Treatment of child anxiety. an exploratory study of the role of maternal anxiety and behaviours in treatment outcome

Anxiety disorders are common among parents of anxious children and have been found to impede child treatment outcomes, yet it is unclear whether it is parental anxiety that needs to be targeted in therapy or associated parental behaviours. Twenty-two children (6-12 years) with a current anxiety disorder and their mothers received cognitive-behavioural treatment (CBT) for child anxiety. In addition, of the 12 mothers who met criteria for a current anxiety disorder, 6 received CBT for their own disorder. Assessments were made of the mother-child interaction. The main findings were: (1) children did less well from treatment where their mothers had a current anxiety disorder; (2) treatment of maternal anxiety disorder did not improve child treatment outcome; and (3) maternal overinvolvement and expression of fear was associated with child treatment outcome. The results suggest that in the context of maternal anxiety disorder, child treatment outcome may be improved by specifically targeting parenting behaviours. Copyright (C) 2008 John Wiley & Sons, Ltd.

Resistance to the anticoagulant rodenticides – the deployment of the new molecular methodology to identify mutations of the VKORC1 ‘resistance gene’, and understanding their potential impact on treatment outcome

Anticoagulants rodenticides have already known for over half a century, as effective and safe method of rodent control. However, discovered in 1958 anticoagulant resistance has given us a very important problem for their future long-term use. Laboratory tests provide the main method for identification the different types of anticoagulant resistances, quantify the magnitude of their effect and help us to choose the best pest control strategy. The main important tests are lethal feeding period (LFP) and blood clotting response (BCR) tests. These tests can now be used to quantify the likely effect of the resistance on treatment outcome by providing an estimate of the ‘resistance factor’. In 2004 the gene responsible for anticoagulant resistance (VKORC1) was identified and sequenced. As a result, a new molecular resistance testing methodology has been developed, and a number of resistance mutations, particularly in Norway rats and house mice. Three mutations of the VKORC1 gene in Norway rats have been identified to date that confer a degree of resistance to bromadiolone and difenacoum, sufficient to affect treatment outcome in the field.

Perfectionism as a transdiagnostic process: a clinical review

Perfectionism is a risk and maintaining factor for eating disorders, anxiety disorders and depression. The objective of this paper is to review the four bodies of evidence supporting the notion that perfectionism is a transdiagnostic process. First, a review of the literature was conducted that demonstrates the elevation of perfectionism across numerous anxiety disorders, depression, and eating disorders compared to healthy controls. Data is presented that shows perfectionism increases vulnerability for eating disorders, and that it maintains obsessive–compulsive disorder, social anxiety and depression as it predicts treatment outcome in these disorders. Second, evidence is examined showing that elevated perfectionism is associated with co-occurrence of psychopathology. Third, the different conceptualisations of perfectionism are reviewed, including a cognitive-behavioural conceptualisation of clinical perfectionism that can be utilised to understand this transdiagnostic process. Fourth, evidence that treatment of perfectionism results in reductions in anxiety, depression and eating pathology is reviewed. Finally,the importance of clinicians considering the routine assessment and treatment of perfectionism is outlined.

Antipsychotic drug action: antagonism, inverse agonism or partial agonism

The positive, psychotic symptoms of schizophrenia can be treated by antipsychotic drugs and it has been assumed that these are antagonists at the D-2 and D-3 dopamine receptors in the brain. Recently, the D-2/D-3 partial agonist aripiprazole has been introduced as an antipsychotic drug. It has also been realized that, using in vitro assays, the other antipsychotic drugs are in fact inverse agonists at D-2/D-3 dopamine receptors. This raises questions about how these disparate drugs can achieve a similar clinical outcome. In this review, I shall consider the efficacies of these drugs in signalling assays and how these efficacies might affect treatment outcomes. It seems that the treatment outcome might depend on the overall level of cell stimulation, which is in turn dependent on the level of residual dopamine and the efficacy of the drug in signalling assays.

Verb retrieval in fluent aphasia: a clinical study

Background: Problems with lexical retrieval are common across all types of aphasia but certain word classes are thought to be more vulnerable in some aphasia types. Traditionally, verb retrieval problems have been considered characteristic of non-fluent aphasias but there is growing evidence that verb retrieval problems are also found in fluent aphasia. As verbs are retrieved from the mental lexicon with syntactic as well as phonological and semantic information, it is speculated that an improvement in verb retrieval should enhance communicative abilities in this population as in others. We report on an investigation into the effectiveness of verb treatment for three individuals with fluent aphasia. Methods & Procedures: Multiple pre-treatment baselines were established over 3 months in order to monitor language change before treatment. The three participants then received twice-weekly verb treatment over approximately 4 months. All pre-treatment assessments were administered immediately after treatment and 3 months post-treatment. Outcome & Results: Scores fluctuated in the pre-treatment period. Following treatment, there was a significant improvement in verb retrieval for two of the three participants on the treated items. The increase in scores for the third participant was statistically nonsignificant but post-treatment scores moved from below the normal range to within the normal range. All participants were significantly quicker in the verb retrieval task following treatment. There was an increase in well-formed sentences in the sentence construction test and in some samples of connected speech. Conclusions: Repeated systematic treatment can produce a significant improvement in verb retrieval of practised items and generalise to unpractised items for some participants. An increase in well-formed sentences is seen for some speakers. The theoretical and clinical implications of the results are discussed.

Feasibility of guided CBT self-help for childhood anxiety disorders in primary care

Anxiety disorders in childhood are common, disabling and run a chronic course. Cognitive Behaviour Therapy (CBT) effective but is expensive and trained therapists are scarce. Guided self-help treatments may be a means of widening access to treatment. This study aimed to examine the feasibility of guided CBT self-help for childhood anxiety disorders in Primary Care, specifically in terms of therapist adherence, patient and therapist satisfaction and clinical gain. Participants were children aged 5-12 years referred to two Primary Child and Adolescent Mental Health Services (PCAMHSs) in Oxfordshire, UK, who met diagnostic criteria for a primary anxiety disorder. Of the 52 eligible children, 41 anxious children were assessed for anxiety severity and interference before and after receiving CBT self-help, delivered via the parent (total therapy time= 5 hours) by Primary Mental Health Workers (PMHWs). Therapy sessions were rated for treatment adherence and patients and PMHWs completed satisfaction questionnaires after treatment completion. Over 80% of therapy sessions were rated at a high level of treatment adherence. Parents and PMHWs reported high satisfaction with the treatment. 61% of the children assessed no longer met criteria for their primary anxiety disorder diagnosis following treatment, and 76% were rated as ‘much’/’very much’ improved on the Clinician’s Global Impression-Improvement scale. There were significant reductions on parent and child report measures of anxiety symptoms, interference, and depression. Preliminary exploration indicated that parental anxiety was associated with child treatment outcome. The findings suggest that guided CBT self-help represents a promising treatment for childhood anxiety in primary care.

Cognitive, affective and behavioural characteristics of mothers with anxiety disorders in the context of child anxiety disorder

Parental emotional distress, particularly high maternal anxiety, is one of the most consistent predictors of child anxiety treatment outcome. In order to identify the cognitive, affective and behavioural parenting characteristics of mothers of children with anxiety disorders who themselves have an anxiety disorder, we assessed the expectations and appraisals of 88 mothers of anxious children (44 not anxious (NONANX) and 44 with a current anxiety disorder (ANX)) before and after interacting with their 7-12 year old children. There were no observed differences in anxiety and avoidance among children of ANX and NONANX mothers, but, compared to NONANX mothers, ANX mothers held more negative expectations and differed on observations of intrusiveness, expressed anxiety, warmth and the quality of the relationship. Associations were moderated by the degree to which children expressed anxiety during the tasks. Maternal reported negative emotions during the task significantly mediated the association between maternal anxiety status and the observed quality of the relationship. These findings suggest that maternal anxiety disorder is associated with reduced tolerance of children’s negative emotions. This may interfere with the maintenance of a positive, supportive mother-child interaction under conditions of stress, and as such impede optimum treatment outcomes. The findings identify potential cognitive, affective and behavioural targets to improve treatment outcomes for children with anxiety disorders in the context of a current maternal anxiety disorder.

Predicting outcomes following cognitive behavior therapy in child anxiety disorders: the influence of genetic, demographic and clinical information

Background. Within a therapeutic gene by environment (GxE) framework, we recently demonstrated that variation in the Serotonin Transporter Promoter Polymorphism; 5HTTLPR and marker rs6330 in Nerve Growth Factor gene; NGF is associated with poorer outcomes following cognitive behaviour therapy (CBT) for child anxiety disorders. The aim of this study was to explore one potential means of extending the translational reach of G×E data in a way that may be clinically informative. We describe a ‘risk-index’ approach combining genetic, demographic and clinical data and test its ability to predict diagnostic outcome following CBT in anxious children. Method. DNA and clinical data were collected from 384 children with a primary anxiety disorder undergoing CBT. We tested our risk model in five cross-validation training sets. Results. In predicting treatment outcome, six variables had a minimum mean beta value of 0.5: 5HTTLPR, NGF rs6330, gender, primary anxiety severity, comorbid mood disorder and comorbid externalising disorder. A risk index (range 0-8) constructed from these variables had moderate predictive ability (AUC = .62-.69) in this study. Children scoring high on this index (5-8) were approximately three times as likely to retain their primary anxiety disorder at follow-up as compared to those children scoring 2 or less. Conclusion. Significant genetic, demographic and clinical predictors of outcome following CBT for anxiety-disordered children were identified. Combining these predictors within a risk-index could be used to identify which children are less likely to be diagnosis free following CBT alone or thus require longer or enhanced treatment. The ‘risk-index’ approach represents one means of harnessing the translational potential of G×E data.

Cortical thickness changes in the non-lesioned hemisphere associated with non-paretic arm immobilization in modified CI therapy

Recent evidence suggests that immobilization of the upper limb for 2–3 weeks induces changes in cortical thickness as well as motor performance. In constraint induced (CI) therapy, one of the most effective interventions for hemiplegia, the non-paretic arm is constrained to enforce the use of the paretic arm in the home setting. With the present study we aimed to explore whether non-paretic arm immobilization in CI therapy induces structural changes in the non-lesioned hemisphere, and how these changes are related to treatment benefit. 31 patients with chronic hemiparesis participated in CI therapy with (N = 14) and without (N = 17) constraint. Motor ability scores were acquired before and after treatment. Diffusion tensor imaging (DTI) data was obtained prior to treatment. Cortical thickness was measured with the Freesurfer software. In both groups cortical thickness in the contralesional primary somatosensory cortex increased and motor function improved with the intervention. However the cortical thickness change was not associated with the magnitude of motor function improvement. Moreover, the treatment effect and the cortical thickness change were not significantly different between the constraint and the non-constraint groups. There was no correlation between fractional anisotropy changes in the non-lesioned hemisphere and treatment outcome. CI therapy induced cortical thickness changes in contralesional sensorimotor regions, but this effect does not appear to be driven by the immobilization of the non-paretic arm, as indicated by the absence of differences between the constraint and the non-constraint groups. Our data does not suggest that the arm immobilization used in CI therapy is associated with noticeable cortical thinning.

Photocatalytic degradation of humic acid in saline waters. Part 1. Artificial seawater: influence of TiO2, temperature, pH, and air-flow

We report the first systematic study on the photocatalytic oxidation of humic acid (HA) in artificial seawater (ASW). TiO2 (Degussa P25) dispersions were used as the catalyst with irradiation from a medium-pressure mercury lamp. The optimum quantity of catalyst was found to be between 2 and 2.5 g l(-1); whiled the decomposition was fastest at low pH values (pH 4.5 in the range examined), and the optimum air-flow, using an immersion well reactor with a capacity of 400 ml, was 850 ml min(-1). Reactivity increased with air-flow up to this figure, above which foaming prevented operation of the reactor. Using pure. oxygen, an optimal flow rate was observed at 300 nil min(-1), above which reactivity remains essentially constant. Following treatment for 1 h, low-salinity water (2700 mg l(-1)) was completely mineralised, whereas ASW (46000 mg l(-1)) had traces of HA remaining. These effects are interpreted and kinetic data presented. To avoid problems of precipitation due to change of ionic strength humic substances were prepared directly in ASW, and the effects of ASW on catalyst suspension and precipitation have been taken into account. The Langmuir-Hinshelwood kinetic model has been shown to be followed only approximately for the catalytic oxidation of HA in ASW. The activation energy for the reaction derived from an Arrhenius treatment was 17 ( +/-0.6) kJ mol(-1). (C) 2003 Elsevier Science Ltd. All rights reserved.