[N-of-1 trials in child and adolescent psychiatry: a closer look at stimulants]. / N=1-trials in de kinder- en jeugdpsychiatrie: gebruik van stimulantia bij ADHD.

BACKGROUND: An N-of-1 trial is a clinical trial studying the response of an individual to a particular intervention or different interventions in an objective, systematic way. AIM: To evaluate both the applications and the methodology of N-of-1 trials in child and adolescent psychiatry. METHOD: A systematic review using PubMed and Embase assessing N-of-1 trials published during the period 1986 - July 2016 with the following key-word: 'N-of-1'. RESULTS: 20 articles were included. All articles used N-of-1 trials to evaluate the effect of stimulant medications in children and adolescents with ADHD. Most articles recommended the use of the N-of-1 methodology in clinical practice, despite the large variation in methodology and in outcome interpretation of N-of-1 trials. The 20 articles didn't meet the current quality standards for N-of-1 trials. CONCLUSION: Despite the advantages of N-of-1 trials, the applications in child and adolescent psychiatry turn out to be rather limited and specific. N-of-1 trials have more to offer regarding both clinical practice and research in child and adolescent psychiatry. If the methodological recommendations are sufficiently met, N-of-1 trials could provide a useful and applicable tool for the child- and adolescent psychiatrist to offer individual patient care.

A meta-analysis of intervention effects on challenging behaviour among persons with intellectual disabilities.

BACKGROUND: Persons with intellectual disabilities (ID) often show challenging behaviour. We review distinct interventions that are applied to treat these challenging behaviours, and analyse intervention effects and moderating variables. METHODS: A literature search was conducted using the databases ERIC, PsycINFO, Web of Science and Medline. A random-effects meta-analysis was carried out, supplemented with sensitivity, subgroup, meta-regression and publication bias analyses. RESULTS: Eighty potential articles were identified, from which 30 contained sufficient data to enable statistical meta-analysis. From these 30 studies, 18 described a biological, 13 a psychotherapeutic and nine a contextual intervention, either applied alone or combined. The overall standardised mean difference was 0.671 (SD = 0.051). As shown by sensitivity analysis, this summary effect size is robust. Assessed through subgroup and meta-regression analysis, all tested moderators showed no statistically significant association with the treatment effects. After applying a funnel plot-, a fail-safe N-, and Duval's and Tweedie's trim and fill-analysis, we conclude that our meta-analysis does not suffer much from publication bias effects. CONCLUSIONS: Several biological, psychotherapeutic and contextual interventions effectively reduce challenging behaviours among persons with ID.

Depression, attribution style and self-esteem in chronic fatigue syndrome and fibromyalgia patients: is there a link?

The aims of the present study were to compare a single diagnosis (chronic fatigue syndrome, CFS) and a double diagnosis (CFS + fibromyalgia, CFS+FM) group regarding depression, attribution style and self-esteem as well as to examine whether attribution style is a mediator in the relationship between self-esteem and depression. Eighty-five patients (CFS: 47, CFS+FM: 38) completed questionnaires on attribution style, self-esteem and depression. The single and double diagnosis groups tended to differ slightly, but the differences were never statistically significant. In addition, only one condition was met of the four conditions mentioned by Baron and Kenny to establish that mediation exists between two variables. In conclusion, an external attribution style does not protect the CFS or CFS+FM patients with a low self-esteem from depression. The prevalence rate of depression was high in both patient samples, of which clinicians should be aware.

The Melbourne Family Grief Study, II: Psychosocial morbidity and grief in bereaved families.

OBJECTIVE: The aim of this study was to describe the intensity of grief, the psychosocial morbidity, and the coping patterns in members of families classified according to a typology of family functioning comprising supportive, conflict-resolving, intermediate, sullen, and hostile classes. METHOD: One hundred fifteen families were assessed longitudinally 6 weeks (time 1), 6 months (time 2), and 13 months (time 3) after the death of a parent (constituting 670 individual responses) on measures of grief intensity, psychological state, social adjustment, and family coping. A previously described typology of perceptions of family functioning was applied. Repeated measures multivariate analysis of variance based on both individuals and families and post hoc comparisons of significant results were undertaken. RESULTS: Sullen families displayed the most intense grief and the most severe psychosocial morbidity. Well-functioning families (supportive and conflict-resolving) resolved their grief and adjusted more adaptively than their dysfunctional counterparts (intermediate, sullen, and hostile families). There were no cluster-by-time interactions. The clusters accounted for 15.7% of the variance in depression (Beck Depression Inventory) and 27.9% of the variance in social functioning (Social Adjustment Scale). Well-functioning families used more family coping strategies (Family Crisis Oriented Personal Evaluation Scales). CONCLUSIONS: More intense grief and greater psychosocial morbidity are found in sullen, hostile, and intermediate bereaved families than in the more adaptive supportive and conflict-resolving types. At-risk families are identifiable and could be treated preventively to reduce morbidity.

The Melbourne Family Grief Study, I: Perceptions of family functioning in bereavement.

OBJECTIVE: The aim of this study was to identify patterns of family functioning in adult families after the death of a parent. METHOD: One hundred fifteen families completed measures of family functioning, grief, psychological state, and social adjustment 6 weeks (time 1), 6 months (time 2), and 13 months (time 3) after the death of a parent (a total of 670 individual responses). Cluster analytic methods were applied to develop a typology of perceptions of family functioning during bereavement. RESULTS: Five types of families emerged from dimensions of cohesiveness, conflict, and expressiveness on the Family Environment Scale. Thirty-six percent of the families were considered supportive because of their high cohesiveness, and another 23% resolved conflict effectively. Two types were dysfunctional: hostile families, distinguished by high conflict, low cohesiveness, and poor expressiveness, and sullen families, who had more moderate limitations in these three areas; they declined in frequency from 30% at time 1 to 15% at time 3. The remaining type (26%), termed intermediate, exhibited midrange cohesiveness, low control, and low achievement orientation. The typology at time 1 predicted typologies at time 2 and time 3. There were no age or gender differences among the family types, but offspring, as compared with spouses, were overrepresented in the hostile families. CONCLUSIONS: Family types can be identified, allowing at-risk families to be helped to prevent complications of grief. Screening with the family relationship index of the Family Environment Scale would facilitate such a family-centered approach.

Psychophysical evidence for a general temporal processing deficit in children with dyslexia.

The hypothesis of a general (i.e. cross-modal) temporal processing deficit in dyslexia was tested by examining rapid processing in both the auditory and the visual system in the same children with dyslexia. Participants were 10- to 12-year-old dyslexic readers and age-matched normal reading controls. Psychophysical thresholds were estimated for auditory gap and visual double flash detection, using a two-interval, two-alternative forced-choice paradigm. Significant group differences were found for the auditory and the visual test. Furthermore, temporal processing measures were significantly related to word and pseudo-word reading skills. As 70% of the dyslexic readers had significantly higher thresholds than controls for both auditory and visual temporal processing, the evidence tends to support the hypothesis of a general temporal processing deficit in children with dyslexia.

Comparing correlated kappas by resampling: is one level of agreement significantly different from another?

Researchers comparing diagnostic systems or screening tests frequently need to compare indices of agreement such as the kappa coefficient. While asymptotic methods exist for comparing kappas derived from independent samples, no satisfactory approach exists for comparing kappas derived from the same or related samples. Resampling methods for comparing kappa coefficients obtained from the same sample are presented. Easily undertaken using readily available software, these methods are illustrated by application to a small sample of psychiatric data, as well as to several thousand samples of simulated data. An acceptable type I error rate was exhibited. Resampling techniques-easily implemented and making few assumptions-deserve wider application in psychiatric research.

Etiopathogenesis of reflex sympathetic dystrophy: a review and biopsychosocial hypothesis.

Reflex sympathetic dystrophy (RSD) is an enigmatic condition. Many clinicians, however, believe that psychological factors could contribute to the onset and persistence of the syndrome. In this article we critically review the evidence from psychometric and psychodynamic/biographical studies that suggests a role for such factors. An etiopathogenetic hypothesis based on the authors' clinical experience and the foregoing literature also encompasses elements of stress-coping theory, cognitive-behavioral views on chronic pain, and the psychobiological approach to sympathetic nervous system dysfunction. Implications of this model for future psychological research and the therapeutic treatment of RSD are discussed.

Premorbid "overactive" lifestyle in chronic fatigue syndrome and fibromyalgia. An etiological factor or proof of good citizenship?

OBJECTIVE: In a former study, we have shown that patients suffering from chronic fatigue syndrome (CFS) or chronic pain, when questioned about their premorbid lifestyle, reported a high level of "action-proneness" as compared to control groups. The aim of the present study was to control for the patients' possible idealisation of their previous attitude towards action. METHODS: A validated Dutch self-report questionnaire measuring "action-proneness" (the HAB) was completed by 62 randomly selected tertiary care CFS and fibromyalgia (FM) patients, as well as by their significant others (SOs). RESULTS: HAB scores of the patients and those of the SOs were very similar and significantly higher than the norm values. Whether or not the SO showed sympathy for the patient's illness did not influence the results to a great extent. SOs with a negative attitude towards the illness even characterized the patients as more "action-prone." CONCLUSIONS: These results provide further support for the hypothesis that a high level of "action-proneness" may play a predisposing, initiating and/or perpetuating role in CFS and FM.

Does high 'action-proneness' make people more vulnerable to chronic fatigue syndrome? A controlled psychometric study.

Degree of premorbid 'action-proneness' was measured, using a self-administered questionnaire, in 35 patients suffering from chronic fatigue syndrome (CFS), all the members of 'ME'-self help groups and all those meeting CDC-criteria of CFS. The results were compared with those of 30 chronic idiopathic musculoskeletal pain patients, 34 patients with a chronic organic condition, and 34 neurotic patients without primary somatic complaints. Statistical analysis showed that CFS patients described themselves as significantly more 'action-prone' than the last two groups, and to a degree which was comparable with the chronic pain group. The results could not be explained by concomitant depression and are in accordance with anecdotal reports of premorbid hyperactive lifestyle in CFS patients. Further investigations seem worthwhile to test the hypothesis that hyperactivity might be a predisposing factor for chronic illness behaviour in CFS patients.

Accurate confidence intervals for measures of test performance.

The use of confidence intervals to estimate population parameters is briefly reviewed. Exact binomial confidence intervals can be calculated through the use of tables or statistical software packages. As an alternative, a microcomputer program to calculate sensitivity and specificity, point estimates and binomial confidence intervals for false-negative and -positive rate, positive and negative predictive power, prevalence of cases and non-cases, correct classification rate, and misclassification rate has also been developed. Characteristics of the computer program, 'AccuCon', which is available from the authors, are described.

Randomization tests for restricted alternating treatments designs.

Alternating Treatments Designs (ATD) with random assignment of the treatments to the measurement times provide very powerful single-case experiments. However, complete randomization might cause too many consecutive administrations of the same treatment to occur in the design. In order to exclude these possibilities, an ATD with restricted randomization can be used. In this article we provide a general rationale for the random assignment procedure in such a Restricted Alternating Treatments Design (RATD), and derive the corresponding randomization test. A software package for randomization tests in RATD, ATD and other single-case experimental designs [Van Damme & Onghena Single-case randomization tests, version 1.1, Department of Psychology, Katholieke Universiteit Leuven, Belgium] is discussed.

Parenting, family contexts, and personality characteristics in youngsters with VCFS.

Parenting, family contexts, and personality characteristics in youngsters with VCFS: The personality profiles for 48 youths with Velo-Cardio-Facial syndrome (VCFS) were described using the California Child Q-Set (CCQ). Associations between personality characteristics and parenting (i.e., Control and Warmth vs. Anger) and family contexts (i.e., Experienced Family Stress, Marital Conflict and Parental Consistency) were investigated. Personality characteristics were found to be related to parenting (in particular, Parental Warmth vs. Anger) but not to family contexts. Parents who reported more Parental Warmth (and less Anger) in interactions had children with higher Agreeableness, Conscientiousness and Emotional Stability and with lower Irritability and Dependency. Parental Control was positively related to children's Dependency and negatively to children's Conscientiousness. Compared to fathers, mothers exerted more Control. Differences in parenting and family contexts were related to the mode of inheritance but not to IQ, age, gender, and cardiac defects. Families in which a familial deletion occurred reported higher levels of Marital Conflict and lower Warmth in the parent-child interactions.

Personality profiles of youngsters with velo-cardio-facial syndrome.

The personality profile of 48 youngsters (24 males and 24 females, mean age 8 years, 5 months) with Velo-Cardio-Facial Syndrome (VCFS) was compared with a group of 240 non VCFS control youngsters (matched on age and gender), and, in addition, with groups of youngsters with Prader-Willi (PWS), Fragile X (FXS), and Williams Syndromes (WS). Personality characteristics of each youngster were rated by both parents, using the California Child Q-set (CCQ). The scores on eight personality dimensions were compared, i.e., Extraversion, Agreeableness, Conscientiousness, Emotional Stability, Openness, Motor Activity, Irritability, and Dependency. Moreover, Individual differences in personality of VCFS youngsters were related to IQ level, presence or absence of cardiac defects, and de novo versus familial origin of VCFS. The personality profile of VCFS youngsters was markedly different from all non-VCFS groups. Compared to the 240 control children, they were equally extravert and agreeable, less conscientious and emotional stable and more Irritable and dependent. Some personality characteristics in youngsters with VCFS were related to IQ and Age, but not to cardiac defects or de novo versus familial genetic origin of the 22q11 deletion.

Assessing the additional impact of fitness training in depressed psychiatric patients receiving multifaceted treatment: a replicated single-subject design.

PURPOSE: Exercise has been put forward as a therapeutic means for the treatment of clinical depression. METHODS: In this study, 29 patients, all with diagnosed with mood disorder, completed daily measurements of depression and physical well-being during periods ranging from 77 to 436 days (M = 146.5). Fitness training was added to the treatment after a period and changes before (A-phase) and after (B-phase) the implementation of this training were the subject of investigation. Data were analysed by means of randomization tests with an AB-design and time-series analysis. Replication of the findings was investigated using Fisher's multiplicative method. RESULTS: Adding fitness training to the treatment of clinical depression does not systematically lead to changes in self-reported feelings of depression on top of benefits that may be due to other treatments. CONCLUSIONS: Since the present findings are not in agreement with previous studies, the absence of statistically significant changes in self-reported feelings of depression is discussed within the complexity of the 'exercise - depression' relationship in inpatient populations. These included the severity of their depression, the potential ceiling effect of a multifaceted treatment programme and the initial increase in depression due to the confrontational nature of the intervention.

Some issues in the statistical analysis of completely randomized and repeated measures designs for speech, language, and hearing research.

Contemporary investigators in the areas of speech, language, and hearing rely heavily on inferential statistical procedures to answer both basic and applied research questions. Such statistical procedures typically involve a number of assumptions that need to be fulfilled in order for the procedure to be appropriate for a specific data set. Unfortunately, a review of recent publications in the Journal of Speech, Language, and Hearing Research indicated that some pivotal issues related to those underlying assumptions, although widely discussed and emphasized in the statistical literature, often appear to be neglected in these fields of research. This tutorial therefore addresses two issues that are particularly important for an appropriate and accurate use of some of the most commonly used statistical procedures. The first issue concerns the importance of addressing the sphericity assumption in studies with a repeated measures design. The second issue concerns the definition of the experimental units in a statistical analysis and applies to both completely randomized and repeated measures designs. Theoretical aspects associated with each issue are discussed, and appropriate strategies for data entry and analysis are presented.

An open study of sertraline in acute and continuation treatment of depressed out-patients.

The efficacy and tolerability of sertraline in 422 out-patients with major depression (DSM-III-R) was evaluated in an open multicentre 8-month study. Patients received sertraline 50 mg/day; if there was insufficient response at week 4, the dose was increased to 100 mg/day. After 8 weeks, 68.6% of patients had responded (> or = 50% reduction in Montgomery Asberg depression rating scale and clinical global impression scale scores of two or less (improvement of illness) and three or less (severity of illness); of patients receiving continuation treatment, 87.9% maintained at least a partial response at the final visit. The clinical response to the 50 mg/day dose was maintained throughout the acute treatment in 64% of patients. In all, 23% of the patients had mild or moderate drug-related gastrointestinal disturbances, which generally disappeared after 2 weeks. Only 8% of the patients withdrew because of side-effects. Just over half of the patients were taking other psychotropic drugs. Nevertheless the results of this open study are consistent with those of controlled studies in which sertraline was effective and well tolerated, in acute and continuation treatment for major depression, at 50 mg/day in most patients.

Circaseptennian (about 7-year) periodicity in the distribution of birth years of Nobel laureates for physics.

The distribution of birth years for Nobel physicists shows a circaseptennian (about 7-year) periodicity. This observation extends an earlier observation of a circaseptennian pattern in the distribution of birth years for early quantum physicists. In both categories, birth rate tends to maximize in years belonging to the (7n + 4) phase.

A multilevel meta-analysis of single-case and small-n research on interventions for reducing challenging behavior in persons with intellectual disabilities.

The effectiveness of different interventions for challenging behavior (CB) in persons with intellectual disabilities (ID) was reviewed by means of a two-phase study. First, a systematic review of 137 meta-analyses and reviews on group-study interventions for CB in persons with ID was conducted. Based on this review, hypotheses concerning the effectiveness of divergent interventions for CB and concerning the impact of variables moderating treatment effectiveness were systematically generated. Second, these hypotheses were tested by means of a multilevel meta-analysis of single-case and small-n research. Two hundred and eighty-five studies reporting on 598 individuals were examined. The average treatment effect was large and statistically significant. However, this effect varied significantly over the included studies and participants. Compared to the meta-analyses and reviews focusing on group-studies in this research domain, the results of the present multilevel meta-analysis of single-case and small-n intervention research provided more detailed knowledge on which specific CB and intervention components moderate the interventions' effectiveness.