Empirically supported treatments in pediatric psychology: nocturnal enuresis.

OBJECTIVE: To review the medical and psychological literature concerning enuresis treatments in light of the Chambless criteria for empirically supported treatment. METHOD: A systematic search of the medical and psychological literature was performed using Medline and Psychlit. RESULTS: Several review studies and numerous well-controlled experiments have clearly documented the importance of the basic urine alarm alone as a necessary component in the treatment of enuresis or combined with the "Dry-Bed Training" intervention, establishing them as "effective treatments." Other multicomponent behavioral interventions that also include the urine alarm such as "Full Spectrum Home Training" have further improved the outcome for bed-wetters, but are classified as "probably efficacious" at this time because independent researchers have not replicated them. Less rigorously examined approaches that focus on improving compliance with treatment or include a "cognitive" focus (i.e., hypnosis) warrant further study. CONCLUSIONS: We recommend a "biobehavioral" perspective in the assessment and treatment of bed-wetting and suggest that combining the urine alarm with desmopressin offers the most promise and could well push the already high success rates of conditioning approaches closer to 100%. Much important work is yet to be completed that elucidates the mechanism of action for the success of the urine alarm and in educating society about its effectiveness so that its availability is improved.

Empirically supported treatments in pediatric psychology: constipation and encopresis.

OBJECTIVE: To review the empirical research examining behavioral and medical treatments for constipation and fecal incontinence. METHOD: Sixty-five articles investigating intervention efficacy were identified and reviewed. Twenty-three of the studies were excluded because they were case studies or were less well-controlled single-case designs. The intervention protocol for each study was identified and coded, with studies employing the same interventions matched and evaluated according to the Chambless criteria. RESULTS: From the literature base to date, no well-established interventions have emerged. However, four probably efficacious treatments and three promising interventions were identified. Two different medical interventions plus positive reinforcement fit the criteria for the probably efficacious category (one with fiber recommendation and one without). Three biofeedback plus medical interventions fit efficacy category criteria: one probably efficacious for constipation with abnormal defecation dynamics (full medical intervention plus biofeedback for paradoxical contraction), and two fit the promising intervention criteria for constipation and abnormal defecation dynamics (full medical intervention plus biofeedback for EAS strengthening, correction of paradoxical contraction and home practice; and biofeedback focused on correction of paradoxical contraction, medical intervention without fiber recommendation, and positive reinforcement). Two extensive behavioral interventions plus medical intervention also met efficacy criteria for constipation plus incontinence (medical intervention without laxative maintenance plus positive reinforcement, dietary education, goal setting, and skills building presented in a small-group format fits criteria for a promising intervention; and positive reinforcement and skills building focused on relaxation of the EAS during defecation, but without biofeedback, plus medical intervention meets the probably efficacious criteria). CONCLUSIONS: A discussion of the current weaknesses in this research area follows. Specific recommendations for future research are made including greater clarity in treatment protocol and sample descriptions, reporting cure rates rather than success rates, utilization of adherence checks, and investigation of potential differential outcomes for subgroups of children with constipation and incontinence.

Typologies of nonadherence in cystic fibrosis.

The complex and arduous treatments required to maintain the health and prolong the life of patients with cystic fibrosis combine with other factors to create a climate within which the active following of prescribed medical treatment is often compromised. The authors' clinical experience and collection of descriptions of more than 1,200 critical incidents from 223 patients and members of their immediate families has led to the description of three basic typologies of nonadherence or noncompliance in the medical treatment of this illness. These are inadequate knowledge, psychosocial resistance, and educated nonadherence. Clinical use of this conceptual framework may enhance diagnostic and treatment efforts. Although the specific application described is concerned with cystic fibrosis, it seems reasonable to conclude that the same principles are applicable to other chronic illnesses of childhood.

A modified habit reversal procedure in a recalcitrant case of trichotillomania.

An 11-year-old girl with a severe and recalcitrant case of trichotillomania was successfully treated with a modified habit reversal procedure. Erosion estimates and serial photographic assessment methods were used to document client progress over a one-year period. Treatment effects were socially validated by attractiveness ratings of 20 same-aged children. Results extend the use of habit reversal procedures to a severe case and address the need for reliable and valid assessment procedures as well as extended follow-up.