Priorities for research in miscarriage: a priority setting partnership between people affected by miscarriage and professionals following the James Lind Alliance methodology

OBJECTIVES

To identify and prioritise important research questions for miscarriage.

DESIGN

A priority setting partnership using prospective surveys and consensus meetings following methods advocated by the James Lind Alliance.

SETTING

UK.

PARTICIPANTS

Women and those affected by miscarriage working alongside healthcare professionals.

RESULTS

In the initial survey, 1093 participants (932 women who have experienced miscarriage, 8 partners, 17 family members, friends or colleagues, 104 healthcare professionals and eight charitable organisations) submitted 3279 questions. A review of existing literature identified a further 64. Non-questions were removed, and the remaining questions were categorised and summarised into 58 questions. In an interim electronic survey, 2122 respondents chose their top 10 priorities from the 58 summary questions. The 25 highest ranked in the survey were prioritised at a final face-to-face workshop. In summary, the top 10 priorities were ranked as follows: research into preventative treatment, emotional aspects in general, investigation, relevance of pre-existing medical conditions, emotional support as a treatment, importance of lifestyle factors, importance of genetic and chromosomal causes, preconception tests, investigation after different numbers of miscarriage and male causal factors.

CONCLUSIONS

These results should be the focus of future miscarriage research. Presently, studies are being conducted to address the top priority; however, many other priorities, especially psychological and emotional support, are less well researched areas. We hope our results will encourage both researchers and funders to focus on these priorities.

Predicting drinking outcomes: Evidence from the United Kingdom Alcohol Treatment Trial (UKATT)

AIMS

To explore client characteristics that predict drinking outcomes using data from the UK Alcohol Treatment Trial (UKATT).

METHODS

Multiple linear regression was used to determine if there were any characteristics, measured before the start of treatment, that could predict drinking outcomes at three and 12months, as measured by percent day abstinent (PDA) and drinks per drinking day (DDD) over the preceding 90days.

RESULTS

Lower baseline DDD score and greater confidence to resist drinking predicted lower DDD at both three and twelve months following entry to treatment. In addition to baseline PDA and having greater confidence to resist heavy drinking, female gender, aiming for abstinence, more satisfaction with family life and a social network that included less support for drinking were predictors of percent days abstinent.

CONCLUSIONS

Overall the strongest and most consistent predictors of outcome were confidence to avoid heavy drinking and social support for drinking. More predictors were identified for percent of days abstinent than for drinks per drinking day. For percent of days abstinent, a number of client characteristics at baseline consistently predicted outcome at both month three and month twelve.

Empowering family and friends: a new approach to the secondary prevention of addiction

This paper presents a typology and transactional model of how close relatives cope with excessive drinking, drug-taking or gambling in the family. These are illustrated with four examples taken from a series of research projects in which relatives have been interviewed to understand better how they react and respond. Such information is the groundwork for a World Health Organization initiative to help primary health care workers respond to the needs of relatives. The philosophy behind this initiative, and the steps that primary health care workers might take, are outlined. It is proposed that such workers can help close relatives to find the best coping methods in their circumstances, and that this approach might constitute an important, and hitherto neglected, form of secondary prevention.

Exploring treatment attendance and its relationship to outcome in a randomized controlled trial of treatment for alcohol problems: secondary analysis of the UK Alcohol Treatment Trial (UKATT)

AIMS

To identify client characteristics that predict attendance at treatment sessions and to investigate the effect of attendance on outcomes using data from the UK Alcohol Treatment Trial.

METHODS

Logistic regression was used to determine whether there were characteristics that could predict attendance and then continuation in treatment. Linear regression was used to explore the effects of treatment attendance on outcomes.

RESULTS

There were significant positive relationships between treatment attendance and outcomes at Month 3. At Month 12, these relationships were only significant for dependence and alcohol problems for those randomized to motivational enhancement therapy (MET). There were significant differences between groups in attendance, with MET clients more likely to attend than clients allocated to social behaviour and network therapy (SBNT). MET clients were also more likely to attend all sessions (three sessions) compared with SBNT (eight sessions). MET clients with larger social networks and those with confidence in their ability not to drink excessively were more likely to attend. SBNT clients with greater motivation to change and those with more negative short-term alcohol outcome expectancies were more likely to attend. No significant predictors were found for retention in treatment for MET. For those receiving SBNT, fewer alcohol problems were associated with continuation in treatment.

CONCLUSION

Attending more sessions was associated with better outcomes. An interpretation of these findings is that, to improve outcomes, methods should be developed and used to increase attendance rates. Different characteristics were identified that predicted attendance and continuation in treatment for MET and SBNT.

Dilated and echogenic fetal bowel and postnatal outcomes: a surgical perspective. Case series and literature review

INTRODUCTION

Foetal dilated or echogenic bowel have been described as markers for a variety of conditions including bowel obstruction, chromosomal and infectious disorders and cystic fibrosis. We aim to describe possible surgical interventions and outcomes.

METHODS

A 5-year review was performed of the clinical course of infants with antenatally diagnosed isolated echogenic bowel and/or dilated bowel or intraabdominal echogenic foci presenting at Princess Margaret Hospital for Children, Perth, Western Australia.

RESULTS

Abnormal antenatal findings were present in 35 foetuses. Twelve babies underwent surgery for intestinal atresia, meconium ileus and duplication cysts. Postoperative courses and outcomes were good.

CONCLUSIONS

Echogenic bowel on antenatal ultrasound is a non-specific marker for a variety of disorders. Although associated with higher rates of foetal loss, the majority of neonates are normal at delivery. Bowel dilatation with or without echogenicity is often predictive of bowel obstruction requiring surgery. Surgical outcomes are, however, very good. Echogenic foci elsewhere in the abdomen have little postnatal significance.

SAGE & THYME: a model for training health and social care professionals in patient-focussed support

OBJECTIVE

To develop a model for addressing the emotional concerns of patients or their caregivers; to teach the model in a three-hour workshop and to assess the impact of that training on a wide range of health and social care staff.

METHODS

A multi-specialty team, including a cancer patient, developed a model based on the evidence relating to emotional support and communication skills. The model (SAGE & THYME) consists of nine steps (see Box 1). The purpose of the model is to enable staff of all grades and roles to fulfil the most important objectives of support: enabling patients to describe their concerns and emotions if they wish to do so, holding and respecting those concerns; identifying the patients' support structures; exploring the patients' own ideas and solutions before offering advice or information. Over 800 health and social care staff of all grades and students have participated in the three-hour SAGE & THYME training workshops.

RESULTS

Analysis from 412 participants suggests that the workshops had a significant positive effect on self-confidence (p<.0005), self-perception of competence (p<.0005) and willingness to explore the emotional concerns of patients (p<.0005). 95% felt that the workshop would be very likely to have an impact on their practice.

CONCLUSIONS

The workshops have been successful in increasing the self-perceptions of confidence, competence and willingness to explore the emotional concerns of patients. The model 'SAGE & THYME' has been welcomed by participants.

PRACTICE IMPLICATIONS

Staff groups will require training for patients or their caregivers to have their concerns heard without interruption and to be allowed to explore their own resolutions. The three-hour SAGE & THYME training may go some way towards helping patients and staff form sound partnerships which assist patients to participate constructively in their own care.

Drinking and gambling: a comparison with implications for theories of addiction

There is current concern about the level of excessive gambling in a number of countries, but problem gambling still occupies an uncertain place in the addictions field. The present paper presents results from a pilot study comparing 16 problem gamblers and 16 problem drinkers. Results from a new Attachment Questionnaire suggested that gamblers were just as strongly attached to gambling as drinkers to drinking, although they were significantly less likely to experience withdrawal symptoms. Interviews with the problem gamblers suggested that excessive attachment to gambling was maintained by cyclical processes involving strong, negative feelings associated with gambling losses, shortage of money and the need to keep the extent of gambling secret. It is proposed that these 'secondary' processes, along with primary incentive motivation and the tertiary effects of losses associated with excessive behaviour, are sufficient to explain addiction. It is further suggested that neuroadaptation, tolerance and withdrawal, often thought to be central to the process of addiction, may in fact be of comparatively little importance.

SETTING STANDARDS FOR TRAINING AND COMPETENCE: THE UK ALCOHOL TREATMENT TRIAL

AIMS

To examine factors that influence the recruitment and training of therapists and their achievement of competence to practise two psychological therapies for alcohol dependence, and the resources required to deliver this.

METHODS

The protocol for the UK Alcohol Treatment Trial required trial therapists to be competent in one of the two trial treatments: Social Behaviour and Network Therapy (SBNT) or Motivational Enhancement Therapy (MET). Therapists were randomised to practise one or other type of therapy. To ensure standardisation and consistent delivery of treatment in the trial, the trial training centre trained and supervised all therapists.

RESULTS

Of 76 therapists recruited and randomised, 72 commenced training and 52 achieved competence to practise in the trial. Length of prior experience did not predict completion of training. However, therapists with a university higher qualification, and medical practitioners compared to other professionals, were more likely to complete. The average number of clients needed to be treated before the trainee achieved competence was greater for MET than SBNT, and there was a longer duration of training for MET.

CONCLUSIONS

Training therapists of differing professional backgrounds, randomised to provide a specific therapy type, is feasible. Supervision after initial training is important, and adds to the training costs.

Mechanisms by which area-based regeneration programmes might impact on community health: a case study of the new deal for communities initiative

STUDY OBJECTIVE

To explore mechanisms by which area-based regeneration initiatives may impact on health.

DESIGN

Case study of the New Deal for Communities programme, part of the UK National Strategy for Neighbourhood Renewal.

MAIN RESULTS

Health impacts may result from three mechanisms: sociospatial stigma, community participation and the commissioning of projects designed to change the distribution of determinants of health, including access to services and healthy lifestyles.

CONCLUSIONS

The present UK National Strategy for Neighbourhood Renewal includes improving health status as one of its key outcome measures. Area-based regeneration schemes such as the New Deal for Communities initiative should, intuitively, bring about health gain through their participatory approach to changing the physical and socio-economic environments. At present, however, the direction and magnitudes of these impacts are not clear.

Androgen and oestrogen receptor status of the human appendix testis

Since the human appendix testis is a Mullerian duct derivative it has been theorised that rising oestrogen levels in puberty result in enlargement of this organ and consequent predisposition to torsion. This study sought to establish the presence or absence of both androgen and oestrogen receptors in the human appendix testis. Bilateral appendix testis specimens surgically excised from ten patients undergoing scrotal exploration for acute scrotum were stained immunohistochemically for androgen and oestrogen receptors. These were examined by light microscopy. The human appendix testis was found to express both oestrogen and androgen receptors. Marked regional variation of androgen and oestrogen receptor positivity was demonstrated. The surface epithelium and some stromal cells were androgen receptor positive, whereas oestrogen receptors were confined to ductular invaginations, gland-like structures and some stromal cells. Rising levels of androgens and oestrogens in pubertal boys may account for enlargement and the predisposition of the human appendix testis for torsion since this structure contains receptors for both.

A prospective comparison of tissue glue versus sutures for circumcision

The safety of wound closure with tissue glue after surgery has been well established. The efficacy of its use in circumcision is poorly documented. The aim of this study was to carry out a comparative study of tissue glue versus suture closure after circumcision. The duration of the operative procedure, pain score, cosmesis and postoperative complications were evaluated. There were no complications in either group. There was no statistically significant difference in the pain score in both groups. However the mean time taken for tissue glue was 16.6 minutes and the mean time taken for sutures was 23.7 minutes. (p < 0.0001) which was statistically significant. The cosmetic appearance was found to be superior in the tissue glue group as there were no suture marks on the join of the shaft skin and foreskin base.

Mechanisms for the development of esophageal atresia

BACKGROUND

There is no universally accepted theory to explain esophageal embryology and the abnormal development that produces esophageal atresia.

METHODS

The impact of Adriamycin administration on the pathogenesis of esophageal atresia was studied in the rat model of VATER association, from embryonic day (ED) 10 to ED 13.

RESULTS

Tissues in the ED10 Adriamycin-exposed embryos displayed less cell proliferation as shown by the reduced population of MIB-5-labelled cells. Cell apoptosis that is characteristic of the normal ED 12 lateral epithelial folds of the foregut (the prospective site of tracheoesophageal septation) was absent in the foregut of the Adriamycin-exposed embryo. Histologic examination of the ED 11-exposed embryo showed the presence of abnormal notochord that was stretched, split, or tethered to the foregut. This contrasts with the normal embryo in which the notochord was localized in close vicinity of the ventral part of the neural tube and separated from the foregut by ample amount of mesenchyme. The abnormal localization of the notochord was accompanied by the lack of down-regulation of the sonic hedgehog (Shh) activity in the prospective site of future tracheoesophageal separation in the exposed ED 12 embryo.

CONCLUSION

The authors proposed that the ectopic location of the notochord leads to the disruption in Shh signalling that may underpin the development of esophageal atresia.

Ways of coping and the health of relatives facing drug and alcohol problems in Mexico and England

AIMS

To compare two contrasting socio-cultural groups in terms of parameters relating to the stress - coping - health model of alcohol, drugs and the family, and to test hypotheses derived from the model in each of the two groups separately.

DESIGN

Cross-sectional, comparative and correlational, using standard questionnaire data, supplemented by qualitative interview data to illuminate the findings.

PARTICIPANTS

One hundred close relatives, mainly partners or parents, from separate families in Mexico City, and 100 from South West England. Data sources. Coping Questionnaire (CQ), Family Environment Scale (FES), Symptom Rating Test (SRT), Semi-structured interview.

FINDINGS

Mean symptom scores were high in both groups, and not significantly different. The hypothesis that relatives in Mexico City, a more collectivist culture, would show more tolerant - inactive coping was not supported, but there was support for the prediction that relatives in South West England would show more withdrawal coping. This result may be as much due to differences in poverty and social conditions as to differences in individualism - collectivism. As predicted by the stress - coping - health model, tolerant - inactive coping was correlated with symptoms, in both groups, after controlling for family conflict, but there was only limited support for a moderating role of coping. Wives of men with alcohol problems in Mexico City, and wives of men with other drug problems in South West England, reported particularly high levels of both engaged and tolerant - inactive coping.

CONCLUSIONS

Tolerant - inactive coping may be bad for relatives' health: causality may be inferred but is not yet proved. Certain groups are more at risk of coping in this way. Qualitative data help understand the nature of tolerant - inactive coping and why it occurs despite the view of relatives themselves that it is counter-productive.

Addiction as excessive appetite

The excessive appetite model of addiction is summarized. The paper begins by considering the forms of excessive appetite which a comprehensive model should account for: principally, excessive drinking, smoking, gambling, eating, sex and a diverse range of drugs including at least heroin, cocaine and cannabis. The model rests, therefore, upon a broader concept of what constitutes addiction than the traditional, more restricted, and arguably misleading definition. The core elements of the model include: very skewed consumption distribution curves; restraint, control or deterrence; positive incentive learning mechanisms which highlight varied forms of rapid emotional change as rewards, and wide cue conditioning; complex memory schemata; secondary, acquired emotional regulation cycles, of which 'chasing', 'the abstinence violation effect' and neuroadaptation are examples; and the consequences of conflict. These primary and secondary processes, occurring within diverse sociocultural contexts, are sufficient to account for the development of a strong attachment to an appetitive activity, such that self-control is diminished, and behaviour may appear to be disease-like. Giving up excess is a natural consequence of conflict arising from strong and troublesome appetite. There is much supportive evidence that change occurs outside expert treatment, and that when it occurs within treatment the change processes are more basic and universal than those espoused by fashionable expert theories.

The family and alcohol: effects of excessive drinking and conceptualizations of spouses over recent decades

There is much debate in the addiction literature about the extent to which excessive drinking affects nondrinking family members. The issue is considered in this review by examining and evaluating research relating to the effects of drinking on children, family systems, and partners of drinkers. The latter group have, historically, been blamed and apologized for their partner's drinking, although more recent theories have adopted a stress and coping paradigm, thus normalizing individuals and their behaviors. Conceptualizations of spouses over the last five decades are described and evaluated in the second part of the review. Finally, the review considers the impact of the recent stress and coping paradigm on clinical interventions for excessive drinkers and their families, and suggestions are made for future research.

Oesophageal atresia in twins

The twin incidence is higher in infants with oesophageal atresia (OA) than in the general population. The purpose of this study was to review the twin OA information from five institutions and evaluate possible links between the development of OA and the twinning process. Data were compared, combined, and analysed. There was a total of 1,215 infants with OA, of whom 50 were from a twin pregnancy and 1 from a triplet pregnancy. Two sets of twins were concordant for OA. Mean birth weights and gestational ages were lower in the twin infants (P < 0.0005) and survival was lower in twins (65%, P < 0.005) than singletons. The anatomical variant of pure OA without fistula was seen in proportionally fewer twins (4%) than in singletons (7%). Multiple anomalies were present in 40% of twins compared with 33% of singletons, although this did not reach statistical significance. OA in our multicentre population was more common in twins. Several possible mechanisms are put forward to explain the apparent link between twinning and OA. Further analysis of this aspect of OA may aid in understanding the aetiology of this congenital anomaly.

Tolerate, engage or withdraw: a study of the structure of families coping with alcohol and drug problems in south west England and Mexico City

AIMS

To explore the structure underlying individual differences in the ways family members cope with drinking or drug problems.

DESIGN

Cross-sectional interview and questionnaire study of a series of family members in two contrasting socio-cultural groups.

SETTING

Mexico City and South West England.

PARTICIPANTS

Two hundred and seven family members from separate families, three-quarters women, one-quarter men, mostly partners or parents.

DATA

Long semi-structured interviews; the Coping Questionnaire (CQ).

FINDINGS

Factor and subscale analyses of the CQ data and textual analysis of the interview reports were used to test the hypothesis that the underlying structure to coping could be described in terms of eight or nine coherent and distinct ways of coping. Neither form of analysis gave strong support to this hypothesis.

CONCLUSIONS

It is concluded that the structure of coping can best be described in terms of three broad coping positions: tolerating, engaging and withdrawing. These conclusions challenge some previous assumptions about functional and dysfunctional ways of coping with excessive appetitive behaviour in the family.

Bleomycin therapy for cystic hygroma

Intralesional bleomycin injection was used as sclerosant therapy for sixteen patients with cystic hygroma. An excellent (complete clinical resolution) response was obtained in seven (44%) patients, a good (> 50% response) result in seven (44%), and a poor or no response in two (12%). Minor transient side effects (fever, vomiting, cellulitis, skin discoloration) were seen in six patients, and there were no serious side effects. The results suggest that bleomycin intralesional sclerosant is effective therapy for cystic hygroma, with response rates comparable to those of surgical removal, but with the advantage of avoiding inadvertent nerve damage and scarring.

The families of problem drug users: a study of 50 close relatives

The research described in this paper resulted from a collaborative multi-centre study of the relatives of problem drug users involving six practitioners and researchers, in four centres within the south-west of England. The objective of this research was simply to interview 50 close relatives of identified problem drug users, with the identification occurring through clinics and self-help groups. Quantitative and qualitative results show that large numbers of these relatives reported many negative experiences. The partners of illicit drug users reported both more and differently patterned problematic behaviours than those of prescribed tranquillizer users. The partners of illicit users also reported different problems to those of the parents. Relatives reported many negative effects in terms of how they viewed the drug user, and how the experiences had affected their health. They also described various coping mechanisms, and the extent of the support which they had received. The results are discussed in terms of coping, and similarity with research into the families of problem drinkers.

The adult adjustment of offspring of parents with drinking problems

One hundred and sixty-four 16-35-year-old offspring of parents with drinking problems, recruited from a variety of clinical and community sources, were compared with 80 respondents of similar ages from similar sources who did not have parents with drinking problems. Each was interviewed using a semistructured interview. Adult adjustment was similar in the two groups, but the offspring of parents with drinking problems did report considerably more disharmony in their families of origin, and many more childhood difficulties. Factor analysis of the adult adjustment data for the samples combined showed four factors which accounted for 41% of the variance; these factors differed little in their effect in the two groups. The groups' reports of the drinking problems of their siblings, however, suggests that this sample might be unrepresentative of the true risk to the children of parents with drinking problems for the development of alcohol-related (although not other) difficulties in adulthood: 16% of this group reported a sibling with a drink problem and a further 9% were unsure, but only one member of the comparison group reported a sibling with a drink problem, and one was unsure. Path analysis showed that both parental problem drinking and family disharmony are related in complex ways to adjustment difficulties in adulthood. 'Demoralisation', the largest of the four factors, was particularly related to disharmony in the family of origin: in the absence of disharmony, offspring versus comparison status was negatively correlated to demoralisation in adulthood, suggesting that having a parent with a drinking problem might sometimes be a strengthening experience.

Drinking amongst medical patients: levels of risk and models of change

Results are reported of a study in which 547 general hospital medical in-patients were screened, using a computer-administered questionnaire, for alcohol consumption, problems and concerns. Of males, 22.5% were classified as 'risk drinkers', of women 6.5%. Rates of risk were particularly high amongst younger male patients. It was concluded that certain screening questionnaire items were more useful than others in the general hospital context, and that standard questionnaires developed for other populations should not automatically be used in general hospitals. Comparisons with items relating to other health behaviours suggested that the medical profession, the general public and the patients themselves might be relatively insensitive to the risks associated with heavy drinking in comparison to those associated with smoking, weight and lack of exercise. Data from initial screening and from 75% of patients who were asked to repeat the questionnaire six months later, were used to test certain assumptions of a model of change based in part upon that of Prochaska & DiClemente (1986). Results suggested that processes of change were more complex than the model supposed.

Control, confront or collude: how family and society respond to excessive drinking

Research on excessive drinking in the family context has revealed the range of ways of coping used by close relatives. Case material from ongoing research in England and Mexico is used to illustrate this point. This research is also revealing the ways in which the family, close and extended, often fail to support the coping actions of close relatives. The analogy is drawn between coping with excessive drinking in the family and coping in the work setting. In the latter context explicit alcohol policies have been developed. These often recommend combining confrontative and supportive coping. It may be difficult for relatives, in the family setting, to adopt such a policy without support. The forms of coping identified in family research and in work policies correspond to basic and universal dimensions of interpersonal behaviour: dominance-submissiveness and friendliness-hostility. These forms of responding to excessive drinking may be identified beyond the microsocial systems of family and workplace. They are evident, also, in the responses of community agents such as police and social workers, and at the level of local and national government.

The environmental intergenerational transmission of alcohol problems: a comparison of two hypotheses

Two competing hypotheses concerning the mechanism of transmission of excessive substance use from one generation to the next are tested, using data from a study of 16- to 35-year-old offspring of problem-drinking parents. The 'positive influence' hypothesis predicts that the more positive has been the offspring's relationship with the problem-drinking parent during upbringing, the greater the risk of excessive drinking or drug taking in young adulthood. This hypothesis received support only for women with fathers with drinking problems. The 'relationship deficiency' hypothesis predicts that those offspring most at risk are those who have had the more negative relationships with parents. This hypothesis received some support in the case of men with mothers with drinking problems: this subgroup of offspring were more at risk if they reported having had poor relationships with their fathers. It is concluded that the environmental intergenerational transmission of problems of excessive substance use occurs via a variety of mechanisms which are likely to be of differential importance in different subgroups.

Young adult offspring of parents with drinking problems: recollections of parents' drinking and its immediate effects

One hundred and seventy 16- to 35-year-old offspring of parents with drinking problems were recruited from a variety of clinical and community sources and each was interviewed at length using a semi-structured interview. The present paper focuses upon carefully reconstructed recollections of childhood, and presents quantitative information from the whole sample and three briefly described individual examples. Large variances on quantitative measures and very varied qualitative accounts of childhood were evident. The large majority described parental drinking problems which spanned their childhood and adolescent years without interruption and without treatment. Amongst the most frequently recalled effects on life at home were parental moodiness, unreliability, and a tendency to upset or fail to join in with family activities. Amongst negative childhood experiences recalled most frequently were worry and uncertainty, a feeling of family instability, the experience of being caught between the interests of two parents, and the adoption of certain adult roles. Those with mothers with drinking problems scored significantly higher on a scale of negative childhood experiences and mothers with drinking problems were more likely to have drunk regularly at home. Those offspring from families of higher social status estimated their parental problems to have started slightly later in childhood. Qualitative analysis suggested that whether excessive parental drinking is perceived as alien to or integral with family life may have been a neglected variable.

Offspring of parents with drinking problems: drinking and drug-taking as young adults

One hundred and seventy 16 to 35 year-old offspring of parents with drinking problems and 80 comparison young adults were recruited from a variety of clinical and community sources. Each was interviewed at length using a semi-structured interview and 86% were re-interviewed one year later. No between-group differences were found in current quantity of alcohol consumption nor in percentages who had ever used or were currently using illicit or prescribed drugs. However, larger numbers of offspring had commenced alcohol use in their early teens and had used other drugs in their later teens, and more offspring than comparisons were currently using alcohol in a risky way, more were using illicit drugs more than occasionally, and more were heavy smokers. These differences were not great, and gender and source of recruitment (clinical versus community) were equally important predictor variables. Analyses conducted within the offspring group offered no support for hypotheses linking adulthood risk with years of exposure, severity of childhood effects and experiences, maternal as opposed to paternal problems, or problems in the same sex parent. However, some support was found for the importance of having had two parents with drinking problems and having had a drinking parent who often drank at home.

The effects on children and adolescents of parents' excessive drinking: an international review

The effects during childhood, adolescence, and adulthood of having a parent with a drinking problem has interested researchers in several countries. The greatest number of reports related to this subject have appeared in the U.S. literature and in the literature from countries of Eastern Europe. This review encompasses the findings of researchers in these countries as well as workers in Western Europe, Latin America, and Japan. This review does not include biological, physiological, or neurological data. The epidemiologic evidence from several countries shows significant points of agreement. Problem drinking by a parent markedly increases health risks to children and adolescents. Such risks include diminished intellectual capacity and development, increased neuroticism, and a wide range of psychological and behavioral disorders. Parents who drink excessively are also likely to have children who experience long-term adverse consequences. These include heavy and problem-causing psychoactive substance use, criminality, suicide, depression, personality disorders, and psychological and behavioral disturbances. Parents who drink heavily are also especially likely to produce children who subsequently abstain from alcohol or drink only lightly.

Expressed emotion and perceived family interaction in the key relatives of elderly patients with dementia

Four groups of families were investigated using an interview designed to assess expressed emotion (EE) in relatives of psychiatric patients and a family interaction questionnaire (FIQ) based upon the Leary and Benjamin schemes for coding interpersonal behaviour. The families included 25 containing a psychiatric patient aged between 18 and 46, and three groups of 12 families each, all containing a patient over 60 (patients with dementia, a functional psychiatric disorder, or a chronic physical disorder respectively). In all cases data were obtained from key relatives. The FIQ clearly separated out the group of dementia relatives who reported the most dominant and protective behaviours and the highest levels of hostile-dominance and the lowest levels of affection. EE was not found to be so sensitive to interactions occurring in families with a member with dementia, and the possible reasons for this are discussed.

Abstinence or controlled drinking in clinical practice: indications at initial assessment

Previous research has suggested two leading hypotheses concerning which excessive drinkers can re-establish control: one based upon level of dependence, the other upon the client's personal persuasion. Using initial assessment data from 46 clients of a clinical psychology alcohol problems service (30 men, 16 women), an attempt was made to operationalize the concepts of dependence and personal persuasion using a variety of indicators of each. Although SADQ scores and Rand definite alcoholism were in general agreement, there were a number of borderline instances and cases of disagreement, and neither was in good agreement with estimates of problem duration, nor with reports of recent or earlier attainment of abstinence or control. Indicators of personal persuasion were more consistent. Those with dependence indicators for abstinence tended to prefer abstinence as a goal, but there were many departures from this pattern particularly for women. It is concluded that in clinical practice it will be very difficult to make a clear cut recommendation about treatment goal at initial assessment except in a few cases.

Gender differences in the functions and effects of moderate and excessive drinking

In a study comparing abstinence and controlled drinking treatments, differences were found between men (n = 30) and women (n = 16) which confirmed some previous views on sex differences and problem drinking, and which have implications for choice of drinking treatment goal. On average women had problems of shorter duration, were less likely to have previously received out-patient specialist treatment only, reported consuming smaller quantities of alcohol, and reported a more regular recent pattern of consumption. Mean SADQ scores, and numbers 'definitely alcoholic' by Rand criteria, were similar, as were the numbers reporting a positive family history of drinking problems. Contrary to expectations, women were no more likely than men to report interpersonal functions and effects of drinking. Men were more likely than women to report drinking for positive emotional or social reasons or because of social pressure, were more likely to report positive effects of drinking, and among negative effects were more likely than women to report effects on work, finances, leisure, and fitness. Levels of self-esteem were very similar, but men described more positive effects of moderate drinking upon self-esteem than women.

Children of alcoholics. Report of a preliminary study and comments on the literature

Familial relationships in 11 families in which 1 parent is an alcoholic are discussed in the context of literature on the children of alcoholics.

Alcoholism: a controlled trial of "treatment" and "advice"

Two groups of alcoholics received either one counseling session or several months of in- and outpatient treatment. One year later there were no significant differences in outcome between the two groups.

The cohesiveness of alcoholism-complicated marriages and its influence on treatment outcome

One-hundred husbands, diagnosed as suffering from alcoholism, and their wives, were followed up twelve months after initial consultation and assessment. Follow-up information was complete in 89 cases. On the basis of both husband and wife accounts of the husband's drinking behaviour during the follow-up period, and their assessment of the drinking problem at twelve-months follow-up, 28 were classified as having a 'good' outcome and 29 as having a 'bad' outcome. In the remaining 32 cases outcome was considered 'equivocal'. A composite measure of marital cohesion was predictive of twelve-month outcome classification, cohesive marriages being significantly more likely to have a good outcome. The measure of marital cohesion was based upon husband and wife reports of mutual affection and of husband involvement in family tasks, favourable spouse perceptions and meta-perceptions, and optimism about the future of the marriage. Composite measures of dominance balance within the marriage were not predictive of outcome. Husband's job status, husband's self-esteem, and wife's reported hardship were not independent of marital cohesion, and were themseleves predictive of twelve-months outcome. When these variables were partially controlled it was found that marital cohesion remained predictive for husbands with relatively low status jobs and husbands with relatively low levels of self-esteem. It is an over-simplification to state that either the marriage, the spouse, or the severity of the patient's condition is alone the cause of variation in outcome. It is possible to integrate these findings with those of other studies on the influence of family variables on the outcom of conditions other than alcoholism. Together these studies suggest a general hypothesis linking a breakdown in the cohesiveness, or mutual rewardingness, of family relationships and unfavourable outcomes following treatment or consultation for psychological disorder.