior as rated by mothers than those in the CG during Step 1 (Step 1: TG vs. CG). In the CG, according to reports of the blinded clinician and the mother, the reduction of children's disruptive behavior was stronger during Step 2 than during Step 1 (CG: Step 1 vs. Step 2). In the TG, improvement of child outcome did not differ across treatment steps (TG: Step 1 vs. Step 2).

CONCLUSIONS

Intensive treatment of the mother including pharmacotherapy and psychotherapy may have small positive effects on the child's disruptive behavior. PCT may be a valid treatment option for children with ADHD regarding disruptive behavior, even if mothers are not intensively treated beforehand.

TRIAL REGISTRATION

ISRCTN registry ISRCTN73911400 . Registered 29 March 2007.

Child-based treatment of oppositional defiant disorder: mediating effects on parental depression, anxiety and stress

Previous research has shown that child-oppositional defiant disorder (ODD) and conduct disorders (CD) are associated with parental symptoms of depression, anxiety and/or stress, probably in a bidirectional relationship with mutual influences. It is, therefore, reasonable to assume that in child-centered treatment, a decrease in child-oppositional behavior problems constitutes (at least in part) a mechanism of change for a subsequent reduction in parental psychopathology. The aim of the present study (Clinical trials.gov Identifier: NCT01406067) was to examine whether the reduction in ODD symptoms due to child-based cognitive behavioral treatment (CBT) led to a reduction in parental depression, anxiety and stress. Eighty-one boys (age 6-12 years) with a diagnosis of ODD/CD were randomized either to a cognitive behavioral intervention group or an educational play group (acting as control group). Mediation analyses were conducted using path analysis. The stronger reduction in child ODD symptoms in the CBT group compared to the control group led to a decrease in parental depression and stress, as indicated by significant indirect effects (ab = 0.07 and ab = 0.08, p < 0.05). The proposed model for mechanisms of change was, therefore, confirmed for two of the three outcome parameters. Parental psychopathology and stress can be modified by child-centered CBT. The preceding reduction in ODD symptoms acts as a mediator for at least some of the changes in parental depression and stress. However, due to some limitations of the study, other possible explanations for the results found cannot be completely ruled out and are, therefore, discussed.

Social skills training and play group intervention for children with oppositional-defiant disorders/conduct disorder: Mediating mechanisms in a head-to-head comparison

Objective: Social-cognitive information processing, social skills, and social interactions are problem-maintaining variables for aggressive behavior in children. We hypothesized that these factors may be possible mediators of the mechanism of change in the child-centered treatment of conduct disorders (CDs). The aim of the present study (Clinical trials.gov Identifier: NCT01406067) was to examine putative mechanisms of change for the decrease in oppositional-defiant behavior resulting from child-centered treatment of patients with oppositional-defiant disorder (ODD) or CD. Method: 91 children (age 6-12 years) with ODD/CD were randomized to receive either social skills training or to a resource activating play group. Mediator analyses were conducted using path analyses. Results: The assumed mediating effects were not significant. However, alternative models with the putative mediators and outcome in reversed positions showed significant indirect effects of the oppositional-defiant symptoms as mediator for the decrease of disturbance of social-information processing, social skills, and social interactions. Conclusions: The proposed model for mechanisms of change could not be confirmed, with the results pointing to a reversed causality. Variables other than those hypothesized must be responsible for mediating the effects of the intervention on child oppositional-defiant behavior. Possible mechanisms of change were discussed.

Dysfunktionale Attributionen von Eltern und ihre Bedeutung für ihr Erziehungsverhalten und für expansives Problemverhalten von Kindern

Zusammenfassung. Theoretischer Hintergrund: Dysfunktionale elterliche Attributionen bei kindlichem Fehlverhalten werden als wichtiger Einflussfaktor für ungünstiges Erziehungsverhalten und assoziierte kindliche expansive Verhaltensauffälligkeiten diskutiert. Fragestellung: In einer Stichprobe von Kindern mit externalisierenden Verhaltensstörungen wurden nach einer psychometrischen Überprüfung des Fragebogens zur Erfassung dysfunktionaler elterlicher Attributionen (FDEA) die Zusammenhänge der elterlichen Attributionen mit expansiven Verhaltensproblemen und erziehungsbezogenen Maßen analysiert. Methode: Neben internen Konsistenzanalysen erfolgten eine Überprüfung der Faktorenstruktur sowie korrelative Analysen. Ergebnisse: Das angenommene 2-Faktoren-Modell konnte mit einer guten bis befriedigenden internen Konsistenz bestätigt werden. Dysfunktionale Attributionen zeigten Zusammenhänge mit der expansiven Symptomatik sowie mit erziehungsbezogenen Variablen. Schlussfolgerung: Bei der Erforschung expansiver Verhaltensauffälligkeiten und ungünstigen Erziehungsverhaltens sollten dysfunktionale elterliche Attributionen stärker berücksichtigt werden. Sie können mittels des FDEA reliabel und valide erhoben werden.

Phenotypic heterogeneity in aneuploid multiple myeloma indicates pre-B cell involvement

The expression of early and mature B cell markers, surface beta 2-microglobulin (B2M) and cytoplasmic immunoglobulin (clg) by aneuploid tumor cells in bone marrow aspirates from 44 patients with multiple myeloma was evaluated by correlated DNA immunofluorescence flow cytometry. Myeloma tumor cells of almost 90% of the patients contained monoclonal clg and expressed the mature plasma cell antigen R1-3 as well as surface B2M; common acute lymphoblastic leukemia antigen (CALLA) was present in 55%, B2 in 17%, and B4 in 23% of samples studied. Coexpression of CALLA and clg in 46% of all patients identified a novel myeloma phenotype without known counterpart in the normal differentiation of B cells. CALLA and clg were independently expressed and gave rise to CALLA+/clg-, CALLA+/clg+, and CALLA-/clg+ cells. The association of CALLA and mature plasma cell markers may define discrete stages of neoplastic plasma cell differentiation.

Characterization of the chromatin acceptor sites for the avian oviduct progesterone receptor using monoclonal antibodies

Monoclonal antibodies (MAb) against the chromatin acceptor sites for the avian oviduct progesterone receptor were prepared with highly purified hen oviduct acceptor proteins reconstituted to hen DNA. Addition of the MAbs to a cell-free assay blocked progesterone receptor from chick oviduct (PRov) binding to native-like acceptor sites on nucleoacidic protein (NAP) representing a partially deproteinized chromatin, which has been shown to be enriched in these binding sites. However, the antibodies do not block PRov binding to pure DNA, nor do they affect the receptor itself. Estrogen receptor binding to NAP was not inhibited, supporting a receptor specificity of the PRov acceptor sites as reported previously from direct competition studies. These data support earlier studies showing that (1) the reconstituted PRov acceptor sites resemble the native sites, (2) the acceptor sites are receptor specific, and (3) the PRov binding sites of NAP are different from those of pure DNA. While some animal-species specificity in the PRov binding inhibition was observed, no tissue specificity was seen. Direct binding of the antibodies to native acceptor sites was demonstrated in an enzyme-linked immunosorbent assay (ELISA) system. The antibodies showed little recognition of free acceptor protein or DNA alone, indicating specificity for the protein-DNA complex. A partial evolutionary conservation of the nuclear acceptor sites for PRov was shown by the fact that about 50% of the inhibition seen with hen NAP was obtained with NAPs from several other species, and this partial cross-reactivity of the MAbs with the same NAPs from other animal species was also seen in the ELISA.

Monoclonal antibodies recognizing the nuclear binding sites of the avian oviduct progesterone receptor

Monoclonal antibodies which block the binding of the avian oviduct progesterone receptor (PR) to nuclear acceptor sites have been prepared. We have previously shown that such acceptor sites consist of complexes of specific nonhistone proteins and DNA. The antigen was a reconstituted, enriched nuclear site for avian oviduct PR formed by reannealing a partially purified acceptor protein to pure hen DNA to reconstitute native-like acceptor sites. These reconstituted acceptor sites were then partially digested with deoxyribonuclease I and injected into BALB/c mice. The spleen cells were fused with NS-1 mouse myeloma cells. Hybridomas were then grown and tested for the ability of their culture media to 1) inhibit PR binding to avian oviduct nucleoacidic protein (NAP) which contains the native-like acceptor sites, but 2) to not inhibit PR binding to pure hen DNA. Three hybridoma clones produced ascites fluids which inhibited PR binding to intact oviduct chromatin and NAP but not to pure hen DNA. Control ascites fluids, prepared against other protein antigens, showed no inhibition of PR binding. The three positive ascites fluids contained low concentrations of immunoglobulin (0.3-0.5 mg/ml). The antibodies did not affect the stability of the receptor and did not interact with PR when analyzed by sucrose density gradient sedimentation. Direct binding of the antibodies to the NAP is shown by an enzyme-linked immunosorbent assay. The monoclonal antibodies display a partial species specificity with regard to the source of NAP in that PR binding to hen oviduct NAP was inhibited by greater than 90%, while PR binding to human uterine NAP was inhibited less than 40% by the antibodies. Further characterization of these candidate antiacceptor site monoclonal antibodies with regard to tissue, species, and steroid receptor specificities are underway.

Role of intracisternal A-particles and of RNA molecules in plasmacytoma-associated immunodeficiency

A subcellular fraction from murine plasmacytoma cells was shown to suppress the primary antibody response when injected into normal mice. The active subcellular fraction copurified with intracisternal A-particles. The RNA extracted from subcellular fractions enriched in A-particles was also immunosuppressive. This activity was due to a population of RNA molecules that contained polyadenylic acid. Upon fractionation on a sucrose gradient, two populations of immunosuppressive RNA were obtained with sedimentation velocities of 12 to 18S and 40 to 50S. The 40 to 50S RNA was shown to be a thermolabile aggregate of molecules that contained the 12 to 18S RNA molecules. Plasmacytoma-derived material with similar physicochemical characteristics had previously been shown to induce in normal mouse lymphocytes surface immunoglobulins with the plasmacytoma idiotype, supporting the possibility that one of the mechanisms responsible for the development of immunological deficiency is the change of surface immunoglobulins of nonmalignant B-cells.