Quality assessment for three common conditions in primary care: validity and reliability of review criteria developed by expert panels for angina, asthma and type 2 diabetes

OBJECTIVES

To field test the reliability, validity, and acceptability of review criteria for angina, asthma, and type 2 diabetes which had been developed by expert panels using a systematic process to combine evidence with expert opinion.

DESIGN

Statistical analysis of data derived from a clinical audit, and postal questionnaire and semi-structured interviews with general practitioners and practice nurses in a representative sample of general practices in England.

SETTING

60 general practices in England.

MAIN OUTCOME MEASURES

Clinical audit results for angina, asthma, and type 2 diabetes. General practitioner and practice nurse validity ratings from the postal questionnaire.

RESULTS

54%, 59%, and 70% of relevant criteria rated valid by the expert panels for angina, asthma, and type 2 diabetes, respectively, were found to be usable, valid, reliable, and acceptable for assessing quality of care. General practitioners and practice nurses agreed with panellists that these criteria were valid but not that they should always be recorded in the medical record.

CONCLUSION

Quality measures derived using expert panels need field testing before they can be considered valid, reliable, and acceptable for use in quality assessment. These findings provide additional evidence that the RAND panel method develops valid and reliable review criteria for assessing clinical quality of care.

Susceptibility genes for a trait measure of attention deficit hyperactivity disorder: a pilot study in a non-clinical sample of twins

Attention deficit hyperactivity disorder (ADHD) is a highly heritable disorder, and molecular genetic studies are underway, with most researchers focusing on identifying susceptibility genes in clinical samples with ADHD. An alternative approach is to search for quantitative trait loci underlying the trait measure of ADHD in non-clinical samples. Positive findings of association of the dopamine transporter DAT1 480 bp allele (allele 10) and the DRD4 7 repeat allele with clinical ADHD have been previously reported. In this pilot study, we examined these polymorphisms in a selected population-based sample of twins (50 high scoring pairs, 42 low scoring pairs). There was a trend for an increase in the frequency of the dopamine receptor DRD4 7 repeat allele in the high-scoring concordant monozygotic twins (odds ratio=1.4). Although this result was not statistically significant, the frequency of the 7 repeat allele was similar to that reported for our clinic sample of ADHD patients drawn from the same geographical area. There was a non-significant trend for an increased frequency of the DAT1 allele 10 (odds ratio=1.3). These results suggest that a molecular genetic study based on a questionnaire-derived measure of ADHD in a non-clinical sample is feasible and the results appear to be comparable with those from studies of clinical cases. However, sample size and power are key issues to consider when using this approach.

No association between CHRNA7 microsatellite markers and attention-deficit hyperactivity disorder

Attention-deficit hyperactivity disorder (ADHD) is a highly heritable, common psychiatric disorder of childhood that probably involves several genes. There are several lines of evidence suggesting that the nicotinic system may be functionally significant in ADHD. First, nicotine promotes the release of dopamine and has been shown to improve attention in adults with ADHD, smokers, and nonsmokers. Second, ADHD is a significant risk factor for early initiation of cigarette smoking in children and maternal cigarette smoking appears to be a risk factor for ADHD. Finally, animal studies in rats and monkeys also suggest that nicotine may be involved in attentional systems and locomotor activity. The nicotinic system has previously been studied in schizophrenia where the neuronal nicotinic acetylcholine receptor alpha 7 subunit gene (CHRNA7) has been implicated in decreased P50 inhibition and attentional disturbances in patients with schizophrenia and in many of their nonschizophrenic relatives. Three known microsatellite markers (D15S165, D15S1043, and D15S1360) near the nicotinic acetylcholine alpha 7 receptor gene, CHRNA7, were studied in 206 ADHD parent-proband trios of children aged 5-16 with ADHD according to DSM-IV criteria. Children with known major medical or psychiatric conditions or mental retardation (IQ < 70) were excluded from the study. Markers D15S165 and D15S1360 were in linkage disequilibrium. The extended Transmission Disequilibrium Test analyses demonstrated no evidence that variation at the microsatellite markers D15S1360, D15S1043, and D15S165 influences susceptibility to ADHD. However, it remains possible that the CHRNA7 gene and other nicotinic system genes may be involved in conferring susceptibility to ADHD.

Bias in conceptual priming

In recent years, Ratcliff, McKoon, and colleagues have argued that priming in perceptual implicit memory tests is the result of biases in information processing. Three experiments are presented that extend this framework to the conceptual implicit memory domain. Participants studied a list of words before receiving a set of general knowledge questions. For some questions, participants studied the correct answer; for others, they studied a similar but incorrect answer. Although study of a correct answer facilitated performance, study of the similar alternative hurt performance. Costs and benefits of previous study were observed in both production and forced-choice tasks. However, there was no benefit of previous study when participants studied both the correct answer and the similar but incorrect alternative. The pattern of results indicates that participants were biased to respond with previously studied words on the conceptual implicit memory test. This pattern is concordant with the biased information-processing approach to priming.

Identifying predictors of high quality care in English general practice: observational study

OBJECTIVES

To assess variation in the quality of care in general practice and identify factors associated with high quality care.

DESIGN

Observational study.

SETTING

Stratified random sample of 60 general practices in six areas of England.

OUTCOME MEASURES

Quality of management of chronic disease (angina, asthma in adults, and type 2 diabetes) and preventive care (rates of uptake for immunisation and cervical smear), access to care, continuity of care, and interpersonal care (general practice assessment survey). Multiple logistic regression with multilevel modelling was used to relate each of the outcome variables to practice size, routine booking interval for consultations, socioeconomic deprivation, and team climate.

RESULTS

Quality of clinical care varied substantially, and access to care, continuity of care, and interpersonal care varied moderately. Scores for asthma, diabetes, and angina were 67%, 21%, and 17% higher in practices with 10 minute booking intervals for consultations compared with practices with five minute booking intervals. Diabetes care was better in larger practices and in practices where staff reported better team climate. Access to care was better in small practices. Preventive care was worse in practices located in socioeconomically deprived areas. Scores for satisfaction, continuity of care, and access to care were higher in practices where staff reported better team climate.

CONCLUSIONS

Longer consultation times are essential for providing high quality clinical care. Good teamworking is a key part of providing high quality care across a range of areas and may need specific support if quality of care is to be improved. Additional support is needed to provide preventive care to deprived populations. No single type of practice has a monopoly on high quality care: different types of practice may have different strengths.

Examining the comorbidity of ADHD-related behaviours and conduct problems using a twin study design

BACKGROUND

Although attention-deficit hyperactivity disorder (ADHD) and conduct disorder (CD) frequently co-occur, the underlying mechanisms for this comorbidity are not well understood.

AIMS

To examine whether ADHD and conduct problems share common risk factors and whether ADHD+CD is a more heritable variant of ADHD.

METHOD

Questionnaires were sent to 2846 families. Parent-rated data were obtained for 2082 twin pairs and analysed using bivariate genetic analysis and a liability threshold model approach.

RESULTS

The overlap of ADHD and conduct problems was explained by common genetic and non-shared environmental factors influencing both categories. Nevertheless, the two categories appeared to be partly distinct in that additional environmental factors influenced conduct problems. It appeared that ADHD+CD was a genetically more severe variant of ADHD.

CONCLUSIONS

Conduct problems and ADHD share a common genetic aetiology; ADHD+CD appears to be a more severe subtype in terms of genetic loading as well as clinical severity.

Are serum anticonvulsant levels in people with epilepsy appropriately monitored?

The medical care of people with epilepsy has often been described as being poor, although objective markers for the quality of epilepsy care are lacking. This paper describes the results of using a simple quality marker, appropriate measuring of serum anticonvulsant levels, in assessing the quality of epilepsy care. The checking of serum phenytoin levels in certain clinical circumstances is advocated, whereas the checking of serum sodium valproate levels is not generally supported. A total of 1254 people with epilepsy in the community had their medical records examined for evidence of checking of anticonvulsant levels and 1204 of these individuals completed questionnaires about their epilepsy and its treatment. Of those on phenytoin, only 26% to 47% had phenytoin levels checked appropriately; 23% of patients on sodium valproate were inappropriately having their serum levels checked. The only clinical or organizational factor that predicted whether checking of serum phenytoin levels was performed was whether or not patients reported three common phenytoin side-effects but this still showed a small effect size (odds ratio 2.4).

Examining for association between candidate gene polymorphisms in the dopamine pathway and attention-deficit hyperactivity disorder: a family-based study

Attention-deficit hyperactivity disorder (ADHD) is a highly heritable childhood-onset psychiatric condition characterized by developmentally inappropriate inattention, hyperactivity, and impulsiveness. The pathophysiology of ADHD is currently unknown. However, the therapeutic effects of stimulant medication together with findings from animal and neuroimaging studies as well as from several molecular genetic studies of the dopamine receptor D4 gene and dopamine transporter gene have implicated involvement of the dopaminergic system. To test the dopaminergic hypothesis further, we have looked for association between ADHD and alleles of seven dopamine-related candidate genes using a family-based association approach in a sample of 150 children diagnosed with ADHD. We tested polymorphisms in genes encoding three dopamine receptors (DRD3, DRD4, and DRD5) and four dopamine-relevant enzymes: tyrosine hydroxylase [tyrosine hydroxylase (TH)], dopamine beta hydroxylase (DbetaH), catechol-O-methyltransferase (COMT), and monoamine oxidase A (MAOA). We were unable to detect a significant association with any of the polymorphisms genotyped, although there was a trend for preferential transmission of the DRD5 148 bp marker allele and the MAOA 122 bp marker allele. We conclude that none of the alleles we have tested makes a major contribution to ADHD, although much larger samples are required to exclude small effects.

The effects of aging on reaction time in a signal detection task

The effects of aging on response time are examined in 2 simple signal detection tasks with young and older subjects (age 60 years and older). Older subjects were generally slower than young subjects, and standard Brinley plot analyses of response times showed typical results: slopes greater than 1 and (mostly) negative intercepts. R. Ratcliff, D. Spieler, and G. McKoon (2000) showed that the slopes of Brinley plots measure the relative standard deviations of the distributions of response times for older versus young subjects. Applying R. Ratcliff's (1978) diffusion model to fit the response times, their distributions, and response accuracy, it was found that the larger spread in older subjects' response times and their slowness relative to young subjects comes from a 50-ms slowing of the nondecision components of response time and more from conservative settings of response criteria.

False recall and false recognition induced by presentation of associated words: effects of retention interval and level of processing

The effects of retention interval and level of processing on false recall and false recognition of associates were examined. False recall and false recognition were induced by presenting subjects with words closely associated with a non-studied word. Both level of processing and retention interval affected false recall (Experiment 1) and false recognition (Experiment 2) in the same direction with which they affected accurate recall and accurate recognition. That is, semantically processed lists exhibited higher levels of later false recall and false recognition than did superficially processed lists. Furthermore, a decline in false recall and false recognition occurred across retention intervals of 0, 2, and 7 days. However, the decline in false recall and false recognition was less pronounced than the decline in accurate recall and accurate recognition. Results are consistent with source monitoring and fuzzy trace explanations of false recall and false recognition.

Does the definition of ADHD affect heritability?

OBJECTIVE

A twin study design was used to examine the genetic validity of attention-deficit hyperactivity disorder (ADHD)-related phenotypes.

METHOD

Questionnaires covering ADHD symptoms were sent to the families of 2,846 school-age twins. Parent-rated symptoms were obtained for 2,082 twin pairs and teacher-rated symptoms were available for 1,470 twin pairs.

RESULTS

Broadly defined parent-rated, teacher-rated, and "pervasive" (both parent- and teacher-rated) ADHD categories were found to be highly heritable. Significant shared environmental effects were also detected for teacher-rated ADHD. A common genetic factor was found to have a modest influence on both parent- and teacher-rated symptom scores and categories, but additional genetic and environmental influences were also found forteacher-rated ADHD. Consistent with previous findings, ADHD symptom scores were again found to be highly heritable. Maternal contrast effects were found for the Rutter A scale items but could not be detected for the DuPaul ADHD rating scale.

CONCLUSIONS

Broadly defined pervasive ADHD appears to be as heritable as ADHD behaviors defined by maternal reports alone. A common genetic factor influences maternally rated and teacher-rated ADHD but does not account for all of the genetic variance for teacher-rated ADHD. ADHD symptom scores are highly heritable, and maternal contrast effects appear to vary for different measures.

A family-based and case-control association study of the dopamine D4 receptor gene and dopamine transporter gene in attention deficit hyperactivity disorder

Attention deficit hyperactivity disorder (ADHD) is a highly heritable psychiatric condition of early childhood onset characterised by marked inattention, hyperactivity and impulsiveness. Molecular genetic investigations of ADHD have found positive associations with the 480-bp allele of a VNTR situated in the 3' untranslated region of DAT1 and allele 7 of a VNTR in exon 3 of DRD4. A number of independent studies have attempted to replicate these findings but the results have been inconsistent. We used both family-based and case control approaches to examine these polymorphisms in a sample of 137 children diagnosed with ICD-10, DSM-IV or DSM-III-R ADHD. We found no evidence of association with the DAT1 polymorphism, despite a sample size that has up to 80% power to detect a previously reported effect size. We observed a significant increase in the DRD4 7 repeat allele amongst ADHD probands (21.7%) and their parents (18.9% in mothers, 22.3% in fathers), compared to ethnically matched controls (12.8%). However TDT analysis showed no preferential transmission of allele 7 to ADHD probands.

Genetic basis of attention deficit and hyperactivity

BACKGROUND

Hyperkinetic disorder or attention-deficit hyperactivity disorder (ADHD) is an important clinical condition.

AIMS

The research evidence for a genetic contribution to ADHD is reviewed.

METHOD

Measurement of the phenotype, the extent to which attention deficit and hyperactivity are heritable and molecular genetic findings are discussed. Future research directions are also considered.

RESULTS

ADHD is a familial disorder. Available adoption evidence suggests genetic influences are important. Twin studies have primarily focused on trait measures which have consistently been found to be highly heritable Molecular genetic studies of clinical disorder so far have suggested the involvement of the dopamine DRD-4 receptor gene and dopamine transporter gene (DAT1). However, these findings await further replication.

CONCLUSIONS

Advances in psychiatric genetics and current research interest in the genetics of ADHD should improve our understanding of aetiological factors and have an impact on treatment.

Validity of the shortened Mood and Feelings Questionnaire in a community sample of children and adolescents: a preliminary research note

The Mood and Feelings Questionnaire (MFQ) was designed to detect clinical depression in children and adolescents. Our aim was to investigate the relationship between symptom scores obtained using the short-version MFQ and psychiatric disorders in a non-clinical sample. Seventy-eight parents and 71 twins, who had completed the MFQ, were interviewed separately using a semistructured diagnostic interview, the Child and Adolescent Psychiatric Assessment. Parent-rated MFQ scores (MFQ-P) were found to distinguish those with ICD-10 (point biserial correlation = 0.345) and DSM-III-R depression (point biserial correlation = 0.369) from non-depressed cases. MFQ-P scores also differentiated depressed cases from those with 'other psychiatric diagnoses' (any anxiety disorder, oppositional defiant disorder and conduct disorder, hyperkinetic disorder/attention deficit hyperactivity disorder and adjustment disorder/post-traumatic disorder). The MFQ-P at the chosen cut-off point showed a sensitivity of 0.75 and specificity of 0.73 for an ICD-10 diagnosis of depression and a sensitivity of 0.86 and specificity of 0.87 for DSM-III-R depression. The number of self-rated reports (MFQ-C) was small, but overall the results suggest that self-rated MFQ scores may show less specificity. The MFQ-C at the selected cut-off point showed a sensitivity of 0.6 and specificity of 0.61 for ICD-10 depression, and a sensitivity of 0.75 and specificity of 0.74 for DSM-III-R depression.

Life events and depressive symptoms in childhood--shared genes or shared adversity? A research note

A twin study design was used to examine to what extent genetic and environmental factors mediate the association between life events and depressive symptoms. Questionnaire measures (maternally rated) of depressive symptoms and life events were obtained for a systematically ascertained sample of 270 twin pairs aged 8 to 17 years. Bivariate genetic model fitting showed that depressive symptoms and some life events (total events, negative impact) share a common genetic influence. The covariation of independent life events and depressive symptoms was explained by a shared environmental influence common to both. At least part of the association between life events and depressive symptoms is mediated by familial factors that include both genes and shared environment.

Genes and social skills

Evidence for one or more loci on the human X chromosome influencing social cognition was recently presented by Skuse et al. The imprinted locus is only expressed from a paternally inherited X chromosome, which means that boys do not express it because their only X chromosome comes from their mother. This raises the possibility of genetic as well as cultural influences on sex differences in behaviour and cognition. It may also offer some explanation for why boys are more vulnerable to developmental disorders that affect social behaviour, such as autism.

Attitudes of general practitioners towards health care for people with intellectual disability and the factors underlying these attitudes

An intellectual disability attitude questionnaire was used to explore the attitudes of general practitioners (GPs) towards primary health care, organizing health promotion and the role of specialist services for people with intellectual disability. The results of this questionnaire from GPs in Gwent (Wales) and GPs in west Gloucestershire (England) were compared. The GPs in both areas responded similarly and tended to agree that they were responsible for the medical care of people with intellectual disability in the community. They also tended to feel that the move from hospitals to the community of people with intellectual disability would greatly increase their workload. The GPs in both areas were generally against a responsibility on their part for health promotion and health screening initiatives for people with intellectual disability. However, GPs in west Gloucestershire felt more strongly against these issues. Further analysis of the data revealed factors which influenced the response of GPs to the questionnaire, including their position regarding health promotion and screening, and their view of the role of specialist health services. The GPs generally felt that community learning disability teams provided useful support, and there is clearly scope for team members to liaise more closely with GP practices and to provide helpful information to GPs about intellectual disability and the specialist health services available. Professionals seeking to work collaboratively with GPs should be sensitive to their workload pressures and to their attitudes towards health promotion initiatives and health screening.

Anxiety and depressive symptoms in childhood--a genetic study of comorbidity

Anxiety and depressive symptoms commonly co-occur yet the underlying mechanisms for this covariation remain poorly understood. Genetic strategies are a useful means of investigating whether the comorbidity of two sets of symptoms or disorders can be explained by the same aetiological factors. In this paper we use a systematically ascertained sample of 172 twin pairs aged 8 to 16 years to examine the causes of covariation of maternally rated anxiety and depressive symptoms. The results suggest that most of the covariation can be explained by a common set of genes that influence anxiety and depressive symptoms. Some covariation between anxiety and depressive symptoms is also explained by environmental influences of the non-shared type. In addition, depressive symptoms also appear to be influenced by specific genetic factors.

A twin study of antisocial and neurotic symptoms in childhood

There is some evidence to suggest that the role of genetic and environmental influences may vary for different types of psychiatric symptoms in childhood. The aim of this study was to examine to what extent genetic and environmental factors influence parent-rated conduct and neurotic symptoms in childhood and adolescence, using data obtained from a systematically ascertained sample of twins (198 same sex pairs) aged between 8 and 16 years. For symptoms of antisocial behaviour, transmission could be explained entirely by shared environmental factors. Social class effects were also found to have a significant influence on antisocial behaviour, although these effects only accounted for a small proportion of the variance explained by shared environmental factors. In contrast, transmission of neurotic symptoms was best explained by additive genetic influences alone with no contribution from shared environment. Non-shared environmental factors accounted for a substantial component of the variation for both antisocial behaviour and neurotic symptoms.

Genetic influences on life events in childhood

Until recently, life events were considered as chance occurrences. However, there is now increasing evidence that reported life events, at least in adult life are not random. Life events not only tend to cluster in families but also appear to be influenced by genetic factors. The aim of this study was to investigate whether genetic factors also influence reported life events in childhood using a systematically ascertained sample of 376 twin pairs aged 8 to 17. Overall, reported life events in this younger population were found to be heritable. However, the degree of genetic and environmental influence appeared to vary across the sexes, at least for parent-rated life events and according to whether life events were rated by the parents or the children themselves. Genetic influences appeared to be more important for self reports, suggesting that individual differences in cognition play a role in reporting life events.

Interruptions during general practice consultations--the patients' view

BACKGROUND

Although most aspects of the consultation have been extensively reported there is very little information on the effects of interruptions on the consultation.

OBJECTIVE

We wished to discover the patients' view of interruptions.

METHODS

In this pilot study the sources and frequency of interruptions to the consultations of a single general practitioner were measured. The effects of interruptions on 102 patients whose consultations were interrupted were then ascertained using a simple questionnaire.

RESULTS

The overall interruption rate was found to be 10.2%. The telephone was the commonest source of interruption, accounting for 50% of interruptions. Although most patients did not perceive the interruption as having an important effect on the consultation, 20% of patients did feel that the interruption had a bad effect on the consultation and 40% of patients felt it would have been better not to have been interrupted. A majority of patients (52%) did not feel that the reason for the interruption was important. Although most patients did not feel affected by the interruption, a significant minority (18%) of patients had a strongly negative emotional response to the interruption.

CONCLUSIONS

In view of these findings the need for further work has been highlighted.

Reverse-interference effect in free recall

D. J. Burns (1989) demonstrated that free recall of second-list response terms was better in an interference (A-B, A-C) condition than in a control (D-B, A-C) condition. This reversal of the traditional interference effect was referred to as the reverse-interference effect. Results from Experiments 2-4 in this article discounted several possible explanations of the reverse-interference effect, and the results from Experiment 5-7 supported a stimulus accessibility account of the reverse-interference effect. That is, when asked for free recall of the response terms, participants covertly retrieved stimulus terms to serve as cues for the responses. The reverse-interference effect reflects the greater accessibility of stimulus terms in the interference condition than in the control condition.

Attitudes of general practitioners to caring for people with learning disability

BACKGROUND

The views of general practitioners on their increasing role in caring for people with learning disability in the community are not known.

AIM

A study was carried out to assess the views of general practitioners with regard to providing routine care, organizing health promotion and specific health checks for people with learning disability and the role of specialists.

METHOD

A postal questionnaire was sent to all 242 general practitioners in Gwent, south Wales. Participants had to mark their level of agreement with 20 attitude statements regarding learning disability.

RESULTS

A total of 126 general practitioners (52%) responded. Respondents generally agreed that general practitioners were responsible for the medical care of people with learning disability. Respondents tended to be opposed to providing regular structured health promotion for people with learning disability, such as annual health checks and assessing hearing and eyesight. Specialist services were generally valued by respondents.

CONCLUSION

General practitioners largely accepted their role as primary health care providers for people with learning disability. In contrast, their role as providers of health promotion for this patient group was not generally accepted. Further research into the appropriateness and opportunity costs of health screening for people with learning disability is needed.

A strategic account of the cue-depreciation effect

A word fragment is less likely to be completed if it is presented incrementally (R______P, R____R _ P, R_I__R_P, R_I__R O P) than if it is presented all at once (e.g., R_I__R O P). This phenomenon is known as the cue-depreciation effect. The present study examined the role of strategies in this phenomenon. The magnitude of the cue-depreciation effect was increased when subjects were asked to adopt a passive generation approach to word fragment completion. The current study investigated an extension of Bruner and Potter's (1964) early hypothesis-generation account of the cue-depreciation effect. Findings demonstrated the influence of completion strategies for a general theory of fragment completion.

Childhood hyperactivity scores are highly heritable and show sibling competition effects: twin study evidence

Hyperactivity has consistently been shown to be familial. Until recently however, due to a lack of systematic twin evidence, it has remained uncertain to what extent familial transmission can be explained by genetic factors. We used a systematically ascertained population-based sample of twin pairs aged between 8 and 16 years old to explore the role of genetic influences on maternally rated hyperactivity scores. Hyperactivity scores were found to be substantially heritable. The data were best explained by a model which incorporated sibling competitive effects as well as additive genetic factors. These findings suggest not only that hyperactivity scores are influenced by genetic factors but that sibling interaction effects are also of importance.

Are anxiety symptoms in childhood heritable?

Although childhood anxiety appears to aggregate in families, transmission could be explained by both genetic and shared environmental factors. Twin studies can be used to disentangle genetic and environmental effects. In this study, a systematically ascertained sample of twins was used to investigate whether anxiety symptoms are heritable. Parent-rated anxiety symptoms could best be explained by an additive genetic model with heritability estimated at 59%. However, when self ratings were analysed (in the adolescent subsample), familial transmission could be accounted for by shared environmental factors only.

Mirror effect in frequency discrimination

In recognition, types of stimuli that are relatively easy to classify as old when old are also relatively easy to classify as new when new. The experiments reported here extend this mirror effect to discriminations among above-zero situational frequencies. Frequency discrimination exhibits a mirror effect when words are compared with nonwords or when low-linguistic-frequency words are compared with high-linguistic-frequency words. Accurate knowledge concerning the relative memorability of test items is neither necessary nor sufficient for the presence of a mirror effect.

A twin study of depressive symptoms in childhood

BACKGROUND

Although depression in childhood appears to be familial, transmission of symptoms could be genetic or environmental. Twin studies enable us to separate these effects. Our aim was to assess the importance of genetic and environmental factors on depressive symptoms during childhood and adolescence in an epidemiological sample of twins.

METHOD

Questionnaires (including the Mood and Feelings questionnaire) were mailed to a systematically ascertained sample (411 twin pairs) aged between 8 and 16 years. The overall response rate was 77%.

RESULTS

Data for the whole sample were best explained by an additive genetic model, with heritability of depressive symptom scores estimated at 79%. However, on splitting the sample, symptoms in children (aged 8 to 11) could be explained by shared environmental factors only, while symptoms in adolescents (aged 11 to 16) remained highly heritable.

CONCLUSIONS

The results suggest that although depressive symptoms appear to be largely heritable, the influence of genetic and environmental factors may vary with age.

Mirror effect in frequency discrimination

In recognition, types of stimuli that are relatively easy to classify as old when old are also relatively easy to classify as new when new. The experiments reported here extend this mirror effect to discriminations among above-zero situational frequencies. Frequency discrimination exhibits a mirror effect when words are compared with nonwords or when low-linguistic-frequency words are compared with high-linguistic-frequency words. Accurate knowledge concerning the relative memorability of test items is neither necessary nor sufficient for the presence of a mirror effect.

The genetics of mental retardation

Individuals affected by mental retardation are a clinically and aetiologically heterogeneous group. This heterogeneity is particularly highlighted when we consider the genetics of mental retardation. Recent advances in molecular genetic techniques have enabled us to understand more about the molecular basis of several genetic syndromes associated with mental retardation. In contrast, where there is no discrete cause, the interplay of genetic and environmental influences remains poorly understood.

Effects of level of processing on implicit and explicit tasks

The series of experiments presented in this article replicate the interaction that B. H. Challis and D. R. Brodbeck (1992) reported between list design (blocked or mixed) and level of processing for word fragment completion: The advantage for semantically processed words over shallowly processed words was greater when the conditions were blocked than when they were mixed on the study list. A similar interaction was found for perceptual identification (a data-driven implicit task) and priming in general knowledge questions (a conceptually driven implicit task). However, both data-driven and conceptually driven explicit tasks failed to reveal such a pattern.

The heritability of memory in the Western Reserve Twin Project

The heritability of memory ability was examined using 137 monozygotic and 127 same-sex dizygotic twin pairs from the Western Reserve Twin Project. Memory was assessed by eight measures drawn from the following batteries: the Wechsler Intelligence Scale for Children--Revised, the Colorado Test of Specific Cognitive Abilities, and the Cognitive Abilities Test. The results indicate that phenotypic correlations are generally low across these memory measures and heritability varies as a function of memory measure. These findings suggest that the heritability of memory varies as a function of the memory measure employed. Therefore, future studies investigating heritability estimates of memory should use a multimeasure battery to study this construct.

Educating asthmatic patients in primary care: a pilot study of small group education

Patient education is an important part of asthma management. Individual education is usually used for this task. The object of this study was to assess whether another educational technique, educating patients in small groups, would be as effective and as acceptable as individual counselling in improving knowledge about asthma. A specially designed questionnaire was used to assess knowledge and other variables before and after education. Thirty-four patients were educated individually and 34 patients were educated in small groups. There were significant improvements in knowledge scores after both types of education. However group education took 4.5 hours for 34 patients whereas individual counselling took 14.25 hours for the same number. The results of this study suggest that educating patients in small groups is as effective as individual counselling in improving knowledge of asthma, is acceptable to patients and takes much less time.

Evidence against a short-term-store account of long-term recency effects

When subjects perform a distractor task before and after every item on a list, recall of the last item is much higher than recall of items from the middle of the list. Koppenaal and Glanzer (1990) have shown that this long-term recency effect can be eliminated by using, after the last item, a distractor task different from that used elsewhere on the list. They interpreted this finding as evidence in favor of a short-term-store account of long-term recency effects. This account is challenged by the results reported here. Practice either on the task or on time-sharing between the task and list items had little impact on the recency effect. Also, substantial recency effects were found when a different distractor task occurred after every list position. Thus, it is not true that long-term recency effects are found only when subjects have an opportunity to adapt to the distractor task. Our results are not consistent with a short-term-store account of recency effects.

Treatment of childhood encopresis--a review

Children with encopresis may present to a number of different professionals. The literature on different treatment methods is reviewed. The roles of verbal psychotherapy, physical treatment, behaviour therapy and mixed treatment programmes are discussed.

Psychological sequelae of miscarriage: a controlled study using the general health questionnaire and the hospital anxiety and depression scale

This study was carried out to assess whether psychiatric morbidity after a miscarriage is higher than that associated with early pregnancy. A total of 60 consecutive women admitted to a Swansea hospital with a miscarriage were compared with 62 consecutive women who attended an antenatal clinic at the same hospital, using the 28-item general health questionnaire and the hospital anxiety and depression scale. These were completed both at initial contact and six weeks later. Women who had had a miscarriage were found to be significantly more anxious and scored higher on the subscale for severe depression than the pregnant women, both at initial assessment and six weeks later. At the six week assessment more somatic symptoms were also experienced by the group who had had a miscarriage. This study highlights the psychological disturbance associated with miscarriage. The primary health care team and hospital staff need to take this into consideration when organizing follow up for women who have had a miscarriage.

The genetics of personality disorder

Most measurable aspects of normal personality appear to be at least moderately heritable, with direct evidence coming from family, twin and adoption studies and indirect support deriving from psychophysiological research and breeding experiments on animals. Interestingly, genetic studies also shed light on the environmental sources of variation in personality and suggest that shared family environment rarely, if ever, has any positive effect on similarity between relatives. Despite problems of classification, and variations in the use of terms, a survey of the literature provides reasonably consistent evidence of a genetic contribution to several categories of abnormal personality, which we here divide into three groups, antisocial, anxious/avoidant, and schizoid-schizotypal personalities. However, personality disorders are complex traits that do not show simple mendelian patterns of inheritance and so far molecular genetics has been of no help in understanding their aetiology. Fortunately, techniques are now becoming available that enable the detection and potential localisation of genes of small effect and which may help elucidate the molecular basis even of (probably) polygenic traits such as abnormal personality.

Psychiatric disorder in the medical profession

Psychiatric disorder among doctors is an important and yet an often unacknowledged problem. Alcoholism, drug dependence and affective disorder appear to be the commonest problems. Preventive measures, early detection and intervention need to be emphasized.