Systematic Review and Meta-Analysis of the Effectiveness of Teacher Delivered Interventions for Externalizing Behaviors

This systematic review and meta-analysis explores the effectiveness of teacher interventions supporting children with externalizing behaviors based on teacher and child outcomes. A systematic search was conducted using 5 electronic databases. From 5714 papers, 31 papers that included interventions delivered directly to teachers and aimed to benefit either teachers and/or children with externalizing behaviors were included. The review focused on qualified teachers working with children aged 2-13. The results of the current meta-analysis revealed a positive effect of teacher intervention on teacher and child outcomes, including the increased use of teacher-appropriate strategies, as well as significant and moderate improvements in teacher-child closeness, and small reductions in teacher-child conflict. For child outcomes, the interventions reduced externalizing behavior problems and ADHD symptoms and enhanced prosocial behavior. Only one fully blinded analysis for conduct problems was possible and revealed a moderate but significant reduction in favor of intervention. These findings provide evidence to support the role of teacher interventions for both teachers and children with externalizing behaviors. Future research should include more PBLIND measurements so that MPROX findings can be confirmed. More research should be done to evaluate the influence of teacher interventions on teachers' well-being.

Development and evaluation of an online education tool on attention deficit hyperactivity disorder for general practitioners: the important contribution of co-production

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is underdiagnosed in the UK and the assessment and diagnosis pathway often involves a general practitioner (GP) referral to secondary care services. GPs' levels of knowledge and understanding about ADHD is often a significant barrier in patients accessing care. The development of an online education resource could improve GPs knowledge of ADHD and optimise appropriate referrals. Involving end-users in co-creating interventions may enhance their clinical utility and impact routine clinical practice. However, there is limited published evidence describing how to meaningfully involve stakeholders in both the design and development components of co-production.

METHOD

We report a step wise, co-production approach towards developing an online ADHD education intervention for GPs. Preparatory work highlighted the relevant topics to be included in the intervention, from which educational videos were then developed. Workshops were then conducted with GPs, leading to further refinement of the video content and subsequently the final intervention. A pilot usability study (n = 10 GPs) was then conducted to assess the intervention's acceptability, feasibility and accessibility.

RESULTS

The development of the online intervention was greatly facilitated by the involvement of GPs. Having a co-production development process ensured the consistent adaptation of the intervention to meet GPs' needs. The usability study showed that the content of the intervention was suitable, easily accessible, engaging and delivered at an acceptable level of intensity, validating the development approach taken.

CONCLUSION

While further studies are needed to evaluate the efficacy of the developed intervention, preliminary findings demonstrated that it was acceptable and well received. The importance of co-development was highlighted in developing an intervention that addresses specific needs for GPs. This development approach may be useful for other researchers and developers of clinical interventions.

Awareness of ADHD in primary care: stakeholder perspectives

BACKGROUND

Attention Deficit Hyperactivity Disorder (ADHD) is underdiagnosed in many European countries and the process of accessing care and diagnosis is complex and variable. In many countries, general practitioners (GPs) refer on to secondary care where individuals receive an assessment and, if appropriate, a diagnosis and access to care. It is therefore essential that GPs have a clear understanding of the disorder and its care pathways. While previous studies have highlighted potential barriers in GPs' ADHD awareness, this qualitative study aims to further explore individual stakeholders' experiences.

METHODS

Semi-structured interviews explored the views of multiple stakeholders- GPs (n = 5), healthcare specialists (n = 5), patients (adults with ADHD n = 5) and parents (n = 5) with experience of the presentation and management of ADHD in primary care. These interviews were analysed using thematic analyses and following principles of grounded theory.

RESULTS

Stakeholders described ADHD assessment, diagnosis and treatment as an intricate process. Many factors affected this process such as complex pathways, lack of services, limited GP recognition and knowledge, and communicative difficulties between and within multiple stakeholders.

CONCLUSION

This analysis underlines the significant impact that receiving (or not) a diagnosis can have, and further explores muddled ADHD care pathways, highlighting key issues around GP identification and the shortage of adult services. Implications for practice and future research are discussed, suggesting a strong need for more commissioned pathways and GP specific educational programs.

Barriers and facilitators to understanding of ADHD in primary care: a mixed-method systematic review

Attention deficit hyperactivity disorder (ADHD) is a developmental disorder affecting up to 5% of children and adults and is underdiagnosed in many European countries. The process of access to care for this disorder is complex and variable across countries. In general, those affected, or their caregiver, will seek help through their primary care practitioners who are then often responsible for referral to other professionals for diagnosis and provision of treatment. Previous studies have highlighted that many barriers to recognition exist in primary care settings (such as misconceptions, lack of education or lack of resources), preventing access to care for this population and potentially affecting diagnosis rate. This systematic review aims to establish the barriers and facilitators with regard to attitudes, beliefs and experiences of ADHD within primary care. Electronic searches of multiple databases identified 3898 articles of which 48 met our inclusion criteria-primary care professionals from any country, understanding, knowledge, awareness, attitude and recognition of ADHD. Four main themes were identified: (1) need for education, (2) misconceptions and stigma, (3) constraints with recognition, management and treatment, and (4) multidisciplinary approach. The findings suggest many interacting factors are at play in the recognition of ADHD by primary care practitioners with a strong recurring theme of a significant need for better education on ADHD. Implications for research and practice are discussed, suggesting that educational interventions for primary care practitioners could improve the recognition of ADHD in this setting.

The economic burden of adult attention deficit hyperactivity disorder: A sibling comparison cost analysis

AIM

Attention Deficit Hyperactivity Disorder (ADHD) is a lifespan disorder associated with considerable economic cost. While the economic burden of ADHD has been widely estimated, there is considerable variation in reported costs between studies, which typically focus on health outcomes only, lack adequate control and fail to correct for the influence of genetic and shared environmental factors. The aim of this study is to overcome these limitations to reach a fuller understanding of the economic burden of ADHD.

METHOD

Using the Danish National Registers 5269 adults with a diagnosis of ADHD in adulthood who had not received a diagnosis in childhood were identified. Excluding cases with missing data, comorbid diagnoses, and cases without a same sex sibling free of any diagnosed psychiatric diagnoses, a final cohort was formed consisting of 460 sibling dyads. Using a cross-sectional method focusing on the year 2010, cost differences between each adult with ADHD and their sibling were calculated from data retrieved from health, education, crime, employment and social care registers.

RESULTS

Adults with ADHD had considerably lower disposable income and paid less tax than their siblings. They also received more state benefits, had higher costs for health, social care, and crime than their siblings. The total average costs difference for the year 2010 was 20,134 euros more than their sibling for each adult with ADHD.

CONCLUSION

ADHD is associated with considerable costs which are borne by both the individual and the state and underlines the need to consider the wider economic impact of ADHD beyond income and healthcare utilisation costs.

The Effectiveness of a Psychoeducation Intervention delivered via WhatsApp for mothers of children with Autism Spectrum Disorder (ASD) in the Kingdom of Saudi Arabia: A randomized controlled trial

BACKGROUND

Mothers of children with autism spectrum disorder (ASD) report high levels of stress and lower levels of well-being than parents of typically developing children. Current interventions for ASD typically focus on working with the child rather than delivering strategies to help support parents.

OBJECTIVE

To evaluate the effectiveness of a psychoeducation intervention developed to support mothers of children with ASD in Saudi Arabia.

METHOD

Sixty-two mothers (23-52 years) of children (26-78 months) were recruited to a multisite randomized controlled trials of the intervention. The intervention consisted of one face-to-face session (60 min) and four virtual sessions (30 min each) delivered using WhatsApp. Parenting stress was the primary outcome, with secondary outcomes focusing on maternal depression, anxiety, and happiness, and child behaviour problems and ASD symptoms. Data were collected at baseline T1, immediately postintervention T2 and 8-week follow-up T3.

RESULTS

One-way analysis of covariance was used at T2 and T3 with T1 scores entered as a covariate. Improvements were found at T2 for stress (F = 234.34, p = .00, and d = -1.52) and depression (F = 195.70, p = .00, and d = -2.14) but not anxiety, and these results were maintained at T3. Changes in child behaviour problems were limited to improvements in hyperactivity at T2 (F = 133.66, p = .00, and d = -1.54). Although changes in stress and depression were statistically significant, change to clinically normal levels was limited to depression. None of the participants had recovered after the intervention (Parent Stress Index Short Form stress scores), whereas 23 mothers (71.87%) in the intervention group had recovered at T2 and 22 (68.75%) at T3 (Hospital Anxiety and Depression Scale depression scores).

CONCLUSION

This intervention with WhatsApp support is beneficial but may need to be augmented with other forms of support for mothers of children with ASD including more condensed sessions on stress and interventions targeting anxiety.

Effectiveness and cost-effectiveness of a brief school-based group programme for parents of children at risk of ADHD: a cluster randomised controlled trial

BACKGROUND

National Institute for Health and Care Excellence guidelines recommend a stepped care approach for the identification and management of children with, or at risk of, attention-deficit/hyperactivity disorder (ADHD). We investigated the effectiveness, cost-effectiveness and acceptability of a group parenting intervention programme (+/- a teacher session) for children at risk of ADHD.

METHODS

In a three-arm cluster randomised controlled trial, 12 primary schools were randomly assigned to control, parent-only and combined (parent + teacher) intervention arms. Eligible children had high levels of parent-rated hyperactivity/inattention (n = 199). At 6 month follow-up, the primary outcome measure was the parent-completed Conners' Rating Scale - Revised (ADHD index). Secondary outcomes included the Conners' sub-scales (hyperactivity, cognitive problems/inattention and oppositional behaviour), the teacher-completed Conners' Rating Scale - Revised, child health-related quality of life, parental burden and parental mental health. The cost-effectiveness analyses reflected a health and personal social services perspective.

TRIAL REGISTRATION

ISRCTN87634685.

RESULTS

Follow-up data were obtained from 76 parents and 169 teachers. There was no effect of the parent-only (mean difference = -1.1, 95% CI -5.1,2.9; p = 0.57) or combined interventions (mean difference = -2.1, 95% CI -6.4,2.1; p = 0.31) on the ADHD index. The combined intervention was associated with reduced parent-reported hyperactivity symptoms (mean difference = -5.3; 95% CI -10.5,-0.01; p = 0.05) and the parent-only intervention with improved parental mental health (mean difference = -1.9; 95% CI -3.2,-0.5; p = 0.009). The incremental costs of the parent-only and the combined interventions were £73 and £123, respectively. Above a willingness-to-pay of £31 per one-point improvement in the ADHD index, the parent-only programme had the highest probability of cost-effectiveness. Participants found the interventions acceptable.

CONCLUSIONS

For children at risk of ADHD, this school-based parenting programme was not associated with improvement in core ADHD symptoms. Secondary analyses suggested a possible reduction in parent-reported hyperactivity and parental mental health problems. Future research should compare targeted interventions against watchful waiting and specialist referral.

Beyond symptom control for attention-deficit hyperactivity disorder (ADHD): what can parents do to improve outcomes?

Attention-deficit hyperactivity disorder (ADHD) and its associated behavioural manifestations develop and progress as the result of complex gene-environment interactions. Parents exert a substantial influence and play a major role in their child's social environment. Despite this, recent evidence has suggested that adapting the child's environment via parenting interventions has minimal effects on child ADHD symptoms when analysing data from informants who are probably blind to treatment allocation. However, adverse parenting and family environments may act as a source of environmental risk for a number of child outcomes beyond ADHD symptoms. This is a narrative review that critically discusses whether parenting interventions are beneficial for alternative functioning outcomes in ADHD including neuropsychological, academic and social functioning and disruptive behaviour and how parenting and familial environments may be associated with these outcomes. In addition, the review explores how parental depression and parenting efficacy impact on capacity for optimal parenting and whether parenting interventions benefit parents too. A review of the evidence suggests that with modification, parenting interventions are beneficial for a number of outcomes other than ADHD symptom reduction. Improving the parent-child relationship may have indirect benefits for disruptive behaviour. Furthermore, parenting behaviours may directly benefit child neuropsychological, academic and social functioning. Parenting interventions can have therapeutic benefits for parents as well as children, which is important as parent and child well-being is likely to have a transactional relationship. Evaluation of the clinical success of parenting interventions should focus on a wider range of outcomes in order to aid understanding of the multifaceted benefits that they may be able to offer. Parenting interventions should not be seen as a redundant adjunct to medication in multi-modal treatment approaches for ADHD; they have the potential to target outcomes that, at present, medication seems less able to improve.

Attention-deficit hyperactivity disorder (ADHD): an updated review of the essential facts

Attention-deficit hyperactivity disorder (ADHD) is a complex disorder that can affect individuals across the lifespan. It is associated with substantial heterogeneity in terms of aetiology, clinical presentation and treatment outcome and is the subject of extensive research. Because of this, it can be difficult for clinicians to stay up to date with the most relevant findings and know how best to respond to parents' questions and concerns about the disorder and interventions. This is a narrative review that aims to summarize key findings from recent research into ADHD and its treatment that clinicians can share with families in order to increase their knowledge about ADHD and intervention options. ADHD develops as a result of complex interplay between interdependent genetic and non-genetic factors. The disorder is associated with substantial impairments in functioning and poor long-term outcomes. Pharmacological and non-pharmacological treatment options are available for symptom management and to improve function, but functioning outcomes often fail to normalize in children with ADHD. Despite extensive advances in understanding this complex disorder, it is clear that there is still a long way to go. In particular, we address the need for future non-pharmacological interventions to be more specifically targeted for ADHD symptoms and its commonly associated functioning deficits in order to ensure the best long-term outcomes for children with ADHD.

Genome-wide association study of body mass index in 23 000 individuals with and without asthma

BACKGROUND

Both asthma and obesity are complex disorders that are influenced by environmental and genetic factors. Shared genetic factors between asthma and obesity have been proposed to partly explain epidemiological findings of co-morbidity between these conditions.

OBJECTIVE

To identify genetic variants that are associated with body mass index (BMI) in asthmatic children and adults, and to evaluate if there are differences between the genetics of BMI in asthmatics and healthy individuals.

METHODS

In total, 19 studies contributed with genome-wide analysis study (GWAS) data from more than 23 000 individuals with predominantly European descent, of whom 8165 are asthmatics.

RESULTS

We report associations between several DENND1B variants (P = 2.2 × 10(-7) for rs4915551) on chromosome 1q31 and BMI from a meta-analysis of GWAS data using 2691 asthmatic children (screening data). The top DENND1B single nucleotide polymorphisms(SNPs) were next evaluated in seven independent replication data sets comprising 2014 asthmatics, and rs4915551 was nominally replicated (P < 0.05) in two of the seven studies and of borderline significance in one (P = 0.059). However, strong evidence of effect heterogeneity was observed and overall, the association between rs4915551 and BMI was not significant in the total replication data set, P = 0.71. Using a random effects model, BMI was overall estimated to increase by 0.30 kg/m(2) (P = 0.01 for combined screening and replication data sets, N = 4705) per additional G allele of this DENND1BSNP. FTO was confirmed as an important gene for adult and childhood BMI regardless of asthma status.

CONCLUSIONS AND CLINICAL RELEVANCE

DENND1B was recently identified as an asthma susceptibility gene in a GWAS on children, and here, we find evidence that DENND1B variants may also be associated with BMI in asthmatic children. However, the association was overall not replicated in the independent data sets and the heterogeneous effect of DENND1B points to complex associations with the studied diseases that deserve further study.

Development of a recovery manual for suicidal patients with schizophrenia: consumer feedback

A recovery-oriented manual was developed for patients with schizophrenia and suicidality. It included psychoeducational information, vignettes, "workbook" sections and was reviewed by experts in suicidology, recovery, patient education, manual development and psychosocial interventions. The revised version was tested in 22 consumers with schizophrenia and a history of suicidality. Consumer-based focus groups yielded five key themes which were used to further refine the manual. A satisfaction survey indicated that 85% stated the manual was 'somewhat easy', 'easy' or 'very easy to read.' All stated it was 'very useful', 'useful' or 'somewhat useful. Thus, the manual appears to be acceptable and useful.

Self-help parenting interventions for childhood behaviour disorders: a review of the evidence

The use of self-help interventions for parents of children with behaviour problems is becoming more prevalent. This review critically evaluated the evidence supporting the efficacy of such programmes for children with behaviour problems. Using a systematic literature search, two modes of delivery were evaluated, namely bibliotherapy and multimedia. Programmes that included minimal therapist support were also included. Overall, there is good evidence supporting the efficacy of self-help programmes in improving child behaviour, over the short and longer term. Self-help programmes led to outcomes similar to those achieved with more intensive therapist input. Including minimal levels of therapist support in addition to self-help materials enhances child and parent outcomes. Parents view self-help favourably but significantly less so than programmes including some form of therapist input. The future directions for self-help parent programmes include the need for longer-term follow-ups, the identification of moderators of outcome and economic evaluations of self-help programmes.

Incredible Years parent training support for foster carers in Wales: a multi-centre feasibility study

BACKGROUND

the incidence of conduct disorder in young children is 10% in the general population and 37% among fostered children. Up to 40% of untreated children diagnosed with conduct disorder develop problems later in life including drug misuse, criminal and violent behaviour. There are more than 80,000 looked after children in the UK, with 5000 in Wales. Challenging child behaviour is the main reason for placement breakdown and has huge cost implications as challenging children cost up to 10 times more in service use than children without conduct disorder. The Incredible Years (IY) evidence-based parenting programme is an effective, low cost solution in improving child behaviour and social competence in 'conventional' families and thus has the potential to support foster carers in managing difficult behaviours. Our main aims were to establish: • The feasibility of delivery and the effectiveness of the IY parenting programme in supporting carers in managing difficult behaviour in looked after children. • Service use costs for foster carers and looked after child.

METHODS

This was a 12-month trial platform study with 46 foster carers in three authorities in Wales. Carers were allocated 2:1 intervention to waiting-list control. Validated measures were used to assess 'parenting' competency, carers' depression levels, child behaviour and service use. Measures were administered at baseline and 6-month follow-up. Intervention carers received the programme between baseline and follow-up.

RESULTS

Analyses showed a significant reduction in child problem behaviour and improvement in carers' depression levels for intervention families at follow-up, compared with control. Unexpectedly, there was a significant improvement in control carers' self-reported 'parenting' strategies. Special education was the greatest service cost for looked after children.

CONCLUSIONS

Initial foster carer training could incorporate the IY programme to support carers in establishing positive relationships and managing difficult child behaviour. Programme participation may lead to reduced service use and improved placement stability.

Cystic fibrosis modifier genes related to Pseudomonas aeruginosa infection

Cystic fibrosis (CF) is one of the most common life-shortening genetic disorders, and the CF transmembrane conductance regulator (CFTR) is the major causal gene. However, a substantial clinical variability among patients with identical CFTR genotypes suggests the presence of modifier genes. We tested the effect of four genes involved in Pseudomonas aeruginosa infection. Analysis of a primary cohort detected eight candidate polymorphisms that were genotyped in the secondary cohort of 1579 patients; lung function and age at first infection with P. aeruginosa were considered as the phenotypes. Both additive and codominant models were considered, adjusting for confounding variables but not for multiple comparisons. In the secondary cohort, heme oxygenase-1 (HMOX1) rs2071749 had the most significant effect on lung function in the pediatric group (P=0.01; P(corrected)=0.03), and complement factor 3 (C3) rs11569393 and HMOX1 rs2071746 in the adult groups (P=0.03 for both variants; P(corrected)=0.16, 0.09). No polymorphism of complement factor B (CFB) or toll-like receptor 4 (TLR4) had a significant modifying effect on lung function in either group. We have identified two genes that showed nominal association with disease severity among CF patients. However, because of the multiple comparisons made, further studies are required to confirm the interaction between these modifying genes and CFTR.

ADHD and academic performance: why does ADHD impact on academic performance and what can be done to support ADHD children in the classroom?

This paper reviews the relationship between attention deficit hyperactivity disorder (ADHD) and academic performance. First, the relationship at different developmental stages is examined, focusing on pre-schoolers, children, adolescents and adults. Second, the review examines the factors underpinning the relationship between ADHD and academic underperformance: the literature suggests that it is the symptoms of ADHD and underlying cognitive deficits not co-morbid conduct problems that are at the root of academic impairment. The review concludes with an overview of the literature examining strategies that are directed towards remediating the academic impairment of individuals with ADHD.

The Teacher-Pupil Observation Tool (T-POT)

Teacher-pupil relationships do not solely impact children’s academic development; they also influence emotional and behavioural development. Positive teacher-pupil relationships help reduce maladaptive behaviour while negative ones can lead to increased academic, social and behavioural difficulties. Identifying and measuring teacher-pupil relationship through classroom behaviours and interactions is therefore important as an index of classroom-based influences on child outcome. This article illustrates the development and testing of a classroom observation measure - the Teacher-Pupil Observation Tool (T-POT) - in a small-scale study of 12 teachers and 107 children in 12 reception classrooms. To assess validity and reliability, observed behaviours on the T-POT were correlated with each other (internal validity), and with teacher rated reports of classroom behaviour (discriminant and concurrent validity). Observer agreement was also assessed (inter-rater reliability). The T-POT showed promising psychometric properties in all cases. The T-POT is currently the main outcome measure in four funded evaluation studies in Gwynedd, North Wales, and an outcome measure in a funded evaluation study in Clondalkin, Ireland. These studies will further benefit the measure’s validity and reliability and test the sensitivity of the T-POT in detecting change in teacher-pupil behaviour over time.

Attention deficit hyperactivity disorder in pre-school children: current findings, recommended interventions and future directions

This paper outlines the presentation, aetiology and treatment of attention deficit hyperactivity disorder (ADHD) in pre-school children. A review of current parenting training interventions demonstrates that there is good evidence for their efficacy in reducing symptoms of ADHD in pre-school children, and three interventions are evaluated: The new forest parent training programme (NFPP); the triple P - positive parenting programme and the incredible years parent training programme (IY). The evaluation of the NFPP provides strong evidence demonstrating its effectiveness for pre-school children with ADHD, while the efficacy of the Triple - P and the IY programme have, to date, only been demonstrated on children with conduct problems and co-morbid ADHD. It is suggested that parent training should be the first choice treatment for pre-school children presenting signs of ADHD, and medication introduced only for those children where parent training is not effective. Few moderators of outcome have been identified for these interventions, with the exception of parental ADHD. Barriers to intervention and implementation fidelity will need to be addressed to achieve high levels of attendance, completion and efficacy. The IY programme is a good model for addressing fidelity issues and for overcoming barriers to intervention. The future directions for parent training are also discussed.

Treatment fidelity as a predictor of behaviour change in parents attending group-based parent training

BACKGROUND

Change in parenting skills, particularly increased positive parenting, has been identified as the key component of successful evidence-based parent training (PT), playing a causal role in subsequent child behaviour change for both prevention and treatment of Conduct Disorder. The amount of change in parenting skills observed after PT varies and may be accounted for by both the content of the programme and by the level of PT implementer process skills. Such variation in implementer skills is an important component in the assessment of treatment fidelity, itself an essential factor in successful intervention outcome.

AIMS

To establish whether the Leader Observation Tool, a reliable and valid process skills fidelity measure, can predict change in parenting skills after attendance on the Incredible Years PT programme.

RESULTS

Positive leader skills categories of the Leader Observation Tool significantly predicted change in both parent-reported and independently observed parenting skills behaviour, which in turn, predicted change in child behaviour outcome.

CONCLUSIONS

Delivering an intervention with a high level of treatment fidelity not only preserves the behaviour change mechanisms of the intervention, but can also predict parental behaviour change, which itself predicts child behaviour change as a result of treatment.

Expressed emotion in children: associations with sibling relationships

OBJECTIVE

To investigate the reliability and validity of the expressed emotion (EE) measure, the Pre-school Five Minute Speech Sample (PFMSS), in child-to-child sibling relationships.

METHOD

A total of 106 boys aged 7-11 were recruited from 12 mainstream primary schools in North Wales. The children completed the PFMSS regarding their sibling and two self-report measures of sibling relationship: the Sibling Relationship Questionnaire (SRQ) and a Child Visual Analogue Scale (CVAS). The parents of 60 participants completed the Strengths and Difficulties Questionnaire regarding the behavioural problems of the participating child and his younger sibling.

RESULTS

The PFMSS demonstrated good inter-rater and code-recode reliability. The significant associations between EE dimensions such as relationship, positive comments and critical comments with various components of the SRQ and CVAS provided support for the concurrent validity of the PFMSS. Significantly higher levels of Conflict and Rivalry and significantly lower levels of Warmth/Closeness on the SRQ were reported by children with high EE, demonstrating good discriminant validity for the PFMSS. There was no significant association between the child's EE profile and the behavioural difficulties of both siblings as reported by parents.

CONCLUSIONS

The study found that the PFMSS is a valid and reliable measure of child EE. Future research is needed to clarify the concurrent validity of the warmth and initial statement components of the measure as well as the association between EE dimensions and behaviour.

The Leader Observation Tool: a process skills treatment fidelity measure for the Incredible Years parenting programme

BACKGROUND

Despite recognition of the need to deliver evidence-based programmes in the field of mental health, there is little emphasis on implementing such programmes with fidelity. Attempts by programme developers to ensure adherence to their programmes include the development of training, manuals and content scales, but these alone may be insufficient to ensure fidelity in replication. Observational measures lend themselves as a potentially useful assessment of intervention outcomes, providing accurate and objective accounts of the intervention process.

AIM

To develop a reliable and valid observational treatment fidelity tool of process skills required to deliver the Incredible Years (IY) BASIC parenting programme effectively.

METHODS

An objective observational fidelity measure was developed to assess adherence to the IY BASIC parenting programme protocol. Observations were conducted on 12 IY BASIC parenting programme groups, attended by parents of pre-school children displaying signs of early onset conduct disorder.

RESULTS

The Leader Observation Tool (LOT) achieved high internal reliability and good code-recode and inter-rater reliability. Evidence of concurrent validity was also obtained.

CONCLUSIONS

Having demonstrated that the LOT is a reliable and valid measure of implementation fidelity, further research is necessary to examine the relationship between LOT scores and intervention outcome.

Efficacy of the Incredible Years Programme as an early intervention for children with conduct problems and ADHD: long-term follow-up

BACKGROUND

This study examined the long-term efficacy of the Incredible Years (IY) BASIC Parenting Programme delivered as a preventive intervention with parents of pre-school children who display signs of attention deficit hyperactivity disorder (ADHD) and conduct problems. Families were followed up after the completion of a controlled trial with 11 Sure Start areas in North and Mid-Wales and North West England.

METHODS

Participants in the study were 50 pre-school children whose parents had received the intervention. Child ADHD symptoms were assessed at baseline, at follow-up one (6 months after baseline); at follow-up two (12 months after baseline); and at follow-up three (18 months after baseline). Families in the original waiting-list control group were not assessed after follow-up one as they had subsequently received the same intervention.

RESULTS

The significant post-intervention improvements in child ADHD symptoms evident at follow-up one were maintained over time, as demonstrated by statistical and clinical stability of measures. No significant differences were found for ADHD symptoms across each follow-up, indicating that the gains made post intervention were maintained for at least 12 months, with 57% of the sample maintaining scores below the clinical cut-off on the Conners. Eighty-six, 58, and 30 per cent respectively had maintained at least a modest, large, or very large improvement in ADHD symptoms at follow-up three.

CONCLUSIONS

Findings from this study suggest that the IY psychosocial treatment programme is a valuable intervention in the longer term for many pre-school children displaying early signs of ADHD.

Efficacy of the Incredible Years Basic parent training programme as an early intervention for children with conduct problems and ADHD

BACKGROUND

The efficacy of the Incredible Years (IY) Basic parent training (PT) programme for a community-based sample of families with pre-school children at risk of developing both conduct problems and attention deficit hyperactivity disorder (ADHD) was examined.

METHODS

Pre-school children displaying signs of both early-onset conduct problems and ADHD were randomly allocated to either IY PT intervention, or to a waiting list (WL) control group. Child symptoms were assessed before and after the intervention.

RESULTS

Post intervention, the intervention group was associated with significantly lower levels of parent-reported inattention and hyperactive/impulsive difficulties, even after controlling for post-intervention changes in child deviance. In addition, 52% of those in the intervention condition, compared with 21% in the control condition, displayed clinically reliable improvements post intervention, giving an absolute risk reduction of 31% and a number needed to treat of 3.23.

CONCLUSIONS

Findings from this study indicate that the IY PT programme is a valuable intervention for many pre-school children displaying early signs of ADHD.

Attention deficit hyperactivity disorder: a review of the essential facts

Abstract Attention deficit hyperactivity disorder (ADHD) is a complex disorder, where both genetic and environmental influences make a substantial contribution to the risk for the disorder. One of the challenges facing clinicians is to simplify for parents the multifaceted reasons why their child may have developed ADHD, explain the associated symptoms, and encourage parents to participate in intervention. Increasing parents understanding about ADHD should make them better informed about the disorder, more likely to consent to intervention, and increase adherence to both psychosocial and pharmacological treatment. The aim of this review is to provide clinicians with a brief synopsis of our current understanding about the aetiology of ADHD, co-morbidity and associated problems, developmental course and intervention options.

Teachers' emotional expression about disruptive boys

OBJECTIVES

To assess teachers' emotional expression about pupils using the Five Minute Speech Sample (FMSS) and coding procedures for parental expressed emotion (EE). To compare EE for disruptive and non-disruptive pupils.

METHOD

Twenty-one teachers provided speech samples for both a disruptive and a non-disruptive pupil in their class selected using standard behaviour rating scales.

RESULTS

Teachers' emotional expression was reliably measured using EE codings. Teachers displayed no emotional overinvolvement (EOI) and made few critical comments. High EE, characterized by criticism and a lack of positive comments, was associated with children's behavioural difficulties. Multiple regression suggested that conduct problems rather than hyperactivity were associated with high EE.

DISCUSSION

Results support the application of certain elements of the EE construct to teachers' emotional expression about pupils. However, there was an absence of EOI and a lack of association between relationship and other EE categories. The absence of this association suggests that EE might be most usefully considered as a measure of teachers' emotional response to pupils, rather than the emotional quality of the teacher-pupil relationship.

Mothers' expressed emotion towards children with and without intellectual disabilities

OBJECTIVES

To identify factors associated with maternal expressed emotion (EE) towards their child with intellectual disability (ID).

DESIGN AND METHOD

A total of 33 mothers who had a child with ID and at least one child without disabilities between the ages of 4 and 14 years participated in the study. Mothers completed self-assessment questionnaires which addressed their sense of parenting competence, beliefs about child-rearing practices, and their reports of behavioural and emotional problems of their child with ID. Telephone interviews were conducted to assess maternal EE towards the child with ID and towards a sibling using the Five Minute Speech Sample (FMSS; Magana et al. 1986), and also to assess the adaptive behaviour of the child with ID using the Vineland Adaptive Behaviour Scale (VABS; Sparrow et al. 1984).

RESULTS

Mothers with high EE towards their child with ID were more satisfied with their parenting ability, and their children had more behaviour problems. Analysis of differential maternal parenting, through comparisons of EE towards their two children, showed that mothers were more negative towards their child with ID for all domains of the FMSS except dissatisfaction.

CONCLUSIONS

A small number of factors associated with maternal EE towards children with ID were identified. Differences in maternal EE towards their child with ID and their other child suggest that EE is child-driven rather than a general maternal characteristic. Implications of the data for future research are discussed.

Assessing expressed emotion in mothers of preschool AD/HD children: psychometric properties of a modified speech sample

OBJECTIVE

To examine the reliability and validity of a modified coding measure of expressed emotion (Preschool Five Minute Speech Sample [PFMSS]), suitable for parents of preschool AD/HD children.

DESIGN

Mothers of preschool AD/HD children identified through a three-stage screening programme were compared with mothers of non-AD/HD children on the PFMSS.

METHOD

Mothers of 80 AD/HD and 20 non-AD/HD children participated in the PFMSS. They had 10 mins of play interaction with their child and completed the Feelings on Parenting scales from the Family Impact Questionnaire.

RESULTS

With the exception of emotional over-involvement, the PFMSS demonstrated acceptable code-recode and inter-rater reliability, and adequate test-retest reliability. It also demonstrated acceptable validity, being associated with less affection and greater maternal direction during play interaction and discriminated between the parents of preschool AD/HD and non-AD/HD children.

CONCLUSION

This study shows that in a revised form, the Five Minute Speech Sample can provide a useful measure of expressed emotion during the preschool period.

Comparison of three methods for obtaining principal components from family data in genetic analysis of complex disease

Three multivariate techniques used to derive principal components (PCs) from family data were compared for their ability to model family data and power to detect linkage. Using the simulated data from Genetic Analysis Workshop 12, the five quantitative traits were first adjusted for age, sex, and environmental factors 1 and 2. Then, standard PCs, PCs obtained from between-family covariance, and PCs obtained from within-family genetic covariance were derived and subjected to multivariate sib pair linkage analysis. The standard PCs obtained from the overall correlation matrix allowed identification of key features of the true genetic model more readily than did the other methods. For detection of linkage, standard PCs and PCs obtained from the between-family genetic covariance performed similarly in terms of both power and type 1 error, and both methods performed better than the PCs obtained from within-family genetic covariance.

Parent-based therapies for preschool attention-deficit/hyperactivity disorder: a randomized, controlled trial with a community sample

OBJECTIVE

To evaluate two different parent-based therapies for preschool attention-deficit/hyperactivity disorder (ADHD) in a community sample.

METHOD

Three-year-old children displaying a preschool equivalent of ADHD (n = 78) were randomly assigned to either a parent training (PT; n = 30), a parent counseling and support (PCO&S; n = 28), or a waiting-list control group (n = 20). The PT group received coaching in child management techniques. The PC&S group received nondirective support and counseling. Measures of child symptoms and mothers' well-being were taken before and after intervention and at 15 weeks follow-up.

RESULTS

ADHD symptoms were reduced (F2,74 = 11.64; p < .0001) and mothers' sense of well-being was increased by PT relative to both other groups (F2,74 = 10.32; p < .005). Fifty-three percent of children in the PT group displayed clinically significant improvement (chi 2 = 4.08; p = .048).

CONCLUSIONS

PT is a valuable treatment for preschool ADHD. PC&S had little effect on children's behavior. Constructive training in parenting strategies is an important element in the success of parent-based interventions. Psychostimulants are not a necessary component of effective treatment for many children with preschool ADHD.

Self-help group attendance and participation among cocaine dependent patients

The authors examined frequency and patterns of self-help group attendance and active participation over a 6-month period among 411 patients receiving treatment in the NIDA Collaborative Cocaine Treatment Study. Nearly two-thirds of patients attended at least one self-help group, and nearly all of these actively participated. Alcoholics Anonymous and Narcotics Anonymous meetings were attended most frequently. Statistical analyses included chi square, one-way analyses of variance, and cluster techniques. While patterns of attendance were relatively consistent over time, findings suggest that a treatment emphasizing the importance of self-help groups is likely to encourage more self-help group attendance and participation over time.

Psychosocial treatments for cocaine dependence: National Institute on Drug Abuse Collaborative Cocaine Treatment Study

BACKGROUND

This was a multicenter investigation examining the efficacy of 4 psychosocial treatments for cocaine-dependent patients.

METHODS

Four hundred eighty-seven patients were randomly assigned to 1 of 4 manual-guided treatments: individual drug counseling plus group drug counseling (GDC), cognitive therapy plus GDC, supportive-expressive therapy plus GDC, or GDC alone. Treatment was intensive, including 36 possible individual sessions and 24 group sessions for 6 months. Patients were assessed monthly during active treatment and at 9 and 12 months after baseline. Primary outcome measures were the Addiction Severity Index-Drug Use Composite score and the number of days of cocaine use in the past month.

RESULTS

Compared with the 2 psychotherapies and with GDC alone, individual drug counseling plus GDC showed the greatest improvement on the Addiction Severity Index-Drug Use Composite score. Individual group counseling plus GDC was also superior to the 2 psychotherapies on the number of days of cocaine use in the past month. Hypotheses regarding the superiority of psychotherapy to GDC for patients with greater psychiatric severity and the superiority of cognitive therapy plus GDC compared with supportive-expressive therapy plus GDC for patients with antisocial personality traits or external coping style were not confirmed.

CONCLUSION

Compared with professional psychotherapy, a manual-guided combination of intensive individual drug counseling and GDC has promise for the treatment of cocaine dependence.

Predictors of dropout from psychosocial treatment of cocaine dependence

The current study assessed demographic, drug and psychiatric predictors of dropout in the pilot/training phase of a large, multi-site psychotherapy outcome study for patients with cocaine dependence. The different predictors of dropout were assessed throughout the phases of the study: screening, intake, stabilization and assessment phase, and following randomization to treatment. Results showed that (1) younger patients were less likely to keep their intake appointment. (2) Of the patients who had an intake visit, those who did not complete high school and with more days of cocaine use in the previous month were less likely to complete an initial stabilization and assessment phase requiring 1 week of abstinence from all drugs. A survival analysis was used to examine time to dropout for the 286 patients randomized to individual treatment. (3) Again, younger age was associated with dropout after randomization. (4) Drug use variables did not predict time to dropout. (5) Presence of any current Axis I disorder was associated with later dropout from treatment. Minority treatment information seekers and treatment initiators were less likely to go on to complete the full treatment program.

A cluster of meningococcal disease in western Sydney, Australia initially associated with a nightclub

Fourteen cases of meningococcal disease (MD) occurred in August September 1996 in western Sydney, Australia. Seven of the 10 young adults affected had a direct or indirect link with a local nightclub. Ten of 11 systemic meningococcal isolates had the phenotype C:2a:P1.5 and showed close genetic relationship by pulsed-field gel electrophoresis (PFGE). Organisms of this phenotype have not previously caused outbreaks in Australia, but have been associated with outbreaks and hyperendemic serogroup C MD in Europe, Canada, and the United States. This is the largest cluster of serogroup C MD reported in urban Australia, and the first involving a nightclub. The strain differentiation results were available rapidly enough to augment epidemiological investigations on a daily basis. Public health staff could thus establish links between cases quickly, follow the spread of new cases in the community, give accurate information to health officials and the press, and utilize existing knowledge about the characteristics of this phenotype to predict likely developments during the outbreak and afterwards. The strain differentiation data was also very helpful when the role of vaccination was considered, and existing guidelines on the management of outbreaks of MD could be used effectively for the first time in western Sydney.

Peritonitis associated with a CDC group EO-3 organism

A 63-year-old female with chronic renal failure on continuous ambulatory peritoneal dialysis developed chronic peritonitis. A CDC group EO-3 organism was isolated from the peritoneal dialysis fluid on five occasions over a period of 4 months. This is the first reported isolation of this organism in which it is associated with a patient on continuous ambulatory peritoneal dialysis.

The National Institute on Drug Abuse Collaborative Cocaine Treatment Study. Rationale and methods

The National Institute on Drug Abuse Collaborative Cocaine Treatment Study is a large, multisite psychotherapy clinical trial for outpatients who meet the DSM-IV criteria for cocaine dependence. For 480 randomized patients, the outcomes of 4 treatments are compared for an 18-month period. All treatments include group drug counseling. One treatment also adds cognitive therapy, one adds supportive-expressive psychodynamic therapy, and one adds individual drug counseling; one consists of group drug counseling alone. In addition, 2 specific interaction hypotheses, one involving psychiatric severity and the other involving degree of antisocial personality characteristics, are being tested. This article describes the main aims of the project, the background and rationale for the study design, the rationale for the choice of treatments and patient population, and a brief description of the research plan.

Essential role of growth hormone in ischemia-induced retinal neovascularization

Retinal neovascularization is the major cause of untreatable blindness. The role of growth hormone (GH) in ischemia-associated retinal neovascularization was studied in transgenic mice expressing a GH antagonist gene and in normal mice given an inhibitor of GH secretion (MK678). Retinal neovascularization was inhibited in these mice in inverse proportion to serum levels of GH and a downstream effector, insulin-like growth factor-I (IGF-I). Inhibition was reversed with exogenous IGF-I administration. GH inhibition did not diminish hypoxia-stimulated retinal vascular endothelial growth factor (VEGF) or VEGF receptor expression. These data suggest that systemic inhibition of GH or IGF-I, or both, may have therapeutic potential in preventing some forms of retinopathy.

Constitutive expression of B7-1 (CD80) on mouse keratinocytes does not prevent development of chemically induced skin papillomas and carcinomas

Expression of the B7-1 (CD80) costimulatory molecule in a variety of tumor cell lines leads to an enhanced CD8+ T cell response to tumor Ags. We used transgenic mice constitutively expressing B7-1 on keratinocytes (K14/B7-1 line) to determine whether keratinocyte B7-1 expression would inhibit the development of papillomas and carcinomas following two-stage chemical carcinogenesis in skin. FVB inbred mice carrying the K14/B7-1 transgene and controls were initiated with 25 micrograms of 7,12-dimethylbenz[a]anthracene and promoted weekly with 5 micrograms of 12-O-tetradecanoylphorbol-13-acetate for 20 wk. Expression of the B7-1 transgene did not result in statistically significant decreases in the mean number of papillomas or carcinomas compared with controls. The incidence of carcinomas in both transgenic and control mice reached 90% or greater by 60 wk after initiation. Carcinoma cell lines established from the K14/B7-1 mice maintained expression of B7-1 and Kq. These B7-1 expressing carcinomas grew progressively following intradermal injection into syngeneic FVB mice, further demonstrating their inability to evoke protective tumor immunity. These same carcinoma cell lines were rapidly rejected by minor alloantigen-mismatched SWR mice, confirming their susceptibility to immune effector mechanisms. The failure of constitutive B7-1 expression on keratinocytes to prevent the growth of squamous cell papillomas and carcinomas may reflect the limited immunogenicity of tumors arising after initiation-promotion carcinogenesis. Our results in this transgenic model system are further evidence that B7-1 gene therapy alone may not be sufficient to induce protective immunity to some types of tumors.

An evaluation of the in vitro activity of piperacillin/tazobactam

Tazobactam is a new, irreversible inhibitor of bacterial beta-lactamases of staphylococci, plasmid-mediated beta-lactamases of the TEM and SHV types found in Escherichia coli and Klebsiella species and beta-lactamases of anerobes such as Bacteroides species. Its combination with piperacillin, a broad spectrum ureido-penicillin, would be expected to improve the activity of piperacillin against staphylococci, TEM and SHV beta-lactamase producing Gram negative bacteria and anerobes. Minimal inhibitory concentrations (MIC) of piperacillin/tazobactam were determined for 1952 individual patient isolates of Gram positive and negative bacteria causing significant infections and compared with MIC values for cefotaxime, ceftazidime, ciprofloxacin, imipenem, ticarcillin/clavulanic acid. MICs were determined by agar dilution (NCCLS 1990 and 1992). Piperacillin/tazobactam had excellent activity against methicillin susceptible staphylococci, Streptococcus pneumoniae, Haemophilus influenzae, enterococci and organisms of the Bacteroides fragilis group. It was also active against the majority of Enterobacteriaceae and Pseudomonas aeruginosa isolates tested. It was not active against extended spectrum beta-lactamase (ESBL) producing Klebsiella species and some high level TEM and SHV beta-lactamase producing E. coli and Klebsiella species. Activity against Gram negative organisms capable of producing chromosomally mediated beta-lactamases was good, since in most organisms tested, the enzymes were not induced in sufficient quantities to cause antibiotic resistance. However some Enterobacter species were derepressed hyperproducing mutants; these isolates showed resistance to piperacillin/tazobactam since tazobactam does not inhibit these Class I beta lactamases. Activity was superior to ticarcillin/clavulanic acid for Gram negative rods. Imipenem was the most active agent against ESBL producing Klebsiella species. Piperacillin/tazobactam has a suitable spectrum of activity in vitro to suggest its use in monotherapy of mixed anerobic infections, mixed respiratory infections such as aspiration pneumonia and, in combination with an aminoglycoside, it would provide Gram positive as well as Gram negative cover of febrile episodes in immunosuppressed patients.

Constitutive expression of B7-1 (CD80) on mouse keratinocytes does not prevent development of chemically induced skin papillomas and carcinomas

Expression of the B7-1 (CD80) costimulatory molecule in a variety of tumor cell lines leads to an enhanced CD8+ T cell response to tumor Ags. We used transgenic mice constitutively expressing B7-1 on keratinocytes (K14/B7-1 line) to determine whether keratinocyte B7-1 expression would inhibit the development of papillomas and carcinomas following two-stage chemical carcinogenesis in skin. FVB inbred mice carrying the K14/B7-1 transgene and controls were initiated with 25 micrograms of 7,12-dimethylbenz[a]anthracene and promoted weekly with 5 micrograms of 12-O-tetradecanoylphorbol-13-acetate for 20 wk. Expression of the B7-1 transgene did not result in statistically significant decreases in the mean number of papillomas or carcinomas compared with controls. The incidence of carcinomas in both transgenic and control mice reached 90% or greater by 60 wk after initiation. Carcinoma cell lines established from the K14/B7-1 mice maintained expression of B7-1 and Kq. These B7-1 expressing carcinomas grew progressively following intradermal injection into syngeneic FVB mice, further demonstrating their inability to evoke protective tumor immunity. These same carcinoma cell lines were rapidly rejected by minor alloantigen-mismatched SWR mice, confirming their susceptibility to immune effector mechanisms. The failure of constitutive B7-1 expression on keratinocytes to prevent the growth of squamous cell papillomas and carcinomas may reflect the limited immunogenicity of tumors arising after initiation-promotion carcinogenesis. Our results in this transgenic model system are further evidence that B7-1 gene therapy alone may not be sufficient to induce protective immunity to some types of tumors.

Genetic heterogeneity and unmapped genes for colorectal cancer

Colorectal cancer (CRC) has a strong familial component. Candidate genes for colorectal cancer have been identified through mutations in four mismatch repair genes (hMSH2, hMLH1, hPMS1, and hPMS2) and genes that are deleted or mutated in tumors (DCC, APC, and p53). Linkage analysis of candidate loci/regions was performed in 10 kindreds ascertained for common colorectal cancer from the Utah Population Database. Evidence for linkage to candidate genes was assessed using two- or three-point logarithm of the odds ratio scores with markers spanning the region of localization. One kindred is linked to hMSH2 and also fits the criteria for hereditary nonpolyposis colorectal cancer, having early age of onset and high penetrance for CRC. The remaining nine kindreds are unlinked to the candidate genes tested. These kindreds have a later age of onset and a lower penetrance than hereditary nonpolyposis colorectal cancer kindreds. these results indicate that further unmapped susceptibility loci may be responsible for much of the familial aggregation of CRC.

The Revised Helping Alliance Questionnaire (HAq-II) : Psychometric Properties

The concept of the therapeutic alliance and its operationalization have received much attention in recent years. One of the early self-report measures of the therapeutic alliance was the Helping Alliance questionnaire (HAq-I). This scale was recently revised to exclude the items that explicitly reflect improvement. Using the revised 19-item HAq-II on a sample of 246 patients diagnosed with DSM-III-R cocaine dependence, the authors found that the new scale had excellent internal consistency and test-retest reliability. Further, the HAq-II demonstrated good convergent validity with the California Psychotherapy Alliance Scale (CALPAS) total score. Alliance levels as measured by the CALPAS or the Helping Alliance questionnaire during early sessions were not associated with pretreatment psychiatric severity or level of depression.