Attachment Stories in Middle Childhood: Reliability and Validity of Clinical and Nonclinical Children's Narratives in a Structured Setting.

Middle childhood is one of the most understudied periods of development and lacks a gold standard for measuring attachment representations. We investigated the reliability and validity of a Dutch version of the Story-Stem Battery coded using the Little Piggy Narrative (LPN) Coding System in a clinical (N = 162) and a nonclinical group (N = 98) of 4-10-year-old children. Their attachment stories were furthermore coded using the coherence scale. Factor analyses showed that the items of the LPN system formed four attachment scales and a separate scale reflecting distress/anxiety, with sufficient internal consistency for the scales and high interrater reliability (n = 20). Furthermore, we studied construct and discriminatory validity. The attachment scores correlated with coherence and child behavioral problems in the expected direction. Results showed age and gender differences, indicating that separate norm groups are necessary. In particular, disorganized attachment, coherence and distress/anxiety differ between clinical and nonclinical children across age and gender. Results for the other three organized attachment scales were more complex. For instance, older boys from the nonclinical group had higher scores on secure attachment than their clinical peers, while girls from the clinical and nonclinical groups did not differ, even though girls in the nonclinical group had higher secure attachment scores than boys. Results are discussed in light of attachment theory and developmental pathways in middle childhood, as well as their clinical implications.

Measuring individual significant change on the Beck Depression Inventory-II through IRT-based statistics.

Several researchers have emphasized that item response theory (IRT)-based methods should be preferred over classical approaches in measuring change for individual patients. In the present study we discuss and evaluate the use of IRT-based statistics to measure statistical significant individual change on the Beck Depression Inventory-II (BDI-II, Beck, Steer, & Brown, 1996). We compare results obtained with a simple IRT-based statistical test (Z-test) to those obtained with the Reliable Change Index (RCI) in a sample of clinical outpatients. Mean group differences between the Z-test and the RCI were similar, but for some individuals change classifications differed. Differences were most evident for change scores within the lower range of depression scores. We show that this may have consequences for the measurement of individual change in psychotherapy outcome research and clinical practice.

On the factor structure of the Beck Depression Inventory-II: G is the key.

The Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996) is intended to measure severity of depression, and because items represent a broad range of depressive symptoms, some multidimensionality exists. In recent factor-analytic studies, there has been a debate about whether the BDI-II can be considered as one scale or whether subscales should be distinguished. In the present study, we applied a bifactor model to evaluate the extent to which scores reflect a single variable in a large sample of 1,530 clinical outpatients. We found that total scale score variation reflected some multidimensionality, but not enough to justify the scoring of subscales. We conclude that the BDI-II total scale score reflects a single construct and that reporting and interpreting subscale scores may result in misleading conclusions.

Changes in symptoms and interpersonal problems during the first 2 years of long-term psychoanalytic psychotherapy and psychoanalysis.

OBJECTIVES: Longitudinal measurements can provide important information regarding variations in developmental trajectories of patients in long-term treatment. The present study investigated changes in general symptoms, depression, anxiety, and interpersonal problems during the first 2 years of long-term psychoanalytic psychotherapy (PP) and psychoanalysis (PA). It was expected that interpersonal problems would diminish more slowly compared to symptomatic dysfunction. DESIGN: An accelerated longitudinal design with five consecutive measurement points across two cohorts of patients was used. METHODS: Changes on the Symptom Checklist-90-R (SCL-90-R), Beck Depression Inventory-II (BDI-II), State-Trait Anxiety Inventory (STAI), and Inventory of Interpersonal Problems-64 (IIP-64) were investigated during the first 2 years of long-term PP (n = 73) and PA (n = 40). Linear regression analysis was performed to model the different courses of improvement. RESULTS: After 2 years of treatment, patients in both groups still presented moderate to high levels of symptoms and interpersonal problems compared to non-clinical populations. As expected, interpersonal problems changed less rapidly. PP patients changed both with regard to symptomatic and interpersonal problems, whereas the only significant change in the PA group was on one of the symptomatic subscales. Slopes in the PA group and in PP group did not differ significantly from each other, except for the IIP-64 scale intrusive, with PP patients showing significantly more improvement than PA patients. The height of intake values of the outcome variables appeared to predict the speed of symptomatic recovery. CONCLUSIONS: Symptoms and interpersonal problems did not decrease notably within the first 2 years of psychoanalytic treatment. This is consistent with the idea that significant change takes time for patients with chronic mental disorders and personality pathology. In regular practice, it is advisable to monitor changes routinely in order to identify slow responders more quickly and change the treatment plan, if necessary.

The effects of long-term psychoanalytic treatment on healthcare utilization and work impairment and their associated costs.

Long-term psychoanalytic treatment is perceived as an expensive ambulatory treatment for mental illnesses. However, there are indications that psychoanalytic treatment can result in cost savings in the long term. In this study, we investigated the effects of long-term psychoanalytic treatment on healthcare utilization and work impairment and calculated the associated societal costs. We assessed healthcare utilization and work impairment of patients before, during, and after long-term psychoanalytic treatment (N=231). Our results show that the difference in total costs associated with healthcare utilization and work impairment between pre- and post-treatment was euro2444 (U.S.$3070 using average exchange rates for 2006, the year for which these data were calculated) per person per year. Two years after treatment termination, these cost savings had increased to euro3632 ($4563) per person per year. This indicates that we can expect decreased consumption of medical care and higher work productivity right after psychoanalytic treatment, but also that longterm psychoanalytic treatment can generate economical benefits in the long run. However, we cannot conclude that all invested costs will be earned back eventually. More research is needed on the cost-effectiveness of psychoanalytic treatment.

A cost-utility analysis of psychoanalysis versus psychoanalytic psychotherapy.

OBJECTIVES: Despite the considerable and growing body of research about the clinical effectiveness of long-term psychoanalytic treatment, relatively little attention has been paid to economic evaluations, particularly with reference to the broader range of societal effects. In this cost-utility study, we examined the incremental cost-effectiveness ratio (ICER) of psychoanalysis versus psychoanalytic psychotherapy. METHODS: Incremental costs and effects were estimated by means of cross-sectional measurements in a cohort design (psychoanalysis, n = 78; psychoanalytic psychotherapy, n = 104). Quality-adjusted life-years (QALYs) were estimated for each treatment strategy using the SF-6D. Total costs were calculated from a societal perspective (treatment costs plus other societal costs) and discounted at 4 percent. Psychoanalysis was more costly than psychoanalytic psychotherapy, but also more effective from a health-related quality of life perspective. The ICER--that is, the extra costs to gain one additional QALY by delivering psychoanalysis instead of psychoanalytic psychotherapy--was estimated at 52,384 euros per QALY gained. CONCLUSIONS: Our findings show that the cost-utility ratio of psychoanalysis relative to psychoanalytic psychotherapy is within an acceptable range. More research is needed to find out whether cost-utility ratios vary with different types of patients. We also encourage cost-utility analyses comparing psychoanalytic treatment to other forms of (long-term) treatment.

Clinical significance of long-term psychoanalytic treatment.

The present study evaluated the clinical significance of long-term psychoanalytic treatment in four groups of about 60 patients in different phases of treatment (before, during, after, follow-up) with normative comparisons on four symptom questionnaires (SCL-90, BDI-II, STAI, IIP-64) and two personality assessment instruments (MMPI-2, Rorschach-CS). In each group, the proportion of patients with clinically elevated scores was calculated by comparing their scores with clinical and nonclinical reference groups for each instrument. The authors also calculated a combined percentage of clinically elevated scores based on the six instruments as a conservative estimate of improvement to nonclinical levels after long-term psychoanalytic treatment. Compared to pretreatment levels, the authors found a significant decrease in the percentage of clinical cases after treatment. For the personality assessment, these results became even more evident at follow-up. It appears that long-term psychoanalytic treatment was clinically significant for patients with chronic mental disorders. In the discussion, the authors point out that the evaluation of clinical significance at group level should be followed by an examination of individual changes over a longer period of time.

Identifying clinical cases among patients assigned to psychoanalytic treatment.

The present study compared 89 patients assigned to long-term psychoanalytic psychotherapy or psychoanalysis in the Netherlands with psychiatric and nonclinical norm groups with regard to symptoms and personality pathology as assessed with six instruments. Patients filled in four self-report questionnaires (Symptom Checklist-90-Revised [SCL-90-R], Beck Depression Inventory-II [BDI-II], State-Trait Anxiety Inventory [STAI]) and underwent a personality assessment (Minnesota Multiphasic Personality Inventory-2 [MMPI-2], Rorschach-CS). The authors used statistically defined cutoff values for each measure. For each instrument separately, about 50% of the patients reported clinical levels of psychopathology, some patients being more depressed and others reporting other symptoms. By combining the test scores of the different instruments, the authors found that 91% of the patients were identified as clinical cases. Compared to psychiatric norm groups, these patients appeared to report lower levels of symptom distress, but similar levels of personality pathology. The next step will be to investigate the level of improvement after long-term psychoanalytic treatment.

Mental health characteristics of patients assigned to long-term ambulatory psychoanalytic psychotherapy and psychoanalysis in the Netherlands.

The present study investigated mental health characteristics of 170 patients assigned to long-term psychoanalytic psychotherapy (PP) versus psychoanalysis (PA) across treatment and studies. Both univariate and multivariate statistics showed that the main difference between treatments was found in the interpersonal domain. PA patients reported significantly more interpersonal problems (as measured by the Inventory for Interpersonal Problems-64), scored higher on the avoidant coping style and lower on the perceptual thinking index of the Rorschach-Comprehensive System, and scored lower on Aggressiveness and Psychoticism Minnesota Multiphasic Personality Inventory-2 PSY-5 scales compared with PP patients. Compared with psychoanalytic patients in other studies, our patients had similar levels of mental health problems, although not always in the same health areas. Limitations of the study were noted, such as the lack of outcome data and other comparison groups.

The quality of children's home environment and attachment security in Indonesia.

The authors examined the relation of the Home Observation for Measurement of the Environment (HOME) Inventory (B. M. Caldwell & R. H. Bradley, 1984) for 0- to 6-year-old Sundanese Indonesian children with the quality of the mother-child attachment relationship (n=44) and attachment-related behaviors during play interactions (n=37) and with characteristics of the Indonesian caregiving context (N=77). Results showed that infants and toddlers with secure attachment relationships lived in higher quality home environments than did children with insecure attachment relationships. In particular, children with insecure-resistant attachment relationships lived in more unsafe and less organized homes with less play material available. For preschoolers, a lower quality home environment predicted more negativity and noncompliance toward their mothers in a play setting outside the home. With regard to the caregiving context, the socioeconomic status of the family was strongly related to the quality of preschoolers' home environment. Scores on the HOME Inventory for Infants/Toddlers and the HOME Inventory for Early Childhood were related to other culture-specific contextual characteristics for 0- to 6-year old Indonesian children as well. As a whole, the HOME was a good indicator of the general quality of the Sundanese Indonesian home environment.

Preventing preschool externalizing behavior problems through video-feedback intervention in infancy.

In the present study (1) intervention effects on children's preschool behavior problems were evaluated in a high risk sample with an overrepresentation of insecure adult attachment representations in 77 first-time mothers, and (2) predictors and correlates of child problem behavior were examined. Early short-term video-feedback intervention to promote positive parenting (VIPP) focusing on maternal sensitivity and implemented in the baby's first year of life significantly protected children from developing clinical Total Problems at preschool age. Also, compared with the control group, fewer VIPP children scored in the clinical range for Externalizing Problems. No intervention effects on Internalizing clinical problem behavior were found. The VIPP effects on Externalizing and Total clinical Problems were not mediated by VIPP effects on sensitivity and infant attachment or moderated by mother or child variables. Maternal satisfaction with perceived support appeared to be associated with less children's Internalizing, Externalizing, and Total Problems. More research is needed to find the mechanisms triggered by VIPP, but the outcomes could be considered as promising first steps in the prevention of disturbing, externalizing behavior problems in young children.