Resources for Interns - Western State Hospital Internship Program

October 10 2016

Friday Factoids: Working With Children Who Have Early-Onset Schizophrenia

Though diagnostic criteria for early-onset schizophrenia are the same for adults and children, the treatment approach may differ. For instance, discussing the symptoms of psychosis with children can be challenging. Often parental report is utilized when discussing symptoms; however, as noted by Caplan (2011), parents may be unaware of the experience of hallucinations by their child.

Children may not spontaneously talk about hallucinations due to others negating the experience (e.g., It’s nothing; It’s only your imagination), being scared to talk about it, feeling they will burden their parents with it, or believing that talking about the hallucination will make it happen (Caplan, 2011). Clinicians should use careful wording to ask about hallucinations. Delusions, like hallucinations, should be differentiated from normal developmental phenomena (e.g., fantasies, magical thinking; Caplan, 2011). Though morbid fantasies may be upsetting, they too are common (Caplan, 2011); however, if they are pervasive and acted upon they might be “precursors of delusions” (Caplan, 2011, p. 60). Disorganized speech and thought disorders are reflected in illogical thinking, loose associations, and impaired discourse skills (Caplan, 2011; Shatkin, 2015). This communication difficulty must be distinguished from language problems related to language disorders or intellectual disability (Caplan, 2011; Stentebjerg-Olesen et al., 2016); thus it may be beneficial to refer to speech or language therapist to help clarify diagnoses.

Compared to adults, negative symptoms are more prominent in children and adolescents (Harvey, James, & Shields, 2016). Additionally, negative symptoms are noted to be predictors of poorer clinical and functional outcomes (Harvey et al., 2016). Other symptoms related to early-onset schizophrenia are abnormalities of gait, posture, and muscle tone (Shatkin, 2015).

Given the trajectory and progressive course of schizophrenia, early identification and intervention should be emphasized, especially in light of the findings that longer duration of untreated psychosis and poorer premorbid adjustment are associated with poorer outcomes (Stentebjerg-Olesen, Pagsberg, Fink-Jensen, Correll, & Jeppesen, 2016). Furthermore, early-onset schizophrenia is often refractory to treatment. Recent research has indicated that clozapine demonstrated greater efficacy compared to other antipsychotics (Kasoff, Ahn, Gochman, Broadnax, & Rapoport, 2016), where as other research (Harvey et al., 2016) demonstrated that antipsychotics showed a trend of reduction of symptoms compared to placebos, but only olanzapine and risperidone demonstrated statistically significant improvements for positive symptoms, as well as general psychopathology as measured by the Positive and Negative Syndrome Scale (PANSS).

References
Caplan, R. (2011). Childhood schizophrenia: Diagnostic and treatment challenges. Cutting Edge Psychiatry in Practice, 3(1), 55-67.

Harvey, R. C., James, A. C., & Shields, G. E. (2016). Assess the relative efficacy of antipsychotics for the treatment of positive and negative symptoms in early-onset schizophrenia. CNS Drugs, 30(1), 27-39.

Kasoff, L. I., Ahn, K., Gochman, P., Broadnax, D. D., & Rapoport, J. L. (2016). Strong treatment response and high maintenance rates of clozapine in childhood-onset schizophrenia. Journal of Child and Adolescent Psychopharmacology, 26(5), 428-435.

Shatkin, J. P. (2015). Child & adolescent mental health: A practical, all-in-one guide. New York: W. W. Norton & Company.

Stentebjerg-Olesen, M., Pagsberg, A. K., Fink-Jensen, A., Correll, C. U., & Jeppesen, P. (2016). Clinical characteristics and predictors of outcome of schizophrenia-spectrum psychosis in children and adolescents: A systematic review. Journal of Child and Adolescent Psychopharmacology, 26(5), 410-427.

Dannie S. Harris
WKPIC Doctoral Intern

September 09 2016

Friday Factoids: Effective Parenting

In a press release for the American Psychological Association, Hamilton (2015) reviewed Larzelere’s presentation on effective parenting. Larzelere and his research team interviewed 102 mothers who described five times they disciplined their toddlers (ages 17 months to 3 years) for hitting, whining, defiance, negotiating, or not listening. The findings indicated that regardless of the type of behavior, compromising was the most effective for immediate behavioral improvement. For mildly annoying behaviors, reasoning was the next most effective. Punishments (e.g., timeout or taking away something) were more effective than reasoning for defiance or hitting; yet punishments were least effective for negotiating or whining. Additionally, reasoning was not effective for defiance or hitting.

When interviewed two months later, a different pattern emerged. Children were reportedly acting worse when mothers too frequently used compromising for hitting or defiance. Reasoning was reportedly the most effective over time, even though it was noted to be the least effective for these behaviors when used immediately. For defiant children, a moderate use of timeouts and other punishments resulted in improved behavior.

Hamilton (2015) also discussed Cipani’s research on punishment. Capani indicated that often timeouts do not work because they are not used properly. For example, spur of the moment timeouts are noted to not be effective. Capani indicated that children should know ahead of time what behaviors result in timeout and that consistent use of time out for specified behaviors has shown to significantly reduce problem behaviors.

Consequences of parental discipline style has been linked to both internalizing (e.g., withdrawal, anxiety, depression) and externalizing (e.g., aggression, delinquency, hyperactivity) behaviors in youth (Parent, McKee, & Forehand, 2016). Harsh discipline (e.g., physical or corporal punishment [hitting or spanking when angry]) often reinforces oppositional behavior (Granic & Patterson, 2006, as cited in Parent et al., 2016) and models hostile interaction patterns (Pettit et al., 1993, as cited in Parent et al., 2016). With regard to lax discipline (permissiveness and inconsistency), permissiveness often results in both internalizing and externalizing behaviors in children, where as inconsistency is associated with the development of more externalizing behavior than internalizing behavior (Parent et al., 2016).

Seesaw discipline, which is considered both harsh and lax, has been linked to high levels of internalizing problems in youth (Parent et al., 2016). Though parental education often focuses on the consequences of harsh and permissive discipline, it may be beneficial to discuss seesaw discipline as well, and paying close attention to the consequences of youth internalizing behaviors (Parent et al., 2016).

Further consideration related to parents suffering from psychopathology may also need to be discussed. Research has indicated that parents with psychopathology tend to create chaotic and unpredictable home environments, which may be aligned with inconsistent parental discipline (Parent et al., 2016); thus, psychoeducation and training for this population may be beneficial.

Dannie S. Harris
WKPIC Doctoral Intern

References

Hamilton, A. (2015). Punishing a child is effective if done correctly. Retrieved from http://www.apa.org/news/press/releases/2015/08/punishing-child.aspx

Parent, J., McKee, L. G., & Forehand, R. J. (2016). Seesaw discipline: The interactive effect of harsh and lax discipline on youth psychological adjustment. Journal of Child and Family Studies, 25, 396-406.

August 08 2016

Friday Factoids Catch-Up: Schizophrenia Symptoms Reduced Through Exercise

Schizophrenia symptoms in the acute phase are often characterized by hallucinations and delusions, which are usually treatable with medication. However, most patients are still troubled with pervasive cognitive deficits, which include poor memory, impaired information processing, and loss of concentration. Antipsychotic medications have little impact on improving cognition, and other pharmacological approaches towards treating cognitive deficits have demonstrated limited efficacy thus far. Non-pharmacological interventions have been developed to specifically target cognitive symptoms, including cognitive remediation therapy (CRT). This therapeutic approach involves completing tasks designed to train various cognitive functions such as memory, attention, and problem-solving skills. However, CRT has only a small effect on psychiatric symptoms, and improvements are lost over time.

A number of recent meta-analyses have shown that structured exercise can significantly improve positive symptoms, negative symptoms, and social functioning in this population. A meta-analysis study combined the data from ten independent clinical trials with a total of 385 patients diagnosed with Schizophrenia. According to a new study from University of Manchester researchers, around 12 weeks of aerobic exercise training can significant improve patients’ brain functioning. The research showed that patients who are treated with aerobic exercise programs, such as treadmills and exercise bikes, in combination with their medication, will improve their overall brain functioning more than those treated with medications alone. There was also evidence among the studies that programs, which used greater amounts of exercise and those which were most successful for improving fitness, had the greatest effects on cognitive functioning.

Furthermore, by increasing cardiorespiratory fitness and metabolic health, exercise may also reduce the physical health problems associated with Schizophrenia, such as obesity and diabetes, which contribute towards reduced life expectancy and adversely affect cognitive functioning. Exercise has also been found to increase hippocampal volume and white matter integrity in healthy older adults and those with Schizophrenia. Additionally, cross-sectional research has demonstrated that physical activity and fitness are associated with better cognitive performance and higher levels of neurotrophic factors which promote brain plasticity. Results from cognitive outcomes showed that exercise improves global cognition significantly more than control conditions. Analyses suggested that supervision from physical health instructors results in better cognitive outcomes. This may be due to increased exercise engagement among participants or better program delivery resulting in more favorable outcomes.

Meta-regression analyses indicated that higher weekly duration of exercise tends to be associated with greater improvement in cognition. The amount that an individual exercises appears to be an important factor for achieving cognitive enhancement. Previous studies have shown that the amount of exercise achieved by participants during an intervention is a significant predictor of cognitive improvements. Additional studies have previously examined the relative influence of exercise duration, frequency, and intensity on cognitive improvements following a 12-week exercise program. The result indicated that exercise intensity was the best predictor variable. This also suggests that aerobic exercise may be more effective for cognition in Schizophrenia than yoga, which previous meta-analyses have found to only be effective for long-term memory.

This meta-analysis study indicated that exercise has similar effects on cognition in Schizophrenia to CRT. Individual studies have shown significantly greater improvements from combining CRT with aerobic exercise for various cognitive subdomains, along with significantly greater reductions in negative symptoms of Schizophrenia. There is also some preliminary evidence supporting the role of brain-derived neurotrophic factor (BDNF) as a mediating factor for cognitive improvements from exercise.

The two other domains, which showed significant changes in response to exercise, were attention and working memory. Since these factors are strong predictors of functional recovery after a first episode of Schizophrenia, implementing exercise interventions from the early stages of illness may facilitate functional recovery. Indeed, exercise may confer even greater benefits in the early psychosis, as cognitive enhancement interventions are more effective at this time than later in the illness. Consistent with this, three recent studies in young patients with first-episode psychosis (aged 23–26) have observed large cognitive improvements from moderate/vigorous exercise after just 10–12 weeks. With the currently limited evidence, it is unclear whether this high level of responsiveness to exercise among first-episode patients is due to their younger age or their earlier stage of illness.

References:
Firth, J., Stubbs, B., Rosenbaum, S., Vancampfort, D., Malchow, B., Schuch, F.,…Yung, A.R. (2016). Aerobic exercise improves cognitive functioning in people with schizophrenia: a systematic review and meta-analysis. Schizophrenia Bulletin. DOI: 10.1093/schbul/sbw115

Jonathan Torres, M.S.
WKPIC Doctoral Intern

(Director’s Note: We have come to our final Friday Factoids post from the 2015-2016 intern class. Stay tuned for the first offerings of the 2016-2017 crew!)

August 08 2016

Friday Factoids Catch-Up: Effects of Multitasking

Many business leaders think of multitasking as a great asset and they envision employees who can get more work accomplished. People also believe that the Millennial generation (ages 18 to 34) is better equipped to juggle multiple tasks. For the most part this is true. Millennials are known for being adept with all forms of technology and moving from one job to another, shifting between priorities with relative ease. Most employers post “The ability to multitask” as a skill on several job openings. Unfortunately, the latest research conducted in psychology and business productivity suggests we have gotten it all wrong.

The average Millennial switches their attention among media platforms 27 times per hour. Research shows that performing a mental task while multitasking yields similar results to performing the same task if you got no sleep the previous night. Additionally, prolonged multitasking will actually damage your brain. Regular multitaskers have less brain density in areas controlling cognitive and emotional functions. Alternating between tasks will lower your emotional intelligence. If you are switching your gaze from your laptop to your smartphone to a TV screen and back again, you stand to miss a lot of subtle nonverbal signals from the person you are talking with simultaneously. Researchers revealed that the brain cannot effectively handle more than two complex related activities at once.

Multitasking doesn’t always live up to the dream. Instead, it tends to mean a lack of focus and an increase in impulsivity. Experts predicted that the impact of networked living on youth today will increase their desire for instant gratification, cause them to settle for quick choices, and cause them to lack patience. Researchers at Stanford University conducted a famous experiment 50 years ago where children were given the chance to eat a single marshmallow immediately, or wait until someone returned later, at which point they would receive a second marshmallow. The kids were tracked later in life and it turns out those who waited for that second marshmallow fared much better than those who chose instant gratification. The participants who did not wait were more likely to have behavioral problems, be obese, use drugs and spend time in jail.

There’s a financial cost, too. Lack of productivity due to multitasking equates to global losses of $450 million per year and Millennial job-hopping costs the U.S. economy more than $30 million per year. Nearly nine out of ten Millennials plan to stay in a job less than three years and 21 percent say they have changed jobs in the past year. While the average job tenure for all workers 25 and older is 5.5 years, it is only three years for Millennials. The cost of job-hopping to employers is not marginal, either. The loss of one Millennial employee runs between $15,000 to $25,000, for most companies.

In terms of the turnover issue, employers can discourage Millennials from leaving too soon by offering finite terms of employment from the get-go. Giving Millennials a sense of purpose through meaningful work and projects that require a variety of skills has been shown to deter job-hopping. To help reduce the effects of multitasking, you should schedule blocks of uninterrupted time. There is time management method called the Pomodoro Technique that allows you to work for 25-minute chunks of time and then take a five-minute break. During this time you focus all your attention on a single task and take short breaks as a way to increase focus and productivity. Lastly, you can increase the ability to focus, concentrate, and reduce stress throughout the day by practicing either (or better yet, both) yoga or meditation. However you choose to do it, cutting back on or eliminating multitasking is well worth the effort. You will work more productively and finish tasks more quickly.

References:
Clapp, W., Rubens, M., Sabharwal, J., Gazzaley, A. (2011). Deficit in switching between functions underlies the impact of multitasking memory in older adults. Proceedings of the National Academy of Sciences of the United States of America. 108(17), 7212-7217.

Sanbonmatsu, D., Strayer, D., Medeiros-Ward, N., Watson, J. (2013). Who multi-tasks and why? Multi-tasking ability, perceived multi-tasking ability, impulsivity, and sensation seeking. PLOSOne. 8(1), e54402.

Zetlin, M. (2016, July 30). Constant Multitasking Is Damaging Millennial Brains, Research Shows. Retrieved from: http://www.inc.com/minda-zetlin/constant-multitasking-is-damaging-millennial-brains-research-shows.html

Jonathan Torres, M.S.
WKPIC Doctoral Intern

August 08 2016

Friday Factoids Catch-Up: What Exactly Does Psychosomatic Mean?

When patients who are presenting to physicians for treatment hear the word “psychosomatic” they usually feel immediately discredited. This term is often followed by a referral to see a psychologist, which patients often do not choose to do.

First, the term psychosomatic means something different to physicians and most patients than it does to psychologists and mental health professionals. When physicians resort to telling patients they feel their condition is psychosomatic, it is often after much frustration and perceived treatment failures. Physicians note that these patients report very high levels of symptomatology, but testing and evaluations cannot identify concrete pathology. Physicians may also notice that patients seem to be reporting higher levels of symptoms than what seems to make sense in light of physical findings. The model that many physicians were trained in (Cartesian Model) creates a mindset that all medical conditions can be diagnosed with a methodical and logical approach. If this approach yields no solid support to reported symptoms, the problem is determined to be psychosomatic—or essentially not real. Laypeople (patients) typically identify the term psychosomatic in the same context. It can be a painful word for patients to hear and understand, and they often feel insulted by the resultant referral to see a psychologist.

Psychologists do not identify the term psychosomatic the same way as physicians and patients may define it. Many psychologists conceptualize health problems from a multi-faceted approach in which physical and biological conditions interact with their environment. “Somatic” research generally approaches physical conditions as inseparable from the mind. This under no circumstances means that psychologists think “every problem” is in the mind. In fact, it means that all systems in which a person functions interact with each other. Chronic pain is an example of a problem in which many systems interact. Emotions have been identified as one factor in decreasing pain tolerance, and biological changes can result from emotional state. So, feelings can make pain worse, and worsening pain increases emotional issues—and the problems can spiral.

Explaining to patients that seeing a psychologist is a part of treatment for medical conditions and not a result of practitioners deciding that patients are “faking” or “just emotional,” may help facilitate following up with recommendations. Patients who experience chronic illnesses often feel very misunderstood and disrespected, and more could be done to help patients understand that psychologists may be an instrumental part of their healthcare. This simple step could result in significant improvements in overall outcome for many conditions.

Rain Smith, MS
WKPIC Doctoral Intern

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Category Archives: Resources for Interns

Friday Factoids: Working With Children Who Have Early-Onset Schizophrenia

Friday Factoids: Effective Parenting

Friday Factoids Catch-Up: Schizophrenia Symptoms Reduced Through Exercise

Friday Factoids Catch-Up: Effects of Multitasking

Friday Factoids Catch-Up: What Exactly Does Psychosomatic Mean?

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