A Group-Facilitated, Internet-Based Intervention to Promote Mental Health and Well-Being in a Vulnerable Population of University Students: Randomized Controlled Trial of the Be Well Plan Program

BACKGROUND

A growing literature supports the use of internet-based interventions to improve mental health outcomes. However, most programs target specific symptoms or participant groups and are not tailored to facilitate improvements in mental health and well-being or do not allow for needs and preferences of individual participants. The Be Well Plan, a 5-week group-facilitated, internet-based mental health and well-being group intervention addresses these gaps, allowing participants to select a range of activities that they can tailor to their specific characteristics, needs, and preferences.

OBJECTIVE

This study aims to test whether the Be Well Plan program was effective in improving primary outcomes of mental well-being, resilience, anxiety, and depression compared to a waitlist control group during the COVID-19 pandemic; secondary outcomes included self-efficacy, a sense of control, and cognitive flexibility. The study further seeks to examine participants' engagement and satisfaction with the program.

METHODS

A randomized controlled trial (RCT) was conducted with 2 parallel arms, an intervention and a waitlist control group. The intervention involved 5 weekly 2-hour sessions, which were facilitated in group format using Zoom videoconferencing software. University students were recruited via social media posts, lectures, emails, flyers, and posters.

RESULTS

Using an intentional randomization 2:1 allocation strategy, we recruited 215 participants to the trial (n=126, 58.6%, intervention group; n=89, 41.4%, waitlist control group). Of the 126 participants assigned to the intervention group, 75 (59.5%) commenced the program and were included in modified intention-to-treat (mITT) analyses. mITT intervention participants attended, on average, 3.41 sessions (SD 1.56, median 4); 55 (73.3%) attended at least 4 sessions, and 25 (33.3%) attended all 5 sessions. Of the 49 intervention group participants who completed the postintervention assessment, 47 (95.9%) were either very satisfied (n=31, 66%) or satisfied (n=16, 34%). The mITT analysis for well-being (F_1,162=9.65, P=.002, Cohen d=0.48) and resilience (F_1,162=7.85, P=.006, Cohen d=0.44) showed significant time × group interaction effects, suggesting that both groups improved over time, but the Be Well Plan (intervention) group showed significantly greater improvement compared to the waitlist control group. A similar pattern of results was observed for depression and anxiety (Cohen d=0.32 and 0.37, respectively), as well as the secondary outcomes (self-efficacy, Cohen d=0.50; sense of control, Cohen d=0.42; cognitive flexibility, Cohen d=0.65). Larger effect sizes were observed in the completer analyses. Reliable change analysis showed that the majority of mITT participants (58/75, 77.3%) demonstrated a significant reliable improvement in at least 1 of the primary outcomes.

CONCLUSIONS

The Be Well Plan program was effective in improving mental health and well-being, including mental well-being, resilience, depression, and anxiety. Participant satisfaction scores and attendance indicated a high degree of engagement and satisfaction with the program.

TRIAL REGISTRATION

Australian New Zealand Clinical Trial Registry ACTRN12621000180819; https://tinyurl.com/2p8da5sk.

Using the Intervention Mapping Approach to Develop a Mental Health Intervention: A Case Study on Improving the Reporting Standards for Developing Psychological Interventions

Replicating or distilling information from psychological interventions reported in the scientific literature is hindered by inadequate reporting, despite the existence of various methodologies to guide study reporting and intervention development. This article provides an in-depth explanation of the scientific development process for a mental health intervention, and by doing so illustrates how intervention development methodologies can be used to improve development reporting standards of interventions. Intervention development was guided by the Intervention Mapping approach and the Theoretical Domains Framework. It relied on an extensive literature review, input from a multi-disciplinary group of stakeholders and the learnings from projects on similar psychological interventions. The developed programme, called the “Be Well Plan”, focuses on self-exploration to determine key motivators, resources and challenges to improve mental health outcomes. The programme contains an online assessment to build awareness about one’s mental health status. In combination with the exploration of different evidence-based mental health activities from various therapeutic backgrounds, the programme teaches individuals to create a personalised mental health and wellbeing plan. The use of best-practice intervention development frameworks and evidence-based behavioural change techniques aims to ensure optimal intervention impact, while reporting on the development process provides researchers and other stakeholders with an ability to scientifically interrogate and replicate similar psychological interventions.

Testing the Differential Impact of an Internet-Based Mental Health Intervention on Outcomes of Well-being and Psychological Distress During COVID-19: Uncontrolled Intervention Study

BACKGROUND

During COVID-19, the psychological distress and well-being of the general population has been precarious, increasing the need to determine the impact of complementary internet-based psychological interventions on both positive mental health as well as distress states. Psychological distress and mental well-being represent distinct dimensions of our mental health, and congruent changes in outcomes of distress and well-being do not necessarily co-occur within individuals. When testing intervention impact, it is therefore important to assess change in both outcomes at the individual level, rather than solely testing group differences in average scores at the group level.

OBJECTIVE

This study set out to investigate the differential impact of an internet-based group mental health intervention on outcomes of positive mental health (ie, well-being, life satisfaction, resilience) and indicators of psychological distress (ie, depression, anxiety, stress).

METHODS

A 5-week mental health intervention was delivered to 89 participants using the Zoom platform during 2020. Impact on outcomes of distress, well-being, and resilience was assessed at the start and end of the program with multiple analysis of variance (MANOVA) and reliable change indices (RCIs) being used to determine program impact at the group and individual levels, respectively.

RESULTS

The intervention significantly improved all mental health outcomes measured, (F6,83=5.60, P<.001; Wilks Λ=.71; partial η2=.29) showing small to moderate effect sizes on individual outcomes. The largest effect sizes were observed for life satisfaction and overall well-being (η2=.22 and η2=.2, respectively). Larger effect sizes were noted for those with problematic mental health scores at baseline. A total of 92% (82/89) of participants demonstrated reliable change in at least one mental health outcome. Differential response patterns using RCI revealed that more than one-half of the participants showed improvement in both mental well-being and psychological distress, over one-quarter in outcomes of well-being only, and almost one-fifth in distress only.

CONCLUSIONS

The results provide evidence for the significant impact of an internet-based mental health intervention during COVID-19 and indicate the importance of assessing dimensions of both well-being and distress when determining mental health intervention effectiveness.

A needs-based workforce model to deliver tertiary-level community mental health care for distressed infants, children, and adolescents in South Australia: a mixed-methods study

BACKGROUND

High-quality mental health services for infants, children, adolescents, and their families can improve outcomes for children exposed to early trauma. We sought to estimate the workforce needed to deliver tertiary-level community mental health care to all infants, children, adolescents, and their families in need using a generalisable model, applied to South Australia (SA).

METHODS

Workforce estimates were determined using a workforce planning model. Clinical need was established using data from the Longitudinal Study of Australian Children and the Young Minds Matter survey. Care requirements were derived by workshopping clinical pathways with multiprofessional panels, testing derived estimates through an online survey of clinicians.

FINDINGS

Prevalence of tertiary-level need, defined by severity and exposure to childhood adversities, was estimated at 5-8% across infancy and childhood, and 16% in mid-adolescence. The derived care pathway entailed reception, triage, and follow-up (mean 3 h per patient), core clinical management (mean 27 h per patient per year), psychiatric oversight (mean 4 h per patient per year), specialised clinical role (mean 12 h per patient per year), and socioeconomic support (mean 12 h per patient per year). The modelled clinical full-time equivalent was 947 people and budget was AU$126 million, more than five times the current service level.

INTERPRETATION

Our novel needs-based workforce model produced actionable estimates of the community workforce needed to address tertiary-level mental health needs in infants, children, adolescents, and their families in SA. A considerable expansion in the skilled workforce is needed to support young people facing current distress and associated family-based adversities. Because mental illness is implicated in so many burgeoning social ills, addressing this shortfall could have wide-ranging benefits.

FUNDING

National Health and Medical Research Council (Australia), Department of Health SA.

What is the current level of mental health service delivery and expenditure on infants, children, adolescents, and young people in Australia?

OBJECTIVES

The study aim was to estimate the current level of ambulatory mental health service delivery to young people aged 0-24 years in Australia and associated government expenditure. Recognising the importance of the early years for the development of mental illness and socioeconomic outcomes, we were particularly interested in service access by infants and young children.

METHODS

We extracted information from government administrative datasets on the number of people who received mental health services, number of services and expenditure through the health sector for 2014-2015. Results are primarily reported by age groups 0-4, 5-11, 12-17 and 18-24 years.

RESULTS

Less than 1% of 0- to 4-year-olds received a mental health service in any one service setting, whereas nearly 11% of 18- to 24-year-olds received a mental health service through the Medicare Benefits Schedule Better Access programme alone. Many more services were delivered to 12- to 24-year-olds (>4 million) than to 0- to 11-year-olds (552,000). Medicare Benefits Schedule Better Access delivers services to more children and youth than do state/territory community mental health services, although the latter provide more services per client. In 2013-2014, Australian Government expenditure on ambulatory mental health services for 0- to 24-year-olds was AUD428 million, similar to the AUD491 million spent by state/territory governments.

CONCLUSION

The study provides a benchmark for data-driven service planning to ensure that the mental health needs of infants, children and young people are met. Our results indicate that the youngest age group are underserviced relative to need, even noting infants and children may receive services for behavioural/mental health issues from providers not captured in our study (such as paediatricians). The developmental origins of mental illness underlies the urgency of adequate provision by governments of perinatal, infant and child mental health services to avoid loss of life potential and reduce the pressures on the justice, child protection and welfare systems.

Developing a broad categorisation scheme to describe risk factors for mental illness, for use in prevention policy and planning

OBJECTIVES

The prevention of mental illness involves identifying and modifying those characteristics and exposures of an individual that threaten their mental health - commonly referred to as risk factors. Existing categorisations of risk factors for mental illness are either limited in their scope or oversimplified in their description. As part of a large mental health workforce and service planning project, we set out to develop a more detailed and comprehensive categorisation scheme to describe risk factors for mental illness.

METHODS

We conducted a rapid review of MEDLINE and Google Scholar for meta-analytic studies that examined the characteristics and exposures that typify the population with mental illness in order to identify and categorise potential risk factors.

RESULTS

The search uncovered 1628 relevant studies, from which 10 primary and 23 secondary categories of risk factors were identified, ranging from genetic and biomedical to psychological and sociocultural. The review revealed interesting distortions in the focus of the literature, with the majority of studies focused on a few disorders (schizophrenia, depression and neurodegenerative disorders) and genetic, psychological and physiological risks. In contrast, environmental (e.g. media exposure) and occupational (e.g. employee health) were under-represented.

CONCLUSION

The categorisation scheme developed in this paper is a step towards a more detailed taxonomy of risk factors for mental illness; this will be most useful in guiding clinicians, researchers and policy-makers in driving the prevention agenda forward.

How many children in Australia are at risk of adult mental illness?

OBJECTIVE

To estimate the prevalence of children in the Australian population with risk factors for adult mental illness.

METHOD

Key risk factors and risk domains were identified from a 2013 review of longitudinal studies on child and adolescent determinants of adult mental illness. Data items were identified from the Longitudinal Study of Australian Children that map onto the risk domains and were used to estimate the prevalence of these key individual risk factors and the magnitude of multiple risk in children aged 3 months to 13 years.

RESULTS

Even by infancy, risk factors for adult mental illness are highly prevalent, with 51.7% of infants having multiple risks. In 10 infants, 1 was born to mothers who consumed daily alcohol and 1 in 8 to mothers who smoked cigarettes daily during pregnancy. Also, 10.5% of infants were in families where the parents had separated, which increased to 18% in 10-11 year-olds. Psychological problems in the clinical range (based on the Strengths and Difficulties Questionnaire total problems score) ranged from 7.8% to 9.7% across the 4-13 years age range. Risks from negative parenting behaviours were highly prevalent across age groups. Two-thirds of children aged 12-13 years had parents who displayed low warmth or exhibited high hostility/anger. Across childhood, one in seven children are in families exposed to 3+ major life stressors. By age 8-9 years, more than 18% of children are exposed to ⩾5 risk factors.

CONCLUSIONS

We find that modifiable risk factors for adult mental illness occur at the earliest stage in the life course and at greater prevalence than is commonly recognised. Considerable capacity will be required in child and adolescent mental health services and complementary family support programmes if risk factors for adult mental illness that are already apparent in infancy and childhood are to be addressed.

A Comprehensive Critique and Review of Published Measures of Acne Severity

OBJECTIVE

Acne vulgaris is a dynamic, complex condition that is notoriously difficult to evaluate. The authors set out to critically evaluate currently available measures of acne severity, particularly in terms of suitability for use in clinical trials.

DESIGN

A systematic review was conducted to identify methods used to measure acne severity, using MEDLINE, CINAHL, Scopus, and Wiley Online. Each method was critically reviewed and given a score out of 13 based on eight quality criteria under two broad groupings of psychometric testing and suitability for research and evaluation.

RESULTS

Twenty-four methods for assessing acne severity were identified. Four scales received a quality score of zero, and 11 scored ≤3. The highest rated scales achieved a total score of 6. Six scales reported strong inter-rater reliability (ICC>0.75), and four reported strong intra-rater reliability (ICC>0.75). The poor overall performance of most scales, largely characterized by the absence of reliability testing or evidence for independent assessment and validation indicates that generally, their application in clinical trials is not supported.

CONCLUSION

This review and appraisal of instruments for measuring acne severity supports previously identified concerns regarding the quality of published measures. It highlights the need for a valid and reliable acne severity scale, especially for use in research and evaluation. The ideal scale would demonstrate adequate validation and reliability and be easily implemented for third-party analysis. The development of such a scale is critical to interpreting results of trials and facilitating the pooling of results for systematic reviews and meta-analyses.

Caregiver perceptions of mental health problems and treatment utilisation in siblings of children with mental health problems

BACKGROUND

Siblings of children with mental health problems (MHPs) have been found to have higher rates of psychopathology and impaired psychosocial functioning compared to control children. It is not yet known how these siblings are managed within the clinical service context (e.g., are they assessed for mental health problems? Do they receive appropriate psychological treatment?).

AIMS

The following brief report describes a pilot study which aimed to explore (a) the rate of caregiver-identified MHPs in siblings and (b) the proportion of siblings receiving psychiatric or psychosocial treatment or support (i.e., treatment utilisation).

METHODS

Eighty-five caregivers of children receiving treatment at CAMHS were interviewed about the mental health and treatment utilisation of their siblings.

RESULTS

The findings revealed a high rate of caregiver-identified MHPs in siblings (34.1%) and a high rate of treatment utilisation (85.7%).

CONCLUSIONS

The findings suggest that, for the vast majority, when siblings of children with MHPs are identified by their caregivers as having MHPs, they are receiving some kind of support and treatment. Implications for mental health service costs are discussed and recommendations for future research are outlined.

Preventing mental illness: closing the evidence-practice gap through workforce and services planning

BACKGROUND

Mental illness is prevalent across the globe and affects multiple aspects of life. Despite advances in treatment, there is little evidence that prevalence rates of mental illness are falling. While the prevention of cardiovascular disease and cancers are common in the policy dialogue and in service delivery, the prevention of mental illness remains a neglected area. There is accumulating evidence that mental illness is at least partially preventable, with increasing recognition that its antecedents are often found in infancy, childhood, adolescence and youth, creating multiple opportunities into young adulthood for prevention. Developing valid and reproducible methods for translating the evidence base in mental illness prevention into actionable policy recommendations is a crucial step in taking the prevention agenda forward.

METHOD

Building on an aetiological model of adult mental illness that emphasizes the importance of intervening during infancy, childhood, adolescence and youth, we adapted a workforce and service planning framework, originally applied to diabetes care, to the analysis of the workforce and service structures required for best-practice prevention of mental illness.

RESULTS

The resulting framework consists of 6 steps that include identifying priority risk factors, profiling the population in terms of these risk factors to identify at-risk groups, matching these at-risk groups to best-practice interventions, translation of these interventions to competencies, translation of competencies to workforce and service estimates, and finally, exploring the policy implications of these workforce and services estimates. The framework outlines the specific tasks involved in translating the evidence-base in prevention, to clearly actionable workforce, service delivery and funding recommendations.

CONCLUSIONS

The framework describes the means to deliver mental illness prevention that the literature indicates is achievable, and is the basis of an ongoing project to model the workforce and service structures required for mental illness prevention.

Telephone-based low intensity therapy after crisis presentations to the emergency department is associated with improved outcomes

INTRODUCTION

In Australia there is an overwhelming need to provide effective treatment to patients presenting to the Emergency Department (ED) in mental health crisis. We adapted Improving Access to Psychological Therapies service model (IAPT) from the National Health Service (NHS) method for the large scale delivery of psychological therapies throughout the United Kingdom to an Australian ED setting. This telephone-based low intensity therapy was provided to people presenting in crisis to the EDs with combinations of anxiety, depression, substance use, and suicidal thinking.

METHODS

This uncontrolled study utilised session-by-session, before-and-after measures of anxiety and depression via Patient Health Questionnaire (PHQ-9) and Generalised Anxiety Disorder-7 (GAD-7).

RESULTS

Of 347 eligible post-crisis ED referred patients, 291 (83.9%) engaged with the IAPT team. Most patients (65%) had attended the ED previously on an average of 3.9 (SD = 6.0) occasions. Two hundred and forty one patients received an average of 4.1 (SD = 2.3) contacts of low-intensity psychological therapies including 1.2 (SD = 1.7) community outreach visits between 20th Oct 2011 and 31st Dec 2012. Treated patients reported clinically significant improvements in anxiety, depression and suicidal ideation. Uncontrolled effect sizes were moderate for anxiety (0.6) and depression (0.6).

DISCUSSION

The Australian ED IAPT program demonstrated that the UK IAPT program could be adapted for emergency mental health patients and be associated with similar clinical benefits as the original program.

FUNDING

The Flinders Medical Centre IAPT program received Emergency Department project funding from the Australian Commonwealth Government through the Council of Australian Governments (COAG) and the South Australian Government initiative, Every Patient Every Service (EPES).

The validity of the Child Health Utility instrument (CHU9D) as a routine outcome measure for use in child and adolescent mental health services

BACKGROUND

Few cost-utility studies of child and adolescent mental health services (CAMHS) use quality adjusted life years (a combination of utility weights and time in health state) as the outcome to enable comparison across disparate programs and modalities. Part of the solution to this problem involves embedding preference-based health-related quality of life (PBHRQOL) utility instruments, which generate utility weights, in clinical practice and research. The Child Health Utility (CHU9D) is a generic PBHRQOL instrument developed specifically for use in young people. The purpose of this study was to assess the suitability of the CHU9D as a routine outcome measure in CAMHS clinical practice.

METHODS

Two hundred caregivers of children receiving community mental health services completed the CHU9D alongside a standardised child and adolescent mental health measure (the Strengths and Difficulties Questionnaire - SDQ) during a telephone interview. We investigated face validity, practicality, internal consistency, and convergent validity of the CHU9D. In addition, we compared the utility weights obtained in this group with utility weights from other studies of child and adolescent mental health populations.

RESULTS

Participants found the CHU9D easy and quick to complete. It demonstrated acceptable internal consistency, and correlated moderately with the SDQ. It was able to discriminate between children in the abnormal range and those in the non-clinical/borderline range as measured by the SDQ. Three CHU9D items without corollaries in the SDQ (sleep, schoolwork, daily routine) were found to be significant predictors of the SDQ total score and may be useful clinical metrics. The mean utility weight of this sample was comparable with clinical subsamples from other CHU9D studies, but was significantly higher than mean utility weights noted in other child and adolescent mental health samples.

CONCLUSIONS

Initial validation suggests further investigation of the CHU9D as a routine outcome measure in CAMHS is warranted. Further investigation should explore test-retest reliability, sensitivity to change, concordance between caregiver and child-completed forms, and the calibration of the utility weights. Differences between utility weights generated by the CHU9D and other utility instruments in this population should be further examined by administering a range of PBHRQOL instruments concurrently in a mental health group.

The prevalence of psychopathology in siblings of children with mental health problems: a 20-year systematic review

While the importance of looking at the entire family system in the context of child and adolescent mental health is well recognised, siblings of children with mental health problems (MHPs) are often overlooked. The existing literature on the mental health of these siblings needs to be reviewed. A systematic search located publications from 1990 to 2011 in four electronic databases. Thirty-nine relevant studies reported data on the prevalence of psychopathology in siblings of target children with MHPs. Siblings of target children had higher rates of at least one type of psychopathology than comparison children. Risk of psychopathology varied across the type of MHP in the target child. Other covariates included sibling age and gender and parental psychopathology. Significant variations and limitations in methodology were found in the existing literature. Methodological guidelines for future studies are outlined. Implications for clinicians, parents, and for future research are discussed.

A comparison between phone-based psychotherapy with and without text messaging support in between sessions for crisis patients

Background

Few studies have tested whether individually tailored text messaging interventions have an effect on clinical outcomes when used to supplement traditional psychotherapy. This is despite the potential to improve outcomes through symptom monitoring, prompts for between-session activities, and psychoeducation.

Objective

The intent of the study was to explore the use of individually tailored between-session text messaging, or short message service (SMS), as an adjunct to telephone-based psychotherapy for consumers who present to the Emergency Department (ED) in situational and/or emotional crises.

Methods

Over a 4-month period, two therapists offered 68 prospective consumers of a telephone-based psychotherapy service individually tailored between-session text messaging alongside their telephone-based psychotherapy. Attendance and clinical outcomes (depression, anxiety, functional impairment) of those receiving messages were compared against a historical control group (n=157) who received telephone psychotherapy only.

Results

A total of 66% (45/68) of the consumers offered SMS accepted the intervention. A total of 432 messages were sent over the course of the trial, the majority involving some kind of psychoeducation or reminders to engage in therapy goals. There were no significant differences in clinical outcomes between consumers who received the SMS and those in the control group. There was a trend for participants in the intervention group to attend fewer sessions than those in the control group (mean 3.7, SD 1.9 vs mean 4.4, SD 2.3).

Conclusions

Both groups showed significant improvement over time. Individually tailored SMS were not found to improve clinical outcomes in consumers receiving telephone-based psychotherapy, but the study was underpowered, given the effect sizes noted and the significance level chosen. Given the ease of implementation and positive feedback from therapists and clients, individually tailored text messages should be explored further in future trials with a focus on enhancing the clinical impact of the tailored text messages, and utilizing designs with additional power to test for between-group effects.

The IAPT@Flinders Service: adapting the Improving Access to Psychological Therapies model to the emergency department setting in Australia

OBJECTIVE

To describe the implementation of an Improving Access to Psychological Therapies (IAPT) service at Flinders Medical Centre emergency department (IAPT@Flinders). IAPT, a population-based model of guided self-help for anxiety and depression delivered mainly by phone, was rolled-out nationally in the UK in 2010. There is a growing body of evidence demonstrating its clinical effectiveness and efficiency that can improve treatment adherence, reduce stigma, remove appointment attendance barriers and improve access for hard-to-reach populations.

CONCLUSIONS

IAPT@Flinders was the test site for the first IAPT in Australia and also the first IAPT service that was integrated with an emergency department (ED). IAPT@Flinders offers rapid access, low-intensity cognitive behavioural therapy, social prescribing and signposting to clients with adjustment disorders, anxiety and/or depressive symptoms. Successful implementation within an Australian crisis setting has demonstrated that many IAPT structures and protocols are applicable to ED settings and the model can be implemented with fidelity. Adaption required consideration of positioning of the service within the Australian mental health framework; staff qualifications; the referral pathways; and exclusion criteria. It is recommended additional test sites and larger scale trials are conducted to provide further evidence of the applicability of large-scale adoption of the UK IAPT model into Australian ED settings.

Benchmarking the cost efficiency of community care in Australian child and adolescent mental health services: implications for future benchmarking

OBJECTIVE

The purpose of this study was to benchmark the cost efficiency of community care across six child and adolescent mental health services (CAMHS) drawn from different Australian states.

METHOD

Organizational, contact and outcome data from the National Mental Health Benchmarking Project (NMHBP) data-sets were used to calculate cost per "treatment hour" and cost per episode for the six participating organizations. We also explored the relationship between intake severity as measured by the Health of the Nations Outcome Scales for Children and Adolescents (HoNOSCA) and cost per episode.

RESULTS

The average cost per treatment hour was $223, with cost differences across the six services ranging from a mean of $156 to $273 per treatment hour. The average cost per episode was $3349 (median $1577) and there were significant differences in the CAMHS organizational medians ranging from $388 to $7076 per episode. HoNOSCA scores explained at best 6% of the cost variance per episode.

CONCLUSIONS

These large cost differences indicate that community CAMHS have the potential to make substantial gains in cost efficiency through collaborative benchmarking. Benchmarking forums need considerable financial and business expertise for detailed comparison of business models for service provision.

Understanding maltreating mothers: a synthesis of relational trauma, attachment disorganization, structural dissociation of the personality, and experiential avoidance

Treatment options are limited for families in which the child has severe and intractable disturbances of emotion and behavior, in which there is suspected or confirmed maltreatment by the mother, and in which the mother has her own history of childhood neglect and abuse. This paper proposes a model for understanding maltreatment in mother-child dyads, drawing upon the developmental psychopathology, behavior, and trauma literatures. At the core of this model is the hypothesis that a mother's maltreating behavior arises from unconscious attempts to experientially avoid the reemergence of an attachment-related dissociative part of the personality that contains the distress arising from her own early experiences of attachment relationships. The implications of this model for therapy are considered.

Rural children referred for conduct problems: evaluation of a collaborative program

Rural families can find it difficult to access mental health treatment for children’s conduct problems. The current program was designed to provide immediate assistance to families who faced extended waiting times in the south-eastern region of South Australia. In this collaborative project, a primary care professional delivered a telephone-guided version of a clinically based parent training program (Barkley’s Defiant Children) with program support from mental health services. The 12-week trial included 29 children aged 2–12 years who were referred for disruptive behaviour, attention-deficit hyperactivity and learning difficulties. Children were randomised to either a parent training group or a waiting list control group. Parents in the training program were generally satisfied (Therapy Attitude Inventory overall rating = 4.3 measured on a 5-point Likert scale). The main behavioural measure showed significantly better outcomes for the training program (Eyberg Child Behaviour Inventory (ECBI): Intensity scale (F1,27 = 11.39, P < 0.01) and Problem scale (F1,27 = 11.64, P < 0.01). For the parent training group, the mean score for the ECBI Intensity scale was reduced from above the clinical cut-off before treatment to below the cut-off after treatment. The effect sizes were 0.45 for the ECBI Intensity scale and 0.31 for the ECBI Problem scale. This suggests that the Defiant Children parent training can be adapted successfully for use by primary care professionals.