Fathers and Asthma Care: Paternal Involvement, Beliefs, and Management Skills.

OBJECTIVE: To compare asthma care roles of maternal and paternal caregivers, and examine associations between caregiver involvement and the outcomes of adherence, morbidity, and parental quality of life (QoL). METHODS: Mothers and fathers in 63 families of children, ages 5-9 years, with persistent asthma completed semistructured interviews and questionnaires. Adherence was measured via electronic monitoring. Paired t tests compared parental asthma care roles, and analysis of covariance, controlling for socioeconomic status, evaluated associations of asthma outcomes with caregiver involvement scores. RESULTS: Mothers had higher scores on measures of involvement, beliefs in medication necessity, and on four subscales of the Family Asthma Management System Scale interview (Asthma Knowledge, Relationship with Provider, Symptom Assessment, and Response to Symptoms). Maternal QoL was lowest when both maternal and paternal involvement was high. Paternal involvement was associated with increased morbidity. CONCLUSIONS: There is room for enhancement of fathers' asthma care roles. Higher levels of paternal involvement may be driven by family need.

Measuring outcomes in outpatient child psychiatry: reliable improvement, deterioration, and clinically significant improvement.

Given the increasing interest in demonstrating effectiveness in psychiatric treatment, the current paper seeks to advance outcome measurement in child psychiatry by demonstrating how more informative analytic strategies can be used to evaluate treatment in a real world setting using a brief, standardized parent-report measure. Questionnaires were obtained at intake for 1294 patients. Of these, 695 patients entered treatment and 531 (74%) had complete forms at intake and follow-up. Using this sample, we analyzed the data to determine effect sizes, rates of reliable improvement and deterioration, and rates of clinically significant improvement. Findings highlighted the utility of these approaches for evaluating treatment outcomes. Further suggestions for improving outcome measurement and evaluation are provided.

Clinicians' utilization of child mental health telephone consultation in primary care: findings from Massachusetts.

OBJECTIVE: The authors examined utilization of the Massachusetts Child Psychiatry Access Project, a mental health telephone consultation service for primary care, hypothesizing that greater use would be related to severe psychiatric diagnoses and polypharmacy. METHODS: The authors examined the association between utilization, defined as the mean number of contacts per patient during the 180 days following the initial contact (July 2008-June 2009), and characteristics of the initial contact, including consultation question, the child's primary mental health problem, psychotropic medication regimen, insurance status, and time of year. RESULTS: Utilization (N=4,436 initial contacts, mean=3.83 contacts) was associated with initial contacts about medication management, polypharmacy, public and private health insurance, and time of year. The child's primary mental health problem did not predict utilization. CONCLUSIONS: Telephone consultation services address treatment with psychotropic medications, particularly polypharmacy. Joint public-private funding should be considered for such public programs that serve privately insured children.

Medico-legal risk associated with pediatric mental health telephone consultation programs.

Clinicians providing consultation through mental health telephone consultation programs express concern about the potential legal risk of the practice. In this survey of six state mental health telephone consultation program directors, we report the annual number of children referred for consultation and the number of lawsuits against consultant clinicians. Between 2004 and 2010, 3,652 children per year were referred nationally, and there were no medical malpractice lawsuits against clinicians related to telephone consultation program activity. Although medico-legal risk is always present, the findings of this national study suggest the risk for clinicians providing mental health telephone consultation may be lower than perceived.

Using brief clinician and parent measures to track outcomes in outpatient child psychiatry: longer term follow-up and comparative effectiveness.

BACKGROUND: This study explored the feasibility and validity of using brief clinician- and parent-rated measures routinely over 6 months in outpatient child psychiatry. METHOD: All patients under 18 years of age seen for intake in the Child Psychiatry Clinic from 1 August 2007 through 31 July 2010 were eligible for inclusion in the study. Data were collected at intake for 1033 patients and at 3- and 6-month follow-up. RESULTS: ANOVA for repeated measures showed statistically significant improvements in total and subscale scores on all three measures (Brief Psychiatric Rating Scale for Children, Children's Global Assessment Scale, and Pediatric Symptom Checklist) at both second and third assessments. CONCLUSION: The fact that both broadband and narrowband scales showed significant improvements over the first 6 months of care establishes the possibility that these measures could be used in experimental designs studying comparative effectiveness.

Measuring outcomes in outpatient child psychiatry: the contribution of electronic technologies and parent report.

The objective of this study was to evaluate the impact of electronic technologies on the completion of a standardized rating form in an outpatient child psychiatry clinic, and the feasibility of adding a parent-report measure to the form. An electronic Outcomes Rating Form (e-ORF) was used in conjunction with a web-based patient tracking system and digital pens which allowed form data to be directly entered into a database. Clinician forms were collected for 87% of the 248 children seen for intake, a significant increase over the rate of 72% obtained in the same clinic with paper forms. Rating forms were also obtained from 85% of parents. Clinician- and parent-completed measures were moderately correlated with each other. This study showed that 1) the use of electronic technologies is associated with improved clinician completion rates; 2) it is possible to obtain rating forms from most parents; 3) clinician and parent measures provide related but distinct information; and 4) improvements in functioning found with clinician-report measures are corroborated by independent parent reports.

Improving access to mental health care for children: the Massachusetts Child Psychiatry Access Project.

BACKGROUND: Inadequate access to care for mentally ill children and their families is a persistent problem in the United States. Although promotion of pediatric primary care clinicians (PCCs) in detection, management, and coordination of child mental health care is a strategy for improving access, limitations in training, time, and specialist availability represent substantial barriers. The Massachusetts Child Psychiatry Access Project (MCPAP), publicly funded with 6 regional consultation teams, provides Massachusetts PCCs with rapid access to child psychiatry expertise, education, and referral assistance. METHODS: Data collected from MCPAP teams measured participation and utilization over 3.5 years from July 1, 2005, to December 31, 2008. Data were analyzed for 35,335 encounters. PCC surveys assessed satisfaction and impact on access to care. RESULTS: The MCPAP enrolled 1341 PCCs in 353 practices covering 95% of the youth in Massachusetts. The MCPAP served 10,114 children. Practices varied in their utilization of the MCPAP, with a mean of 12 encounters per practice per quarter (range: 0-245). PCCs contacted the MCPAP for diagnostic questions (34%), identifying community resources (27%), and consultation regarding medication (27%). Provider surveys revealed improvement in ratings of access to child psychiatry. The rate of PCCs who reported that they are usually able to meet the needs of psychiatric patients increased from 8% to 63%. Consultations were reported to be helpful by 91% of PCCs. CONCLUSIONS: PCCs have used and value a statewide system that provides access to teams of psychiatric consultants. Access to child mental health care may be substantially improved through public health interventions that promote collaboration between PCCs and child mental health specialists.

Prospective study of health-related quality of life and restorative proctocolectomy in children.

PURPOSE: Although restorative proctocolectomy has become the standard surgical treatment for ulcerative colitis and familial adenomatous polyposis, there are no prospective studies in children of the impact of this intervention on health-related quality of life. METHODS: A prospective study of health-related quality of life in children with ulcerative colitis or familial adenomatous polyposis undergoing restorative proctocolectomy was performed. Patients and their parents who agreed to participate completed standardized health-related quality-of-life surveys (Medical Outcomes Study Short Form-36 and Child Health Questionnaire Parent Form) within one month before colectomy and approximately one year after completion of their surgery. RESULTS: Of the 60 patients who agreed to participate, 44 completed surveys at the appropriate time periods allowing comparison. The parents of 28 of these subjects also completed paired surveys. Before colectomy, patients with ulcerative colitis had substantially lower health-related quality-of-life scores, which were also mirrored in parental surveys. Following surgery patients with ulcerative colitis had significant improvement in 7 of 8 Medical Outcomes Study Short Form-36 patient subscales and all 6 corresponding Child Health Questionnaire Parent Form parental subscales of health-related quality of life. Patients with familial adenomatous polyposis showed improvement in the bodily pain subscale alone, whereas their corresponding parental surveys only showed improvement in the mental health subscale. CONCLUSION: There are clearly significant adverse affects on health-related quality of life in children with ulcerative colitis that dramatically improved following restorative proctocolectomy.

Cognitive behavioral therapy for 4- to 7-year-old children with anxiety disorders: a randomized clinical trial.

OBJECTIVE: To examine the efficacy of a developmentally appropriate parent-child cognitive behavioral therapy (CBT) protocol for anxiety disorders in children ages 4-7 years. DESIGN: Randomized wait-list controlled trial. Conduct: Sixty-four children (53% female, mean age 5.4 years, 80% European American) with anxiety disorders were randomized to a parent-child CBT intervention (n = 34) or a 6-month wait-list condition (n = 30). Children were assessed by interviewers blind to treatment assignment, using structured diagnostic interviews with parents, laboratory assessments of behavioral inhibition, and parent questionnaires. ANALYSIS: Chi-square analyses of outcome rates and linear and ordinal regression of repeated measures, examining time by intervention interactions. RESULTS: The response rate (much or very much improved on the Clinical Global Impression Scale for Anxiety) among 57 completers was 69% versus 32% (CBT vs. controls), p < .01; intent-to-treat: 59% vs. 30%, p = .016. Treated children showed a significantly greater decrease in anxiety disorders (effect size [ES] = .55) and increase in parent-rated coping (ES = .69) than controls, as well as significantly better CGI improvement on social phobia/avoidant disorder (ES = .95), separation anxiety disorder (ES = .82), and specific phobia (ES = .78), but not on generalized anxiety disorder. Results on the Child Behavior Checklist Internalizing scale were not significant and were limited by low return rates. Treatment response was unrelated to age or parental anxiety but was negatively predicted by behavioral inhibition. Gains were maintained at 1-year follow-up. CONCLUSIONS: Results suggest that developmentally modified parent-child CBT may show promise in 4- to 7-year-old children.

Cognitive-behavioral intervention with young anxious children.

Despite evidence that preschool and early elementary school-age children can present with anxiety disorders that may put them at risk for later psychopathology and dysfunction, the cognitive-behavioral protocols available for treating anxiety in children have been tested almost exclusively in older children. However, there could be benefits to treating children earlier, before anxiety disorders begin to impair their social and academic development. This report discusses the adaptations necessary in providing cognitive-behavioral therapy to young anxious children and describes a manualized, cognitive-behavioral intervention, with child and parent components, that was piloted openly in nine families with children aged 4 to 7 years - each of whom had multiple risk factors for developing anxiety disorders, and most of whom had already presented with anxiety disorders. Eight of the nine children were judged "much" or "very much improved" at postintervention on number of anxiety diagnoses, number of DSM-IV anxiety symptoms, and ability to cope with feared situations. Cases are presented to illustrate the way that cognitive-behavioral therapy can be conducted with youngsters in this age range. Whereas randomized, controlled trials are needed to confirm the efficacy of this manualized treatment, our experience suggests that cognitive-behavioral protocols for anxiety can be adapted and successfully implemented with young children.

Prospective open-label pilot trial of mirtazapine in children and adolescents with social phobia.

Mirtazapine is indicated for major depression and used for anxiety in adults; however, little is known about its application in pediatric populations. This is an 8-week open-label pilot study of mirtazapine in children with social phobia age 8-17 years. Primary outcomes were symptom improvement based on clinician rating and self-report, as well as tolerability based on rates of discontinuation due to adverse effects. Fifty-six percent (10/18) responded to treatment, 17% (3/18) achieved full remission. Social phobia symptoms improved significantly during the first 2 weeks of treatment, as did comorbid symptoms of depression and anxiety. Eleven patients (61%) did not complete all 8 weeks of treatment; four patients (22%) discontinued due to adverse effects including fatigue and irritability. The others discontinued due to study burden (28%), insufficient response (6%), or to pursue herbal treatment (6%). Significant weight gain was observed. Larger controlled trials are needed to further evaluate efficacy and safety.

Botulinum toxin A: a novel adjunct treatment for debilitating habit cough in children.

Vocal fold injection with botulinum toxin type A (BTX-A) may be used as an adjunct treatment for habit cough in children. We conducted a retrospective review of 3 cases involving children aged 11 to 13 years with habit cough treated with vocal fold injection of BTX-A. Injections of BTX-A to the thyroarytenoid muscles were effective in breaking the cough cycle in all 3 children. Their coughs recurred but were controlled with 4 to 8 sessions of behavioral therapy. Behavioral therapy remains the first-line treatment, but BTX-A may be a useful complement to behavioral therapy in patients who fail standard treatments or in those with severe cough who have limited or delayed access to mental health professionals. This is the first report, to our knowledge, on the use of BTX-A in the treatment of a habit cough.

Exploring the hand test with medically ill children and adolescents.

Pediatric psychologists use the tools of assessment to evaluate the psychological functioning of youth with chronic and acute medical illnesses. This study is an exploration of the use of a performance-based measure, the Hand Test (HT; Wagner, 1983), with pediatric medical patients. A sample of medical inpatients (n = 27) and psychiatric outpatients (n = 24) were administered the HT, a self-report measure, and a parent-report behavior rating scale. Results indicate that the psychiatric group scored higher than the medical group on HT Aggression, Withdrawal, and Pathological scores. The Aggression (d = 0.90) and Pathological (d = 0.80) variables were particularly robust in differentiating between groups, but the Crippled variable did not differ between groups. Hierarchical logistic regression demonstrated the incremental validity of the HT over behavior ratings alone in the classification of clinical groups. Analyses indicated that the HT can add important information in the differentiation of medically ill children from those with psychological disturbance.

Psychological, behavioral, and family characteristics of pediatric patients with chronic pain: a 1-year retrospective study and cluster analysis.

OBJECTIVES: There has been a longstanding recognition that adult patients with chronic pain are not a homogenous population and that there are subgroups of patients who report high levels of distress and interpersonal difficulties as well as subgroups of patients who report little distress and high functioning. The purpose of the present study was to attempt to identify similar subgroups in a pediatric chronic pain population. METHODS: The sample consisted of 117 children with chronic pain and their parents who were assessed in a multidisciplinary pain clinic during 2001. Participants completed a set of psychologic self-report questionnaires, as well as demographic and pain characteristic information. A cluster analysis was conducted to identify 3 distinct subgroups of patients to replicate similar studies of adult chronic pain sufferers. RESULTS: Overall, mean scores were within population norms on measures of distress and family functioning, with somatic symptoms at a level of clinical significance. The cluster analysis identified the 3 subgroups that were strikingly similar to those identified in adult chronic pain populations: one with high levels of distress and disability, another with relatively low scores on distress and disability, and a third group that scored in between the other 2 on these measures but with marked low family cohesion. DISCUSSION: The similarity of these subgroups to the adult chronic pain population subgroups as well as implications for future studies are discussed.

Physical therapy and cognitive-behavioral treatment for complex regional pain syndromes.

Complex regional pain syndromes (CRPS; type 1, reflex sympathetic dystrophy, and type 2, causalgia) involve persistent pain, allodynia, and vasomotor signs. We conducted a prospective, randomized, single-blind trial of physical therapy (PT) and cognitive-behavioral treatment for children and adolescents with CRPS. Children 8 to 17 years of age (n = 28) were randomly assigned to either group A (PT once per week for 6 weeks) or group B (PT 3 times per week for 6 weeks). Both groups received 6 sessions of cognitive-behavioral treatment. Assessments of pain and function were repeated at two follow-up time periods. Outcomes were compared at the three time points through the use of parametric or nonparametric analysis of variance and post hoc tests. All five measures of pain and function improved significantly in both groups after treatment, with sustained benefit evident in the majority of patients at long-term follow-up. Recurrent episodes were reported in 50% of patients, and 10 patients eventually received sympathetic blockade. Most children with CRPS showed reduced pain and improved function with a noninvasive rehabilitative treatment approach. Long-term functional outcomes were also very good.

A controlled study of minimal-contact thermal biofeedback treatment in children with migraine.

OBJECTIVE: To evaluate the effectiveness of handwarming biofeedback (HWB) and stress management training in comparison to attention (handcooling, HCB) and wait-list control groups. Thermal biofeedback has been used in many pediatric migraine treatment studies and has demonstrated a consistent therapeutic effect. No published studies to date have compared this treatment modality with credible attention control using biofeedback technology. METHODS: Thirty-six children and adolescents (mean age: 12.8 years), as well as the mothers and fathers of these children enrolled in the study, were randomly assigned to the three groups. Thirty-four children completed treatment. Both treatment groups received four sessions of biofeedback training and a portable biofeedback device for home practice. Ratings of treatment credibility showed that the children rated the two treatments as equally credible. Assessment included anxiety and depression questionnaires for the children and both of their parents. RESULTS: Children who had been assigned to the HWB group were more likely to achieve clinical improvement in migraine after treatment than the children in the HCB group. Treatment gains were maintained up to 6 months after treatment. Home practice data reflected a general increase in temperature in the HWB group and a decrease in temperature for the HCB group. CONCLUSIONS: The results of this study confirm the findings of earlier pediatric migraine biofeedback treatment studies and also provide support for the specific effect of treatments including stress management and HWB. Future studies with larger sample sizes will aid in delineating the appropriateness of HCB as a control treatment.