Acceptance and Commitment Therapy versus Cognitive Behavior Therapy for Children With Anxiety: Outcomes of a Randomized Controlled Trial.

Acceptance and Commitment Therapy (ACT) has a growing empirical base in the treatment of anxiety among adults and children with other concerns. This study reports on the main outcomes of a randomized controlled trial of ACT and traditional cognitive behavioral therapy (CBT) in children with a Diagnostic and Statistical Manual of Mental Disorders (4th ed.) anxiety disorder. Participants were 193 children from urban Sydney, Australia, who were block-randomized to a 10-week group-based program of ACT or CBT or a 10-week waitlist control (WLC). Completers included 157 children (ACT = 54, CBT = 57, WLC = 46; M = 11 years, SD = 2.76; 78% Caucasian, 58% female). Pretreatment, posttreatment, and 3 months posttreatment assessments included clinician/self/parent-reported measures of anxiety, quality of life (QOL; anxiety interference, psychosocial and physical health-related QOL), and acceptance/defusion outcomes. Completer and intention-to-treat analyses revealed that ACT and CBT were both superior to WLC across outcomes, reflecting statistically and clinically significant differences, with gains maintained at 3 months posttreatment. Both completer and intention-to-treat analyses found ACT and CBT to produce similar outcomes. There was some support for ACT having greater effect sizes for QOL outcomes but not for avoidance/fusion. Although this study does not suggest that ACT is equivalent to CBT or should be adopted in its place, it does provide evidence that ACT might be another empirically supported treatment option for anxious youth. Further research is needed to replicate these findings.

Family Impact and Infant Emotional Outcomes Following Diagnosis of Serious Liver Disease or Transplantation in Infancy.

OBJECTIVES: Research is lacking into the emotional effects on families of serious chronic illness in infants. We examined the effect of the diagnosis of serious liver disease in infants upon parent psychological symptoms and family functioning. We hypothesized that parent psychological symptoms, family functioning, and father engagement will predict infant emotional outcomes. METHODS: Parents of infants recently diagnosed with serious liver disease completed validated questionnaires about parent stress, family function, impact of the illness on the family, and father engagement. The measures were repeated after 1 year, with the addition of the Child Behavior Checklist (CBCL). RESULTS: Parents of 37 infants participated. Parent stress and family functioning scores were not elevated. Parent psychological symptoms, family function, and father engagement did not predict infant outcome. For mothers, infant diagnosis other than biliary atresia, number of outpatient visits, and impact of the illness on the family explained 32% of the variation in CBCL (P = 0.001). For fathers, socioeconomic status, infant diagnosis other than biliary atresia, whether the infant had had a transplant, and impact of the illness on the family explained 44% of the variation in CBCL (P < 0.001). CONCLUSIONS: Parents and families appear to be resilient in coping with serious infant illness. Infant diagnosis other than biliary atresia and parental perceptions of high impact of the illness on the family are indicators of negative emotional outcomes for infants with serious liver disease. Psychosocial interventions for infants with chronic illness should target reducing the impact of illness on the family.

Emotion circuits differentiate symptoms of psychosis versus mania in adolescents.

The diagnostic boundary between schizophrenia and bipolar disorder can be unclear, particularly with early onset. We assessed if emotion brain circuits differentiate psychosis versus mania symptoms in a series of six early onset patients. Symptoms were dissociated by direction, awareness condition, and brain regions. Greater psychosis symptoms were correlated with greater prefrontal, anterior cingulate, amygdala, and fusiform face area activation during masked fear processing. By contrast, greater mania symptoms were correlated with less amygdala activation during unmasked fear and happy processing. This suggests emotion dysfunction in schizophrenia versus bipolar disorder may arise from partially distinct neural mechanisms of susceptibility.

Facial emotion identification in early-onset psychosis.

Facial emotion identification (FEI) deficits are common in patients with chronic schizophrenia and are strongly related to impaired functioning. The objectives of this study were to determine whether FEI deficits are present and emotion specific in people experiencing early-onset psychosis (EOP), and related to current clinical symptoms and functioning. Patients with EOP (n=34, mean age=14.11, 53% female) and healthy controls (HC, n=42, mean age 13.80, 51% female) completed a task of FEI that measured accuracy, error pattern and response time. Relative to HC, patients with EOP (i) had lower accuracy for identifying facial expressions of emotions, especially fear, anger and disgust, (ii) were more likely to misattribute other emotional expressions as fear or disgust, and (iii) were slower at accurately identifying all facial expressions. FEI accuracy was not related to clinical symptoms or current functioning. Deficits in FEI (especially for fear, anger and disgust) are evident in EOP. Our findings suggest that while emotion identification deficits may reflect a trait susceptibility marker, functional deficits may represent a sequelae of illness.

Acceptance and commitment therapy in the treatment of anxiety: a systematic review.

With a lifetime prevalence of approximately 17% among community-dwelling adults, anxiety disorders are among the most pervasive of contemporary psychiatric afflictions. Traditional Cognitive Behaviour Therapy (CBT) is currently the first line evidence-based psychosocial intervention for the treatment of anxiety. Previous research, however, has found that a significant proportion of patients do not respond to traditional CBT or exhibit residual symptomatology at treatment cessation. Additionally, there is a paucity of evidence among child populations and for the comparative effectiveness of alternative interventions. Acceptance and Commitment Therapy (ACT) has a growing empirical base demonstrating its efficacy for an array of problems. A systematic review was conducted to examine the evidence for ACT in the treatment of anxiety. PsycInfo, PsycArticles, PsycExtra, Medline and Proquest databases were searched, reference lists examined and citation searches conducted. Two independent reviewers analysed results, determined study eligibility and assessed methodological quality. Thirty-eight studies met inclusion criteria (total n=323). The spectrum of DSM-IV anxiety disorders as well as test and public speaking anxiety were examined. Studies were predominantly between-group design and case studies, with few employing control comparisons. Several methodological issues limit conclusions; however results provide preliminary support for ACT. Larger scale, methodologically rigorous trials are needed to consolidate these findings.

The presentation of early-onset psychotic disorders.

OBJECTIVE: This study aims to describe the clinical course of psychotic disorders, including the premorbid history, symptoms and level of functioning in a group of children and adolescents treated by paediatric mental health services, mainly as inpatients. METHOD: A sample of 45 children and adolescents with a psychotic disorder (mean age 13.2 years) was assessed using questionnaires, semi-structured interviews, parent interviews and file audit. The symptoms of those with a schizophrenia spectrum disorder (SSD) were compared to those with a mood disorder (MD). RESULTS: This population showed a high level of premorbid impairment, including previous treatment for other psychiatric disorders. As well as hallucinations and delusions, high levels of self-harm, aggression, anxiety and depression were reported. The SSD and MD groups differed mainly in their levels of premorbid functioning. CONCLUSIONS: While it is well known that childhood-onset schizophrenia is a severe disorder with a poor outcome, this study found that young people diagnosed with other psychotic disorders also have significant impairment and are likely to require high levels of care to maximize their functional recovery.

Risk factors for self-harm in children and adolescents admitted to a mental health inpatient unit.

OBJECTIVE: The aim of this study was to identify risk factors for self-harm for children and adolescents in a mental health inpatient unit. METHODS: A retrospective file audit of patient files over three years (2006-2009) was conducted to determine risk factors associated with self-harm in children and adolescents admitted to a mental health unit. A checklist of potential factors was based on risk factors found in a review of the literature including demographic information, diagnosis, home situation, environmental stressors, childhood trauma and previous mental health care. The study compared those who self-harmed with a control group who did not self-harm. RESULTS: There were 150 patients who self-harmed (mean age 14 years) and 56 patients who did not self-harm with a mean age of 13 years. Several factors were identified that increased the likelihood of self-harm, including a diagnosis of depression, female gender, increasing age, being Australian-born, living with a step parent, not having received previous mental health care, having a history of trauma, and having other stressors including problems within the family. CONCLUSIONS: While increasing age, female gender, a history of trauma and a diagnosis of depression are well known as risk factors for self-harm, this study confirms that family factors, in particular living with a step parent, significantly add to the risk. Child and adolescent services should be aware of the increased risk of self-harm in young people with mental health problems who live in blended families. Treatment approaches need to involve parents as well as the child or young person.

Trauma and psychotic symptoms: data from a pediatric mental health inpatient unit.

This study describes differences in symptoms in young people with psychosis, with and without a history of trauma. The files of 118 mental health inpatients, aged 8 to 18 years, all reporting hallucinations and/or delusions, were reviewed for a history of trauma. Symptoms reported by inpatients with and without a history of trauma were compared. Variables found to be significantly associated with trauma in the univariate analysis were entered into a logistic regression analysis. Variables were entered if they met a significance of p < .05 or an adjusted odds ratio of < 2. Young people with a history of trauma reported a highly significant increase in disturbed behavior, particularly those with a history of sexual assault. This study illustrates the importance of obtaining an adequate assessment of children and adolescents with psychotic symptoms to ensure they receive the most effective treatment.

Temporal trends in self harm and aggression on a paediatric mental health ward.

OBJECTIVE: The aim of this paper is to describe trends in aggression and self harm on a mental health inpatient unit for children and adolescents between January 2006 and August 2009. Various ward interventions and the ward milieu were evaluated as possible explanatory factors for trends. METHOD: This was a retrospective study whereby incidents of aggression, self harm and seclusion were obtained from a computerized Incident Information Management System (IIMS) database. Trends in incidents were analysed using linear regression analyses. RESULTS: Over a 44-month period, 292 incidents of aggression and 139 incidents of self harm were reported. The use of seclusion and the number of aggressive incidents both significantly decreased over time. Trends suggested a positive relationship between the introduction of restraint training, changes in leadership and full staff complement, and a reduction in aggression and seclusion. CONCLUSIONS: Although the findings are limited by their retrospective nature and reliance on formal records, this study suggests that different factors can contribute to decrease the incidence of adverse events on a psychiatric ward. Future prospective research is needed to assess the effectiveness of different interventions in both the prevention and management of self harm, aggression and seclusion in child and adolescent inpatient units.