Behavior Modification Found to Be Effective for Managing Pediatric Aggression

A behavior modification program that features positive and negative incentives reduced the use of psychotropic medications and/or physical interventions to manage agitated outbursts in children hospitalized for aggression, compared with a program that relied on verbal de-escalation techniques. The findings were published online by the Journal of the American Academy of Child & Adolescent Psychiatry.

“[O]ur data support the effectiveness of the [behavior modification program] and suggest that verbal attempts to calm the raging child can be counterproductive,” wrote Gabrielle Carlson, M.D., of the Renaissance School of Medicine at Stony Brook University and colleagues.

Carlson and colleagues assessed research and medical records of five cohorts of children admitted to Stony Brook’s 10-bed children’s psychiatric inpatient unit for aggressive behavior between 2008 and 2018. During this time, the facility transitioned away from a behavior modification program (BMP)—which involved collaborative problem-solving therapy coupled with positive rewards for good behavior and “time outs” for bad behavior—to reduce aggression. The unit switched to a program that used verbal de-escalation or distraction to talk children down from what the authors described as “intensely emotional situations.” Carlson and colleagues noted the switch was due to a perceived inability to provide enough incentives for good behavior as well as a belief that “time outs” were a form of physical restraint.

The final analysis included 347 children admitted during BMP use and 163 admitted during de-escalation use. The researchers found that the use of medications like sedatives or antipsychotics to reduce agitation was significantly lower when BMP was in use. “As needed” medical sedation was used 163 times per 1,000 patient-days when BMP was used compared with 483 times per 1,000 patient-days when de-escalation was used. The need for seclusion or physical restraint also was lower with BMP than with de-escalation (17 times versus 65 times, respectively, per 1,000 patient-days).

“Perhaps the increased attention given to the agitated child by continually talking to him/her, encouraging skill use, and sometimes giving children what they wanted to limit frustration inadvertently reinforced the unwanted behaviors,” wrote Carlson and colleagues as a possible explanation for why verbal de-escalation strategies increased the use of medication and/or restraint. They also suggested that under the de-escalation strategy children may have learned that aggression was a good way to avoid doing an unpleasant task, since staff sometimes let children get their way to calm them. However, the authors also noted the differences seen in outcomes between the two approaches may have been the result of the staff being less familiar with the technique. “It is possible that staff wasn’t adequately trained to execute de-escalation interventions correctly, biasing findings in favor of [BMP],” they wrote.

To read more about this topic, see the American Journal of Psychiatry article “Brain Mechanisms of Attention Orienting Following Frustration: Associations With Irritability and Age in Youths.”

(Image: iStock/KatarzynaBialasiewicz)

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Problem-Solving Therapy May Help Prevent Onset of Major Depression In Elderly, Study Finds

According to a study published in Psychiatric Services, problem-solving therapy for primary care (PST-PC)—an intervention delivered by nonmental health professionals to help patients improve coping skills and confidence—may serve as a beneficial therapy for older adults who are at risk for major depression.

Charles Reynolds III, M.D., a professor of geriatric psychiatry at the University of Pittsburgh Medical Center, and colleagues evaluated the efficacy of PST-PC in preventing episodes of major depression and reducing depressive symptoms in elderly adults. The study, "Early Intervention to Preempt Major Depression Among Older Black and White Adults," included approximately 250 individuals with subsyndromal depressive symptoms who received 15 months of PST-PC, a technique that has been shown to reduce stress, or dietary coaching, which had been shown to reduce depression risk in an elderly population in a previous study by Reynolds. The two cohorts were compared with each other, in addition to being compared with age-matched cohorts from previously published studies of those who received neither therapy for subsyndromal depressive symptoms.

After two years, the analysis showed PST-SC to be just as effective as dietary coaching in preventing episodes of major depression in this at-risk cohort. Incident rates for major depression in both cohorts were approximately 9%, compared with published rates of 20% to 25% in those who received neither treatment. The researchers also observed a significant reduction in depressive symptoms in both PST-SC and dietary-coaching groups.

“Avoiding episodes of major depression can help people stay happy and engaged in their communities...," commented Reynolds. “This project tells us that interventions in which people actively engage in managing their own life problems...tend to have a positive effect on well-being and a protective effect against the onset of depression.”

To read more about the role of problem-solving therapy in treating mental illness, see the Psychiatric News article, "Future Looks Promising for Mental Illness Prevention."

(Photo Courtesy of PUMC)