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Objective: To evaluate the efficacy of attachment-based family therapy (ABFT) compared with a family-enhanced nondirective supportive therapy (FE-NST) for decreasing adolescents’ suicide ideation and depressive symptoms. Method: A randomized controlled trial of 129 adolescents who are suicidal ages 12- to 18-years-old (49% were African American) were randomized to ABFT (n = 66) or FE-NST (n = 63) for 16 weeks of treatment. Assessments occurred at baseline and 4, 8, 12, and 16 weeks. Trajectory of change and clinical recovery were calculated for suicidal ideation and depressive symptoms. Results: There was no significant between-group difference in the rate of change in self-reported ideation (Suicidal Ideation Questionnaire-Jr; F1,127 = 181, p = .18). Similar results were found for depressive symptoms. However, adolescents receiving ABFT showed a significant decrease in suicide ideation (t127 = 12.61, p < .0001; effect size, d = 2.24). Adolescents receiving FE-NST showed a similar significant decrease (t127 = 10.88, p < .0001; effect size, d = 1.93). Response rates (ie, ≥50% decrease in suicide ideation symptoms from baseline) at post-treatment were 69.1% for ABFT versus 62.3% for FE-NST. Conclusion: Contrary to expectations, ABFT did not perform better than FE-NST. The 2 treatments produced substantial decreases in suicidal ideation and depressive symptoms that were comparable to or better than those reported in other more intensive, multicomponent treatments. The equivalent outcomes could be attributed to common treatment elements, different active mechanisms, or regression to the mean. Future studies will explore long-term follow up, secondary outcomes, and potential moderators and mediators. Clinical trial registration information: Attachment-Based Family Therapy for Suicidal Adolescents; http://clinicaltrials.gov; NCT01537419. Published (Publication status)

In psychotherapy research, adherence refers to the extent to which therapists deliver a treatment as intended. This study examined whether therapist adherence to two different manualized treatments was associated with improved client outcomes and whether the association was moderated by therapeutic alliance. The study sample included 320 video recordings of therapy sessions from 118 cases in a randomized controlled trial (RCT) comparing attachment-based family therapy (ABFT) with family-enhanced nondirective supportive therapy (FE-NST). Recordings were selected from early, middle, and late stages of treatment. The adherence measure consisted of 24 items representing essential therapist interventions from both treatments. Trained raters coded tapes from both therapies. Adolescent self-report of alliance was measured at session 4. Adherence to ABFT was associated with a significant increase in family cohesion at mid-treatment but not at posttreatment. Adherence to FE-NST was significantly associated with an increase in suicide ideation posttreatment. Using therapeutic alliance as a moderator, adherence to ABFT was significantly associated with a reduction in suicide ideation, family conflict, and higher client satisfaction posttreatment. Alliance did not positively affect the association of FE-NST adherence to outcomes. Findings suggest that adherence to ABFT interventions may be better linked to treatment outcomes when adolescents feel a strong alliance with their therapist. Implications for future research and therapist training are explored.En la investigación sobre psicoterapia, la adhesión se refiere al grado en el cual los terapeutas brindan un tratamiento según lo previsto. Este estudio analizó si la adhesión del terapeuta a dos tratamientos estandarizados diferentes estuvo asociada con mejores resultados en los pacientes y si la asociación estuvo moderada por la alianza terapéutica. La muestra del estudio incluyó 320 videograbaciones de sesiones de terapia de 118 casos en un ensayo aleatorizado controlado donde se comparó la terapia familiar basada en el apego (TFBA) con la terapia de apoyo no directiva optimizada por la familia (TAND-OF). Se eligieron grabaciones de las etapas iniciales, intermedias y finales del tratamiento. El instrumento de medición de la adhesión consistió en 24 ítems que representaban intervenciones esenciales del terapeuta de ambos tratamientos. Un grupo de calificadores capacitados codificaron las grabaciones de ambas terapias. El autoinforme de alianza de los adolescentes se midió en la cuarta sesión. La adhesión a la TFBA estuvo asociada con un aumento considerable de la cohesión familiar en la mitad del tratamiento, pero no después del tratamiento. La adhesión a la TAND-OF estuvo asociada considerablemente con un aumento de la ideación suicida después del tratamiento. Utilizando la alianza terapéutica como moderadora, la adhesión a la TFBA estuvo asociada considerablemente con una reducción de la ideación suicida, el conflicto familiar y una mayor satisfacción del paciente después del tratamiento. La alianza no afectó positivamente la asociación de la adhesión a la TAND-OF con los resultados. Los resultados sugieren que la adhesión a las intervenciones de TFBA puede asociarse mejor con los resultados del tratamiento cuando los adolescentes sienten una alianza fuerte con su terapeuta. Se analizan las implicancias para futuras investigaciones y para la capacitación de los terapeutas.在心理治疗研究中,治疗一致性是指治疗师按照预设方案提供治疗的程度。本研究考察了治疗师自始至终地执行两种不同的遵循手册式的治疗是否与改善病人治疗结果相关,以及治疗联盟是否调节了这种关联性。研究样本包括来自118例随机对照试验(RCT)的320个治疗过程的视频记录, 试验比较了基于依恋的家庭治疗(ABFT)和家庭赋能强化的非指导性的支持治疗(FE-NST) 这两种方式。从治疗的早期、中期和晚期选取视频记录。治疗一致性措施由24个项目组成, 代表两种治疗手段中的基本的治疗师干预。训练有素的评价员对两种疗法的视频进行编码。在第4阶段测量了青少年关于联盟的自我报告。忠实执行ABFT与治疗中期的家庭凝聚力显著增加有关联, 但治疗后并没有。遵循FE-NST的治疗与治疗后自杀意念增加显著相关。以治疗联盟作为调节因子, 坚持ABFT与治疗后自杀意念的减少、家庭冲突减少和更高的病人满意度显著相关。联盟对FE-NST坚持治疗的一致性结果没有积极影响。研究结果表明, 当青少年感觉与他们的治疗师有很强的联盟时, 坚持ABFT干预可能与治疗结果有更好的联系。本文对未来的研究和治疗师培训的启示都进行了探讨。.

This article describes the application of Attachment-Based Family Therapy (ABFT) to the treatment of a 13-year-old female adolescent presenting with high risk of suicide, complicated by a history of depression and sexual trauma. The article begins with an overview of ABFT, including (a) how attachment theory guides treatment; (b) the structure of the clinical model; and (c) the data that provide empirical support. A case example is then presented that exemplifies the primary clinical procedures used to reach therapeutic goals in ABFT, including attachment repair and autonomy/competence promotion. Weekly changes in suicide ideation and depression scores are presented. The article concludes with a discussion about implications for family-based treatment of suicidal youth.

Objective To evaluate whether Attachment-Based Family Therapy (ABFT) is more effective than Enhanced Usual Care (EUC) for reducing suicidal ideation and depressive symptoms in adolescents. Method This was a randomized controlled trial of suicidal adolescents between the ages of 12 and 17, identified in primary care and emergency departments. Of 341 adolescents screened, 66 (70% African American) entered the study for 3 months of treatment. Assessment occurred at baseline, 6 weeks, 12 weeks, and 24 weeks. ABFT consisted of individual and family meetings, and EUC consisted of a facilitated referral to other providers. All participants received weekly monitoring and access to a 24-hour crisis phone. Trajectory of change and clinical recovery were measured for suicidal ideation and depressive symptoms. Results Using intent to treat, patients in ABFT demonstrated significantly greater rates of change on self-reported suicidal ideation at post-treatment evaluation, and benefits were maintained at follow-up, with a strong overall effect size (ES = 0.97). Between-group differences were similar on clinician ratings. Significantly more patients in ABFT met criteria for clinical recovery on suicidal ideation post-treatment (87%; 95% confidence interval [CI] = 74.6–99.6) than patients in EUC (51.7%; 95% CI=32.4–54.32). Benefits were maintained at follow-up (ABFT, 70%; 95% CI=52.6–87.4; EUC 34.6%; 95% CI=15.6–54.2; odds ratio=4.41). Patterns of depressive symptoms over time were similar, as were results for a subsample of adolescents with diagnosed depression. Retention in ABFT was higher than in EUC (mean = 9.7 versus 2.9). Conclusions ABFT is more efficacious than EUC in reducing suicidal ideation and depressive symptoms in adolescents. Additional research is warranted to confirm treatment efficacy and to test the proposed mechanism of change (the Family Safety Net Study). Clinical Trial Registry Information: Preventing Youth Suicide in Primary Care: A Family Model, URL: http://www.clinicaltrials.gov, unique identifier: NCT00604097.

OBJECTIVE. The objective of this study was to estimate from a random urine drug-testing program for adolescents the proportion of drug tests that are susceptible to interpretation errors. METHODS. This was a secondary analysis of a clinical database and chart review from an adolescent outpatient substance abuse program at a large children's hospital. We analyzed from 110 adolescent patients (13–21 years of age) all 710 urine drug test results that were collected between December 2002 and July 2005 and 85 original laboratory reports for tests that were collected between December 2002 and May 2006 and were confirmed positive for opioids. We calculated the percentage of tests that were too dilute to interpret (potential false-negatives) and the percentage of confirmed positive tests for oxycodone that did not result in a positive initial screen (potential false-negatives). We also reviewed clinical information to determine whether confirmed positive tests resulted from legitimate use of prescription or over-the-counter medication (potential false-positives). RESULTS. Of 710 drug tests, 40 negative tests were too dilute to interpret properly, and 45 of 217 positive tests resulted from prescription medication use for a total of 85 tests that were susceptible to error. Of the 85 confirmatory laboratory reports reviewed, 43 were positive for oxycodone, but only 16 of these had produced a positive opiate screen. CONCLUSIONS. Unless proper procedures are used in collecting, analyzing, and interpreting laboratory testing for drugs, there is a substantial risk for error.

Purpose To determine (1) whether physicians agree with recommendations for home and school drug screening, (2) under what circumstances physicians recommend urine drug tests for adolescents, and (3) how physicians manage adolescent patients with positive results. Few clinical practice guidelines have been published on urine drug testing of adolescents, and it is not known when physicians recommend this procedure or how they manage positive results. Methods Multi-modal survey of a nationally representative sample of physicians conducted April–July 2004. We computed simple frequencies and used backwards selection logistical regression to determine if there were differences in agreement or practices among physicians from different specialties (pediatrics, family medicine, adolescent medicine) or by demographic factors (physician age, gender, practice type or location). Results A total of 359 physicians (43% after eliminating ineligibles) completed the survey. Thirty-eight percent would recommend a drug test if were required to return to school, 41% if a parent was concerned, and 46% based on history (without a parent's concern). Forty-eight percent of physicians would share a positive drug test result with parents. A large majority (83%) disagreed with high school drug testing programs. Conclusions There is little consensus among physicians regarding the indications for drug testing in the general medical clinic. However, most disagree with school drug testing programs. There is little consistency among physicians in how to proceed when a urine drug test is positive. Professional organizations should consider publishing clinical practice guidelines in order to assist physicians in using this procedure effectively.

OBJECTIVES: The goals were to develop and to validate the Internet-based, Behavioral Health Screen (BHS) for adolescents and young adults in primary care. METHODS: Items assessing risk behaviors and psychiatric symptoms were built into a Internet-based platform with broad functionality. Practicality and acceptability were examined with 24 patients. For psychometric validation, 415 adolescents completed the BHS and well-established rating scales. Participants recruited from primary care waiting rooms were 12 to 21 years of age (mean: 15.8 years); 66.5% were female and 77.5% black. RESULTS: The BHS screens in 13 domains by using 54 required items and 39 follow-up items. The administration time was 8 to 15 minutes (mean: 12.4 minutes). The scales are unidimensional, are internally consistent (Cronbach's α = 0.75–0.87), and discriminate among adolescents with a range of diagnostic syndromes. Sensitivity and specificity were high, with overall accuracy ranging from 78% to 85%. Patients with scores above scale cutoff values for depression, suicide risk, anxiety, and posttraumatic stress disorder symptoms were ≥4 times more likely to endorse other risk behaviors or stressors. CONCLUSIONS: The BHS addresses practical and clinical barriers to behavioral health screening in primary care. It is a brief but comprehensive, self-report, biopsychosocial assessment. The psychiatric scales are valid and predictive of risk behaviors, which facilitates exclusion of false-positive results, as well as assessment and triage.

OBJECTIVE To describe providers' experiences screening for and counseling adolescent patients who smoke cigarettes. DESIGN Eight qualitative focus groups were conducted with 51 health care providers in primary care settings. Focus groups were video- and audiotaped; tapes were transcribed for coding by an interdisciplinary team using the constant comparative method. MAIN OUTCOME MEASURES Providers reported experiences screening for and managing adolescent patients who reported smoking cigarettes. RESULTS Providers expressed confidence in their ability to screen adolescent patients for tobacco use, particularly as part of regularly scheduled preventive and medical visits. Providers reported difficulty balancing screening for smoking with their concern for maintaining rapport with their adolescent patients. In addition, providers reported that adolescent smoking patterns differed from those of adults, and consequently, providers were not certain at what level of smoking an adolescent required intervention. Furthermore, providers were unclear regarding what interventions were recommended for and effective with adolescents. CONCLUSION Providers are interested in adolescent evidence-based screening methods and cessation interventions that are supportive of a nonjudgmental and empathic approach to caring for adolescent smokers, particularly those with irregular and situational smoking patterns.

Objective The authors sought to determine the incidence of delirium, its predisposing and precipitating factors, and its implications for rehabilitation outcomes and mortality in elderly patients. Methods This was a prospective cohort study, conducted in Gedera, Israel, from August 2001 to January 2002, with 137 consecutive patients over age 75, with hip fractures, who were admitted to the orthopedic section of the emergency department. They were evaluated at admission, 1 week after the surgery for hip fracture, and 1 month after surgery. The evaluation included assessments of delirium, cognitive, and functional status, and a wide range of demographic and clinical parameters. Results The cumulative incidence of delirium was 11.4%. No significant difference was found between delirium and non-delirium patients in terms of all demographic, socioeconomic, and perioperative parameters. Mild or moderate cognitive impairment before the fracture and four or more regular medications prescribed to the patient were the only predictive factors for the development of delirium in a multivariate model. Delirium was not a significant predictor of any rehabilitation outcome. Conclusion Results documented that the incidence of delirium after hip fracture in elderly patients is much lower than was reported in several previous studies. Premorbid cognitive impairment was the most significant predisposing factor for the development of delirium. Thorough evaluation of earlier cognitive status could improve the probability of the diagnosis of delirium and pinpoint a limited group of patients for a delirium-prevention approach.

Levy, S. (1972). Brit. J. industr. Med., 29, 196-200. A study of the medical causes of absence from duty aboard South African merchant ships. Over a period of four and a half years 556 instances occurred in which crew members were put off duty on medical grounds for a period of four or more days. Illness accounted for 297 cases whereas accidents were responsible for 259 cases. Illiness and accident cases were off duty for an average period of 28 and 34 days respectively. Slightly more working days were thus lost on account of accidents. Admission to hospital was required in 90% of illnesses compared with only 36% of accidents. Appendicitis (of questionable veracity), peptic ulceration, and psychiatric disturbances were among the more common causes of incapacity. Forty percent of accidents occurred on deck and in the cargo holds. Fractures occurred most commonly in the upper limbs, especially the hand. Eleven percent of the accidents occurred ashore, mostly due to assault. Further study is required to elucidate whether the emotional problems encountered are brought to sea by the personnel or are a result of life on board ship. The high incidence of accidents stresses the fact that a sea career is one of the more dangerous occupations.

Prenatal diagnosis of congenital heart disease (CHD) may be beneficial in many ways but it can also increase maternal stress, which may negatively impact both maternal and fetal well-being. Our study objective is to characterize the type and degree of maternal stress incurred by prenatal diagnosis