Neurobiologists find chronic stress in early life causes anxiety, aggression in adulthood

Cold Spring Harbor, NY -- In recent years, behavioral neuroscientists have debated the meaning and significance of a plethora of independently conducted experiments seeking to establish the impact of chronic, early-life stress upon behavior – both at the time that stress is experienced, and upon the same individuals later in life, during adulthood. These experiments, typically conducted in rodents, have on the one hand clearly indicated a link between certain kinds of early stress and dysfunction in the neuroendocrine system, particularly in the so-called HPA axis (hypothalamic-pituitary-adrenal), which regulates the endocrine glands and stress hormones including corticotropin and glucocorticoid. Yet the evidence is by no means unequivocal. Stress studies in rodents have also clearly identified a native capacity, stronger in some individuals than others, and seemingly weak or absent in still others, to bounce back from chronic early-life stress. Some rodents subjected to early life stress have no apparent behavioral consequences in adulthood – they are disposed neither to anxiety nor depression, the classic pathologies understood to be induced by stress in certain individuals. Today, a research team led by Associate Professor Grigori Enikolopov of Cold Spring Harbor Laboratory (CSHL) reports online in the journal PlOS One the results of experiments designed to assess the impacts of social stress upon adolescent mice, both at the time they are experienced and during adulthood. Involving many different kinds of stress tests and means of measuring their impacts, the research indicates that a "hostile environment in adolescence disturbs psychoemotional state and social behaviors of animals in adult life," the team says. The tests began with 1-month-old male mice – the equivalent, in human terms of adolescents -- each placed for 2 weeks in a cage shared with an aggressive adult male. The animals were separated by a transparent perforated partition, but the young males were exposed daily to short attacks by the adult males. This kind of chronic activity produces what neurobiologists call social-defeat stress in the young mice. These mice were then studied in a range of behavioral tests. "The tests assessed levels of anxiety, depression, and capacity to socialize and communicate with an unfamiliar partner," explains Enikolopov. These experiments showed that in young mice chronic social defeat induced high levels of anxiety helplessness, diminished social interaction, and diminished ability to communicate with other young animals. Stressed mice also had less new nerve-cell growth (neurogenesis) in a portion of the hippocampus known to be affected in depression: the subgranular zone of the dentate gyrus. Another group of young mice was also exposed to social stress, but was then placed for several weeks in an unstressful environment. Following this "rest" period, these mice, now old enough to be considered adults, were tested in the same manner as the other cohort. In this second, now-adult group, most of the behaviors impacted by social defeat returned to normal, as did neurogenesis, which retuned to a level seen in healthy controls. "This shows that young mice, exposed to adult aggressors, were largely resilient biologically and behaviorally," says Dr. Enikolopov. However, in these resilient mice, the team measured two latent impacts on behavior. As adults they were abnormally anxious, and were observed to be more aggressive in their social interactions. "The exposure to a hostile environment during their adolescence had profound consequences in terms of emotional state and the ability to interact with peers," Dr. Enikolopov observes. ### The research described in this release was supported by the Russian Foundation for Basic Research and by the National Institute of Mental Health. "Extended Effect of Chronic Social Defeat Stress in Childhood on Behaviors in Adulthood" appears online in PlOS One Tuesday, March 25, 2014. The authors are: Irina L. Kovalenko, Anna G. Galyamina, Dmitry A. Smagin, Tatyana V. Michurina, Natalia N. Kudryavtseva and Grigori Enikolopov. About Cold Spring Harbor Laboratory Founded in 1890, Cold Spring Harbor Laboratory (CSHL) has shaped contemporary biomedical research and education with programs in cancer, neuroscience, plant biology and quantitative biology. CSHL is ranked number one in the world by Thomson Reuters for the impact of its research in molecular biology and genetics. The Laboratory has been home to eight Nobel Prize winners. Today, CSHL's multidisciplinary scientific community is more than 600 researchers and technicians strong and its Meetings & Courses program hosts more than 12,000 scientists from around the world each year to its Long Island campus and its China center LCSW Continuing Education

CWRU study finds mending ruptures in client-therapist relationship during PTSD treatment has positive benefits

In order for prolonged exposure therapy, an evidence-based psychotherapy for PTSD, to reach its full potential, any misperceptions or ruptures in trust and communication between therapist and client need fixing, according to a new Case Western Reserve University study. The study, reported in the Journal of Consulting and Clinical Psychology online article, “Patterns of Therapeutic Alliance: Rupture-Repair Episodes in Prolonged Exposure for PTSD,” is among the first to examine how ruptures in the relationship between the therapist and client can damage a patient’s treatment outcome. An alliance rupture may occur when there is a break in the therapist-client bond. For example, ruptures in the therapeutic relationship may occur when therapeutic progress stalls, negative feelings arise between the therapist and client, or when the work in therapy becomes challenging PTSD - Clinical Practice Guideline for Management of Post Traumatic Stress “We want therapists to know that a rupture in the therapeutic relationship isn’t a bad thing, as long as the therapist tends to it,” said Stephanie Keller, one of the study’s researchers and a Case Western Reserve doctoral student in clinical psychology. “However, if the rupture is not repaired, then your patient may not do as well in treatment.” The research study included 116 people who experienced a traumatic event such as childhood sexual or physical abuse, physical assault, or combat exposure, and had a primary diagnosis of PTSD. Participants engaged in a 10-session treatment program called prolonged exposure (PE) therapy. To help therapists chart progress and examine the therapeutic relationship, each client assessed his or her own PTSD symptoms and perception of their relationship with the therapist during treatment. This helped researchers to identify those clients who experience no ruptures in the therapeutic relationship (a stable relationship), clients who experienced a rupture that was subsequently repaired, and those with ruptures that went unrepaired LCSW Continuing Education The first PE session outlined what would happen over the course of treatment to set specific goals. Exposure-based exercises began in the second session, which included exposure to anxiety-provoking situations that served as trauma-reminders and talking about their traumatic experiences. In this sample, 28 percent of patients experiences a repaired rupture and 18 percent experienced a rupture, or dip in the therapeutic relationship, that was never repaired. An unresolved rupture in the therapist-client relationship became a predictor for a poorer outcome in treatment, Keller said. She also said more research is needed to figure out why these alliance ruptures occur and how to best repair them. The research was funded through a National Institute of Mental Health PTSD research project, directed by Norah Feeny, Ph. D. from Case Western Reserve University and Lori A. Zoellner, Ph. D. from the University of Washington. Other researchers contributing to the project were lead investigator and Case Western Reserve alumna AnnaMaria Aguirre McLauglin, and Eric A. Youngstrom, of the University of North Carolina at Chapel Hill.

Smoking during pregnancy may increase risk of bipolar disorder in offspring

A study published today in the American Journal of Psychiatry suggests an association between smoking during pregnancy and increased risk for developing bipolar disorder (BD) in adult children. Researchers at the New York State Psychiatric Institute and the Department of Epidemiology at the Mailman School of Public Health at Columbia University, in collaboration with scientists at the Kaiser Permanente Division of Research in Oakland, California, evaluated offspring from a large cohort of pregnant women who participated in the Child Health and Development Study (CHDS) from 1959-1966. The study was based on 79 cases and 654 comparison subjects. Maternal smoking during pregnancy was associated with a twofold increased risk of BD in their offspring. Smoking during pregnancy is known to contribute to significant problems in utero and following birth, including low birth weight and attentional difficulties. This is the first study to suggest an association between prenatal tobacco exposure and BD, a serious psychiatric illness marked by significant shifts in mood that alternate between periods of depression and mania. Symptoms typically become noticeable in the late teens or early adulthood. "These findings underscore the value of ongoing public health education on the potentially debilitating, and largely preventable, consequences that smoking may have on children over time," said Alan Brown, MD, MPH, senior author and Professor of Clinical Psychiatry and Epidemiology at the New York State Psychiatric Institute, Columbia University and Mailman School of Public Health. The authors wrote: "Much of the psychopathology associated with prenatal tobacco exposure clusters around the 'externalizing' spectrum, which includes attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), conduct disorder (CD), and substance abuse disorders. Although not diagnostically classified along the externalizing spectrum, BD shares a number of clinical characteristics with these disorders, including inattention, irritability, loss of self-control, and proclivity to drug/alcohol use." In effect, children who were exposed to tobacco smoke in utero may exhibit some symptoms and behaviors that are found in BD. A previous study by Dr. Brown and colleagues found that flu virus in pregnant mothers was associated with a fourfold increased risk that their child would develop BD LCSW Continuing Education ### Funding for the study was provided by the National Institute of Mental Health and the National Institute on Child Health and Development. The authors declare no financial or other conflicts of interest. About Columbia University's Mailman School of Public Health Founded in 1922, Columbia University's Mailman School of Public Health pursues an agenda of research, education, and service to address the critical and complex public health issues affecting New Yorkers, the nation and the world. The Mailman School is the third largest recipient of NIH grants among schools of public health. Its over 450 multi-disciplinary faculty members work in more than 100 countries around the world, addressing such issues as preventing infectious and chronic diseases, environmental health, maternal and child health, health policy, climate change & health, and public health preparedness. It is a leader in public health education with over 1,300 graduate students from more than 40 nations pursuing a variety of master's and doctoral degree programs. The Mailman School is also home to numerous world-renowned research centers including the International Center for AIDS Care and Treatment Programs (ICAP), and the Center for Infection and Immunity. For more information, please visit http://www.mailman.columbia.edu Columbia University Department of Psychiatry & NYS Psychiatric Institute Columbia Psychiatry is ranked among the best departments and psychiatric research facilities in the nation and has contributed greatly to the understanding and treatment of psychiatric disorders. It is home to distinguished clinicians and researchers noted for their clinical and research advances in the diagnosis and treatment of depression, suicide, schizophrenia, BD and anxiety disorders, eating disorders, and childhood psychiatric disorders. Visit http://columbiapsychiatry.org/ for more information. Founded in 1959 by Jacob Yerushalmy at the University of California, Berkeley, The Child Health and Development Studies (CHDS) enrolled 15,000 families who were members of the Kaiser Permanente Medical Care Plan between 1959 and 1967. CHDS scientists discovered ways to make pregnancy safer for mothers and their babies. Now they are discovering connections between early life and cancer, heart disease, diabetes, fertility and mental illness. The National Institute of Child Health and Development of the National Institutes of Health makes this unique research possible through continuing support over 40 years. The CHDS is now a part of the Public Health Institute, Berkeley California. About the Kaiser Permanente Division of Research The Kaiser Permanente Division of Research conducts, publishes and disseminates epidemiologic and health services research to improve the health and medical care of Kaiser Permanente members and the society at large. It seeks to understand the determinants of illness and well-being and to improve the quality and cost-effectiveness of health care. Currently, the Division's 550+ staff are working on more than 350 ongoing research studies in behavioral health and aging, cancer, cardiovascular and metabolic conditions, health care delivery and policy, infectious diseases, vaccine safety and effectiveness, and women's and children's health.

Abusive parenting may have a biological basis

Research led by University of Oregon professor unveils a potential neurobiological trigger EUGENE, Ore. -- Parents who physically abuse their children appear to have a physiological response that subsequently triggers more harsh parenting when they attempt parenting in warm, positive ways, according to new research. Reporting in the quarterly journal Couple and Family Psychology: Research and Practice, a five-member team, led by Elizabeth A. Skowron, a professor in the Department of Counseling Psychology and Human Services in the University of Oregon College of Education, documented connections between the nervous system's ability to calm heart rate -- via electrocardiogram (ECG) measures of parasympathetic activation -- and the type of parenting mothers displayed during a laboratory interaction with their preschool child LCSW Continuing Education Studies of child maltreatment have consistently found that parents who physically abuse their children tend to parent in more hostile, critical and controlling ways. Skowron's team appears to have found evidence of a physiological basis for patterns of aversive parenting -- the use of hostile actions such as grabbing an arm or hand or using negative verbal cues in guiding a child's behavior -- in a sample of families involved with Child Protective Services. For the experiment, mothers and children were monitored to record changes in heart rate while playing together in the lab. Parenting behavior was scored to capture positive parenting and strict, hostile control using a standard coding system. What emerged, Skowron said, were clear distinctions between abusive, neglectful and non-maltreating mothers in their physiological responses during parenting. When abusive mothers were more warm and nurturing, they began to experience more difficulty regulating their heart rate and staying calm. This physiological-based stress response then led the abusive mothers to become more hostile and controlling toward their child a short time later in the interaction. The same was not the case for mothers who had been previously identified as being physically neglectful or for mothers with no history of neglectful or abusive parenting. Participants in the National Institutes of Health-funded study were 141 mothers -- 94 percent Caucasian with a high school degree or less and incomes at or below $30,000 -- and their children, ranged in age from 3 to 5 years old. The research focuses on tracking the effects of physiology on parenting in real time. "Abusive mothers who try to warmly support their child when the child faced a moderate challenge displayed a physiological response that suggested they're stressed, on alert and preparing to defend against a threat of some kind," said Skowron, a researcher at the Child and Family Center/Prevention Science Institute at the UO. "This kind of physiological response then led to a shift in an abusive mother becoming more hostile, strict, and controlling ways with her young child, regardless of how her child was behaving." The findings, she added, suggest that when physically abusive mothers experience being a nurturing parent they find it to be hard work. "It appears to quickly wear them out, perhaps because it challenges them in ways that lower-risk mothers don't experience," she said. "An abusive mother appears caught: When she does a good job with her child, it costs her physiologically, and it negatively affects her because it leads to more aversive parenting." The team's findings help to explain why abusive parenting is so resistant to most interventions, Skowron said. "Most parents who struggle with child maltreatment really love their children and want help improving their parenting skills. Our findings suggest that many are experiencing a biological response during parenting that actively interferes with their efforts to parent in warm and nurturing ways." The next step, she said, is exploring how to translate the new discovery into interventions specifically designed for parents struggling with child abusive. "We have to figure out how to help these high-risk parents calm themselves down more effectively and enjoy the experience of supporting their children in warm, positive ways. First, she noted, it will be important for other researchers to replicate the findings. "Researchers at the University of Oregon continue to yield critical insights that result in more effective prevention strategies," said Kimberly Andrews Espy, vice president for research and innovation and dean of the UO Graduate School. "This research by Dr. Skowron revealing a potential neurobiological trigger involved in abusive parenting may lead to new interventions that could help to improve the lives of children." ### Co-authors with Skowron were Elizabeth Cipriano-Essel and Aaron L. Pincus, both of Pennsylvania State University where Skowron conducted this research, Lorna Smith Benjamin of the University of Utah Neuropsychiatric Institute, and Mark J. Van Ryzin, research associate in the UO Child and Family Center and researcher at the Eugene-based Oregon Social Learning Center. NIH grant RO1 MH079328 to Skowron supported the research through the National Institute of Mental Health. Additional funding was provided by the Administration for Children and Families, through its Children's Bureau of the Administration on Children, Youth and Families, as part of the Federal Child Neglect Research Consortium. About the University of Oregon The University of Oregon is among the 108 institutions chosen from 4,633 U.S. universities for top-tier designation of "Very High Research Activity" in the 2010 Carnegie Classification of Institutions of Higher Education. The UO also is one of two Pacific Northwest members of the Association of American Universities. Source: Elizabeth A. Skowron, associate professor of counseling psychology, 541-346-0913, eskowron@uoregon.edu Links: Skowron faculty page: https://education.uoregon.edu/users/elizabeth-skowron Counseling psychology and human services: https://education.uoregon.edu/department/counseling-psychology-and-human-services Child and Family Center: http://cfc.uoregon.edu/ College of Education: https://education.uoregon.edu/ Audio: 1) Skowron on main finding, 20 seconds: http://uonews.uoregon.edu/sites/uonews.wc-sites.uoregon.edu/files/uploads/AbusiveParenting-Response.mp3 2) Skowron on the challenges of intervention, 66 seconds: http://uonews.uoregon.edu/sites/uonews.wc-sites.uoregon.edu/files/uploads/Intervention%20Challenges.mp3 Follow UO Science on Facebook: http://www.facebook.com/UniversityOfOregonScience UO Science on Twitter: http://twitter.com/UO_Research More UO Science/Research News: http://uoresearch.uoregon.edu Note: The University of Oregon is equipped with an on-campus television studio with a point-of-origin Vyvx connection, which provides broadcast-quality video to networks worldwide via fiber optic network. In addition, there is video access to satellite uplink, and audio access to an ISDN codec for broadcast-quality radio interviews.

PBS Documentary “Brains on Trial”

A convenience store robbery goes horribly wrong: A teenager high on cocaine stands trial for attempted murder. Brains on Trial PBS documentaryUsing this fictional crime, a two-episode PBS program titled “Brains on Trial” explores the brains of the key courtroom players—defendant, witnesses, jurors, and judge. Is a witness lying or telling the truth? How can two people see the same event and yet remember it so differently? These and other questions are what neuroscience currently is being asked to do using brain scans. Join host Alan Alda as he visits and conducts brain scan experiments with neuroscientists, such as the National Institute of Mental Health (NIMH)’s Jay Giedd, M.D., in the quest to answer how brain research can influence and reform the criminal justice system. Dr. Giedd is chief of the Unit on Brain Imaging in the Child Psychiatry Branch at NIMH LCSW Continuing Education

Autism Risk Unrelated to Total Vaccine Exposure in Early Childhood

A child’s risk for developing an autism spectrum disorder (ASD) is not increased by receiving “too many vaccines too soon,” according to a new study published in The Journal of Pediatrics. Although previous scientific evidence has shown that vaccines do not cause autism, more than 1 in 10 parents refuse or delay vaccinations for their young children. A main safety concern of these parents is the number of vaccines administered, both on a single day and over the course of a child’s first 2 years of life. In the first study of its kind, researchers from the CDC and Abt Associates, Inc. compared vaccine records for over 1000 children born from 1994–1999, some of whom were later diagnosed with ASD. The researchers calculated the total number of vaccine antigens each child received between birth and age 2, as well as the maximum number of antigens each child received on a single day. The study found that the total number of vaccine antigens received was the same between children with ASD and those without ASD. Additionally, antigen number was also found to be unrelated to the development of two sub-categories of ASD—autistic disorder and ASD with regression LCSW Continuing Education The researchers concluded, “The possibility that immunological stimulation from vaccines during the first 1 or 2 years of life could be related to the development of ASD is not well-supported by what is known about the neurobiology of ASDs.”

School-wide interventions improve student behavior

An analysis of a school behavior strategy—known as School-Wide Positive Behavioral Interventions and Supports (SWPBIS)—found that these types of programs significantly reduced children's aggressive behaviors and office discipline referrals, as well as improved problems with concentration and emotional regulation. The study, conducted by researchers from the Johns Hopkins Bloomberg School of Public Health, is the first randomized control trial to examine the impact of SWPBIS programs over multiple school years. The results were published October 15 in the journal Pediatrics as an eFirst publication.SWPBIS is a prevention strategy that aims to alter student behavior by setting universal, positively stated expectations for student behavior that are implemented across the entire school. Policies and decisions related to student behaviors are based on data analysis. SWPBIS programs are used in more than 16,000 schools in the U.S."These findings are very exciting, given the wide use of SWPBIS across the country. These results are among the first to document significant impacts of the program on children's problem behaviors, as well as positive behaviors, across multiple years as a result of SWPBIS," said Catherine P. Bradshaw, PhD, MEd, lead author of the study and associate professor in the Bloomberg School's Department of Mental Health.The randomized trial included a representative sample of 12,344 elementary school children from 37 schools. Approximately half of the students received free or reduced-priced meals, and nearly 13 percent received special education services. The researchers analyzed teachers' ratings of students' behavior and concentration problems, social-emotional functioning, pro-social behavior, office discipline referrals, and suspension over 4 school years.Overall, the study found significant improvement in children's behavior problems, concentration problems, social-emotional functioning, and pro-social behavior in schools using SWPBIS. Children in SWPBIS schools also were 33 percent less likely to receive an office discipline referral than those in the comparison schools. The effects tended to be strongest among children who were first exposed to SWPBIS in kindergarten."A unique feature of the model is the overall structure that is formed in schools to support sustainable services for students across a range of behavioral needs LCSW Continuing Education Using this framework, school staff can identify students at greatest need of services and efficiently target programs and resources to them," said Bradshaw.###The author of "Effects of School-Wide Positive Behavioral Interventions and Supports on Child Behavior Problems" include Catherine Bradshaw, PhD, MEd; Tracy E. Waasdorp, PhD, MEd; and Philip J. Leaf, PhD.

Mom's Love Good for Child's Brain

School-age children whose mothers nurtured them early in life have brains with a larger hippocampus, a key structure important to learning, memory and response to stress LCSW Continuing Education

The new research, by child psychiatrists and neuroscientists at Washington University School of Medicine in St. Louis, is the first to show that changes in this critical region of children's brain anatomy are linked to a mother's nurturing.

Their research is published online in the Proceedings of the National Academy of Sciences Early Edition.

"This study validates something that seems to be intuitive, which is just how important nurturing parents are to creating adaptive human beings," says first author Joan L. Luby, MD. "I think the public health implications suggest that we should pay more attention to parents' nurturing, and we should do what we can as a society to foster these skills because clearly nurturing has a very, very big impact on later development."

The brain-imaging study involved children ages 7 to 10 who had participated in an earlier study of preschool depression that Luby and her colleagues began about a decade ago. That study involved children, ages 3 to 6, who had symptoms of depression, other psychiatric disorders or were mentally healthy with no known psychiatric problems.

As part of the initial study, the children were closely observed and videotaped interacting with a parent, almost always a mother, as the parent was completing a required task, and the child was asked to wait to open an attractive gift. How much or how little the parent was able to support and nurture the child in this stressful circumstance — which was designed to approximate the stresses of daily parenting — was evaluated by raters who knew nothing about the child's health or the parent's temperament.

"It's very objective," says Luby, professor of child psychiatry. "Whether a parent was considered a nurturer was not based on that parent's own self-assessment. Rather, it was based on their behavior and the extent to which they nurtured their child under these challenging conditions."

The study didn't observe parents and children in their homes or repeat stressful exercises, but other studies of child development have used similar methods as valid measurements of whether parents tend to be nurturers when they interact with their children.

For the current study, the researchers conducted brain scans on 92 of the children who had had symptoms of depression or were mentally healthy when they were studied as preschoolers. The imaging revealed that children without depression who had been nurtured had a hippocampus almost 10 percent larger that children whose mothers were not as nurturing.

"For years studies have underscored the importance of an early, nurturing environment for good, healthy outcomes for children," Luby says. "But most of those studies have looked at psychosocial factors or school performance. This study, to my knowledge, is the first that actually shows an anatomical change in the brain, which really provides validation for the very large body of early childhood development literature that had been highlighting the importance of early parenting and nurturing. Having a hippocampus that's almost 10 percent larger just provides concrete evidence of nurturing's powerful effect."

Luby says the smaller volumes in depressed children might be expected because studies in adults have shown the same results. What did surprise her was that nurturing made such a big difference in mentally healthy children.

"We found a very strong relationship between maternal nurturing and the size of the hippocampus in the healthy children," she says.

Although 95 percent of the parents whose nurturing skills were evaluated during the earlier study were biological mothers, the researchers say that the effects of nurturing on the brain are likely to be the same, for any primary caregiver — whether they are fathers, grandparents or adoptive parents.

The fact that the researchers found a larger hippocampus in the healthy children who were nurtured is striking, Luby says, because the hippocampus is such an important brain structure.

When the body faces stresses, the brain activates the autonomic nervous system, an involuntary system of nerves that controls the release of stress hormones. Those hormones help us cope with stress by increasing the heart rate and helping the body adapt. The hippocampus is the main brain structure involved in that response. It's also key in learning and memory, and larger volumes would suggest a link to improved performance in school, among other things.

Past animal studies have indicated that a nurturing mother can influence brain development, and many studies in human children have identified improvements in school performance and healthier development in children raised in a nurturing environment. But until now, there has not been solid evidence linking a nurturing parent to changes in brain anatomy in children.

"Studies in rats have shown that maternal nurturance, specifically in the form of licking, produces changes in genes that then produce changes in receptors that increase the size of the hippocampus," Luby says. "That phenomenon has been replicated in primates, but it hasn't really been clear whether the same thing happens in humans. Our study suggests a clear link between nurturing and the size of the hippocampus."

She says educators who work with families who have young children may improve school performance and child development by not only teaching parents to work on particular tasks with their children but by showing parents how to work with their children.

"Parents should be taught how to nurture and support their children. Those are very important elements in healthy development," Luby says.

Luby JL, Barch DM, Belden A, Gaffrey MS, Tillman R, Babb C, Nishino T, Suzuki H, Botteron KN. Maternal support in early childhood predicts larger hippocampal volumes at school age. Proceedings of the National Academy of Sciences Early Edition, Jan. 30, 2012. www.pnas.org/cgi/doi/10.1073/pnas.1118003109.

Funding for this research comes from grants awarded by the National Institute of Mental Health of the National Institutes of Health (NIH).

Washington University School of Medicine's 2,100 employed and volunteer faculty physicians also are the medical staff of Barnes-Jewish and St. Louis Children's hospitals. The School of Medicine is one of the leading medical research, teaching and patient care institutions in the nation, currently ranked fourth in the nation by U.S. News & World Report. Through its affiliations with Barnes-Jewish and St. Louis Children's hospitals, the School of Medicine is linked to BJC HealthCare.

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.

Freeing Yourself from Holiday Debt

'Twas the day after New Year's, when all through the house
Not a creature was stirring, just me and my spouse;
We mused at the holiday cheer we had brought
To all of our dear ones, with gifts we had bought:
From ties, scarves and sweaters to books and CDs,
All manner of lip-smacking delicacies,
The latest high-tech, packed with features and frills,
But now how do we pay off our credit card bills?
If this sounds strangely familiar (and not just because of a brazen similarity to Clement Clark Moore's The Night Before Christmas), then you may be suffering the financial effects of your holiday generosity. You are not alone. Here are some tips that can help you overcome your holiday debt and be better prepared for next year's holiday spending:
• Face the facts; avoid denial – Delaying or avoiding the issue will cost you dearly in late fees and interest charges. It will also worsen your credit score - making your credit cards even more of a burden in the future.
• Make a payment plan and stick to it – Plan to make timely payments on every single card, and follow through on your plan no matter what. Even a single late payment can have disastrous results. For each card, define a fixed monthly payment (preferably more – even a little more – than the minimum due) and stick to it. Do not reduce this fixed amount as the minimum due gets smaller. When you have paid off one card, re-budget by dividing its monthly payment among the other cards.
• Consider a balance transfer – Try to transfer your debt from a high-interest card to a lowerinterest one. Ask your cards' customer service representative for an attractive deal. But pay attention to the terms! If the low interest rate expires before the debt is paid off, you could end
up worse off.
• Negotiate – Many credit cards will lower your interest rate if they fear you are about to transfer your balance and leave them. Cards will also frequently cooperate if you come to them with a payment plan.
• Consider a second job – Extra income can help you pay off more at a time and eliminate your debt faster.
• Give up one habit – Sweeping lifestyle changes may be hard to maintain, but it's easier to forgo a single habit, such as cable TV, high-speed Internet, a manicure, even a gym membership (you can exercise free). Use the extra money to pay off your debt.
• Free up cash to pay down high-interest debt – If you have money in your savings account, it is almost definitely earning less interest than you are paying on your credit card debit. Cash out the savings to pay your debt. If you have a 401(k) plan, you can suspend your contributions, but be careful not to jeopardize your employer's level of matching.
• Make a spending plan – Write down your income, monthly expenses and debts. Budget
realistically, and keep an eye on where you need to cut back. Consider setting aside money for next year's holiday expenses: divide this year's expenditure by 52 and set aside that amount each week.
• Seek help – You can get free or low-cost credit counseling through an agency affiliated with the National Foundation for Credit Counseling (NFCC). Call (800) 388-2227 or log on to www.nfcc.org. Your EAP can also provide you with telephonic financial counseling, delivered by certified professional counselors.
California RN Continuing Education http://www.aspirace.com
LPC Continuing Education http://www.aspirace.com

Older Adult Depression During the Holidays

According to Mental Health America, more than two million of the 34 million Americans age 65 and older suffer from some form of depression - and during the holidays this number climbs. For many Americans, the holiday season is a time of good cheer, family celebrations, and socialization with friends. Yet for some people, particularly the elderly, it's a time of loneliness, reflections of the past and anxiety about the future. During the holidays, older adults may feel more acutely the absence of loved ones, the distance of family members, and the passing of time. Traditions and reunions that were once observed may no longer be possible which may result in an absence of holiday meaning and significance for the elderly individual. Some major factors contributing to holiday depres-sion in the elderly include:

. Being alone or separated from loved ones,
. Loss of independence,
. Financial limitations,
. Failing eyesight (inability to read or write personal holiday correspondence),
. Loss of mobility and/or the inability to attend religious services.

Although sadness and grief are a normal part of life, depression is not a normal part of growing older. Depression is an illness which can be prevented and treated. Some of the warning signs of late-life depression include:

. Persistent sadness
. Lack of energy or interest in things that were once enjoyable
. Withdrawal from regular social activities
. Feelings of worthlessness or helplessness
. Frequent tearfulness
. Slowed thinking or response
. Excessive worry about health or finances
. Weight changes
. Pacing and fidgeting
. Changes in sleep patterns
. Inability to concentrate
. Staring off into space or at the television for prolonged periods of time

For many older adults there may be stigma attached to asking for help and they may have trouble discussing depression or mental illness. Understand that open communication is needed and that it may take more than one conversation to get the individual to agree to get help. If necessary, offer to call the individual's doctor or clergy and accompany the senior to an appointment. It is important to let the older adult know that depression is not part of growing old, that it is treatable, and that their lives can be better.

The National Registry for Evidence-based Programs and Practices

An Introduction

The Substance Abuse and Mental Health Services Administration (SAMHSA) developed the National Registry of Effective Prevention Programs in 1998 to better facilitate effective identification and dissemination of prevention programs targeting substance abuse. The newly revamped system, now the National Registry of Evidence-based Programs and Practices (NREPP), has expanded to include programs and practices for preventing and/or treating mental health and substance use disorders.

NREPP seeks to bridge the science to service gap by providing easily accessible information on the best practices and programs.

Without the identification, broad dissemination, and implementation of evidence-based practices (EBPs) for older adults, this vulnerable population faces delivery of services that are unsystematic and possibly ineffective or harmful. Delivery of effective and reliable services to older adults can decrease the disabilities and impairments associated with mental health problems and substance abuse in late life, while increasing the quality of life for this rapidly growing population.

Inclusion within NREPP is highly valued and potentially advantageous. SAMHSA and many other Federal and State agencies are increasingly awarding grants to programs that utilize EBPs. Because of NREPP's strong adherence to promoting EBPs, it serves as a rich resource for states, communities, public and private researchers and specific programs seeking to implement or promote specific evidence-based mental health and substance abuse prevention and treatment services for older adults.

The TAC is positioned to assist interested programs, practitioners, and researchers to learn more about NREPP and help determine whether they would be solid candidates for NREPP consideration. Programs targeted for the NREPP process are thoroughly evaluated, focusing on program outcomes. As a preliminary step prior to NREPP submission, the TAC analyzes program strengths and gaps to determine if the program is suitable for NREPP review, i.e., has sufficient supporting evidence for submission. If a program is found to be in need of further technical assistance in order to get NREPP-ready, TAC staff is available to work with program staff regarding gaps and ways to address these issues. For those programs ready for submission, the TAC will package their materials and submit them for review and evaluation by three independent NREPP reviewers on the basis of scientific merit and utility.

Programs reviewed by NREPP are placed into one of five categories: (5) Effective Program or Practice, (4) Conditionally Effective Program or Practice, (3) Emerging Program or Practice, (2) Program or Practice of Interest and (1) Insufficient Current Support.

Recently, the TAC highlighted the NREPP process in a poster presentation at the 3rd National Prevention Summit held in Washington, DC. We look forward to the further identification of and coordination with potential NREPP programs. If you are aware of a successful program serving older adults, please contact us at OlderAmericansTAC@westat.com or 1-888-281-8010 and provide the program name, along with contact information. In addition to the identification of programs and support throughout the NREPP process, TAC staff receives frequent requests regarding evidence-based practices and programs. While NREPP itself is unable to focus on knowledge dissemination, the TAC can assist with disseminating successful programs and practices and promote the use of recognized evidence-based activities.
LCSW and Social Worker Continuing Education

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

Have you Thanked a Veteran Today?

Have you Thanked a Veteran Today?
Wednesday, November 10th, 2010
By Kathryn Power, Director CMHS and Military Families Strategic Initiative Lead

When SAMHSA employees and contractors reported for work on Tuesday, November 9, each person found a button on his or her chair asking, “Have you thanked a Veteran today?” Beneath the button was a flyer inviting them to attend a SAMHSA Veterans Day Observance, which featured Korean War Veterans discussing their experiences on the 60th anniversary of that conflict. And on the back of the flyer was a list of SAMHSA employees who responded to our invitation to be listed as U.S. military Veterans, so that we could all take the opportunity to thank them for their service to our country.

Veterans Day, November 11, is the day set aside to honor all men and women who have served honorably in the military during times of both war and peace. Veterans and their families all deserve our thanks, but we also have an obligation to be there to “serve those who served”.

SAMHSA’s third Strategic Initiative , Military Families, strives to facilitate innovative community-based solutions that foster access to evidence-based prevention, treatment, and recovery services for Service Members, Veterans, and their families who are at risk for or experiencing behavioral health problems.

We are proud of all of our initiatives and partnerships that serve these populations. SAMHSA has partnered with the Department of Veterans Affairs to run the Veterans Suicide Prevention Hotline (1-800-273-TALK/8255) and with the National Guard Bureau to pilot test programs in New Mexico and Kansas that expand opportunities in the community to serve National Guard members and their families. In addition to SAMHSA’s initiatives through partnerships, some of SAMHSA’s programs that serve current service members, veterans and their families, include SAMHSA’s Jail Diversion and Trauma Recovery program that prioritizes Veterans,the Access to Recovery program which serves to prevent substance abuse in National Guard communities, and SAMHSA’s new technical assistance center, with the goal of strengthening behavioral health care systems in States, Territories and Tribes. Serving our service members and their families is a top initiative for SAMHSA, so please join me this week in honoring all the men and women who have bravely and honorably served in the U.S. Military.

Have you thanked a Veteran today? And while you’re at it, please take a minute to thank their families, too.

MFT Continuing Education

Certification and Licensure Issues Related to the Treatment of Co-occurring Disorders

Certification and Licensure Issues Related to the Treatment of Co-occurring Disorders.SAMHSA’S Co-Occurring Center for Excellence (COCE)
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Page 2
Overview• Purpose of licensure and certification for professionals is to protect the public and ensure that practitioners have meet standards for practice.• Purpose of licensure and accreditation of programs is to ensure that they meet state regulations and/or national operating standards and also protect the public.
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Page 3
Licensure and Certification of Professionals – Key Definitions• Licensure: A license is a property right of an individual and as a property right a license is backed by the laws of the State in which it is granted. (Shimberg &Roederer, 1994) “…it is illegal for a person to practice a profession without meeting standards imposed by the State.” (Schoon & Smith, 2000)
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Page 4
Licensure and Certification of Professionals - Key Definitions• Certification: A process established by a private sector body that defines standards for professional practice. It may prohibit the use of a title or designation but often does not restrict someone from practicing a profession. (Schoon & Smith 2000)
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Page 5
Licensure and Certification of Professionals – Key Definitions• Difference between licensure and certification is that certification is voluntary, not overseen by a governmental body and usually does not prohibit someone from practicing• Some states use the term “certified to indicate a license-e.g. “certified independent social worker” instead of “licensed independent social worker
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Page 6
Purpose of Licensure and Certification• Provides assurance that practitioners– have met standards of practice – Can perform scope of practice established for the profession– Have demonstrated knowledge and skill to practice• Provides protection from incompetent and unscrupulous professionals
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Page 7
Current Scopes of Practice and Core Competencies• Scopes of Practice for social workers, psychologists and psychiatrists include assessment, diagnosis, treatment of mental, emotional and behavioral disorders • The scopes of practice for psychiatrists, psychologists, social workers, mental health counselors, and marriage and family therapists also include addiction treatment • However, pre-service education for these disciplines contains little content on addictions
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Specialty Credentials• Specialty credentials in addictions exist for psychiatrists, psychologists, social workers and licensed professional counselors• Fewer than 7 percent of practitioners hold these national credentials (Harwood, et al, in press)• Some States (e.g.CT, IL, PA) have developed or are in the process of developing specialty credentials in COD but they are generally for addiction counselors
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Page 9
Specialty Credentials Requirements• Mental Health Practitioners need to know the Transdisciplinary Foundations as described in the Addiction Counseling Competencies (CSAT 1998)– Understanding Addictions (models & theories; behavioral, psychological, physical health and social effects of psychoactive substances)– Treatment knowledge (continuum of care; importance of social, family and other support systems; understanding and application of research; interdisciplinary approach to treatment– Application to Practice (Understanding of diagnostic and placement criteria; understanding of variety of helping strategies– Professional Readiness (Understanding of diverse cultures; disabilities
MFT and LCSW Continuing Education Requirements --------------------------------------------------------------------------------
Page 10
Specialty Credentials• For addiction counselors providing COD treatment the domains that have been identified include:– Assessment/evaluation/diagnosis– Clinical Competence– Case Management– Pharmacology and medical issues– Systems Integration– Professional Responsibility (IAODAPCA 2002)
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Benefits and Risks Related to Specialty Credentials• Enhance competencies of practitioners in providing services to clients with COD • Integrates COD services into practice• Specialty credentials are voluntary and not required for those providing COD services• Lack of pre-service education in COD may preclude effective screening, assessment, intervention and referrals for COD clients
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Page 12
Elements of a COD Certification• Need comprehensive understanding of substance abuse & mental disorders– Remission– Recovery– Resilience• Competencies should include integrated assessment, engagement, integrated treatment planning and treatment, and long term integrated treatment methods (CSAT 2005)
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Page 13
Benefits and Risks of a COD Credential• Currently a specialty credential for COD practice exists mainly for substance abuse professionals in several states• Other disciplines have an addiction certification• Advantage of developing a national COD credential is the creation of a scope of practice and competencies specifically designed for working with COD clients• Risk is further splintering of the field and concerns that all patients would be perceived as needing COD treatment
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Page 14
Program Accreditation and Licensure• Accreditation is a voluntary performance-based process used to assess an organization or institution based on established quality and safety standards. Surveyors are carefully trained to conduct the evaluation; funders and third party payors usually require accreditation of institutions and agencies
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Page 15
Program Accreditation and Licensure• Licensure is a right or permission granted by the state to engage in a business, perform an act or engage in a transaction that would be unlawful with such a right or permission (Merriam-Webster 1996) • States regulate the licensing of programs & hospitals; regulations may include policies, procedures, types of staff, facility safety standards and types of care specific programs can offer
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Core Capabilities for Programs Serving COD Clients• Following services are needed:– Integrated screening and assessment– Staged interventions– Assertive Outreach– Motivational interventions– Simultaneous Interventions– Risk Reduction– Tailored mental health and substance abuse treatment– Counseling– Social Support Interventions– Longitudinal view of remission and recovery– Cultural sensitivity and competence (CSAT 2005)
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Page 17
Current Issues Regarding State Licensure of Programs• COD programs need to have appropriately trained & certified/licensed staff; comprehensive services including a full array of mental health and substance abuse treatment; supportive services; and implementation of evidence-based practices• Most programs are licensed by State mental health and substance abuse agencies respectively: funding streams are separate; different data collection systems; different staffing patterns; distinct service requirements
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Page 18
Models of Licensure Standards for COD Programs • Comprehensive Continuous Integrated System of Care (CCISC) model is being implemented in several states (CSAT 2005)• CCISC integrates mental health and substance abuse systems to provide a comprehensive system of care including policies, financing, programs, clinical practices and basic clinician competencies (Minkoff 2003; CSAT 2005)
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Benefits of Licensure and Accreditation for COD Programs• Elimination of many obstacles that currently exist• Programs would be able to screen and assess for COD and some could be designated as programs to provide enhanced services• Programs that wish to specialize in COD treatment could be recognized• National accreditation would create consistent standards for programs including administrative, staffing and programmatic
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Issues and Future Direction• Little research exists on whether licensed/certified clinicians have better outcomes than those not certified• Though competencies in substance abuse are being added to practice standards few curricula provide adequate education or training• Evidence-based practices for COD treatment need to be incorporated into education and training standards• State program licensure practices still make programs providing COD treatment jump through a maze of regulations• JCAHO has not yet established national standards for dual diagnosis programs
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References• American Association for Marriage and Family Therapy Core Competency Taskforce. (2004) The MFT Core Competencies, Alexandria, VA: AAMFT• Association of Social Work Boards. Model social work practice act. www.aswb.org/Model_law.pdf• Association of State and Provincial Psychology Boards. The practice of psychology. www.asppb.org/exam/practice.asp• Center for Substance Abuse Treatment. 2005. Substance Abuse Treatment for Persons with Co- occurring Disorders. Treatment Improvement Protocol (TIP) Series 42. DHHS Publication No (SMA) 05-3992. Rockville, MD: SAMHSA
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References• Center for Substance Abuse Treatment (1998). Addiction Counseling Competencies: The Knowledge, Skills and Attitudes of Professional Practice. Technical Assistance Publication Series No. 21. DHHS Publication No. (SMA) 98-3171. Rockville, MD: SAMHSA• Harwood, H.J., Kowalski, J., and Ameen, A. (In press). Training on substance abuse of behavioral health professionals. Falls Church, VA: The Lewin Group• Illinois Alcohol and Other Drug Abuse Professional Certification Association. (2002). Mental Illness/Substance Abuse Professional Role Delineation Study. www.iaodapca.org.• Merriwam-Webster. (1996) Merriam-Webster’s Dictionary of Law. Springfield MA: Merriam-Webster.
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References• Minkoff, K. (2003). Comprehensive, continuous, integrated system of care model description. http://www.zialogic.org/CCISC.htm.• Schoon, C.G. & Smith, I.L. (2000). The licensure and certification mission. In C.G. Schoon and I.L. Smith (Eds.) The licensure and certification mission: Legal, social and political foundations (pp1-3). New York: Professional Examination Services.• Shimberg, B. & Roederer, (1994). Questions a legislator should ask. Lexington, KY: The Council on Licensure, Enforcement and Regulation.• Substance Abuse and Mental Health Services Administration (2003).Strategies for developing treatment programs for people with co- occurring substance abuse and mental disorders.DHHS Publication No. (SMA) 03-3782. Rockville, MD: SAMHSA• Substance Abuse and Mental Health Services Administration. (2002) Report to Congress on the prevention and treatment of co-occurring substance abuse disorders and mental disorders. http://als.samshsa.gov/reports/congress2002/CoOccurringRPT.pdf.SAMHSA’S Co-Occurring Center for Excellence (COCE)
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Page 2
Overview• Purpose of licensure and certification for professionals is to protect the public and ensure that practitioners have meet standards for practice.• Purpose of licensure and accreditation of programs is to ensure that they meet state regulations and/or national operating standards and also protect the public.
--------------------------------------------------------------------------------
Page 3
Licensure and Certification of Professionals – Key Definitions• Licensure: A license is a property right of an individual and as a property right a license is backed by the laws of the State in which it is granted. (Shimberg &Roederer, 1994) “…it is illegal for a person to practice a profession without meeting standards imposed by the State.” (Schoon & Smith, 2000)
--------------------------------------------------------------------------------
Page 4
Licensure and Certification of Professionals - Key Definitions• Certification: A process established by a private sector body that defines standards for professional practice. It may prohibit the use of a title or designation but often does not restrict someone from practicing a profession. (Schoon & Smith 2000)
--------------------------------------------------------------------------------
Page 5
Licensure and Certification of Professionals – Key Definitions• Difference between licensure and certification is that certification is voluntary, not overseen by a governmental body and usually does not prohibit someone from practicing• Some states use the term “certified to indicate a license-e.g. “certified independent social worker” instead of “licensed independent social worker
--------------------------------------------------------------------------------
Page 6
Purpose of Licensure and Certification• Provides assurance that practitioners– have met standards of practice – Can perform scope of practice established for the profession– Have demonstrated knowledge and skill to practice• Provides protection from incompetent and unscrupulous professionals
--------------------------------------------------------------------------------
Page 7
Current Scopes of Practice and Core Competencies• Scopes of Practice for social workers, psychologists and psychiatrists include assessment, diagnosis, treatment of mental, emotional and behavioral disorders • The scopes of practice for psychiatrists, psychologists, social workers, mental health counselors, and marriage and family therapists also include addiction treatment • However, pre-service education for these disciplines contains little content on addictions
--------------------------------------------------------------------------------
Page 8
Specialty Credentials• Specialty credentials in addictions exist for psychiatrists, psychologists, social workers and licensed professional counselors• Fewer than 7 percent of practitioners hold these national credentials (Harwood, et al, in press)• Some States (e.g.CT, IL, PA) have developed or are in the process of developing specialty credentials in COD but they are generally for addiction counselors
--------------------------------------------------------------------------------
Page 9
Specialty Credentials Requirements• Mental Health Practitioners need to know the Transdisciplinary Foundations as described in the Addiction Counseling Competencies (CSAT 1998)– Understanding Addictions (models & theories; behavioral, psychological, physical health and social effects of psychoactive substances)– Treatment knowledge (continuum of care; importance of social, family and other support systems; understanding and application of research; interdisciplinary approach to treatment– Application to Practice (Understanding of diagnostic and placement criteria; understanding of variety of helping strategies– Professional Readiness (Understanding of diverse cultures; disabilities
--------------------------------------------------------------------------------
Page 10
Specialty Credentials• For addiction counselors providing COD treatment the domains that have been identified include:– Assessment/evaluation/diagnosis– Clinical Competence– Case Management– Pharmacology and medical issues– Systems Integration– Professional Responsibility (IAODAPCA 2002)
--------------------------------------------------------------------------------
Page 11
Benefits and Risks Related to Specialty Credentials• Enhance competencies of practitioners in providing services to clients with COD • Integrates COD services into practice• Specialty credentials are voluntary and not required for those providing COD services• Lack of pre-service education in COD may preclude effective screening, assessment, intervention and referrals for COD clients
--------------------------------------------------------------------------------
Page 12
Elements of a COD Certification• Need comprehensive understanding of substance abuse & mental disorders– Remission– Recovery– Resilience• Competencies should include integrated assessment, engagement, integrated treatment planning and treatment, and long term integrated treatment methods (CSAT 2005)
--------------------------------------------------------------------------------
Page 13
Benefits and Risks of a COD Credential• Currently a specialty credential for COD practice exists mainly for substance abuse professionals in several states• Other disciplines have an addiction certification• Advantage of developing a national COD credential is the creation of a scope of practice and competencies specifically designed for working with COD clients• Risk is further splintering of the field and concerns that all patients would be perceived as needing COD treatment
--------------------------------------------------------------------------------
Page 14
Program Accreditation and Licensure• Accreditation is a voluntary performance-based process used to assess an organization or institution based on established quality and safety standards. Surveyors are carefully trained to conduct the evaluation; funders and third party payors usually require accreditation of institutions and agencies
--------------------------------------------------------------------------------
Page 15
Program Accreditation and Licensure• Licensure is a right or permission granted by the state to engage in a business, perform an act or engage in a transaction that would be unlawful with such a right or permission (Merriam-Webster 1996) • States regulate the licensing of programs & hospitals; regulations may include policies, procedures, types of staff, facility safety standards and types of care specific programs can offer
--------------------------------------------------------------------------------
Page 16
Core Capabilities for Programs Serving COD Clients• Following services are needed:– Integrated screening and assessment– Staged interventions– Assertive Outreach– Motivational interventions– Simultaneous Interventions– Risk Reduction– Tailored mental health and substance abuse treatment– Counseling– Social Support Interventions– Longitudinal view of remission and recovery– Cultural sensitivity and competence (CSAT 2005)
--------------------------------------------------------------------------------
Page 17
Current Issues Regarding State Licensure of Programs• COD programs need to have appropriately trained & certified/licensed staff; comprehensive services including a full array of mental health and substance abuse treatment; supportive services; and implementation of evidence-based practices• Most programs are licensed by State mental health and substance abuse agencies respectively: funding streams are separate; different data collection systems; different staffing patterns; distinct service requirements
--------------------------------------------------------------------------------
Page 18
Models of Licensure Standards for COD Programs • Comprehensive Continuous Integrated System of Care (CCISC) model is being implemented in several states (CSAT 2005)• CCISC integrates mental health and substance abuse systems to provide a comprehensive system of care including policies, financing, programs, clinical practices and basic clinician competencies (Minkoff 2003; CSAT 2005)
--------------------------------------------------------------------------------
Page 19
Benefits of Licensure and Accreditation for COD Programs• Elimination of many obstacles that currently exist• Programs would be able to screen and assess for COD and some could be designated as programs to provide enhanced services• Programs that wish to specialize in COD treatment could be recognized• National accreditation would create consistent standards for programs including administrative, staffing and programmatic
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Issues and Future Direction• Little research exists on whether licensed/certified clinicians have better outcomes than those not certified• Though competencies in substance abuse are being added to practice standards few curricula provide adequate education or training• Evidence-based practices for COD treatment need to be incorporated into education and training standards• State program licensure practices still make programs providing COD treatment jump through a maze of regulations• JCAHO has not yet established national standards for dual diagnosis programs
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References• American Association for Marriage and Family Therapy Core Competency Taskforce. (2004) The MFT Core Competencies, Alexandria, VA: AAMFT• Association of Social Work Boards. Model social work practice act. www.aswb.org/Model_law.pdf• Association of State and Provincial Psychology Boards. The practice of psychology. www.asppb.org/exam/practice.asp• Center for Substance Abuse Treatment. 2005. Substance Abuse Treatment for Persons with Co- occurring Disorders. Treatment Improvement Protocol (TIP) Series 42. DHHS Publication No (SMA) 05-3992. Rockville, MD: SAMHSA
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References• Center for Substance Abuse Treatment (1998). Addiction Counseling Competencies: The Knowledge, Skills and Attitudes of Professional Practice. Technical Assistance Publication Series No. 21. DHHS Publication No. (SMA) 98-3171. Rockville, MD: SAMHSA• Harwood, H.J., Kowalski, J., and Ameen, A. (In press). Training on substance abuse of behavioral health professionals. Falls Church, VA: The Lewin Group• Illinois Alcohol and Other Drug Abuse Professional Certification Association. (2002). Mental Illness/Substance Abuse Professional Role Delineation Study. www.iaodapca.org.• Merriwam-Webster. (1996) Merriam-Webster’s Dictionary of Law. Springfield MA: Merriam-Webster.
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References• Minkoff, K. (2003). Comprehensive, continuous, integrated system of care model description. http://www.zialogic.org/CCISC.htm.• Schoon, C.G. & Smith, I.L. (2000). The licensure and certification mission. In C.G. Schoon and I.L. Smith (Eds.) The licensure and certification mission: Legal, social and political foundations (pp1-3). New York: Professional Examination Services.• Shimberg, B. & Roederer, (1994). Questions a legislator should ask. Lexington, KY: The Council on Licensure, Enforcement and Regulation.• Substance Abuse and Mental Health Services Administration (2003).Strategies for developing treatment programs for people with co- occurring substance abuse and mental disorders.DHHS Publication No. (SMA) 03-3782. Rockville, MD: SAMHSA• Substance Abuse and Mental Health Services Administration. (2002) Report to Congress on the prevention and treatment of co-occurring substance abuse disorders and mental disorders. http://als.samshsa.gov/reports/congress2002/CoOccurringRPT.pdf.

MFT Continuing Education, LCSW Continuing Education, LPC Continuing Education

Alabama
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW)

Alaska
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW) and Marriage and Family Therapists (MFT, LMFT)
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Professional Counselors (LPC, LPCC)

Arizona
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW)

Arkansas
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Mental Health Counselors (MHC)
No CE Provider status approval required for CE credit for licensed Social Workers (LCSW, LSW)

California
Approved by the California Board of Behavioral Sciences for licensed Marriage and Family Therapists (MFT, LMFT), Marriage and Family Therapist Interns/Trainee (MFTI), Licensed Clinical Social Workers (LCSW) and Associate Clinical Social Workers (ASW).
Approved by the California Certification Board of Alcohol and Drug Counselors for licensed Drug and Alcohol Abuse Counselors (CADC I & II, CPS, CSS, CADCA)

Colorado
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW), Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)

Connecticut
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Social Workers (LCSW, LSW), Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)

Delaware
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Mental Health Counselors (MHC)
Meets qualifications in Rule 7.2.5 for licensed Social Workers (LCSW, LSW) (check with state board for further clarification)

Florida
Approved by the Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling for licensed Social Workers (LCSW, LSW), Marriage and Family Therapists (MFT, LMFT) and Mental Health Counselors (MHC)

Georgia
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW)

Hawaii
No continuing education requirements for license renewal for licensed Social Workers (LCSW, LSW), Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)

Idaho
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
Not approved for licensed Social Workers (LCSW, LSW)

Illinois
Not pre-approved for licensed Marriage and Family Therapists (MFT, LMFT) and Social Workers (LCSW, LSW) (check with state board for CE requirements)
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Professional Counselors (LPC, LPCC)

Indiana
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Social Workers (LCSW, LSW), Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)

Iowa
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Mental Health Counselors (MHC)
Meets requirements stated in Rule 645-281.3 standards of the Iowa Administrative Rules (see state board for further clarification) for licensed Social Workers (LCSW, LSW)

Kansas
No CE Provider status approval required for CE credit for licensed Social Workers (LCSW, LSW), Marriage and Family Therapist and Mental Health Counselors (MHC)

Kentucky
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Professional Counselors (LPC, LPCC)
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Social Workers (LCSW, LSW)
Check state board for approval requirements for licensed Marriage and Family Therapists (MFT, LMFT)

Louisiana
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Professional Counselors (LPC, LPCC)
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW)
Check state board for approval requirements for licensed Marriage and Family Therapists (MFT, LMFT)

Maine
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
Check state board for approval requirements for licensed Social Workers (LCSW, LSW)

Maryland
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
Check state board for approval requirements for licensed Social Workers (LCSW, LSW)

Massachusetts
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Mental Health Counselors (MHC)
Check state board for approval requirements for licensed Marriage and Family Therapists (MFT, LMFT)
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW)

Michigan
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW)
No continuing education requirements for license renewal for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)

Minnesota
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Professional Counselors (LPC, LPCC)
No CE Provider status approval required for CE credit for licensed Social Workers (LCSW, LSW)
Check with board for approval requirements for licensed Marriage and Family Therapists (MFT, LMFT)

Mississippi
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Professional Counselors (LPC, LPCC)
Not pre-approved for licensed Marriage and Family Therapists (MFT, LMFT) and Social Workers (LCSW, LSW) (check with state board for CE requirements)

Missouri
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW)

Montana
Approved by the Montana Board of Social Work Examiners, Professional Counselors & Marriage and Family Therapists for licensed Social Workers (LCSW, LSW), Professional Counselors (LPC, LPCC), and licensed Marriage and Family Therapists (MFT, LMFT)

Nebraska
Meets criteria of an approved continuing education program provider for licensed Social Workers (LCSW, LSW), Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)

Nevada
No CE Provider status approval required for CE credit for licensed Marriage and Family Therapist and Professional Counselors (LPC, LPCC)
Not pre-approved for licensed Social Workers (LCSW, LSW) (check with state board for CE requirements)

New Hampshire
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Social Workers (LCSW, LSW), Marriage and Family Therapists (MFT, LMFT) and Mental Health Counselors (MHC)

New Jersey
Accepts approval from the National Board for Certified Counselors (NBCC) for Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
Not approved for Licensed Social Workers (LCSW, LSW)


New Mexico
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
No CE Provider status approval required for CE credit for licensed Social Workers (LCSW, LSW)

New York
No continuing education requirements for license renewal for licensed Social Workers (LCSW, LSW), Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)

North Carolina
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Professional Counselors (LPC, LPCC)
No CE Provider status approval required for CE credit for licensed Marriage and Family Therapists (MFT, LMFT)
Not approved for licensed Social Workers (LCSW, LSW)

North Dakota
No CE Provider status approval required for CE credit for licensed Marriage and Family Therapist and Professional Counselors (LPC, LPCC)
Not pre-approved for licensed Social Workers (LCSW, LSW) (check with state board for CE requirements)

Ohio
Approved by the Counselor, Social Worker and Marriage and Family Therapist Board of Ohio for licensed Marriage and Family Therapists (MFT, LMFT)
Approved by the Counselor, Social Worker and Marriage and Family Therapist Board of Ohio for licensed Mental Health Counselors (MHC)
Not approved for licensed Social Workers (LCSW, LSW)

Oklahoma
Approved by the Oklahoma State Department of Health - Professional Counselor Licensing Board for licensed Marriage and Family Therapists (MFT, LMFT) and Licensed Professional Counselors (LPC)
Not approved for licensed Social Workers (LCSW, LSW)

Oregon
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW)

Pennsylvania
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Social Workers (LCSW, LSW), Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)

Rhode Island
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Mental Health Counselors (MHC)
Not approved for licensed Social Workers (LCSW, LSW)

South Carolina
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW)

South Dakota
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Mental Health Counselors (MHC)
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW)

Tennessee
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
Meets requirements stated in Rule 1365-01-.09 for CE credit for licensed Social Workers (LCSW, LSW) (see state board for further clarification)

Texas
Approved by the Texas Board of Examiners of Marriage and Family Therapists (MFT, LMFT) for licensed Marriage and Family Therapists (MFT, LMFT)
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Professional Counselors (LPC, LPCC)
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW)

Utah
Meets requirements stated in rule R156-60b-304 for licensed Marriage and Family Therapists (MFT, LMFT) (see state board for further clarification on CE requirements)
Meets requirements stated in rule R156-60c-304 for licensed Professional Counselors (LPC, LPCC) (see state board for further clarification on CE requirements)
Not pre-approved for licensed Social Workers (LCSW, LSW) (see state board for further clarification on CE requirements)

Vermont
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Mental Health Counselors (MHC)
Meets requirements stated in rule 3.3 Formal Activities (2), 3.4(2)(3) for licensed Social Workers (LCSW, LSW) (see state board for further clarification on CE requirements)

Virginia
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW)

Washington
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Social Workers (LCSW, LSW), Marriage and Family Therapists (MFT, LMFT) and Mental Health Counselors (MHC)

West Virginia
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Professional Counselors (LPC, LPCC)
Not pre-approved for licensed Marriage and Family Therapists (MFT, LMFT) (check with state board for CE requirements)
No CE Provider status approval required for Category II (Individual Professional Activities) CE credit for licensed Social Workers (LCSW, LSW)

Wisconsin
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Social Workers (LCSW, LSW), Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)

Wyoming
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Mental Health Counselors (MHC)
Not pre-approved for licensed Marriage and Family Therapists (MFT, LMFT) and Social Workers (LCSW, LSW) (check with state board for CE requirements)


MFT Continuing Education

LCSW Continuing Education

LPC Continuing Education Units, Credits, Hours

Drug and Alchohol Counselor Continuing Education CEUs