Sessions Of Behavioral Therapy Research Articles

What Was Useful about That Session? Clients' and Therapists' Comments after Sessions in the UK Alcohol Treatment Trial (UKATT)

The aim of this study was to report and contrast the aspects of two therapies considered by clients and therapists to be most and least useful. In the UK Alcohol Treatment Trial (UKATT), 742 clients were treated by 49 therapists with up to three sessions of motivational enhancement therapy (MET) or up to eight sessions of social behaviour and network therapy (SBNT). After each treatment session, clients and therapists were asked to independently complete two sentences, one inviting a statement about the 'most useful' and the other about the 'least useful' thing that had happened during the session. The proportion of 'most useful' sentences completed was greater than the proportion of 'least useful' and equally so for MET and SBNT. The content of comments was significantly different for the two treatments: more comments on social aspects followed SBNT and more motivational comments followed MET, with larger numbers of comments following both treatments that were more general. Clients more often completed 'most useful' sentences than therapists and less often completed 'least useful' sentences. There were a number of differences in the content of their comments: notably more 'most useful' client comments about talking to their therapists, and more therapist comments about client engagement. MET and SBNT left distinct impressions on the participants immediately following treatment sessions, adding to the evidence that they are different treatments, and hence deepening the mystery about why outcomes following the two treatments were so similar [UKATT Research Team. (2005) Br Med J 331: 541-58].

Computer‐based psychological treatment for comorbid depression and problematic alcohol and/or cannabis use: a randomized controlled trial of clinical efficacy

To evaluate computer- versus therapist-delivered psychological treatment for people with comorbid depression and alcohol/cannabis use problems. Randomized controlled trial. Community-based participants in the Hunter Region of New South Wales, Australia. Ninety-seven people with comorbid major depression and alcohol/cannabis misuse. All participants received a brief intervention (BI) for depressive symptoms and substance misuse, followed by random assignment to: no further treatment (BI alone); or nine sessions of motivational interviewing and cognitive behaviour therapy (intensive MI/CBT). Participants allocated to the intensive MI/CBT condition were selected at random to receive their treatment 'live' (i.e. delivered by a psychologist) or via a computer-based program (with brief weekly input from a psychologist). Depression, alcohol/cannabis use and hazardous substance use index scores measured at baseline, and 3, 6 and 12 months post-baseline assessment. (i) Depression responded better to intensive MI/CBT compared to BI alone, with 'live' treatment demonstrating a strong short-term beneficial effect which was matched by computer-based treatment at 12-month follow-up; (ii) problematic alcohol use responded well to BI alone and even better to the intensive MI/CBT intervention; (iii) intensive MI/CBT was significantly better than BI alone in reducing cannabis use and hazardous substance use, with computer-based therapy showing the largest treatment effect. Computer-based treatment, targeting both depression and substance use simultaneously, results in at least equivalent 12-month outcomes relative to a 'live' intervention. For clinicians treating people with comorbid depression and alcohol problems, BIs addressing both issues appear to be an appropriate and efficacious treatment option. Primary care of those with comorbid depression and cannabis use problems could involve computer-based integrated interventions for depression and cannabis use, with brief regular contact with the clinician to check on progress.

Commentary] THE LONG ROAD TO PHARMACOTHERAPIES FOR STIMULANT DEPENDENCE

Many marketed antidepressants, dopamine agonists and γ-aminobutyric acid compounds have been trialled and discarded on the long road towards a pharmacotherapy for psychostimulant dependence. Illicit methylamphetamine (MA) can create a particularly debilitating disorder and James Shearer and his colleagues are to be congratulated for their timely trial of modafinil among this population [1]. The headline finding is that modafinil was not associated with adverse events or medication misuse, and that medication compliant participants gave more MA and illicit psychostimulant negative urine tests during treatment. Modafinil is a novel wake-promoting agent and the front-line treatment for narcolepsy idiopathic hypersomnia. It also improves some aspects of neuropsychological test performance in normal volunteers [2] and, in part, this trial can be seen as a means of ameliorating neurocognitive dysfunction among patients and thereby enhancing their acceptance of clinic recovery services in these critical early weeks of recovery. Along with several other stimulant medications, there are now encouraging signs that modafinil may be an effective pharmacotherapy for cocaine and synthetic stimulant dependence [3]. This ‘off label’ application makes sense from a neurobiological perspective although much remains to be understood about the precise mechanisms of action and, of course, larger more powerful trials are needed to firm the evidence base. Good implementation features of the present trial included monitoring of self-administration of trial medication, regular medical assessment of side effects, tolerable patient study attrition and good primary outcome measurement in the form of weekly urinalysis for target substance use (specifying for MA, cocaine and MDMA). There were also challenging aspects for the analysis: up to one third of participants completed their treatment, and the modafinil effect appears to have been moderated by concurrent polydrug use and the over-representation of HIV positive patients in the experimental group. More powerful studies are needed to investigate the pattern of outcome and the characteristics of non-response. Also, the assessment of neuropsychological problems and response during treatment may prove to be a useful avenue on the search for mediation of outcome and patient non-response. Many medication trials in our field rest on a platform of structured psychosocial intervention (four sessions of cognitive behavioural therapy in this instance) as a standard treatment. The Shearer group suggest that modafinil may emerge as a combination therapy alongside a behavioural intervention: this makes good sense and offers real-world generalizability to clinic programmes. It will also be important for future triallists to ensure a high fidelity of their studied behavioural interventions, with their rationale, procedures and monitoring arrangements clearly set out in an accessible protocol or manual. This will facilitate replication of efforts and the translation of results into practice [4]. Making these materials available to the scientific community is now Addiction policy. Dr Marsden holds a research grant from the Medical Research Council to evaluate the feasibility of a multicentre controlled trial of modafinil for cocaine dependence in specialist NHS treatment clinics in England.

Family therapy for adolescents with poorly controlled diabetes: initial test of clinical significance.

We examined a structured family therapy approach in promoting clinically meaningful improvements in parent-adolescent conflict in adolescents with poorly controlled diabetes. Eighteen adolescents with poorly controlled diabetes and their parent(s) participated in 10 sessions of home-based Behavioral Family Systems Therapy (BFST). Outcome comparisons were made using a sample of adolescents with poorly controlled diabetes (n = 40) from a previous study. Clinically significant improvements were determined by calculating SD differences between treatment and comparison groups on measures of diabetes-related and general parent-adolescent conflict. Home-based BFST produced change in diabetes-related family conflict ranging from 1/3 to 1/2 SD and general family conflict ranging from 1/3 to 3/4 SD. BFST produced change in family conflict, a variable shown through previous research to relate to treatment adherence in adolescents with diabetes. The test of clinical significance represents an example of a method useful for pediatric research.

Coronary Heart Disease Risk Reduction Intervention Among Overweight Smokers with a Psychotic Disorder: Pilot Trial

The aim of the present pilot study was to test the feasibility and short-term impact of a multi-component risk factor intervention for reducing (i) coronary heart disease (CHD) risk; (ii) smoking; and (iii) weight among smokers with psychosis. Secondary dependent variables included physical activity, unhealthy eating, substance use, psychiatric symptomatology, treatment retention, general functioning, and quality of life. This was a feasibility study utilizing a pre-post-treatment design with no control group (n=43). All participants provided written informed consent and were assessed before treatment and again a mean of 19.6 weeks later. The treatment consisted of nine individual 1h sessions of motivational interviewing and cognitive behaviour therapy plus nicotine replacement therapy, in addition to treatment as usual. Research assistants who had not been involved in the delivery of the treatment programme conducted post-treatment assessments. The intervention was associated with significant reductions in CHD risk scores, smoking and weight. A significant improvement was also reported in level of moderate physical activity, and a small change in the unhealthy eating index was reported. No improvement in biological measures (cholesterol and blood pressure) was evident. A multi-component CHD risk factor intervention among smokers with psychosis appears to be feasible and effective in the short-term. A randomized controlled trial replicating and extending these findings is warranted.

Acceptance and Commitment Therapy for Treatment-Resistant Posttraumatic Stress Disorder: A Case Study

An adult woman with chronic posttraumatic stress disorder (PTSD) and major depressive disorder who was nonresponsive to 20 sessions of cognitive behavior therapy (CBT) is presented in this case study. Two months after her CBT trial, she was treated with 21 sessions of Acceptance and Commitment Therapy (ACT) for PTSD. Measurements of PTSD severity, depression, anxiety, psychological flexibility and trauma-related thoughts and beliefs were taken at pretreatment, after Sessions 8 and 16, and at posttreatment. Results showed significant reduction on all measures throughout treatment, except for trauma-related thoughts and beliefs, which did not decrease until near the end of treatment. Strengths, limitations, and future directions are discussed.

Cognitive Behavioral Therapy, Sertraline, or a Combination in Childhood Anxiety

Anxiety disorders are common psychiatric conditions affecting children and adolescents. Although cognitive behavioral therapy and selective serotonin-reuptake inhibitors have shown efficacy in treating these disorders, little is known about their relative or combined efficacy. In this randomized, controlled trial, we assigned 488 children between the ages of 7 and 17 years who had a primary diagnosis of separation anxiety disorder, generalized anxiety disorder, or social phobia to receive 14 sessions of cognitive behavioral therapy, sertraline (at a dose of up to 200 mg per day), a combination of sertraline and cognitive behavioral therapy, or a placebo drug for 12 weeks in a 2:2:2:1 ratio. We administered categorical and dimensional ratings of anxiety severity and impairment at baseline and at weeks 4, 8, and 12. The percentages of children who were rated as very much or much improved on the Clinician Global Impression-Improvement scale were 80.7% for combination therapy (P<0.001), 59.7% for cognitive behavioral therapy (P<0.001), and 54.9% for sertraline (P<0.001); all therapies were superior to placebo (23.7%). Combination therapy was superior to both monotherapies (P<0.001). Results on the Pediatric Anxiety Rating Scale documented a similar magnitude and pattern of response; combination therapy had a greater response than cognitive behavioral therapy, which was equivalent to sertraline, and all therapies were superior to placebo. Adverse events, including suicidal and homicidal ideation, were no more frequent in the sertraline group than in the placebo group. No child attempted suicide. There was less insomnia, fatigue, sedation, and restlessness associated with cognitive behavioral therapy than with sertraline. Both cognitive behavioral therapy and sertraline reduced the severity of anxiety in children with anxiety disorders; a combination of the two therapies had a superior response rate. (ClinicalTrials.gov number, NCT00052078.)

Cognitive Behaviour Therapy for Panic Disorder in Chronic Obstructive Pulmonary Disease: Two Case Studies

Anxiety symptoms and panic disorder are common sequelae of chronic obstructive pulmonary disease, an illness that primarily affects older adults. The aim of this paper is to describe the application of cognitive behavioural treatment for two patients with chronic obstructive pulmonary disease and co-morbid panic disorder. The patients attended for eight to twelve sessions of cognitive behaviour therapy. Both improved on a range of indices of anxiety and quality of life. Neither patient met criteria for panic disorder at the end of treatment or over the following year. These two cases provide evidence that interventions of proven efficacy for treating panic disorder in healthy individuals can be adapted to treat patients with chronic obstructive pulmonary disease.

D -Cycloserine Augmentation for Behavioral Therapy

Back to table of contents Previous article Next article Letters to the EditorFull Accessd -Cycloserine Augmentation for Behavioral TherapySEONG S. SHIM M.D, Ph.DMICHAEL D. HAMMONDS Ph.D.MATTHEW M. VRABEL M.D.,SEONG S. SHIM M.D, Ph.DSearch for more papers by this authorMICHAEL D. HAMMONDS Ph.D.Search for more papers by this authorMATTHEW M. VRABEL M.D.Search for more papers by this author,Published Online:1 Aug 2008https://doi.org/10.1176/appi.ajp.2008.08030455AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: In the March 2008 issue of the Journal , Sabine Wilhelm, Ph.D., et al. (1) reported that d -cycloserine augmentation enhanced the efficacy of behavioral therapy for treating obsessive-compulsive disorder (OCD). d -Cycloserine is a partial agonist of the glycine site at the N -methyl- d -aspartate (NMDA) glutamatergic receptor. Occupation of the glycine site at the NMDA receptor is required in order for NMDA agonists to fully activate the receptor. Since the NMDA receptor is crucial in the domains of learning and memory, the Wilhelm et al. study sought to enhance the learning that occurs during behavioral therapy sessions by potentiating the NMDA receptor via stimulation of the glycine site using d -cycloserine. d -Cycloserine is effective in stimulating the glycine site only within the narrow range of low doses (50–125 mg daily [1, 2]), acting as a partial glycine agonist. At higher doses, d -cycloserine does not show efficacy (3) and can exacerbate schizophrenia symptoms (4) , since d -cycloserine blocks full activation of the glycine site at these doses, acting as a full glycine antagonist. In contrast, full agonists such as glycine and d -serine stimulate the glycine site more potently and improve learning and memory more effectively within the high-dose range, as shown in their efficacy in the treatment of cognitive symptoms in schizophrenia (4) . Thus, full glycine agonists are likely to be more effective and safer relative to d -cycloserine in augmenting behavioral therapy for the treatment of OCD. Dr. Wilhelm et al. stated that the efficacy of d -cycloserine augmentation of behavioral therapy was more powerful early in the treatment of OCD, and this efficacy was decreased with prolonged treatment. The authors generalized this conclusion to d -cycloserine augmentation trials in the treatment of Alzheimer’s disease and schizophrenia patients, stating that long-term use of d -cycloserine “has yielded generally disappointing results” ( 1 , pp. 338–339). However, in these trials, the lack of efficacy of d -cycloserine augmentation was likely to have been associated with the nature of d -cycloserine as a partial glycine agonist (4) . Additionally, these trials concluded that glycine agonists began to show efficacy 2 weeks from the time of drug treatment, and their efficacy was measured biweekly for 6- to 12-week trials (4) . This time frame is clearly different from the time period for d -cycloserine augmentation in the treatment of OCD, in which the efficacy of d -cycloserine was measured per an hourly basis. This discrepancy indicates that neuronal mechanisms underlying d -cycloserine augmentation of behavioral therapy for OCD and the augmentation of antipsychotic drugs with glycine agonists for treating schizophrenia and Alzheimer’s disease may be different. Cleveland, OhioThe authors report no competing interests.This letter (doi: 10.1176/appi.ajp.2008.08030455) was accepted for publication in April 2008.

Evaluation of a group cognitive behavioural intervention for women suffering from menopausal symptoms following breast cancer treatment

To evaluate a group cognitive behavioural intervention to alleviate menopausal symptoms in women who have had treatment for breast cancer. A single group design was used with pre- and post-treatment assessment and a 3-months follow-up. Seventeen women who had completed active breast cancer treatment were treated. Following a 2-week daily diary assessment they were offered 6 (90 min) weekly sessions of Group cognitive behaviour therapy (CBT). The CBT included information and discussion, relaxation and paced breathing and CBT to reduce stress and manage hot flushes (HF), night sweats (NS) and sleep. The primary outcome measure was Hot Flush Frequency and Hot Flush Problem Rating; secondary outcomes included the Women's Health Questionnaire (WHQ) and health-related quality of life (SF 36). Beliefs about HF were monitored in order to examine the effects of cognitive therapy. HF and NS reduced significantly following treatment (38% reduction in frequency and 49% in problem rating) and improvements were maintained at 3 months follow-up (49% reduction in frequency and 59% in problem rating). Depressed mood, anxiety and sleep (WHQ) significantly improved, as did aspects of quality of life (SF 36) (emotional role limitation, energy/vitality and mental health). There was a significant reduction in negative beliefs about HF, NS and sleep following CBT. These results suggest that CBT delivered in groups might offer a viable option for women with troublesome menopausal symptoms following breast cancer treatment, but further controlled trials are needed.

Further psychometric analysis of the Florida Obsessive-Compulsive Inventory

This study examined the psychometric properties of the Florida Obsessive-Compulsive Inventory (FOCI [Storch, E. A., Stigge-Kaufman, D., Bagner, D., Merlo, L. J., Shapira, N. A., Geffken, G. R., et al. (2007). Florida Obsessive-Compulsive Scale: development, reliability, and validity. Journal of Clinical Psychology, 63, 851–859]). Participants were 89 adults with OCD presenting for treatment at a specialty clinic. A trained clinician administered the Yale-Brown Obsessive Compulsive Scale and patients completed the FOCI, Obsessive-Compulsive Inventory-Revised, Beck Depression Inventory-Second Edition, and State Trait Anxiety Inventory at baseline and following 14 weekly or daily cognitive behavioral therapy sessions. The internal consistency of FOCI Symptom Checklist and Severity Scale were good, and the concurrent and divergent validity of the FOCI Symptom Checklist and Severity Scale was supported through its associations with clinician-rated OCD symptom severity, and self-reported OCD, depressive, and anxiety measures. In addition, sensitivity to cognitive-behavioral treatment effects was shown as the Severity Scale scores were significantly lower following treatment compared to baseline. These findings not only replicate Storch et al. [Storch, E. A., Stigge-Kaufman, D., Bagner, D., Merlo, L. J., Shapira, N. A., Geffken, G. R., et al. (2007). Florida Obsessive-Compulsive Scale: development, reliability, and validity. Journal of Clinical Psychology, 63, 851–859] but also add unique construct validity data in support of the psychometrics of the FOCI.

Randomized, placebo-controlled trial of bupropion for the treatment of methamphetamine dependence

Objective To compare bupropion to placebo for reducing methamphetamine (MA) use, increasing retention, and reducing the severity of depressive symptoms and MA-cravings. A secondary objective compared bupropion to placebo for reducing cigarette smoking among MA dependent participants. Methods Following a 2-week, non-medication baseline screening period, 73 treatment-seeking MA dependent participants were randomly assigned to bupropion sustained release (150 mg twice daily; N = 36) or placebo (twice daily; N = 37) for 12-weeks under double-blind conditions. Participants attended clinic thrice weekly to provide urine samples analyzed for MA-metabolite, to complete research measures and assessments, and to receive contingency management and weekly cognitive behavioral therapy sessions. Results There were no statistically significant effects for bupropion relative to placebo on MA use verified by urine drug screens, for reducing the severity of depressive symptoms or MA-cravings, or on study retention. In a post hoc analysis, there was a statistically significant effect of bupropion treatment on MA use among participants with lighter (0–2 MA-positive urines), but not heavier (3–6 MA-positive urines) MA use during baseline (OR = 2.81, 95% CI = 1.61–4.93, p < 0.001 for MA-free week with bupropion among light users). Bupropion treatment was also associated with significantly reduced cigarette smoking, by almost five cigarettes per day ( p = 0.0002). Conclusion Bupropion was no more effective than placebo in reducing MA use in planned analyses, though bupropion did reduce cigarette smoking. Post hoc findings of an effect for bupropion among baseline light, but not heavy, MA users suggests further evaluation of bupropion for light-MA users is warranted.

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Cognitive deficits in marijuana users: Effects on motivational enhancement therapy plus cognitive behavioral therapy treatment outcome

Clinical variables that affect treatment outcome for marijuana-dependent individuals are not yet well understood, including the effects of cognitive functioning. To address this, level of cognitive functioning and treatment outcome were investigated. Twenty marijuana-dependent outpatients were administered a neuropsychological battery at treatment entry. All patients received 12 weekly individual sessions of combined motivational enhancement therapy and cognitive behavioral therapy. The Wilcoxon Exact Test was used to compare cognitive functioning test scores between completers and dropouts, and the Fisher Exact Test was used to compare proportion of negative urines between those with higher and lower scores on the cognitive tests. Marijuana abstinence was unrelated to cognitive functioning. However, dropouts scored significantly lower than completers on measures of abstract reasoning and processing accuracy, providing initial evidence that cognitive functioning plays a role in treatment retention of adult marijuana-dependent patients. If supported by further studies, the findings may help inform the development of interventions tailored for cognitively impaired marijuana-dependent patients.

Can Assessment Reactivity Predict Treatment Outcome Among Adolescents with Alcohol and Other Substance Use Disorders?

The objectives of this paper are two-fold: to examine first, if the change from positive to negative alcohol and any other substance use status from baseline assessment to the onset of the first session (i.e., pre-treatment phase) occurs in adolescents, that is, Assessment Reactivity (AR); second, whether AR predicts treatment outcome. Participants were 177 adolescents with alcohol and other substance use disorders (AOSUD) in a 9-weekly group sessions of cognitive behavioral therapy. Drug urinalysis results at baseline assessment, first and last session and self-report for alcohol use were used as outcome measures. Participants showed a highly significant shift to non-use of both alcohol and of other substances from intake assessment to first session and from first to last session. Alcohol and substance use at first session predicted use at last session. This is the first study in youth asserting Assessment Reactivity as a valid construct during the pretreat-ment phase. AR should be considered in any analysis targeting treatment outcomes.

Augmentation of Behavior Therapy With d -Cycloserine for Obsessive-Compulsive Disorder

This study examined whether d-cycloserine, a partial agonist at the N-methyl-D-aspartate (NMDA) glutamatergic receptor, enhances the efficacy of behavior therapy for obsessive-compulsive disorder (OCD). A randomized, double-blind, placebo-controlled trial investigating D-cycloserine versus placebo augmentation of behavior therapy was conducted in 23 OCD patients. Patients first underwent a diagnostic interview and pretreatment evaluation, followed by a psychoeducational/treatment planning session. Then they received 10 behavior therapy sessions. Treatment sessions were conducted twice per week. One hour before each of the behavior therapy sessions, the participants received either D-cycloserine, 100 mg, or a placebo. Relative to the placebo group, the D-cycloserine group's OCD symptoms were significantly more improved at mid-treatment, and the D-cycloserine group's depressive symptoms were significantly more improved at posttreatment. These data provide support for the use of D-cycloserine as an augmentation of behavior therapy for OCD and extend findings in animals and other human disorders suggesting that behavior therapy acts by way of long-term potentiation of glutamatergic pathways and that the effects of behavior therapy are potentiated by an NMDA agonist.

Client personality characteristics predict satisfaction with cognitive behavior therapy

Ratings of treatment satisfaction are a means for cognitive behavior therapy clients to provide their unique personal perspective on their therapy experience. Treatment satisfaction is a variable of growing importance as a predictor of outcome for various medical and psychological treatments including treatments for chronic pain (D. C. Turk et al., 2003). Our goal was to determine whether satisfaction with cognitive behavior therapy sessions varied as a function of patient personality characteristics in a sample of 43 older adults (average age=72.3 years, SD=8.0) participating in a psychosocial pain management therapy program with a cognitive behavioral orientation. Participants completed the NEO Five Factor Inventory (P. T. Costa, Jr. & R. R. McCrae, 1992) prior to the commencement of treatment and a psychometrically valid questionnaire, assessing satisfaction with psychological therapy, after each therapy session. The core personality dimensions of neuroticism, openness, and agreeableness were predictive of aspects of satisfaction with therapy. These findings have the potential of being useful to clinicians concerned with the prediction of response to therapy.

An integrative complexity analysis of cognitive behaviour therapy sessions for borderline personality disorder

Integrative complexity (IC), a measure of cognitive style, was used to analyse discourse in Cognitive Behaviour Therapy (CBT) sessions from patients with borderline personality disorder treated in the BOSCOT trial. It was predicted that patients' level of integrative complexity would be positively associated with the outcome of therapy. That is, an increase in patients' level of integrative complexity would be associated with good outcome. We also predicted that therapists would also show an increase in the level of complexity associated with their patient's increase in integrative complexity and good outcome. Ten patients who received CBT were categorized according to the outcome, good (N=5) and poor (N=5), using an algorithm that incorporated the number of suicide attempts and magnitude of change in severity of depression during therapy. For each patient and their therapist, an early and a late therapy session were transcribed and coded for integrative complexity (IC) (N=20 sessions transcribed). IC scores for patients and therapists were compared across early and late therapy sessions and for good and poor outcomes of therapy. The majority of discourse was at the lower levels of IC. Higher levels of IC at baseline were related to depression and anxiety. Good outcome was not associated with a change in the level of IC between earlier and later CBT sessions. Therapists, however, showed an increase in IC when patient's outcome was poor. In addition, an increase in patient's IC was associated with improvement in social functioning. Therapists may overcompensate for patient's poor outcome by giving more complex explanations to patients. Higher complexity does not necessarily lead to better outcomes.

Differences in Inter‐Rater Reliability and Accuracy for a Treatment Adherence Scale

Inter‐rater reliability and accuracy are measures of rater performance. Inter‐rater reliability is frequently used as a substitute for accuracy despite conceptual differences and literature suggesting important differences between them. The aims of this study were to compare inter‐rater reliability and accuracy among a group of raters, using a treatment adherence scale, and to assess for factors affecting the reliability of these ratings. Paired undergraduate raters assessed therapist behavior by viewing videotapes of 4 therapists' cognitive behavioral therapy sessions. Ratings were compared with expert‐generated criterion ratings and between raters using intraclass correlation (2,1). Inter‐rater reliability was marginally higher than accuracy (p = 0.09). The specific therapist significantly affected inter‐rater reliability and accuracy. The frequency and intensity of the therapists' ratable behaviors of criterion ratings correlated only with rater accuracy. Consensus ratings were more accurate than individual ratings, but composite ratings were not more accurate than consensus ratings. In conclusion, accuracy cannot be assumed to exceed inter‐rater reliability or vice versa, and both are influenced by multiple factors. In this study, the subject of the ratings (i.e. the therapist and the intensity and frequency of rated behaviors) was shown to influence inter‐rater reliability and accuracy. The additional resources needed for a composite rating, a rating based on the average score of paired raters, may be justified by improved accuracy over individual ratings. The additional time required to arrive at a consensus rating, a rating generated following discussion between 2 raters, may not be warranted. Further research is needed to determine whether these findings hold true with other raters and treatment adherence scales.

Botulinum Toxin A: A Novel Adjunct Treatment for Debilitating Habit Cough in Children

Vocal fold injection with botulinum toxin type A (BTX-A) may be used as an adjunct treatment for habit cough in children. We conducted a retrospective review of 3 cases involving children aged 11 to 13 years with habit cough treated with vocal fold injection of BTX-A. Injections of BTX-A to the thyroarytenoid muscles were effective in breaking the cough cycle in all 3 children. Their coughs recurred but were controlled with 4 to 8 sessions of behavioral therapy. Behavioral therapy remains the first-line treatment, but BTX-A may be a useful complement to behavioral therapy in patients who fail standard treatments or in those with severe cough who have limited or delayed access to mental health professionals. This is the first report, to our knowledge, on the use of BTX-A in the treatment of a habit cough.