Empirically supported comprehensive treatments for young children with autism

Aplastic anemia can be either acquired or congenital. The paradigm for the congenital form is Fanconi's anemia (FA). FA is an autosomal recessive, genetic syndrome characterized by progressive bone marrow failure, developmental abnormalities, and a predisposition to malignancy. The clinical manifestations of FA are heterogeneous, but one common outcome in the majority of patients is the development of life-threatening hematologic disease. FA is thought to affect the hematopoietic stem cell, and the hematologic consequences of FA can be effectively treated by complete replacement of patient stem cells by those from a histocompatible donor. Unfortunately, allogeneic stem cell transplantation is currently limited to patients with an unaffected matched sibling donor. Transplantation from alternative donors, while successful in selected cases, is associated with a high risk of graft failure and must be carefully considered in terms of risk and benefit for each individual. For FA patients lacking an appropriate donor, new therapies need to be devised. This review summarizes both the scientific rationale and the progress of gene therapy strategies aimed at correcting the hematopoietic defect of FA.     

Empirically supported individual and group psychological treatments for adult mental disorders.

The experimental literature on individual and group psychological treatments for adult disorders is reviewed. For each of the 11 disorders or problems covered, treatments that fall into the following categories, as defined by D. L. Chambless and S. D. Hollon (1998), are identified: efficacious and specific, efficacious, and possibly efficacious. Behavioral and cognitive–behavioral treatments dominate the lists, especially in the anxiety disorders, with notable exceptions. Reasons for the hegemony of the behavioral and cognitive modalities are discussed, and some limitations of the empirically supported treatment concept are addressed. Continued research is recommended on Aptitude?×?Treatment interactions, cost–benefit ratios, and generalization of treatments to a variety of patient populations, therapists, and treatment settings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Empirically supported treatments: Implications for training.

This article discusses the role of empirically supported treatments (ESTs) in the training of clinical psychologists. Training in ESTs can be integrated in ways that vary depending on the level of training and setting. Predoctoral programs, internships, postdoctoral programs, and continuing education are discussed in regard to special challenges and sequencing of training. A preliminary set of guidelines for training in ESTs is suggested. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Empirically supported treatments in psychology: Implications for Canadian professional psychology.

Examines several interconnected efforts to develop evidence-based practice in professional psychology. We first review the American Psychological Association (APA) Division 12 (Clinical Psychology) Task Force on the Promotion and Dissemination of Psychological Procedures' development of criteria and listings for empirically supported psychological treatments. Next, we present related efforts to develop procedures to identify treatments that have established efficacy and to develop practice guidelines. The possible impact of these initiatives on Canadian professional psychology in the domains of training, credentialing, practice, and research are then examined. Finally, we present recommendations for steps that should be taken by Canadian psychology organizations to respond to these initiatives in order to ensure that psychological practice in Canada is optimally supported by scientific evidence. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Empirically supported treatments and comorbid psychopathology: Spelunking Plato's cave.

Presents two case examples of diagnostic ambiguity and examines the empirical literature to identify appropriate empirically supported treatments (ESTs). The author contends that the examples outlined show the discontinuity between clients with comorbid psychopathology and ESTs. He suggests two agendas for future research and practice: (1) the inevitable limitations of efficacy studies do not excuse clinicians from ignoring scientific evidence. The expensive tradeoff of client heterogeneity for experimental control and statistical power is the cost of keeping the discipline grounded in science and (2) to practice maximally affect practice, researchers need to incorporate more comorbid psychopathology. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Peer social status of children with anxiety disorders.

The peer social status of 6–13-year-old children with anxiety disorders was investigated. Sixteen children who met Diagnostic and Statistical Manual of Mental Disorders (DSM-III) criteria for anxiety disorders were compared with 26 children with conduct disorders and 45 nonreferred children. Anxiety-disorder children were liked significantly less than normal children, but anxious and conduct-disorder children did not differ from one another. The conduct-disorder group received more "like-least"" and "fight-most"" nominations than the anxious and nonreferred groups, which did not differ. Furthermore, the anxious group received the lowest social-impact scores (total like-most and like-least nominations) of any group and were most likely to fall in the socially neglected category of peer status. The lack of popularity of children with anxiety disorders may be limited to those with concurrent depression. Overall, these findings indicate that childhood anxiety disorders, at least when they coexist with depression, are associated with diminished peer popularity. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Empirically supported treatments for panic disorder: Costs, benefits, and stepped care.

Treatment outcome findings suggest that cognitive-behavioral therapy (CBT) and pharmacotherapy offer similar short-term treatment gains for panic disorder and that CBT may afford more optimal maintenance of treatment gains without the need for ongoing treatment. However, efficacy is not the only consideration for patients, and because of limited health care resources, evaluation of the cost-benefit ratio of these treatments is important. In this article, the authors review estimates of the relative efficacy, acceptability, tolerability, and costs of these treatments; empirically examine the costs and outcome of cognitive-behavioral and pharmacologic interventions as they are delivered in an outpatient clinic specializing in these treatments; and comment on how these data inform a stepped care model of treatment. Analysis of the "services" data indicated that CBT was at least equal to pharmacotherapy in terms of pretreatment severity and acute treatment outcome and that CBT is an especially cost-effective treatment option. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Empirically supported treatments: Too little, too late: A commentary.

The impact on Canadian professional psychological treatment practices of the American Psychological Association's Division 12 (Clinical Psychology) Task Force's development of criteria and listings for empirically supported psychological treatments, along with other industrial efforts to standardize the identification of treatments with established efficacy is described in the article by J. Hunsley et al (see record 1999-01869-001). D. R. Evans proposes that the evidence-based movement is too little, in that considerably more, and much more complex evidence for what professional psychologists do is required. It is too late, in that both in Canada and the US professional psychologists have suffered considerable setbacks in both the economic and popularity domains. There is a broad range of treatment proposals professional psychologists make to their clients daily, which are fraught with a lack of research backing. There is a vicious circle in that unless evidence-based practices become the norm, and, hence, the stuff of media, it is difficult to convince new and even some old practitioners to adopt them. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Empirically supported treatments or type I errors? Problems with the analysis of data from group-administered treatments.

When treatments are administered in groups, clients interact in ways that lead to violations of a key assumption of most statistical analyses-the assumption of independence of observations. The resulting dependencies, when not properly accounted for, can increase Type I errors dramatically. Of the 33 studies of group-administered treatment on the empirically supported treatments list, none appropriately analyzed their data. The current authors provide corrections that can be applied to improper analyses. After the corrections, only 12.4% to 68.2% of tests that were originally reported as significant remained significant, depending on what assumptions were made about how large the dependencies among observations really are. Of the 33 studies, 6-19 studies no longer had any significant results after correction. The authors end by providing recommendations for researchers planning group-administered treatment research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Pharmacologic treatment for children and adolescents with anxiety disorders

Pediatric anxiety disorders are common illnesses that, if left untreated, may induce academic, family, and interpersonal problems. Cognitive-behavioral techniques and other psychotherapeutic interventions may be adequate for the treatment of most anxiety disorders. For patients with severe symptoms or for whom psychotherapeutic approaches are not adequate, medications are indicated. Among the available medications, the SSRIs are currently the first choice; however, other medications, such as the benzodiazepines and the TCAs, may be used alone or sometimes in combination with the SSRIs. Caution with respect to medication interactions and side effects is indicated. In particular, long-term side effects in these medications have not been well studied.     

Empirically supported psychological treatments: A natural extension of the scientist–practitioner paradigm.

The impact on Canadian professional psychological treatment practices of the American Psychological Association's Division 12 (Clinical Psychology) Task Force's development of criteria and listings for empirically supported psychological treatments, along with other industrial efforts to standardize the identification of treatments with established efficacy is described in the article by J. Hunsley et al (see record 1999-01869-001). C. M. Morin voices comments on some aspects of the article which may need further thought. The reasons for, and utility of such a movement toward empirically supported treatment (ESTs) is investigated. The defining characteristics of an EST (from the Task Force's perspective) are subject for debate. Why have only 2 categories of ESTs (well established empirical support vs probably efficacious)? The implications of the adoption of EST-based systems will reverberate throughout training, practice, and public health policies. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Social anxiety in children with anxiety disorders: relation with social and emotional functioning

BACKGROUND: Oxygen radicals have been implicated as important mediators in the early pathogenesis of acute pancreatitis, but the mechanism by which they produce pancreatic tissue injury remains unclear. We have, therefore, investigated the effects of oxygen radicals on isolated rat pancreatic acinar cells as to the ultrastructure, cytosolic Ca2+ concentration and energy metabolism. METHODS: Acinar cells were exposed to an oxygen radical-generating system consisting of xanthine oxidase, hypoxanthine and chelated iron ions. Cell injury was assessed by LDH release and electron microscopy. Cytosolic Ca2+ levels and mitochondrial membrane potential were determined by flow cytometry; adenine nucleotide concentrations by HPLC. Mitochondrial dehydrogenase activity was measured by spectrophotometric assay. RESULTS: Oxygen radicals damaged the plasma membrane as shown by a 6-fold LDH increase in the incubation medium within 180 min. At the ultrastructural level, mitochondria were the most susceptible to oxidative stress. In correlation to the pronounced mitochondrial damage, the mitochondrial dehydrogenase activity declined by 70%, whereas the mitochondrial membrane potential was enhanced by 27% after 120 min. Together this may cause the 85% decrease in the ATP concentration and the corresponding increase in ADP/AMP observed in parallel. In addition, an immediate 26% increase in cytosolic Ca2+ was found, a change which could be inhibited by BAPTA, reducing cellular damage. CONCLUSION: Cytosolic Ca2+ synergizes with oxygen radicals causing alterations of the ultrastructure and energy metabolism of acinar cells which might contribute to the cellular changes found in early stages of acute pancreatitis.     

Evaluation of cognitive-behavioral group treatments for childhood anxiety disorders

Chromosome analysis of G-banded peripheral blood lymphocytes was performed on two groups of plutonium workers with 20-50% and >50% maximum permissible body burdens (MPBB) of plutonium from the British Nuclear Fuels plc (BNFL) facility at Sellafield, UK, 10 years after an earlier study had reported increases in both symmetrical and asymmetrical aberrations. For each plutonium exposure group there was a significant difference in frequencies of symmetrical aberrations between plutonium workers, workers with similar histories of exposure to mainly external gamma radiation but with little or no intakes of plutonium, and controls with negligible exposure (<50 mSv). In contrast, no significant differences for asymmetrical aberrations were found, and since these are short-lived, this suggests that recent exposure of mature lymphocytes was minimal. Frequencies of symmetrical aberrations had increased significantly since the earlier sampling time. Additional external radiation exposure was negligible in the plutonium worker groups over this period. These results are consistent with the hypothesis that hemopoietic precursor cells are being irradiated by internally deposited plutonium with subsequent selection resulting in only cells with symmetrical aberrations reaching the peripheral lymphocyte pool. After removal of aberrations involving only chromosomes 7 and/or 14, which are thought to arise in vivo during immunological development, the breakpoints involved in the aberrations were distributed randomly among the chromosomes according to length in all three groups of workers. Within the chromosomes the distribution between terminal, interstitial and centromeric regions for the plutonium workers did not conform to that expected, there being an excess in the terminal regions and a deficit in the interstitial regions.     

Panic and phobic anxiety: defining phenotypes for genetic studies

OBJECTIVE: With recent advances in molecular genetics, the rate-limiting step in identifying susceptibility genes for psychiatric disorders has become phenotype definition. The success of psychiatric genetics may require the development of a "genetic nosology" that can classify individuals in terms of the heritable aspects of psychopathology. The authors' aim is to begin to apply this analysis to the anxiety disorders, focusing on panic and phobic disorders. METHOD: Two parallel traditions of defining anxiety phenotypes are reviewed: the first, more closely identified with clinical psychiatry, has identified categorical diagnoses (e.g., panic disorder and social phobia). The other, more closely identified with psychological studies of personality development, has examined dimensional traits (e.g., neuroticism) and anxious temperament (e.g., behavioral inhibition). RESULTS: The authors suggest that a genetic nosology of panic and phobic disorders may incorporate features of both traditions and discuss strategies for optimizing genetic approaches to anxiety including 1) studying phenotypic extremes, 2) identifying biological trait markers, and 3) using animal models to identify candidate loci. CONCLUSIONS: An important dividend from the effort to define the boundaries of heritable phenotypes for genetic studies of anxiety may be a refinement of the nosology of anxiety disorders.     

Critique of Obler and Terwilliger's "Systematic desensitization with neurologically impaired children with phobic disorders."

Criticizes M. Obler and R. Terwilliger's (see pa, vol. 44:15121) study for (a) confounding of behavioral treatments, (b) unsystematic administration of primary and secondary reinforcers, (c) lack of clarity concerning the therapist's role, (d) absence of behaviorally based pre- and posttreatment measures, (e) inadequate and unsupported definition of awareness, and (f) the use of subjective and retrospective parental ratings. Alternative methodological procedures are suggested and the implications for behavioral research are noted. (25 ref.) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

From the lab to the clinic: Effectiveness of cognitive-behavioral treatments for anxiety disorders.

A controversy exists over whether results of randomized controlled trials of psychological treatment methods generalize to routine clinical practice. To examine the generalizability of cognitive-behavioral interventions for anxiety disorders, a meta-analysis of 11 effectiveness studies was conducted. Only studies that closely approximated real-world clinical practice were included in the present meta-analysis (e.g., studies were conducted in a nonuniversity setting, practitioners had regular caseloads, clients were not excluded if they had comorbid conditions). Cognitive-behavioral interventions were associated with significant improvement in anxiety symptoms at the end of treatment (dw = 1.35) and again at follow-up (dw = 1.14). On the basis of these results, it seems that cognitive-behavioral interventions for anxiety disorders generalize to real-world clinical practice. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Pilot study on the effectiveness of systematic desensitization with neurologically impaired children with phobic disorders.

A modified version of J. Wolpe's systematic desensitization therapy involving direct confrontation with the fear-inducing stimulus was attempted with 30 neurologically impaired children with phobic symptoms. 2 hypotheses were tested: (a) a nonverbal therapeutic technique not requiring motivation will produce successful symptom reduction for these Ss, and (b) awareness of therapeutic procedure is not necessary for successful results. Both hypotheses were confirmed. (23 ref.) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A multidimensional meta-analysis of treatments for depression, panic, and generalized anxiety disorder: An empirical examination of the status of empirically supported therapies.

The authors report a meta-analysis of high-quality studies published from 1990-1998 on the efficacy of manualized psychotherapies for depression, panic disorder, and generalized anxiety disorder (GAD) that bear on the clinical utility and external validity of empirically supported therapies. The results suggest that a substantial proportion of patients with panic improve and remain improved; that treatments for depression and GAD produce impressive short-term effects; that most patients in treatment for depression and GAD do not improve and remain improved at clinically meaningful follow-up intervals; and that screening procedures used in many studies raise questions about generalizability, particularly in light of a systematic relation across studies between exclusion rates and outcome. The data suggest the importance of reporting, in both clinical trials and meta-analyses, a range of outcome indices that provide a more comprehensive, multidimensional portrait of treatment effects and their generalizability. These include exclusion rates, percent improved, percent recovered, percent who remained improved or recovered at follow-up, percent seeking additional treatment at follow-up, and data on both completer and intent-to-treat samples. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A comparison of completers and noncompleters of exposure-based cognitive and behavioral treatment for phobic and anxiety disorders in youth.

This article examined sociodemographic and clinical characteristics of child treatment completers, and noncompleters who received exposure-based cognitive-behavioral treatment. A total of 137 children (46% girls) and their parents (predominantly Euro-American and Hispanic/Latino) participated in this study (106 completers, 31 noncompleters). The majority of noncompleters, received an average of 5 sessions. Findings were generally consistent with past research in terms of lack of differences between completers; and noncompleters. Results are discussed in the context of previous child attrition research and directions for future research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)