Mediating Mechanisms in Cognitive Behavioral Therapy for Childhood OCD: The Role of Dysfunctional Beliefs.

Reframing cognitions is assumed to play an important role in treatment for obsessive-compulsive disorder (OCD). However, there hardly is any empirical support for this assumption, especially for children. The aim of this study was to examine if changing dysfunctional beliefs is a mediating mechanism of cognitive behavioral therapy (CBT) for childhood OCD. Fifty-eight children (8-18 years) with OCD received CBT. Dysfunctional beliefs (OBQ-CV) and OCD severity (CY-BOCS) were measured pre-treatment, mid-treatment, post-treatment, and at 16-week follow-up. Results showed that OCD severity and dysfunctional beliefs decreased during CBT. Changes in severity predicted changes in beliefs within the same time interval. Our results did not support the hypothesis that changing dysfunctional beliefs mediates treatment effect. Future studies are needed to replicate these findings and shed more light on the role of explicit and implicit cognitions in treatment for childhood OCD.

Low carbohydrate high fat ketogenic diets on the exercise crossover point and glucose homeostasis.

In exercise science, the crossover effect denotes that fat oxidation is the primary fuel at rest and during low-intensity exercise with a shift towards an increased reliance on carbohydrate oxidation at moderate to high exercise intensities. This model makes four predictions: First, >50% of energy comes from carbohydrate oxidation at ≥60% of maximum oxygen consumption (VO2max), termed the crossover point. Second, each individual has a maximum fat oxidation capacity (FATMAX) at an exercise intensity lower than the crossover point. FATMAX values are typically 0.3-0.6 g/min. Third, fat oxidation is minimized during exercise ≥85%VO2max, making carbohydrates the predominant energetic substrate during high-intensity exercise, especially at >85%VO2max. Fourth, high-carbohydrate low-fat (HCLF) diets will produce superior exercise performances via maximizing pre-exercise storage of this predominant exercise substrate. In a series of recent publications evaluating the metabolic and performance effects of low-carbohydrate high-fat (LCHF/ketogenic) diet adaptations during exercise of different intensities, we provide findings that challenge this model and these four predictions. First, we show that adaptation to the LCHF diet shifts the crossover point to a higher %VO2max (>80%VO2max) than previously reported. Second, substantially higher FATMAX values (>1.5 g/min) can be measured in athletes adapted to the LCHF diet. Third, endurance athletes exercising at >85%VO2max, whilst performing 6 × 800 m running intervals, measured the highest rates of fat oxidation yet reported in humans. Peak fat oxidation rates measured at 86.4 ± 6.2%VO2max were 1.58 ± 0.33 g/min with 30% of subjects achieving >1.85 g/min. These studies challenge the prevailing doctrine that carbohydrates are the predominant oxidized fuel during high-intensity exercise. We recently found that 30% of middle-aged competitive athletes presented with pre-diabetic glycemic values while on an HCLF diet, which was reversed on LCHF. We speculate that these rapid changes between diet, insulin, glucose homeostasis, and fat oxidation might be linked by diet-induced changes in mitochondrial function and insulin action. Together, we demonstrate evidence that challenges the current crossover concept and demonstrate evidence that a LCHF diet may also reverse features of pre-diabetes and future metabolic disease risk, demonstrating the impact of dietary choice has extended beyond physical performance even in athletic populations.

The adolescent outcome of children with attention deficit hyperactivity disorder treated with methylphenidate or methylphenidate combined with multimodal behaviour therapy: results of a naturalistic follow-up study.

OBJECTIVE: Children with attention deficit hyperactivity disorder (ADHD) who participated in a randomized clinical trial, which compared a brief intensive multimodal behaviour therapy combined with optimally titrated methylphenidate to optimally titrated methylphenidate alone (n = 45), were re-assessed at adolescence in a naturalistic follow-up 4.5 to 7.5 years after treatment. Also a matched normal control group was recruited (n = 23). METHODS: Assessments at follow-up included diagnostic status, ADHD symptoms, oppositional and conduct behaviour, substance abuse symptoms and parenting stress. RESULTS: Of the 24 adolescents participating in the follow-up study, 50% still met diagnostic criteria for ADHD. There were no significant differences between adolescents at follow-up and those lost for follow-up. At follow-up, adolescents in the combined treatment condition used significantly less medication than children in the methylphenidate condition; there were no other significant differences between the treatment conditions. The adolescents showed a significant decline in hyperactivity/impulsivity, oppositional and conduct disorder symptoms from post-test to follow-up. Only inattention symptoms increased from post-test to follow-up but not to pre-test levels. The adolescents originally diagnosed with ADHD fared significantly worse than the matched controls on all outcomes, except on conduct disorder and substance abuse symptoms. CONCLUSIONS: Our study shows in adolescents, diagnosed with ADHD in childhood, age-dependent decline of ADHD symptoms, although they still fared significantly worse than matched normal controls. Implications of results are restricted by small samples size, and the results may be subject to chance findings and need replication before firm conclusions can be drawn.

The association between parenting stress, depressed mood and informant agreement in ADHD and ODD.

OBJECTIVE: In Attention Deficit Hyperactivity Disorder (ADHD) agreement between parents and teachers is often low. Parental depressed mood and parenting stress are considered to decrease informant agreement. This study examined informant agreement in children with ADHD and the association between parental depressed mood, parenting stress and agreement in the ratings of ADHD, ODD and CD symptoms. METHOD: 65 parents completed questionnaires on ADHD behavior of their child, parenting stress and depressed mood, teachers reported on ADHD behavior. RESULTS: Low agreement was found for hyperactive and moderate agreement for inattentive, ODD and CD symptoms. Stepwise regression analyses showed that parenting stress, and not parental depressed mood accounted for 12% of the variance in inattention symptoms disagreement, 14% of the variance in hyperactive symptoms disagreement and 9% in oppositional behavior disagreement. No significant predictors were found for CD disagreement. The found effect was independent of stimulant medication use. CONCLUSION: Parenting stress, but not parental depressed mood, was associated with the disagreement between parents and teachers on both ADHD and ODD symptoms. These results emphasize the importance of considering parenting stress in diagnosing ADHD and comorbid ODD.

Online attentional bias modification training targeting anxiety and depression in unselected adolescents: Short- and long-term effects of a randomized controlled trial.

Based on information processing models of anxiety and depression, we investigated the efficacy of multiple sessions of online attentional bias modification training to reduce attentional bias and symptoms of anxiety and depression, and to increase emotional resilience in youth. Unselected adolescents (N = 340, age: 11-18 years) were randomly allocated to eight sessions of a dot-probe, or a visual search-based attentional training, or one of two corresponding placebo control conditions. Cognitive and emotional measures were assessed pre- and post-training; emotional outcome measures also at three, six and twelve months follow-up. Only visual search training enhanced attention for positive information, and this effect was stronger for participants who completed more training sessions. Symptoms of anxiety and depression reduced, whereas emotional resilience improved. However, these effects were not especially pronounced in the active conditions. Thus, this large-scale randomized controlled study provided no support for the efficacy of the current online attentional bias modification training as a preventive intervention to reduce symptoms of anxiety or depression or to increase emotional resilience in unselected adolescents. However, the absence of biased attention related to symptomatology at baseline, and the large drop-out rates at follow-up preclude strong conclusions.

A psychometric evaluation of the social skills rating system in children with attention deficit hyperactivity disorder.

The social skills rating system (SSRS) was developed to assess social skills of children, as observed by multiple raters (teacher, parent, child). Studies of the SSRS have been conducted with handicapped, mentally retarded and learning disabled children. No studies have reported the psychometric properties of the SSRS in a clinical ADHD sample. This is important, because deficient social functioning is associated with ADHD. The present study assesses the psychometric properties of the teacher, parent and child versions of the SSRS in children with ADHD (n = 123), and normal controls (n = 239). Also, the social skills of children with ADHD, as rated on the SSRS were examined. Results support the factor structure and internal consistency of the original SSRS-teacher version. Moreover, support was found for 3 out of 4 scales of the SSRS-parent version. The factor structure of the SSRS-child version could not be replicated. An explanatory factor analysis on the SSRS-child version yielded two factors. Evidence was found for discriminative ability of the SSRS between normal controls and children with ADHD. Finally, informant agreement between raters was found to be poor.

The influence of respiratory sounds on breathlessness in children with asthma: a symptom-perception approach.

The discordance between the objective and subjective symptoms of asthma has major effects on proper medication and management. In 2 studies the influence of respiratory sounds in the process of symptom perception underlying breathlessness was investigated in children aged 7-17 years. In Experiment 1, asthmatic wheezing sounds were recorded in 16 children during histamine-induced airway obstruction. Breathlessness correlated significantly with rank order of amount of wheezing, but not with lung function. In Experiment 2, after standardized physical exercise, 45 asthmatic and 45 nonasthmatic children were randomly assigned to (a) false feedback of wheezing, (b) quiet respiratory sounds, or (c) no sound. Asthmatic children reported significantly more breathlessness in the 1st versus the 3rd condition. In conclusion, many asthmatic children were easily influenced by wheezing in their estimation of asthma severity, reflected in breathlessness.

Self-statements of test-anxious children: thought-listing and questionnaire approaches.

Two methods of assessing cognition in high, moderate, and low test-anxious children, thought listing and self-statement questionnaire approaches, were investigated under naturalistic test-taking conditions. The amount of cognition, its content, and its relation to level of anxiety and task performance were examined. States of mind (SOM) analyses were performed. Furthermore, the comparability of findings from both methods was examined. Results showed that, relative to the questionnaire method, the thought-listing procedure underestimated positive and coping cognition. The benefits of the questionnaire approach were seen in the power of its scores to predict task performance. Implications for cognitive assessment and treatment of anxious children are discussed.

Coping self-talk and cognitive interference in anxious children.

The present study addressed the as-yet-unresolved issue of whether coping self-talk facilitates or interferes with effective task performance. Tests of the relationship between coping cognition and task performance are reported when potentially confounding relationships of negative cognition and task performance are controlled. The results indicate that coping self-talk of high-anxious children was positively correlated with negative thoughts but did not contribute significantly to performance. Implications for the functional value of coping self-talk are discussed.

Cognition in test-anxious children: the role of on-task and coping cognition reconsidered.

This study investigated cognition in children with high, moderate, and low test anxiety under naturalistic test-taking conditions. Children with high test anxiety not only reported more negative self-evaluations and more off-task thoughts but also more on-task and coping thoughts. Consistent with previous research, no "task-facilitating" role for these on-task and coping cognitions was found. This finding lends support to the notion of "the power of non-negative thinking". The only facilitating role was for positive self-evaluations. It was hypothesized that positive cognition could be task-facilitating under certain conditions. Limited support was found for this idea.

Behavioural and emotional problems in children referred to a centre for special dental care.

This study was conducted among 203 children (103 boys) referred to a centre for special dental care because of a high level of dental fear. It was undertaken to explore to what extent behavioural and emotional problems co-exist in these children compared with children of a Dutch norm group. The children's parents filled out the parental version of the Child Behaviour Checklist (CBCL), before their first appointment at the centre. The behavioural and emotional problems of the children were assessed by this CBCL, and the mean scores of the children in the study were compared with the mean scores of the norm group. The mean scores on all scales, except on the subscale 'sex problems', of the children with a high level of dental fear proved to be significantly higher than the mean scores of the norm group (P< or =0.001). The results indicated that children referred to a special dental care centre not only suffer from high dental fear but also have problems in several other behavioural and emotional areas. These problems appear to be heterogeneous; they were found in several specific problem areas, both external and internal.

The Dental Subscale of the Children's Fear Survey Schedule: a factor analytic study in The Netherlands.

The Dental Subscale of the Children's Fear Survey Schedule (CFSS-DS) is a well-known instrument for assessing dental fear in children. Previous studies have shown that the scale has acceptable reliability and validity. Factor analysis using scores of a group of Finnish schoolchildren resulted in three factors. No other data on the factor structure have been published. In order to report on the factor structure of the Dutch parental version of the CFSS-DS, the present study was undertaken. Factor analysis using scores from a group of Dutch children (n= 150) demonstrated a factor pattern fairly similar to the results found in the Finnish study. Three factors were found: 1) fear of highly invasive dental procedures, 2) fear of less invasive aspects of treatment and 3) fear of medical aspects. Considering that almost all items load substantially (> or =0.20) on more than one factor, it seems that one primary underlying dimension exists: fear of invasive treatment aspects. The CFSS-DS is proposed as a reliable, one-dimensional measure of dental fear.

On the structure of childhood dental fear, using the Dental Subscale of the Children's Fear Survey Schedule.

AIM: The aim of the present study was to assess the structure of childhood dental fear, using the Dutch parent's version of the Dental Subscale of the Children's Fear Survey Schedule (CFSS-DS) and to report on its validity. MATERIALS AND METHODS: Factor analysis (principal components, varimax rotation) was performed using the scores of a group of high fearful children (n=322). Results were compared with those from a previous study among low fearful children, also using the parent's version of the CFSS-DS. In addition, mean item scores between the samples were compared to examine specific differences. RESULTS: Factor analysis resulted in a stronger factor pattern than that found in previous research. Four factors accounting for 60% of the variance were found: 1) fear of general, less invasive aspects of dental treatment; 2) fear of medical aspects; 3) fear of drilling; 4) fear of strangers. CONCLUSION: It was concluded that with increasing fear levels, underlying factors of dental fear can be distinguished more clearly. The CFSS-DS was indicated to be a reliable and valid measure of dental fear.

Childhood dental fear in relation to parental child-rearing attitudes.

The aim of this study was to assess the relation between parental self-reported child-rearing attitudes and dental fear in children. The parents of 51 children with high dental fear and of 56 children with low dental fear, of different age groups, completed the Amsterdam version of the Parental Attitude Research Instrument. In addition, parents were asked to rate their own dental fear. Multivariate analysis of variance (child fear x parental fear x child age) showed a significant main effect only of child dental fear on parental self-complaints (p = .03). For parental dental fear, main effects were found on overprotection and on promotion of autonomy (p < or = .01). No age effects were found. Also, no relation between children's dental fear and parental dental fear was found. Based on the present findings, it was concluded that parents may play a more secondary, mediating role in the etiological process of dental fear in children.

[Children with ADHD]. / Kinderen met ADHD.

An ever increasing number of hyperactive and impulsive children receive the diagnosis Attention-Deficit Hyperactivity Disorder (ADHD). The relatively high prevalence, negative prognosis, and assumed inheritable nature of this behavioral disorder make ADHD one of the most prominent child diagnoses to date. This article discusses the behavioral characteristics, etiology, diagnostics and treatment of ADHD in school-age children. Finally, some suggestions for managing ADHD in the dental practice are given.

Visual search attentional bias modification reduced social phobia in adolescents.

BACKGROUND AND OBJECTIVES: An attentional bias for negative information plays an important role in the development and maintenance of (social) anxiety and depression, which are highly prevalent in adolescence. Attention Bias Modification (ABM) might be an interesting tool in the prevention of emotional disorders. The current study investigated whether visual search ABM might affect attentional bias and emotional functioning in adolescents. METHODS: A visual search task was used as a training paradigm; participants (n = 16 adolescents, aged 13-16) had to repeatedly identify the only smiling face in a 4 × 4 matrix of negative emotional faces, while participants in the control condition (n = 16) were randomly allocated to one of three placebo training versions. An assessment version of the task was developed to directly test whether attentional bias changed due to the training. Self-reported anxiety and depressive symptoms and self-esteem were measured pre- and post-training. RESULTS: After two sessions of training, the ABM group showed a significant decrease in attentional bias for negative information and self-reported social phobia, while the control group did not. There were no effects of training on depressive mood or self-esteem. LIMITATIONS: No correlation between attentional bias and social phobia was found, which raises questions about the validity of the attentional bias assessment task. Also, the small sample size precludes strong conclusions. CONCLUSIONS: Visual search ABM might be beneficial in changing attentional bias and social phobia in adolescents, but further research with larger sample sizes and longer follow-up is needed.

A pilot study of the efficacy of a computerized executive functioning remediation training with game elements for children with ADHD in an outpatient setting: outcome on parent- and teacher-rated executive functioning and ADHD behavior.

OBJECTIVE: This pilot study tested the short- and long-term efficacy (9 weeks follow-up) of an executive functioning (EF) remediation training with game elements for children with ADHD in an outpatient clinical setting, using a randomized controlled wait-list design. Furthermore, in a subsample, that is, those treated with methylphenidate, additive effects of the EF training were assessed. METHOD: A total of 40 children (aged 8-12 years) were randomized to the EF training or wait-list. The training consisted of a 25-session training of inhibition, cognitive flexibility, and working memory. Treatment outcome was assessed by parent- and teacher-rated EF, ADHD, oppositional deviant disorder, and conduct disorder symptoms. RESULTS: Children in the EF training showed significantly more improvement than those in the wait-list condition on parent-rated EF and ADHD behavior in the total sample and in the subsample treated with methylphenidate. Effects were maintained at follow-up. CONCLUSION: This pilot study shows promising evidence for the efficacy of an EF training with game elements.

Prepotent response inhibition predicts treatment outcome in attention deficit/hyperactivity disorder.

OBJECTIVE: Inhibition deficits, including deficits in prepotent response inhibition and interference control, are core deficits in ADHD. The predictive value of prepotent response inhibition and interference control was assessed for outcome in a 10-week treatment trial with methylphenidate. METHODS: Thirty-four children with ADHD (ages 8-12) received 10 weeks of methylphenidate treatment. At pretest prepotent response inhibition was assessed using the Stop-Signal Task; interference control was assessed using the Stroop Color-Word task. Methylphenidate was individually titrated to an optimal dose. Treatment outcome was assessed by parent- and teacher-rated ADHD behavior. RESULTS: Only stop-signal reaction time of the Stop-Signal Task was a significant predictor of parent-rated levels of inattention and hyperactivity/impulsivity at outcome. Children with lower levels of inhibition showed worse outcome after 10 weeks of treatment, independent of medication dose. CONCLUSIONS: Low levels of prepotent response inhibition are associated with worse response to treatment with methylphenidate. Prepotent response inhibition may be an intermediate phenotypical predictor of treatment outcome.