My Networker Login   |   

Clinician's Digest

Rate this item
(0 votes)

Good News for Childhood AD/HD

By Garry Cooper

In the late 1990s, the large-scale Multimodal Treatment Study of Children with AD/HD (MTA) examined over a 14-month period the effectiveness of four different treatments for the disorder—a combination of medications and behavior therapy, medications alone, behavior therapy alone, and community care (essentially leaving parents on their own to use whatever treatment was available to them). The 1999 report on the study found strong differences between the effectiveness of the treatments, with the combination of medications and behavior therapy being most effective and community care being by far the least effective.

When the 14 months of treatment ended, all families were free to continue the same treatments, switch, taper off, or discontinue them without subsequent monitoring. Two years later, the gap between the effectiveness of the combination treatment and that of the others had narrowed by about 50 percent.

Now, say the researchers, who've just published the results of a three-year follow-up study of the subjects, the differences have been "completely lost"—all four groups have improved significantly and now fare equally well (albeit still not as well as non-AD/HD children). That hopeful news, says lead researcher and Columbia University psychiatrist Peter Jensen, suggests that AD/HD is highly treatable, and that the intensive combination treatment should be sustained beyond 14 months. The gap closed, he says, because many of the children in the intensively monitored groups tapered off on their care, while many of the community care group, who made little or no initial gains, switched to different, more closely supervised treatments.

The study, says Jensen, supports the use of medications in conjunction with other treatments, indicating that because of AD/HD's array of physical, social, and behavioral symptoms, neither meds nor behavioral therapy alone can deal as effectively as the combination of the two. Throughout the study's lifetime, there was considerable shifting in med use. After the initial 14 months of treatment, many in the medication groups tapered off or discontinued use of the drugs, while some subjects in the nonmedication groups began taking them. Research has found that the beneficial effects of AD/HD medications level off after a while, so the disappearing gap may also reflect the significant role played by meds at some point in treatment

This study also finds that some families gave up treatments that hadn't worked or had stopped working and tried something new, suggesting that flexibility in treatment at different stages may be effective. The primary message for clinicians is hopeful: families should know that all four treatment groups showed significant progress over time, and that intensive treatment is particularly helpful.

Eyes on Honesty

For years, faculty members of the School of Biology and Psychology at England's Newcastle University have been asked to drop money into the honesty box to pay for their coffee, tea, and milk. However, expenses have always far exceeded revenue, so researchers decided to see whether they couldn't improve the collections. Above the poster that had long listed the prices of the drinks, they added a picture of a pair of eyes staring directly down. On alternate weeks, they replaced the eyes with a picture of flowers.

Lead researcher Melissa Bateson was surprised by the difference the eyes made: revenue ran nearly three times higher under their watchful stare. The eyes had such an effect that she now thinks the experiment may have broader benefits. Adding a pair of eyes to road-safety signs or posters designed to modify antisocial behavior, she says, may increase their effectiveness. "Our brains are programmed to respond to eyes and faces, whether we're consciously aware of it or not," she says.

In 1886, philosopher Friedrich Nietzsche, no student of neurobiology, had a slightly different explanation for why the eyes worked. "Morality," he wrote, "is the fear of one's neighbors' opinions."

Beware of Internet Self-Disclosure

Most therapists are careful about the amount of personal information they share with clients, revealing something only after considerable forethought regarding the clinical implications. Yet, warns psychologist Ofer Zur, an expert on ethics and boundaries in therapy, our own discretion may not be sufficient to protect us against clients' investigations because many personal details about our lives are easily accessible on the Internet.

Clients have searched for information about their therapists for years, but the Internet provides a range of information that would make many therapists cringe. In an online article, Zur tells about a client who connected to a webcam on Catalina Island and watched her therapist and family strolling on the beach and walking around town.

Most information on the Internet about therapists is written, however—by others or by therapists themselves. To find out what clients may be learning about them, Zur recommends that therapists look themselves up regularly on several Internet search engines, using both their professional names and titles and every possible variation. They should also search for their home phone number. After all, that's what any client can do.

Many therapists, Zur says, will be dismayed at what they discover: postings they've sent to listservs, newspapers, or other online forums in both their professional and personal roles; home addresses and phone numbers; legal proceedings that they've either initiated or been subjected to; information about their families, sexual orientation, political, social, or gender views. All that is readily available. More determined clients can join social networking sites like My Space or Facebook and search for therapists' home pages, and with just a little ingenuity, they can sneak past the privacy barriers that limit viewing to approved people.

Clients can also lurk on listservs frequented by their therapists, who often let their hair down and discuss such matters as falsely giving certain diagnoses for insurance purposes or asking for consultation on a particular case. Because these postings are usually archived, their shelf life far outlives their appearance in e-mail inboxes. Although most professional listservs screen new members, the screening is so cursory that virtually anyone can establish a phony professional identity and join.

Zur's advice on the best way to avoid embarrassing Internet disclosures: ask yourself each time you post anything whether you'd want a client to read it someday. Another piece of advice is to stay abreast about what clients can find out about you on the web.

"Supportive" Friendships That Are Toxic

We've long believed that friendships help protect youths from adjustment problems, depression, and anxiety, and we've been warned to worry about depressed or anxious youngsters who lack a good friend. But a longitudinal study finds that girlfriends who coruminate—extensively rehashing their problems and dwelling on negative feelings—actually end up unhappier. Surprisingly, the study finds that isn't the case with coruminating boys. If the findings hold up, we may have to rethink the value of girls' friendships in which they extensively "support" each other in anxious or unhappy times.

In a previous study, University of Missouri psychologist Amanda Rose had found that youths in grades three through nine who coruminate tend to have close, high-quality friendships and more negative internalized symptoms, such as depression and anxiety. But that study couldn't determine whether the coruminating friendships actually contributed to the depression and anxiety. Her latest study, reported in the July issue of Developmental Psychology, tracked 813 boys and girls over six months and found that corumination among girls intensified both the friendship and the negative emotional states. For boys, corumination deepened the friendships, but didn't intensify their depression and anxiety.

Rose's study doesn't explain why this gender difference exists. She speculates, however, that girls are likelier than boys to blame themselves for their emotional difficulties or failures, which intensifies their negative feelings. Thus, when their friends support their feelings, they may also be supporting these self-blaming thoughts.

Clearly, more study needs to be done into the friendship dynamics among girls. For now, however, it seems advisable for parents to keep a closer watch on their daughters' relationships and to monitor exactly how the girls support each other. "In general," says Rose, "talking about problems and getting social support is linked with being healthy." But, she says, when some girls talk extensively about their problems, "the balance tips, and talking about problems with friends can become emotionally unhealthy."

More Therapies for Borderline Personalities

Borderline personality disorder (BPD) was once thought to be virtually impervious to psychotherapy. The reconceptualizing of BPD from a disorder that's an intractable part of personality structure to a condition highly amenable to therapy largely resulted from the effectiveness of Marsha Linehan's empirically supported Dialectical Behavior Therapy (DBT). But even before DBT, some classic psychoanalysts like Otto Kernberg insisted that therapy with BPD worked.

Like much about psychoanalytically oriented therapy, however, the news and research about Kernberg's approach, Transference-Focused Psychotherapy, was seldom accepted or heard about outside psychoanalytic circles, cementing the view that unless you were trained in DBT or didn't mind clients calling you at home or shrieking in your office, you should avoid working with BPD. Now, a study in the June American Journal of Psychiatry comparing DBT and Transference-Focused Psychotherapy with a third treatment approach, Emotionally Supportive Psychotherapy, finds that all three approaches are significantly successful after a year of treatment.

The study is especially useful for clinicians because, unlike many studies that use narrow inclusion criteria to work with "pure" conditions rarely seen in therapists' offices, this one included borderline patients who resemble the kinds of patients who typically seek treatment in community clinics. And while other studies often manualize therapies tightly, therapists in this study were encouraged to conduct treatment in their customary manner. Thus, DBT consisted of weekly individual and group therapy and psychoeducation sessions with telephone consultations as needed. Transference-Focused Psychotherapy consisted of two weekly individual sessions focusing on the emotional themes that emerged between patient and client. Emotionally Supportive Psychotherapy was offered in one weekly session that provided emotional support for facing daily problems, with additional sessions if desired.

The results revealed that although the three therapies were each effective, some worked better than others on different aspects of BPD. Although all therapies produced significant positive change in depression, anxiety, global functioning, and social adjustment, DBT and Transference-Focused Psychotherapy were more effective at decreasing suicidality. Both Transference-Focused Psychotherapy and Emotionally Supportive Psychotherapy were better at reducing impulsivity and anger. Only Transference-Focused Psychotherapy—which ultimately fared better in more domains than the other two therapies—showed significant success in reducing irritability and verbal and nonverbal assaults.

In an editorial accompanying the report, psychiatrist Glen Gabbard cautions against viewing the study as a "horse race" among the three therapies. It may be, he says, that all treatment roads lead to Rome, or at least to a suburb in its vicinity. Or there may well be differential effects, and the future of BPD treatment may lie in tailoring a specific therapy to the most troubling clinical considerations.

Pregnancy and SSRIs

Perhaps the last thing depressed pregnant women need is to have to make an important and difficult decision that may affect themselves and their prospective child for a lifetime. Yet, when it comes to deciding whether to take an SSRI antidepressant, that's what confronts them.

In addition to its profound effects on pregnant women themselves, some researchers suspect that depression directly affects the fetus. They've also found significant evidence that SSRIs taken in the first trimester can be associated with severe neurological and cardiac conditions, and other birth defects. Although the odds that an SSRI will cause those defects aren't high and the actual number of incidences is low, the link is statistically significant.

Now two studies reported in the June 28 New England Journal of Medicine might help depressed mothers decide how to treat their depression. The studies examined the effects of paroxetine (Paxil), sertraline (Zoloft), and fluoxetine (Prozac), finding that they're linked with such conditions as heart defects; craniosyntosis, a premature fusion of the skull resulting in abnormal head shape; and omphalocele, in which infants' intestines protrude from the navel. Overall though, the studies find the incidence of birth defects previously linked to SSRIs, especially cardiac defects, is lower than that reported in other studies.

One of the studies, led by Sura Alwan from the University of British Columbia, and Jennita Reefhuis of the Centers for Disease Control and Prevention, finds that when maternal obesity is coupled with the SSRIs tested, the risk of birth defects increases, so extremely overweight women might be particularly wary of taking SSRIs. Even though Paxil's association with several other birth defects doesn't achieve statistical significance in Alwan's study as it has in others, out of all the SSRIs examined by Alwan and Reefhuis, this medication comes up with the most associations. That's especially striking, says Reefhuis, given that the fewest women reported using Paxil.

Comforting odds offer scant consolation to those who lose, of course. But the relatively few depressed women who take SSRIs and whose babies are born with birth defects should remember that any pregnancy has about a three percent chance of birth defects, Reefhuis says, so they shouldn't blame themselves if, after careful consideration, they decided to take an SSRI and their baby had a problem. What would Reefhuis do if she were pregnant and deeply depressed? Before making any decision, she says, she'd talk to her doctor, psychiatrist, and gynecologist, carefully reviewing both her personal and family history of depression and birth defects. She'd consider the severity of the depression and discuss different kinds of therapy, both medical and nonmedical. Then once she'd made the decision, she'd fervently hope for the best.

Rock �n' Roll Therapy

Therapists could use a little rock 'n' roll in their offices, says psychologist Barry Farber, who insists that there's nearly as much wisdom in rock lyrics about love, depression, anger, identity, grief, freedom, money, and sex and drugs as you'll find in any psychology textbooks. His new book, Rock 'n' Roll Wisdom,offers a compendium of rock and pop lyrics for every therapeutic stage and theme.

Lyrics comprise one of our most common shared cultural experiences, says Farber. They can unlock feelings and memories, quickly helping to establish a therapeutic alliance. Like cinematherapy or bibliotherapy, they provide a safe way for clients to access their most painful or shameful thoughts. "Like any good interpretation or intervention," he says, "lyrics resonate. They're another way for a patient to understand a piece of herself."

For instance, Paul Simon mirrors what many clients think when they first come into therapy: "Like the color of my skin, or the day that I grow old, my life is made of patterns that can scarcely be controlled." And what better words to give to a client at the end of therapy than from America's Tin Man: "Oz never did give nothing to the Tin Man that he didn't . . . already have"?

Yawning in Therapy

Every therapist has strived mightily at one time or another to stifle a yawn while a client was talking. After all, yawning seems rude—a message that you're uninterested. But research from psychologists Gordon and Andrew Gallup at the University at Albany now indicates that yawning has nothing to do with boredom or disinterest. Instead, they say, it's connected to brain temperature and, in fact, may indicate that we've been paying so much attention that our overheated brains are trying to cool down. The Gallups contend that the connection of yawning to boredom—that it's an attempt to bring oxygen to our sleepy brains—has no scientific backing: researchers have tried to stimulate yawning by manipulating oxygen and carbon dioxide levels in people's bloodstreams with no success.

In two experiments presented in the online journal Evolutionary Psychology, by cooling the brain through simple, noninvasive procedures, subjects refrained from yawning even when someone else did, suggesting that cooling the brain can even overcome the well-known contagion of yawning. People who placed an ice pack on their forehead or who breathed through their noses rather than mouths didn't yawn. So the next time you feel a yawn coming on, you might try breathing through your nose (which, the Gallups say, quickly regulates the brain's temperature). And if that doesn't work, explain to your clients that your yawn means that your brain has been working extra hard at paying attention.


AD/HD Treatments:Journal of the American Academy of Child & Adolescent Psychiatry 46, no. 8 (August 2007): 989-1002. Honest Eyes: Biology Letters 2 (June 28, 2006): 412-14. Internet Disclosures: www. Toxic Friendships:Developmental Psychology 43, no. 4 (June 2007): 1019-31. Borderline Personality Treatments: American Journal of Psychiatry 164, no.1 (June 2007):1-8. Pregnancy and SSRIs: New England Journal of Medicine 356, no. 26 (June 28, 2007): 2675-92. Yawning: Evolutionary Biology 5, no. 1 (2007): 92-101.

Leave a comment (existing users please login first)