Neurofeedback for opioid dependent patients in an outpatient setting: a pilot feasibility study.

BACKGROUND: Neurofeedback (NF) has been described as "probably efficacious" when used in conjunction with other interventions for substance use disorders, including the recent studies in the population of individuals with opioid use disorder. Despite these promising outcomes, the seriousness of the opioid epidemic, and the high rate of relapse even with the most effective medication-assisted maintenance treatments NF continues to be an under-researched treatment modality. This article explores factors that affected the feasibility of adding Alpha/Theta Neurofeedback to treatment as usual for opioid dependence in an outpatient urban treatment center. The study strived to replicate previous research completed in Iran that found benefits of NF for opioid dependence. METHODS: Out of approximately two dozen patients eligible for Alpha/Theta NF, about 60% (n = 15) agreed to participate; however, only 2 participants completed treatment. The rates of enrollment in response to active treatment were monitored. RESULTS: The 4 factors affecting feasibility were: (1) the time commitment required of participants and providers, (2) ineffectiveness of standard incentives to promote participation, (3) delayed effects of training, and (4) the challenges of researching treatment options not reimbursed by the insurance companies. CONCLUSIONS: The findings indicate that a large-scale study examining the use of NF for the treatment of opioid use disorder in the United States will likely be difficult to accomplish without modification to the traditional randomized control study approach and suggests challenges to the implementation of this treatment in an outpatient setting. A single-case methodology is proposed as a viable alternative.

Clinical Relevance Versus Statistical Significance: Aman and Colleagues Respond to Editorial.

We would like to respond to the thought-provoking editorial by Dr. Jon McClellan1 regarding our article "Clinical Implications from the Treatment of Severe Childhood Aggression (TOSCA) Study: A Re-Analysis and Integration of Findings," published in the December 2017 issue of JAACAP.2 We address some issues on which we partially disagree, and comment on convergence of opinion.

An Examination of Fluoxetine for the Treatment of Selective Mutism Using a Nonconcurrent Multiple-Baseline Single-Case Design Across 5 Cases.

This study examined the utility of fluoxetine in the treatment of 5 children, aged 5 to 14 years, diagnosed with selective mutism who also demonstrated symptoms of social anxiety. A nonconcurrent, randomized, multiple-baseline, single-case design with a single-blind placebo-controlled procedure was used. Parents and the study psychiatrist completed multiple methods of assessment including Direct Behavior Ratings and questionnaires. Treatment outcomes were evaluated by calculating effect sizes for each participant as an individual and for the participants as a group. Information regarding adverse effects with an emphasis on behavioral disinhibition and ratings of parental acceptance of the intervention was gathered. All 5 children experienced improvement in social anxiety, responsive speech, and spontaneous speech with medium to large effect sizes; however, children still met criteria for selective mutism at the end of the study. Adverse events were minimal, with only 2 children experiencing brief occurrences of minor behavioral disinhibition. Parents found the treatment highly acceptable.

Clinical Implications From the Treatment of Severe Childhood Aggression (TOSCA) Study: A Re-Analysis and Integration of Findings.

OBJECTIVE: The Treatment of Severe Childhood Aggression (TOSCA) project examined augmentation of stimulant treatment and parent training (PT) with risperidone for severe physical aggression. This article summarizes the clinical implications; reanalyzes the data to examine the utility of 4 criteria for deciding to augment; and presents a treatment algorithm. METHOD: The newly analyzed 4 criteria for augmenting after 3 weeks of stimulant and PT treatment consisted of not meeting a Clinical Global Impressions-Improvement (CGI-I) score of 1 and a normal score (≤15) on the Nisonger Child Behavior Rating Form Disruptive-Total (D-Total); a CGI-I score of 1 or 2 plus 25% improvement in D-Total score; a D-Total score no higher than 15; and a CGI-Severity score of 3 (mild) or better. Effect sizes were calculated. Prior TOSCA publications were reviewed for clinically relevant findings. RESULTS: All 4 criteria resulted in medium or better effect sizes (d = 0.59-0.72) when comparing risperidone with placebo. Providing risperidone to children who did not reach a CGI-I score of 1 plus a D-Total score no higher than 15 resulted in the greatest benefit. In addition, a review of clinically relevant data suggests that stimulant plus PT shows further improvement after 3 weeks even without augmentation. CONCLUSION: For those children who did not attain a CGI-I score of 1 and a D-total score no higher than 15, adding risperidone maximized the number of children benefitting from treatment and the average amount of benefit. Unless clinical circumstances dictate otherwise, practitioners should delay an antipsychotic drug for at least 1 month after the optimal stimulant dose is achieved and PT has commenced. Clinical trial registration information-Treatment of Severe Childhood Aggression (The TOSCA Study); http://clinicaltrials.gov; NCT00796302.

Current state of evidence for medication treatment of preschool internalizing disorders.

Psychotropic medications are being prescribed off-label by psychiatrists to treat preschool children diagnosed with internalizing disorders. In this review, the current state of evidence is presented for medications used to treat preschool children (ages 2-5 year olds) diagnosed with anxiety and/or depressive disorders. Eleven studies were systematically identified for this review based on a priori criteria. Overall, the available literature revealed that studies addressing the medication treatment of internalizing disorders in preschoolers are extremely limited and represent relatively weak research methodologies. Given the increasing prevalence of the use of psychotropic medications to treat preschool children and the unique challenges associated with working with this population, it is imperative that mental health practitioners are aware of the current, albeit limited, research on this practice to help make informed treatment decisions. Suggestions about how to monitor potential costs and benefits in those unique cases in which psychopharmacological treatments might be considered for young children are given. Moreover, areas of additional research for this population are discussed.

Empathic and nonempathic interaction in chronic pain couples.

OBJECTIVES: Empathy and empathic response are receiving greater attention in pain research as investigators acknowledge that other forms of interaction may impact the pain process. The purpose of this study was to examine validation and invalidation as forms of empathic and nonempathic responses in chronic pain couples. METHODS: Participants were 92 couples in which at least one spouse reported chronic musculoskeletal pain. Each couple participated in 2 videotaped interactions about the ways in which the pain has impacted their lives together. Trained raters then coded interactions for each partner's use of validation and invalidation. Couples also completed surveys on spouse responses to pain, marital satisfaction, and perceived spousal support. RESULTS: Correlations demonstrated validation by spouses of persons with pain was associated with punishing, solicitous, and distracting spouse responses to pain, marital satisfaction, and perceived spousal support. In contrast, spouses' invalidation scores were correlated with punishing spouse responses. Exploratory factor analyses were then conducted to determine the extent to which spouses' responses to pain and spouse validation and invalidation loaded on similar factors. Validation and invalidation are more closely related to punishing spouse responses than to solicitous or distracting spouse responses. DISCUSSION: This work suggests that empathic and nonempathic communication are distinct from solicitous spouse responses. The findings have implications for theoretical and clinical work on social factors in pain.