The effects of child teacher relationship training on the children of focus: A pilot study.

Head Start teachers (n = 24) were assigned to either the experimental group or the active control group in this pilot study to determine the effects of child–teacher relationship training (CTRT) on 22 disadvantaged preschool children identified with behavioral problems. CTRT is based on the principles and procedures of child–parent relationship therapy (CPRT; Landreth & Bratton, 2006), a structured, time-limited approach that trains young children's caregivers to be active participants in an early mental health delivery system. Results indicate that children whose teachers participated in CTRT made statistically significant improvements in both externalizing behavior problems and total problems when compared with the active control group. Children in the CTRT group demonstrated a large treatment effect on their internalizing behavior problems compared with those in the active control group. The statistical, practical, and clinically significant results of this pilot study indicate that CTRT is a promising option for preschool children with clinically significant behavior problems. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Behavioral and cognitive treatments of geriatric insomnia.

Geriatric insomnia is a prevalent problem that has not received adequate controlled evaluation of psychological treatments. The present study evaluated behavioral and cognitive methods, relative to a wait-list control condition, for treating 27 elderly subjects (mean age?=?67 years) with sleep-maintenance insomnia. Both treatment methods, stimulus control and imagery training, produced significant improvement on the main outcome measure of awakening duration. Stimulus control yielded higher improvement rates than either imagery training or the control condition on awakening duration and total sleep-time measures. Sleep improvements were maintained by the two treatment methods at 3- and 12-month follow-ups. The results were corroborated by collateral ratings obtained from significant others. Subjective estimates of awakening duration and sleep latency correlated highly with objective measures recorded on an electromechanical timer. The findings suggest that geriatric insomnia can be effectively treated with psychological interventions and that behavioral procedures are more beneficial than cognitive procedures for sleep maintenance problems. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Relationship of severity of dementia to caregiving stressors.

In studies of individual differences and longitudinal changes in stress and coping among dementia caregivers, assessing severity of patient impairment is critically important. It is proposed that with the progression of dementia, cognitive impairment may steadily increase, but other stressful behavioral symptoms peak at various stages of dementia. Cross-sectional data from 49 caregiving families and longitudinal follow-up data from 48 families suggest that instrumental self-care deficits begin early in dementia, and basic self-care deficits increase with dementia severity, but that many distressing behavioral symptoms decrease in late dementia. Assessments of dementia patient severity should be multidimensional, and increases and decreases in various dementia patient stressors over time should be considered as factors influencing caregiver coping. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Attachment style and emotion regulation in dementia patients and their relation to caregiver burden

One hundred and sixty-eight patients with mid- to late-stage dementia and their caregivers participated in a study of the relation between patient emotional characteristics, dementia symptomatology, and caregiver burden. Measures included premorbid attachment style, premorbid emotion regulation style, and behavioral symptoms of dementia. The attachment patterns (secure, avoidant, ambivalent) of these elderly patients resembled those obtained in samples of younger individuals in terms of emotion regulation characteristics; however, the distribution of attachment styles was significantly different, with a lower proportion of ambivalently attached individuals in the present sample. In terms of the behavioral symptoms of dementia, ambivalent patients had more depression and anxiety than secure and avoidant patients; the latter patients experienced more activity disturbance than ambivalently attached individuals and were higher on paranoid symptomatology than securely attached persons. Caregivers of securely attached individuals experienced less total burden than did caregivers of both insecure groups. In regression analysis, attachment style accounted for the largest proportion of unique variance in the prediction of caregiver burden (8%); only 1 of 7 patient symptoms contributed a significant independent effect, namely depressed affect, which accounted for 4% of the variance.     

Treatment of sleep-maintenance insomnia in older adults: Sleep period reduction, sleep education, and modified stimulus control.

We evaluated a behavioral treatment package consisting of sleep period restriction, sleep education, and modified stimulus control in the treatment of sleep-maintenance insomnia in older adults. A multiple baseline design was used with 4 chronic insomniac subjects, ages 59, 65, 65, and 72. Sleep diaries and an objective behavioral measure of sleep were used to monitor improvement. Results revealed clinically significant reductions in time awake after sleep onset in 3 subjects, coincident with the initiation of treatment. These improvements were maintained at 2- and 6-month follow-ups. The 4th subject showed little improvement; however, a polysomnogram conducted on this subject at the end of the study revealed a fragmented sleep pattern secondary to periodic movements of sleep (nocturnal myoclonus). These encouraging but preliminary results call for further controlled evaluations of the efficacy of this behavioral treatment package for sleep-maintenance insomnia. The importance of conducting polysomnographic studies on elderly insomniacs is discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Behavioral assessment in Alzheimer's disease: Use of a 24-hr log.

Although behavioral problems are a central feature of Alzheimer's disease (AD), measurement of these behavioral problems has been limited in most studies to retrospective reports of the frequency of behaviors by caregivers. In the present study, 32 caregivers of AD patients completed detailed behavioral logs of their patients' adaptive and ineffective behaviors over a 48-hr period; these logs were then compared with more widely used instruments assessing patients' cognitive functioning, self-care, and behavioral problems. Results illustrate the nature of common behavioral problems in dementia, provide information on the time distribution of behavioral problems, and support the convergent and discriminant validity of one widely used measure of behavioral problems, the Memory and Behavior Problems Checklist. Potential clinical and research uses of the behavioral-log method are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A comparison of weight control and weight control plus body image therapy for obese men and women.

Participants were 65 obese men and women who were randomly assigned to either weight control or weight control plus cognitive–behavioral body image therapy. Both conditions showed clinically significant improvements in body image at posttreatment and 1-year follow-up. Adding body image therapy to weight control did not result in greater psychological improvements and did not result in better maintenance of body image change when participants regained weight after treatment. Weight loss and maintenance were equivalent between groups. Adding body image therapy did not improve or detract from weight loss. Although body image therapy has been shown to be effective in obese persons, it appears that a well-rounded cognitive–behavioral weight control program is effective as well. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Nonpharmacological interventions for insomnia in older adults: A meta-analysis of treatment efficacy.

The benefit of nonpharmacological interventions for insomnia in old age was investigated. A total of 13 single-outcome studies from 1966–1998 involving 388 patients (mean age exceeding 60 years, minimum age in sample, 50 years) were included in a meta-analysis of treatment efficacy. This analysis demonstrated that behavioral interventions produce improvements in sleep parameters of older insomniacs, measured in terms of sleep-onset latency, number of nocturnal awakenings, time awake after sleep onset, and total sleep time. Clinical improvements seen at posttreatment were maintained at followups (averaging 6 months). It is concluded that behavioral treatments produce significant and long-lasting improvements in the sleep pattern of older insomniacs. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treatment for agitation in dementia patients: A behavior management approach.

This article presents a standardized, social-learning-based, behavioral approach to the treatment of agitation in patients with dementia. It describes a multisite, randomized, controlled clinical trial designed to evaluate this approach and illustrates the use of this approach in 4 cases from 3 different sites. 41 patients with a diagnosis of probable or possible Alzheimer's disease (AD) participated. Treatment consisted of 8 weekly and 3 biweekly sessions for a total of 11 sessions over 16 weeks. Throughout treatment, therapists helped caregivers identify and modify "target" behaviors; behaviors associated with agitation that were distressing to the caregiver and/or patient. Videotapes provided didactic information and practical examples of problem-solving, and supplemental take-home reading materials were provided. Results from the case studies of a 71-yr-old man and 3 women, aged 55, 71, and 79 yrs, indicate that the structured behavioral approach appears successful in helping caregivers modify the agitated behaviors of patients with AD. These cases also illustrate the diversity of problems and the creativity needed by therapists, even with a structured approach, and the importance of a committed, involved caregiver. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Behavioral treatment of chronic insomnia in psychiatrically ill patients

BACKGROUND: Psychiatric patients often have residual intractable insomnia as a serious problem. METHOD: Forty-eight psychiatrically ill patients (DSM-IV diagnoses) who had failed to respond to medicinal treatment for chronic insomnia were referred for and completed behavioral therapy as an adjunct to the pharmacologic treatment of their insomnia. The behavioral treatments included structured sleep hygiene, progressive muscle relaxation, stimulus control, and sleep restriction. The treatment program was accomplished in 6 sessions over 2 months. Follow-up evaluations were completed at 2, 6, and 12 months from the beginning of the treatment program. The outcome of the treatment program was evaluated in terms of the change in (1) self-reported specific sleep parameters, (2) self-ratings of sleep-related day-time state, (3) self-rating of quality of sleep, (4) the use of sleep medication, and (5) the therapist's global rating of improvement. RESULTS: There was a statistically significant change from the baseline in all self-reported specific sleep parameters after 2 months that was sustained after 6 and 12 months. Sleep-related characteristics of daytime state showed statistically significant changes after 2 and 6 months that were maintained after 12 months. Sleep quality had a statistically significant change after 2 months, continued to improve statistically after 6 months, and was maximum after 12 months. Over half the patients (52.7%; 20 of 38) either reduced their sleep medication by half or stopped it completely. The therapist's global rating showed an improvement in 29.2% (N = 14) of patients after 2 months, 56.2% (N = 27) after 6 months, and 68.7% (N = 33) after 12 months. CONCLUSION: The use of concomitant behavioral and pharmacologic treatment of chronic insomnia in psychiatrically ill patients results in improving sleep and sleep-related state and reduces the risk of return of insomnia for 10 months after finishing active treatment.     

Predictors of the effect of cognitive behavioral therapy for chronic insomnia comorbid with breast cancer.

Prior studies have supported the efficacy of cognitive behavioral therapy (CBT) for insomnia comorbid with cancer. This article reports secondary analyses that were performed on one of these studies to investigate the predictive role of changes in dysfunctional beliefs about sleep, adherence to behavioral strategies, and some nonspecific factors on sleep changes assessed subjectively and objectively. Fifty-seven women with chronic insomnia comorbid with breast cancer received CBT for insomnia. At posttreatment, subjective sleep improvements were best predicted by higher initial levels of treatment expectancies, but also by decreased dysfunctional beliefs about sleep; the most consistent predictors of polysomnography (PSG) assessed sleep improvements were reduced dysfunctional beliefs about sleep and a higher avoidance of day napping. At 6-month follow-up, subjectively assessed sleep improvements were best predicted by adherence to behavioral strategies, whereas none of the predictors was significantly associated with PSG-assessed sleep improvements. This study gives some support to the importance of targeting erroneous beliefs about sleep and poor sleep habits in the treatment of cancer-related insomnia, but also to the importance of enhancing patients’ expectancies for improvement. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Comparative meta-analysis of behavioral interventions for insomnia and their efficacy in middle-aged adults and in older adults 55+ years of age.

Meta-analyses support the effectiveness of behavioral interventions for the treatment of insomnia, although few have systematically evaluated the relative efficacy of different treatment modalities or the relation of old age to sleep outcomes. In this meta-analysis of randomized controlled trials (k = 23), moderate to large effects of behavioral treatments on subjective sleep outcomes were found. Evaluation of the moderating effects of behavioral intervention type (i.e., cognitive-behavioral treatment, relaxation, behavioral only) revealed similar effects for the 3 treatment modalities. Both middle-aged adults and persons older than 55 years of age showed similar robust improvements in sleep quality, sleep latency, and wakening after sleep onset. A research agenda is recommended to examine the mechanisms of action of behavioral treatments on sleep with increased attention to the high prevalence of insomnia in older individuals. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Workshop report. National initiative to improve cancer survival information

The relationship between psychological morbidity in caregivers and depression in patients with dementia was examined using data collected on 193 patient-caregiver dyads attending a memory disorders clinic. Caregivers had high rates and levels of psychological morbidity which were associated with the severity of dementia (but neither the type nor duration), with the caregiver being a spouse and female and living with the person with dementia. A logistic regression analysis identified clinician-rated patient depression score and demanding problem behaviors as being independently and significantly associated with caregiver psychological morbidity. This new finding of a link between patient depression and caregiver psychological morbidity has implications for more focused treatment programs for both caregivers and patients.     

Sleep-related violence, injury, and REM sleep behavior disorder in Parkinson's disease

OBJECTIVE: To determine the occurrence of REM sleep behavior disorder (RBD) and sleep-related injury (SRI) in an outpatient PD practice. BACKGROUND: RBD is a frequent cause of SRI in older individuals. Although RBD is seen in PD, the association of SRI and RBD in PD has not been previously assessed. DESIGN/METHODS: Consecutive patients with PD and their caregivers were interviewed using a structured questionnaire assessing the presence of RBD and SRI. Patients fulfilling the International Classification of Sleep Disorders (ICSD) criteria for RBD were compared with non-RBD patients. In a separate analysis, patients with a prior SRI were compared to those without. RESULTS: Of the 61 patient/caregiver pairs, 15% (7 men and 2 women) met the clinical criteria for RBD. There were more episodes of SRI in the RBD group, with 33% causing injury to themselves or to their caregivers compared with 6% of the non-RBD group (chi(2) = 13, p = 0.005). In the second analysis, 15% (all men) patient/caregiver pairs reported SRI. Of these, 66% of the patients had behaviors resembling those seen in RBD, and 33% had recalled dream content. There is a significant association between SRI and RBD for dream-enacting sleep behaviors (Fisher's exact test, p = 0.0001). CONCLUSION: PD patients with SRI frequently have behavioral features of RBD. If RBD underlies most SRI, treatment with appropriate pharmacologic agents, such as clonazepam, may prevent future occurrences of SRI.     

An attempt to establish the experimental construct validity of cognitive and behavioral approaches to assertiveness training.

Cognitive, behavioral, and combined assertiveness treatments for dysfunctional job-interviewing skills were evaluated in a design that included high-demand and waiting list control treatments as well. Cognitive, behavioral, generalization, and control measures were used to determine the construct validity of hypothesized improvements. The cognitive treatment had no impact on any outcome variable. Some evidence to favor the behavioral treatment appeared on the cognitive assessment battery. However, given the failure of the behavioral treatment to register parallel changes on the behavioral battery, these cognitive improvements are not clearly attributable to behavioral theory. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cognitive-behavior therapy for late-life insomnia.

24 older adults with persistent psychophysiological insomnia were randomly assigned to an immediate or a delayed cognitive-behavioral intervention in a waiting-list control group design. Cognitive-behavior therapy consisted of an 8-wk group intervention aimed at changing maladaptive sleep habits and altering dysfunctional beliefs and attitudes about sleeplessness. Treatment was effective in reducing sleep latency, wake after sleep onset, and early morning awakening, and in increasing sleep efficiency. The magnitude of changes obtained on polysomnographic measures was smaller but in the same direction as that obtained on daily sleep diaries. Sleep improvements obtained by the immediate-treatment group were replicated with the delayed treatment condition. Therapeutic gains were well maintained at 3- and 12-mo follow-ups. Clinical validation of outcome was obtained through collateral ratings from the patients and their significant others. Findings indicate that late-life insomnia can be effectively treated with nonpharmacological interventions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Improving the quality of life of caregivers of persons with spinal cord injury: A randomized controlled trial.

Objective: To assess the efficacy of two psychosocial interventions for caregivers of older persons with spinal cord injury (SCI). Design: A multisite, three-group, randomized controlled trial comparing two active intervention conditions with each other and to an information-only control group. One hundred seventy-three caregiver and care-recipient dyads were randomly assigned to one of three conditions: a caregiver-only treatment condition in which caregivers received a multicomponent intervention based on their risk profile; a dual-target condition in which the caregiver intervention was complemented by a treatment targeting the care recipient, designed to address both caregiver and care recipient risk factors; and an information-only control condition in which the caregiver received standard printed information about caregiving, SCI, and aging. Outcome Measures: A multivariate outcome comprised of six indicators linked to the goals of the interventions was the primary outcome of the study. The multivariate outcome included measures of depressive symptoms, burden, social support and integration, self-care problems, and physical health symptoms. Results: At 12 months, caregivers in the dual-target condition had improved quality of life as measured by our multivariate outcome when compared to the control condition. Using the dyad as the unit of analysis, the dual-target condition was superior to both the control condition and the caregiver-only condition in our multivariate outcomes analysis. Dyads enrolled in the dual-target condition had significantly fewer health symptoms than control condition and caregiver-only condition participants and were less depressed when compared to participants in the caregiver-only condition. In follow-up analyses we found that a higher proportion of caregivers in the dual-target condition had clinically significant improvements in depression, burden, and health symptoms when compared with the caregiver-only condition. Conclusion: Caregivers are in need of and can benefit from interventions that help them manage the medical and functional limitations of the care recipient. Intervention strategies that target both the caregiver and care recipient are particularly promising strategies for improving the quality of life of caregivers. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Sleep Disturbances and Fatigue in Critically Ill Patients

Sleep disturbances and fatigue are significant problems for critically ill patients. Existing sleep disorders, underlying medical/surgical conditions, environmental factors, stress, medications, and other treatments all contribute to a patient's inability to sleep. Sleep disturbance and debilitating fatigue that originate during acute illness may continue months after discharge from intensive care units (ICUs). If these issues are unrecognized, lack of treatment may contribute to chronic sleep problems, impaired quality of life, and incomplete rehabilitation. A multidisciplinary approach that incorporates assessment of sleep disturbances and fatigue, environmental controls, appropriate pharmacologic management, and educational and behavioral interventions is necessary to reduce the impact of sleep disturbances and fatigue in ICU patients. Nurses are well positioned to identify issues in their own units that prevent effective patient sleep. This article will discuss the literature related to the occurrence, etiology, and risk factors of sleep disturbance and fatigue and describe assessment and management options in critically ill adults.