Adding Psychotherapy to Medication Treatment Improves Outcomes in Pediatric OCD

Source: NIMH

Youth with obsessive compulsive disorder (OCD) who are already taking antidepressant medication benefit by adding a type of psychotherapy called cognitive behavior therapy (CBT), according to an NIMH-funded study published September 21, 2011, in the Journal of the American Medical Association LCSW Continuing Education

Background

Several studies have shown that, among adults with OCD, a form of CBT involving controlled exposure to feared situations plus training that helps the person refrain from compulsions is effective both alone and in combination with antidepressant medication. However, few studies of this type of combination therapy have been conducted among children. In addition, many children with OCD tend to respond only partially to antidepressant medication. Studies have found that among adults who only partially respond to antidepressant medication, adding CBT can be effective. However, until now, there have been no studies testing this same approach in youth.

Martin Franklin Ph.D., of the University of Pennsylvania, Jennifer Freeman Ph.D., of Brown University, John March M.D.,MPH, of Duke University, and colleagues set out to determine whether CBT can effectively augment antidepressant treatment in children who partially respond to the medication. Among 124 children ages 7-17, they compared three treatment options:
Medication management only (MM), prescribed and managed by a physician. All patients were taking a type of antidepressant known as a selective serotonin reuptake inhibitor (SSRI).
MM plus Instructional CBT (I-CBT), a shorter, less intensive version of CBT administered by the prescribing physician.
MM plus CBT provided by a trained CBT therapist. The CBT included a type of therapy called exposure plus response prevention (ERP), in which children are exposed to feared situations and taught how to respond to the resulting anxiety without engaging in compulsions.

Results

After 12 weeks of treatment, nearly 69 percent of those receiving MM+CBT had responded to treatment, compared to 34 percent receiving MM+I-CBT and 30 percent receiving MM. Those receiving MM+CBT showed more improvement in all respects, compared to those receiving MM and MM+I-CBT.

Significance

The findings are consistent with other studies demonstrating that ERP is an effective treatment strategy for OCD, both alone and in combination with SSRIs. The researchers conclude that the full version of CBT with ERP should be widely disseminated as opposed to a brief version that may not be effective.

What’s next

The researchers were unsure why there was so little difference in treatment response between the MM group and the MM+I-CBT group. They reasoned that the I-CBT was generally ineffective because it was brief and less intensive than the CBT. It also did not include key treatment components that are central to the full CBT protocol, such as exposure practices during the treatment sessions themselves. Future efforts should focus on making the full CBT with ERP more widely available in community settings, they concluded.

Citation

Franklin ME, Sapyta J, Freeman JB, Khanna M, Compton S, Almirall D, Moore P, Choate-Summers M, Garcia A, Edson AL, Foa EB, March JS. Cognitive behavior therapy augmentation of pharmacotherapy in pediatric obsessive compulsive disorder: the Pediatric OCD Treatment Study (POTS II) randomized controlled trial. Journal of the American Medical Association. 21 Sept 2011.

Attention woes in kids with Tourette syndrome likely caused by co-occurring ADHD

Co-occurring attention deficit hyperactivity disorder (ADHD) may be at the root of attention problems in children with Tourette syndrome (TS), according to NIMH-funded researchers. Their findings also support the theory that children with TS develop different patterns of brain activity in order to function at the same level as children without TS. The study was published in the November 2010 issue of the Journal of the American Academy of Child & Adolescent Psychiatry. LCSW Continuing Education
Background
Tourette syndrome is a chronic neurological disorder associated with repetitive, involuntary movements and vocalizations called tics. Many with TS also experience neurobehavioral problems such as inattention, hyperactivity, and impulsivity—symptoms that overlap with ADHD. In fact, researchers estimate that between 50-90 percent of youth with TS also have ADHD.

To explore the role of co-occurring ADHD in TS, Denis Sukhodolsky, Ph.D., of the Yale Child Study Center, and colleagues studied 236 children, of which:

56 had TS only
64 had ADHD only
45 had TS+ADHD
71 had neither and served as a comparison group.
The researchers used well-known, standardized measures to evaluate the children's performance on tasks requiring:

Sustained attention and inhibitory control—Participants were shown various letters on a computer screen and told to press a button when they saw certain letters but not press the button when they saw a non-target letter.
Cognitive inhibition—Participants were shown an array of dots on sheets of paper and asked to name their color (red, green, blue) as quickly as possible. In related tasks, participants were shown pages with similarly arrayed words ("red," "green," "blue") printed in black ink or a mismatched color of ink (such as "red" printed in green ink) and asked to read the words as quickly as possible.
Fine motor control—Participants placed small pegs in a specially designed pegboard in 30-second trials using only their dominant hand, only their non-dominant hand, and both hands at the same time.
Visual-motor integration—Participants copied 24 geometric designs, presented in order of increasing difficulty.
Results of the Study
Children with TS+ADHD showed similar problems with sustained attention as children with ADHD only. However, unlike those with ADHD only, children with TS+ADHD performed at the same level as the comparison group on all other tasks.

Children with TS only performed at the same level as the comparison group in tasks involving response inhibition and visual-motor integration. They performed at a slightly lower level than comparison children on the fine motor control task. Girls with TS only scored higher than boys with TS only on fine motor control tasks using their dominant hands.

Significance
The study helps to identify brain functions specific to particular disorders and the mechanisms underlying these functions.

Similarities in performance between children with TS+ADHD and those with ADHD only suggest that co-occurring ADHD may underlie attention problems in children who have TS, according to the researchers.

The researchers also noted that the children with TS only didn't show impairment in response inhibition, lending support to a theory that such children develop compensatory brain mechanisms in an effort to control involuntary tics. Past imaging studies have shown that, during tasks involving response inhibition, children with TS have greater than normal activity in brain areas associated with cognitive control.

Differences in fine motor skills between girls and boys with TS may indicate differing developmental pathways and patterns of brain growth between the sexes. Because problems with fine motor control in childhood are associated with more severe tics in adulthood, the researchers highlighted this finding as an area for further study.

What's Next
Future studies may help advance the understanding of how TS arises and changes in brain growth and functioning that are associated with the disorder.

Reference
Sukhodolsky DG, Landeros-Weisenberger A, Scahill L, Leckman JF, Schultz RT. Neuropsychological functioning in children with Tourette syndrome with and without attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2010 Nov;49(11):1155-64.

Holiday Fire Safety Tips

Sanford, FL -Seminole County Fire Department (SCFD) joins efforts with the National Fire Protection Association (NFPA) and the U.S. Fire Administration (USFA) to provide Holiday Decorating Fire Safety Tips. Decorating homes and businesses is a long-standing tradition around the holiday season. Unfortunately, these same decorations may increase your chances of fire. Based on data from the NFPA and the USFA, an estimated 250 home fires involving Christmas trees and another 170 home fires involving holiday lights and other decorative lighting occur each year. Together, these fires resulted in 21 deaths and 43 injuries.

Following a few simple fire safety tips can keep the ever popular Christmas tree, electric lights, and candles from creating a tragedy. Help ensure that you have a fire safe holiday season.

Christmas Trees
What's a traditional Christmas morning scene without a beautifully decorated tree? If your household includes a natural tree in its festivities, take to heart the sales person's suggestion - “Keep the tree watered.”

Christmas trees account for hundreds of fires annually. Typically, shorts in electrical lights or open flames from candles, lighters or matches start tree fires. Well-watered trees are not a problem. A dry and neglected tree can be.

Selecting a Tree for the Holidays
Needles on fresh trees should be green and hard to pull back from the branches, and the needles should not break if the tree has been freshly cut. The trunk should be sticky to the touch. Old trees can be identified by bouncing the tree trunk on the ground. If many needles fall off, the tree has been cut for too long and, has probably dried out, and is a fire hazard.

Caring for Your Tree
Do not place your tree close to a heat source, including a fireplace or heat vent. The heat will dry out the tree, causing it to be more easily ignited by heat, flame or sparks. Be careful not to drop or flick cigarette ashes near a tree. Do not put your live tree up too early or leave it up for longer than two weeks. Keep the tree stand filled with water at all times.

Disposing of Your Tree
Never put tree branches or needles in a fireplace or wood-burning stove. When the tree becomes dry, discard it promptly. The best way to dispose of your tree is by taking it to a recycling center or having it hauled away by a community pick-up service.

Holiday Lights
Maintain Your Holiday Lights
Inspect holiday lights each year for frayed wires, bare spots, gaps in the insulation, broken or cracked sockets, and excessive kinking or wear before putting them up. Use only lighting listed by an approved testing laboratory.

Do Not Overload Electrical Outlets
Do not link more than three light strands, unless the directions indicate it is safe. Connect strings of lights to an extension cord before plugging the cord into the outlet. Make sure to periodically check the wires - they should not be warm to the touch.
LCSW Continuing Education

Candle Care
Avoid Using Lit Candles
If you do use lit candles, make sure they are in stable holders and place them where they cannot be easily knocked down. Never leave the house with candles burning.

Never Put Lit Candles on a Tree
Do not go near a Christmas tree with an open flame - candles, lighters or matches.

Seminole County Fire Department reminds all citizens to have a working and properly maintained smoke alarm in all sleeping areas and on each floor of your home.

Preface from...A Frontier Army Christmas

General Crook's Headquarters, Fort Fetterman (Harper's Weekly, December 17, 1876)

A number of significant military events have occurred during the Christmas season. George Washington's crossing of the Delaware River on the night of December 25, 1776, to attack unsuspecting Germans partaking in a little too much Christmas cheer became one of the most legendary events in history. Less known than Washington's holiday feat, the annual Christmas celebration at West Point in 1826 deteriorated into a mutinous "eggnog riot" involving more than a third of the corps of cadets. Following a decree that the holiday should be observed without alcohol, high-spirited Southern cadets (in particular) smuggled whiskey into the academy barracks and holiday festivities deteriorated into violence, including attempted murder. Cadet Jefferson Davis led the riot, while Cadet Robert E. Lee managed to remain aloof.

The Mexican War saw the sharp Christmas-day Battle of Bracito, which left sixty-three Mexicans dead. The victorious American troops, who suffered no deaths, celebrated Christmas night by throughly enjoying captured Mexican food, wine, and cigarillos. A generation later in 1864 General William Tecumseh Sherman sent a "Christmas card" in the form of a telegram to President Lincoln presenting the city of Savannah as a Christmas gift. The frontier army itself carried out several campaigns around the Christmas season, and the reality of bloodshed provided stark contrast to the usual joyous festivities. A dramatic example was the Indian survivors of the Wounded Knee Massacre, who were taken to a makeshift chapel hospital still decorated with Christmas finery.

As the army moved to foreign soil in more recent times, so did Christmastime conflicts. American-held Bastogne withstood a Christmas-day attack by the Germans in 1944. The Vietnam War had dragged on throughout many Christmases before President Nixon ordered the "Christmas bombing" of Hanoi and Haiphong in 1972, an effort which failed to produce victory. And you may recall Christmas 1991 and seeing the video of American soldiers bringing food to starving children in Somalia.

Clearly, Christmas is woven into the fabric of our military history. Nowhere was this history more charming, tragic, elegant, and memorable than in our own frontier army of 1865-1900. As you will see in A Frontier Army Christmas, these celebrations of Christmas were frequently dependent upon the whims of history and the fortunes of war.
Online MFT and LMFT Continuing Education http://www.aspirace.com

Lori A. Cox-Paul and Dr. James Wengert

Ten Tips for a Peaceful Holiday Season: Helping Kids Relax

From Patti Teel
Kids get pretty anxious over the holidays. It’s a time of excitement and wonder, and they often have a hard time relaxing, staying calm and sleeping well. Here are some tips to help your kids stay relaxed and on a healthy sleep schedule.
1. Don't overschedule your children. Cut back on the tasks and activities which are likely to overwhelm them. For example, avoid long trips to the mall with young children; short spurts of shopping will be more fun for everyone. Don't try to
change your child's temperament; accept that he or she may be naturally timid and soft-spoken, or boisterous and loud. An activity level that might be comfortable for one child could be overwhelming for another—even in the same family.
2. Have activity-based celebrations. For instance, spend time with children making cards, decorations, cookies and gifts. You may wish to let each child select one activity for the whole family to do over the holidays.
3. Have children stay physically active. Don't allow busy holiday schedules to crowd out active play time. Physical activity is one of the simplest and most effective ways to reduce stress and ensure that a child gets a good night’s sleep. Children
should have at least 30 minutes of moderate-intensity activity every day. (However, vigorous activities should not be done within several hours of bedtime because it raises the metabolic rate and may make it difficult for your child to relax.)
4. When possible, have your children play outdoors. Exposure to daytime sunlight helps children to sleep better at night.
5. Teach your children relaxation skills such as stretching, progressive relaxation, deep breathing and guided visualization. Relaxation can be a delightful form of play and it’s easy to incorporate the holidays in imaginative ways. For example, play a relaxing game of “Santa Says.” Direct children to stretch and relax by curling up like a snowball, to move their arms and legs slowly in and out like a snow angel, or to open their mouths widely to catch snowflakes.
6. Banish bedtime fears and help kids put worries to bed. Make a ceremony out of putting worries or fears away for the night. Have children pretend, or actually draw a picture of what’s bothering them. Fold, (or pretend to fold) the worry or fear
until it’s smaller and smaller. Then put it away in a box and lock it with a key. It’s often helpful for older children and teens to list their worries in a journal before putting them away for the night.
7. Make your home a sanctuary from the overstimulation of the outside world by making family “quiet time” a part of every evening.
• Limit total screen time, including computer games, video games and time spent watching television. Advertisements scandalously target children and the more they watch, the more they soak up the commercial messages of the season…instead of the real spirit of the holidays.
• Tell or read inspiring holiday stories.
• Sing and listen to soothing holiday music.
• Give each other a gentle massage.
8. Maintain the bedtime routine. While routines are likely to be thrown off during the holidays, it’s important to maintain a consistent bedtime, allowing plenty of time for a relaxed bedtime routine. Don't let holiday parties or activities interfere with your child getting a good night’s sleep.
9. Instill compassion and encourage generosity.
• Provide opportunities for your children to help others. Opportunities abound: have your child draw pictures and help bake and deliver food, encourage them to donate some or their clothes, toys or books; or regularly visit an elderly
person who needs companionship.
• Read or tell stories that emphasize giving.
• Perform simple rituals to symbolize your care for others. Light a candle as you and your children send your good wishes or say a prayer for those who are in need.
10. Instill appreciation and gratitude. It’s not possible to be upset and worried while feeling appreciative. Share good things that happened during your day and have your child do the same. They don't need to be major events; emphasize
actions that demonstrate the blessings of the season. It could be a hug, words of love, the sound of the birds in the morning or a beautiful snowfall. Depending on your beliefs, you may wish to incorporate prayers of appreciation and thankfulness.
LMFT and LCSW Continuing Education http://www.aspirace.com