Impact of a national audit on child and adolescent psychiatrists' prescribing practices

BACKGROUND

A look back review of South Kerry Child and Adolescent Mental Health Services (CAMHS) in Ireland, known as the 'Maskey report' (MR), highlighted substandard prescribing practices. The aim of this 'Maskey Impact Study' (MIS) was to explore changes to child and adolescent psychiatrists' prescribing practices following the MR.

METHOD

The study was cross-sectional and mixed method. A study specific questionnaire was distributed electronically to psychiatrists working in CAMHS (n = 160).

RESULTS

102 psychiatrists participated in the study (response rate 63.8%). Perceived improvement in prescribing practices included improved medical record keeping (63.7%), consent documentation (53.9%), medication information provision (41.2%) and physical health monitoring (60.8%). However, 43.1% of psychiatrists reported a reluctance to prescribe medication even when clinically indicated and 50% were more likely to avoid off-label use. Most respondents reported increased stress levels (80.4%) with higher stress being significantly associated with reticence in prescribing (χ2 = 11.746, p < .001) and avoiding off-label use (χ2 = 15.392, p < 0.001). Thematic analysis highlighted increased medication hesitancy, enforced 'meaningless' bureaucracy and medication mistrust among families.

DISCUSSION

Although improvements reported are welcomed, the increased hesitancy of medication use, avoidance of prescribing more than one medication, and avoidance of off-label use, is of concern with potential unintended adverse consequences. Reluctance in prescribing may deprive youth of access to evidence-based treatments and limit exposure of NCHDs to the safe practice of consultant-initiated psychopharmacology. Further research will be important to determine if this impacts clinical care. Continued education in psychopharmacology is essential along with increased public awareness of the evidence for medication, to help restore public confidence and trust in psychopharmacology.

Sleep problems in children and adolescents in an attention deficit hyperactivity disorder service

OBJECTIVES

Sleep problems are common amongst children and adolescents with attention deficit hyperactivity disorder (ADHD). The purpose of this study was to investigate sleep problems in children and adolescents attending a specialist ADHD service.

METHODS

This was a cross-sectional online survey combined with a retrospective chart review, conducted in the ADHD Assessment, Diagnosis, Management, initiation, Research and Education (ADMiRE) service, the first public specialist ADHD service for young people in Ireland. Participants were caregivers of children and adolescents with ADHD attending ADMiRE. Sleep was assessed using The Children's Sleep Habits Questionnaire (CSHQ) and ADHD symptoms were assessed using an abbreviated version of the Swanson, Nolan and Pelham Teacher and Parent Rating Scale (SNAP-IV). Details regarding patient demographics, co-morbidities and medication were collected from patient records.

RESULTS

Eighty-four percent of young people scored above the clinical cut-off for a sleep disorder. The most frequently reported sleep problems were related to sleep onset and sleep duration, and 64% of respondents met the criteria for two or more sleep problems. ADHD severity was associated with greater sleep problems. Co-morbid physical, neurodevelopmental, and mental health disorders as well as stimulant use were not associated with greater sleep problems.

CONCLUSION

Sleep problems are very common amongst children and adolescents with ADHD. This study has demonstrated an association between more sleep problems and ADHD severity. These findings highlight the need for both effective ADHD treatment to ensure optional sleep in young people as well as effective interventions for sleep problems to prevent worsening of ADHD symptoms.

Therapeutic Anticoagulation with Heparin in Noncritically Ill Patients with Covid-19

BACKGROUND

Thrombosis and inflammation may contribute to the risk of death and complications among patients with coronavirus disease 2019 (Covid-19). We hypothesized that therapeutic-dose anticoagulation may improve outcomes in noncritically ill patients who are hospitalized with Covid-19.

METHODS

In this open-label, adaptive, multiplatform, controlled trial, we randomly assigned patients who were hospitalized with Covid-19 and who were not critically ill (which was defined as an absence of critical care-level organ support at enrollment) to receive pragmatically defined regimens of either therapeutic-dose anticoagulation with heparin or usual-care pharmacologic thromboprophylaxis. The primary outcome was organ support-free days, evaluated on an ordinal scale that combined in-hospital death (assigned a value of -1) and the number of days free of cardiovascular or respiratory organ support up to day 21 among patients who survived to hospital discharge. This outcome was evaluated with the use of a Bayesian statistical model for all patients and according to the baseline d-dimer level.

RESULTS

The trial was stopped when prespecified criteria for the superiority of therapeutic-dose anticoagulation were met. Among 2219 patients in the final analysis, the probability that therapeutic-dose anticoagulation increased organ support-free days as compared with usual-care thromboprophylaxis was 98.6% (adjusted odds ratio, 1.27; 95% credible interval, 1.03 to 1.58). The adjusted absolute between-group difference in survival until hospital discharge without organ support favoring therapeutic-dose anticoagulation was 4.0 percentage points (95% credible interval, 0.5 to 7.2). The final probability of the superiority of therapeutic-dose anticoagulation over usual-care thromboprophylaxis was 97.3% in the high d-dimer cohort, 92.9% in the low d-dimer cohort, and 97.3% in the unknown d-dimer cohort. Major bleeding occurred in 1.9% of the patients receiving therapeutic-dose anticoagulation and in 0.9% of those receiving thromboprophylaxis.

CONCLUSIONS

In noncritically ill patients with Covid-19, an initial strategy of therapeutic-dose anticoagulation with heparin increased the probability of survival to hospital discharge with reduced use of cardiovascular or respiratory organ support as compared with usual-care thromboprophylaxis. (ATTACC, ACTIV-4a, and REMAP-CAP ClinicalTrials.gov numbers, NCT04372589, NCT04505774, NCT04359277, and NCT02735707.).

Therapeutic Anticoagulation with Heparin in Critically Ill Patients with Covid-19

BACKGROUND

Thrombosis and inflammation may contribute to morbidity and mortality among patients with coronavirus disease 2019 (Covid-19). We hypothesized that therapeutic-dose anticoagulation would improve outcomes in critically ill patients with Covid-19.

METHODS

In an open-label, adaptive, multiplatform, randomized clinical trial, critically ill patients with severe Covid-19 were randomly assigned to a pragmatically defined regimen of either therapeutic-dose anticoagulation with heparin or pharmacologic thromboprophylaxis in accordance with local usual care. The primary outcome was organ support-free days, evaluated on an ordinal scale that combined in-hospital death (assigned a value of -1) and the number of days free of cardiovascular or respiratory organ support up to day 21 among patients who survived to hospital discharge.

RESULTS

The trial was stopped when the prespecified criterion for futility was met for therapeutic-dose anticoagulation. Data on the primary outcome were available for 1098 patients (534 assigned to therapeutic-dose anticoagulation and 564 assigned to usual-care thromboprophylaxis). The median value for organ support-free days was 1 (interquartile range, -1 to 16) among the patients assigned to therapeutic-dose anticoagulation and was 4 (interquartile range, -1 to 16) among the patients assigned to usual-care thromboprophylaxis (adjusted proportional odds ratio, 0.83; 95% credible interval, 0.67 to 1.03; posterior probability of futility [defined as an odds ratio <1.2], 99.9%). The percentage of patients who survived to hospital discharge was similar in the two groups (62.7% and 64.5%, respectively; adjusted odds ratio, 0.84; 95% credible interval, 0.64 to 1.11). Major bleeding occurred in 3.8% of the patients assigned to therapeutic-dose anticoagulation and in 2.3% of those assigned to usual-care pharmacologic thromboprophylaxis.

CONCLUSIONS

In critically ill patients with Covid-19, an initial strategy of therapeutic-dose anticoagulation with heparin did not result in a greater probability of survival to hospital discharge or a greater number of days free of cardiovascular or respiratory organ support than did usual-care pharmacologic thromboprophylaxis. (REMAP-CAP, ACTIV-4a, and ATTACC ClinicalTrials.gov numbers, NCT02735707, NCT04505774, NCT04359277, and NCT04372589.).

Limited phenological and pollinator-mediated isolation among selfing and outcrossing Arabidopsis lyrata populations

Transitions from outcrossing to selfing have been a frequent evolutionary shift in plants and clearly play a role in species divergence. However, many questions remain about the initial mechanistic basis of reproductive isolation during the evolution of selfing. For instance, how important are pre-zygotic pre-pollination mechanisms (e.g. changes in phenology and pollinator visitation) in maintaining reproductive isolation between newly arisen selfing populations and their outcrossing ancestors? To test whether changes in phenology and pollinator visitation isolate selfing populations of Arabidopsis lyrata from outcrossing populations, we conducted a common garden experiment with plants from selfing and outcrossing populations as well as their between-population hybrids. Specifically, we asked whether there was isolation between outcrossing and selfing plants and their between-population hybrids through differences in (1) the timing or intensity of flowering; and/or (2) pollinator visitation. We found that phenology largely overlapped between plants from outcrossing and selfing populations. There were also no differences in pollinator preference related to mating system. Additionally, pollinators preferred to visit flowers on the same plant rather than exploring nearby plants, creating a large opportunity for self-fertilization. Overall, this suggests that pre-zygotic pre-pollination mechanisms do not strongly reproductively isolate plants from selfing and outcrossing populations of Arabidopsis lyrata.

Anti-Thrombotic Therapy to Ameliorate Complications of COVID-19 (ATTACC): Study design and methodology for an international, adaptive Bayesian randomized controlled trial

Background:

Mortality from COVID-19 is high among hospitalized patients and effective therapeutics are lacking. Hypercoagulability, thrombosis and hyperinflammation occur in COVID-19 and may contribute to severe complications. Therapeutic anticoagulation may improve clinical outcomes through anti-thrombotic, anti-inflammatory and anti-viral mechanisms. Our primary objective is to evaluate whether therapeutic-dose anticoagulation with low-molecular-weight heparin or unfractionated heparin prevents mechanical ventilation and/or death in patients hospitalized with COVID-19 compared to usual care.

Methods:

An international, open-label, adaptive randomized controlled trial. Using a Bayesian framework, the trial will declare results as soon as pre-specified posterior probabilities for superiority, futility, or harm are reached. The trial uses response-adaptive randomization to maximize the probability that patients will receive the more beneficial treatment approach, as treatment effect information accumulates within the trial. By leveraging a common data safety monitoring board and pooling data with a second similar international Bayesian adaptive trial (REMAP-COVID anticoagulation domain), treatment efficacy and safety will be evaluated as efficiently as possible. The primary outcome is an ordinal endpoint with three possible outcomes based on the worst status of each patient through day 30: no requirement for invasive mechanical ventilation, invasive mechanical ventilation or death.

Conclusion:

Using an adaptive trial design, the Anti-Thrombotic Therapy To Ameliorate Complications of COVID-19 trial will establish whether therapeutic anticoagulation can reduce mortality and/or avoid the need for mechanical ventilation in patients hospitalized with COVID-19. Leveraging existing networks to recruit sites will increase enrollment and mitigate enrollment risk in sites with declining COVID-19 cases.

Biopsychosocial factors associated with depression and anxiety in older adults with intellectual disability: results of the wave 3 Intellectual Disability Supplement to The Irish Longitudinal Study on Ageing

BACKGROUND

Depression and anxiety are amongst the most prevalent mental health disorders in the older population with intellectual disability (ID). There is a paucity of research that pertains to associative biopsychosocial factors for depression and anxiety in this population. The aim of this study is to determine the biopsychosocial factors associated with depression and anxiety in a population of older adults with ID in Ireland.

METHODS

The study was part of 'The Intellectual Disability Supplement to The Irish Longitudinal Study on Ageing'. Depressive symptoms were assessed using the Glasgow Depression Scale for people with a Learning Disability. Anxiety symptoms were measured using the Glasgow Anxiety Scale for people with a Learning Disability. The cross-sectional associations of depression and anxiety with biopsychosocial parameters were measured using a variety of self-report and proxy-completed questionnaires.

RESULTS

For the study population, 9.97% met the criteria for depression, and 15.12% met the criteria for an anxiety disorder. Participants meeting criteria for depression were more likely to be taking regular mood stabiliser medications and to exhibit aggressive challenging behaviour. Participants meeting criteria for anxiety were more likely to have sleep difficulties and report loneliness. Participants meeting criteria for either/both depression and anxiety were more likely to report loneliness.

CONCLUSIONS

This study identified both treatable and modifiable, as well as unmodifiable, biopsychosocial factors associated with depression and/or anxiety in older adults with ID. A longitudinal study follow-up will further develop our knowledge on the causality and direction of associated biopsychosocial factors with depression and anxiety in older adults with ID and better inform management strategies, prevention policies and funding of services.

Multianalyte assay system developed for drugs of abuse

A simple, 10-min immunoassay system has been developed that simultaneously screens for five different classes of drugs of abuse in a urine sample. This system tests for amphetamines, cannabinoids, cocaine metabolites, opiates, and phencyclidine, and each assay has a specific preset cutoff concentration. Accuracy is &gt; 99% for reporting positive or negative results for samples with 200% or 50%, respectively, of the cutoff concentrations of the drugs. Tests of a panel of 96 compounds yielded only three cases of nonspecific reactivity (at a drug concentration of 100 mg/L). Another panel of 12 compounds that could normally be found in urine samples was also evaluated and no interferences were observed. Concordance was &gt; 95% between this system and the comparable automated immunoassays for detecting drugs of abuse. Greater than 98% of GC/MS-confirmed positive samples gave positive results with this assay system.

The association of life events and mental ill health in older adults with intellectual disability: results of the wave 3 Intellectual Disability Supplement to The Irish Longitudinal Study on Ageing

BACKGROUND

Exposures to life events are associated with emotional, psychological and behavioural problems in those with intellectual disability (ID). Older adults with ID may experience different life events given differences in living circumstances, cognitive decline, greater dependency on others and less autonomy. This study examines the relationship of life events and mental ill health in an older ID population in Ireland.

METHODS

The study was part of 'The Intellectual Disability Supplement to The Irish Longitudinal Study on Ageing'. The frequency of life events was assessed using a 20-item checklist, and the level of stress experienced was assessed using a three-point Likert scale measuring the burden of the life event. The associations of life events with factors associated with mental ill health were measured using a variety of self-report and proxy completed questionnaires.

RESULTS

For the study population, 88.1% had been exposed to at least one life event in the preceding 12 months and 64.5% to two or more life events. Frequency and burden of life events were significantly higher in individuals living in institutional settings and in individuals with any current psychiatric condition, increased depressive and anxiety symptoms, challenging behaviour and reported poorer self-rated mental and physical health. More life events were significantly associated with new psychiatric diagnoses as well as initiation and increased dosage of mood stabilising, hypnotic and sedative medications.

CONCLUSIONS

Life events are significantly associated with mental ill health in the older ID population. Service providers must focus on limiting the exposure to these events and, in situations where they cannot be avoided, should support and manage individuals compassionately and effectively, prioritising their mental and physical well-being.

Immunogenicity of a Staphylococcus aureus-cholera toxin A2/B vaccine for bovine mastitis

Staphylococcus aureus causes a chronic, contagious disease of the udder, or mastitis, in dairy cows. This infection is often refractory to antibiotic treatment, and has a significant economic impact on milk production worldwide. An effective vaccine to prevent S. aureus mastitis would improve animal health, reduce antibiotic dependence and inform human vaccine approaches. The iron-regulated surface determinant A (IsdA) and clumping factor A (ClfA) are conserved S. aureus extracellular-matrix adhesins and target vaccine antigens. Here we report the results of two bovine immunogenicity trials using purified IsdA and ClfA-cholera toxin A₂/B chimeras (IsdA-CTA₂/B and ClfA-CTA₂/B). Cows were intranasally inoculated with IsdA-CTA₂/B + ClfA-CTA₂/B at dry off and followed for 70 days. Trial 1 utilized three groups with one or two booster doses at a total concentration of 600 or 900 μg. Trial 2 utilized two groups with one booster at a total concentration of 1200 μg. Humoral immune responses in serum and milk were examined by ELISA. Responses in serum were significant between groups and provide evidence of antigen-specific IgG induction after vaccination in both trials. Cellular proliferation was detected by flow cytometry using antigen-stimulated PBMCs from day 60 of Trial 2 and revealed an increase in CD4+ T cells from vaccinated cows. IsdA and ClfA stimulation induced IL-4 expression, but not IFN-γ or IL-17, in PBMCs from day 60 as determined by cytokine expression analysis. Opsonophagocytosis of S. aureus confirmed the functional in vitro activity of anti-IsdA antibodies from Trial 2 serum and milk. The vaccine was well tolerated and safe, and results support the potential of mucosally-delivered CTA₂/B chimeras to protect cows from mastitis caused by S. aureus.

Analysis of steroids in songbird plasma and brain by coupling solid phase extraction to radioimmunoassay

It is a common practice to extract steroids from plasma, serum, or tissue samples prior to steroid measurement by radioimmunoassay (RIA) or enzyme immunoassay (EIA). Steroid extraction is critical because it can remove substances that interfere with the RIA or EIA. Steroid extraction is commonly achieved using organic solvents, such as diethyl ether or dichloromethane. However, organic solvent extractions can suffer from low recovery, imprecise recovery, or incomplete removal of assay interference. Here, we describe validations of a simple protocol to extract steroids (e.g., dehydroepiandrosterone, corticosterone, and estradiol) from avian plasma, serum, and brain tissue using solid phase extraction (SPE) with commercially available C18 columns. We compare various methods for (1) eluting steroids from columns, (2) drying eluates, and (3) resuspending dried eluates prior to RIA. The SPE method yields high and consistent recoveries. The SPE method also effectively separates steroids from interfering substances, even when extracting steroids from lipid-rich plasma and brain tissue. These data indicate that SPE is superior to organic solvent extraction on several measures. SPE should be broadly useful for extracting steroids from plasma or tissue samples.

Determinants of within- and among-clutch variation in yolk corticosterone in the European starling

Maternal glucocorticoids are known to affect offspring phenotype in numerous vertebrate taxa. In birds, the maternal transfer of corticosterone to eggs was recently proposed as a hormonal mechanism by which offspring phenotype is matched to the relative quality of the maternal environment. However, current hypotheses lack supporting information on both intra- and inter-clutch variation in yolk corticosterone for wild birds. As such, we examined variation in yolk corticosterone levels in a wild population of European starlings (Sturnus vulgaris). Maternal condition, clutch size and nesting density were all negatively related to yolk corticosterone deposition; females with high condition indices, those laying larger clutches and those nesting in high-density associations deposited lower amounts of the hormone into eggs than those with low condition indices, laying small clutches and nesting in isolation. Alternatively, we found no effects of maternal age or human disturbance on yolk corticosterone deposition. Intra-clutch variation of yolk corticosterone was significant, with levels increasing across the laying sequence in all clutch sizes examined, with the difference between first and last-laid eggs being greater in large versus small clutches. Given the reported effects of yolk corticosterone on offspring size and growth, intra-clutch variation in yolk corticosterone has the potential to alter the competitive environment within a brood. Furthermore, our results indicate that variation in yolk corticosterone can originate from variation in both the mother's quality as well as the quality of her breeding environment. The presence of inter-female variation in particular is an important pre-requisite in testing whether the exposure of offspring to maternally-derived corticosterone is a mechanistic link between offspring phenotypic plasticity and maternal quality.

Youth alcohol and other drug use in the United States and Australia: a cross-national comparison of three state-wide samples

Although youth drug and alcohol harm minimization policies in Australia are often contrasted with the abstinence and zero tolerance policies adopted in the United States, there has been little research directly comparing youth substance use behaviour in the two countries. Three state representative samples in Victoria, Australia (n = 7898) and in the US states of Oregon (n = 15,224) and Maine (n = 16,245) completed a common cross-sectional student survey. Rates of alcohol use (lifetime alcohol use, recent use in the past 30 days), alcohol use exceeding recommended consumption limits (binge drinking: five or more drinks in a session), other licit drug use (tobacco use), and norm-violating substance use (substance use at school, use in the past 30 days of marijuana or other illicit drug use) were compared for males and females at ages 12-17. Rates were lower (odds ratios 0.5-0.8) for youth in Maine and Oregon compared to Victoria for lifetime and recent alcohol use, binge drinking and daily cigarette smoking. However, rates of recent marijuana use and recent use of other illicit drugs were higher in Maine and Oregon, as were reports of being drunk or high at school. In contradiction of harm minimization objectives, Victoria, relative to the US states of Oregon and Maine, demonstrated higher rates of alcohol use exceeding recommended consumption limits and daily tobacco use. However, findings suggested that aspects of norm-violating substance use (substance use at school, marijuana use and other illicit drug use) were higher in the US states compared to Victoria.

Consultations with adolescents: the gap between their expectations and their experiences

AIM

To study the expectations and experiences of adolescents when in consultation with doctors, particularly with regard to issues of confidentiality.

METHODS

In a cross-sectional study, 613 seventh- and ninth-grade students (347 students aged 13 y and 266 students aged 15 y) completed a 40-item questionnaire specifically developed for this study. Students anonymously completed the self-administered questionnaire at school.

RESULTS

Of these adolescents, 89% aged 13 y and 57% aged 15 y were accompanied by one of their parents to appointments with private practitioners. Of the respondents, 33%/52% (13-y-olds/15-y-olds) said that seeing the doctor alone for some time was important but only 18%/20% were given the opportunity to do so. Although 79%/90% of respondents stated that it was important for the doctor to keep information confidential, on request, only 37%/40% of private practitioners had spoken about confidentiality; 64%/78% of adolescents said that doctors should give assurance of confidentiality even with regard to their parents. However, only 26%/27% of private practitioners explicitly assured confidentiality with regard to parents. Acceptance of conditional confidentiality was high in all subpopulations. Short waiting times and the opportunity to talk about topics such as nutrition, drugs and sexuality were rated as important.

CONCLUSION

Physicians should adapt their consultation style to the needs of adolescents by seeing the adolescent patient alone for some time and by assuring them of conditional confidentiality. Furthermore, they should provide opportunities to talk specifically about issues of potential concern to adolescents such as nutrition, drugs and sexuality. To accomplish these tasks, educational curricula in adolescent healthcare are required for physicians.

Family risk factors for cannabis use: a population-based survey of Australian secondary school students

The objective of this study was to investigate relationships between adolescent cannabis use and indices of parent - child attachment, family functioning and parent attitudes to drugs and delinquency. A total of 2848 year 9 and 2363 year 11 students participated in the Victorian Adolescent Health and Well-Being Survey (1999). The study was a school-based random sample of 535 metropolitan and rural, government and non-government secondary schools throughout Victoria, Australia. Cannabis use was defined as 'any' and 'weekly' use in the last 30 days. Multivariate logistic regression was used to identify independent associations between cannabis use and parent - child attachment, family functioning and parent attitudes to drugs and delinquency. Cannabis use in year 9 was associated with permissive parent attitudes to drugs and delinquency (any use: adjusted odds ratio (OR) = 8.1; weekly use: adjusted OR = 7.6), and was particularly sensitive to small changes in the quality of the parent - child relationship with risk increasing threefold for those describing their attachment as 'good' compared with 'very good' (any use: adjusted OR = 2.8, weekly use adjusted OR = 2.9). A similar, but more moderate pattern association was evident in year 11. After adjusting for other family and background factors, poor family functioning showed minimal association with level of cannabis use at both year levels. Results suggest that intervention efforts might sensibly target strengthening parent - children relationships and promoting less permissive parent attitudes to drug use.

Adolescent chronic illness: a qualitative study of psychosocial adjustment

INTRODUCTION

The purpose of this study was to investigate the psychosocial issues facing young people living with a chronic medical condition.

MATERIALS AND METHODS

Subjects were young people with a range of medical conditions who were on a waiting list to participate in the Chronic Illness Peer Support programme at the Centre for Adolescent Health, Royal Children's Hospital, Melbourne, Australia. Young people agreed to in-depth interviews which were taped and transcribed. Thematic analysis was undertaken by two researchers working independently.

RESULTS

Thirty-five young people were interviewed. Thematic analysis revealed five broad themes: control (in control, under control, out of control); emotional reactions (happiness, frustration, anger, sadness, anxiety); acceptance (of illness, of others, of self); coping strategies, and; a search for meaning. The importance of social connections was emphasised. While illustrating the difficulties of managing a chronic medical condition during adolescence, a generally positive message emerges about these young people.

CONCLUSIONS

Many young people with chronic illness appear relatively resilient in the face of the adjustment challenges presented by their illness. Interventions that allow a young person to explore meaning, build self-esteem, and acceptance through positive social connections are likely to improve adjustment outcomes in this group.

Does bullying cause emotional problems? A prospective study of young teenagers

OBJECTIVES

To establish the relation between recurrent peer victimisation and onset of self reported symptoms of anxiety or depression in the early teen years.

DESIGN

Cohort study over two years.

SETTING

Secondary schools in Victoria, Australia.

PARTICIPANTS

2680 students surveyed twice in year 8 (aged 13 years) and once in year 9.

MAIN OUTCOME MEASURES

Self reported symptoms of anxiety or depression were assessed by using the computerised version of the revised clinical interview schedule. Incident cases were students scoring >/=12 in year 9 but not previously. Prior victimisation was defined as having been bullied at either or both survey times in year 8.

RESULTS

Prevalence of victimisation at the second survey point in year 8 was 51% (95% confidence interval 49% to 54%), and prevalence of self reported symptoms of anxiety or depression was 18% (16% to 20%). The incidence of self reported symptoms of anxiety or depression in year 9 (7%) was significantly associated with victimisation reported either once (odds ratio 1.94, 1.1 to 3.3) or twice (2.30, 1.2 to 4.3) in year 8. After adjustment for availability of social relations and for sociodemographic factors, recurrent victimisation remained predictive of self reported symptoms of anxiety or depression for girls (2.60, 1.2 to 5.5) but not for boys (1.36, 0.6 to 3.0). Newly reported victimisation in year 9 was not significantly associated with prior self report of symptoms of anxiety or depression (1.48, 0.4 to 6.0).

CONCLUSION

A history of victimisation and poor social relationships predicts the onset of emotional problems in adolescents. Previous recurrent emotional problems are not significantly related to future victimisation. These findings have implications for how seriously the occurrence of victimisation is treated and for the focus of interventions aimed at addressing mental health issues in adolescents.

Building capacity for system-level change in schools: lessons from the Gatehouse Project

The Gatehouse Project is an innovative, comprehensive approach to mental health promotion in secondary schools. It sets out to promote student engagement and school connectedness as the way to improve emotional well-being and learning outcomes. The key elements of the whole-school intervention are the establishment and support of a school-based adolescent health team; the identification of risk and protective factors in each school's social and leaning environment from student surveys; and, through the use of these data, the identification and implementation of effective strategies to address these issues. The project evaluation used a cluster-randomized controlled trial design involving 26 schools with initial results demonstrating considerable success in reducing smoking rates among Year 8 children. This article describes and accounts for how system-level changes have been made in schools through a process of capacity building. This encourages teachers, parents, and students to view the core business of education differently.

Identification of a contaminating Mycobacterium tuberculosis strain with a transposition of an IS6110 insertion element resulting in an altered spoligotype

Molecular fingerprinting with the IS6110 insertion sequence is useful for tracking transmission of Mycobacterium tuberculosis within a population or confirming specimen contamination in the laboratory or through instrumentation. Secondary typing with other molecular methods yields additional information as to the relatedness of strains with similar IS6110 fingerprints. Isolated, relatively rare, random events within the M. tuberculosis genome alter molecular fingerprinting patterns with any of the methods; therefore, strains which are different by two or more typing methods are usually not considered to be closely related. In this report, we describe two strains of M. tuberculosis, obtained from the same bronchoscope 2 days apart, that demonstrated unique molecular fingerprinting patterns by two different typing methods. They were closely linked through the bronchoscope by a traditional epidemiologic investigation. Genetic analysis of the two strains revealed that a single event, the transposition of an IS6110 insertion sequence in one of the strains, accounted for both the differences in the IS6110 pattern and the apparent deletion of a spacer in the spoligotype. This finding shows that a single event can change the molecular fingerprint of a strain in two different molecular typing systems, and thus, molecular typing cannot be the only means used to track transmission of this organism through a population. Traditional epidemiologic techniques are a necessary complement to molecular fingerprinting so that radical changes within the fingerprint pattern can be identified.

Development and validation of the Adolescent Asthma Quality of Life Questionnaire (AAQOL)

Current asthma-specific quality of life questionnaires have major conceptual and methodological deficiencies for use in adolescents. The aim of this study was to develop and validate the "Adolescent Asthma Quality of Life Questionnaire (AAQOL)", specifically developed for adolescents with asthma. One-hundred and eleven adolescents with frequent-episodic or persistent asthma aged 12-17 yrs were recruited from three tertiary paediatric asthma clinics. The standardized multi-step method consisted of: 1) item selection including semistructured interviews (n=14); 2) item reduction and validation (n=66); and 3) assessment of reproducibility (n=31). Item reduction was performed applying the clinical impact method. The 32 item AAQOL covers six domains: symptoms, medication, physical activities, emotion, social interaction and positive effects. There was high internal consistency for the six domains (alpha=0.70-0.90) and for the total score (alpha=0.93). Test-retest reliability was high for all domain scores (r=0.76-0.85) and the total score (r=0.90), indicating high reproducibility of the AAQOL. There was high correlation with the paediatric Asthma Quality of Life Questionnaire (rho=0.81) which focuses primarily on symptoms and emotional well-being. There was weak to moderate correlation with clinical parameters of asthma severity (rho=0.25-0.65). The 32-item Adolescent Asthma Quality of Life Questionnaire is a valid, developmentally age-appropriate and dimensionally comprehensive asthma-specific quality of life measure for use in adolescents.

The Gatehouse Project: a systematic approach to mental health promotion in secondary schools

OBJECTIVE

The objective of this paper is to outline the conceptual background and strategy of intervention for a systematic and sustainable approach to mental health promotion in secondary schools.

METHOD

The conceptual origins of the Gatehouse Project are described in terms of the epidemiology of adolescent mental health problems, attachment theory, education reform research and health promotional theory and practice. The elements of health promotional work are described in terms of structural change and priority setting; implementation at multiple levels within the participating schools is described.

RESULTS

The conceptual framework of the Gatehouse Project emphasises healthy attachments with peers and teachers through the promotion of a sense of security and trust, effective communication and a sense of positive self-regard based on participation in varied aspects of school and community life. A school social climate profile is derived from a questionnaire survey of students. An adolescent health team uses this information to set priorities for change within the school. Interventions may focus on the promotion of a positive social climate of the whole school or in the classroom. Curriculum-based health education is also used and based on materials that are relevant to the normal developmental experiences of teenagers. These are integrated into the mainstream curriculum and incorporate a strong component of teacher professional development. Lastly, the intervention promotes linkage between the school and broader community with a particular emphasis on the needs of young people at high risk of school drop-out.

CONCLUSIONS

Educational environments are complex systems undergoing continuous and simultaneous changes. The Gatehouse Project will provide unique information on the relationship between the social environment and the emotional wellbeing of young people. More importantly it outlines a sustainable process for building the capacity of schools to promote the social and emotional development of young people.

The Gatehouse Project: a systematic approach to mental health promotion in secondary schools

OBJECTIVE

The objective of this paper is to outline the conceptual background and strategy of intervention for a systematic and sustainable approach to mental health promotion in secondary schools.

METHOD

The conceptual origins of the Gatehouse Project are described in terms of the epidemiology of adolescent mental health problems, attachment theory, education reform research and health promotional theory and practice. The elements of health promotional work are described in terms of structural change and priority setting; implementation at multiple levels within the participating schools is described.

RESULTS

The conceptual framework of the Gatehouse Project emphasises healthy attachments with peers and teachers through the promotion of a sense of security and trust, effective communication and a sense of positive self-regard based on participation in varied aspects of school and community life. A school social climate profile is derived from a questionnaire survey of students. An adolescent health team uses this information to set priorities for change within the school. Interventions may focus on the promotion of a positive social climate of the whole school or in the classroom. Curriculum-based health education is also used and based on materials that are relevant to the normal developmental experiences of teenagers. These are integrated into the mainstream curriculum and incorporate a strong component of teacher professional development. Lastly, the intervention promotes linkage between the school and broader community with a particular emphasis on the needs of young people at high risk of school drop-out.

CONCLUSIONS

Educational environments are complex systems undergoing continuous and simultaneous changes. The Gatehouse Project will provide unique information on the relationship between the social environment and the emotional wellbeing of young people. More importantly it outlines a sustainable process for building the capacity of schools to promote the social and emotional development of young people.

Immunisation uptake, services required and government incentives for users of formal day care

OBJECTIVES

To determine immunisation uptake in children attending formal day care prior to the introduction of certificates (state) and parent incentives (federal), and to document parent and child carers' attitudes to these strategies.

METHOD

In 1997, 60 child care centres and 300 family day carers in suburban Melbourne were randomly sampled. Immunisation dates, service use and preference, and views on government incentives were obtained from parents of children under three years of age.

RESULTS

From 2,454 eligible children, information was obtained for 1,779, of whom 84% (95% CI 82-86) were completely immunised. Low income (OR 1.8, 95% CI 1.2-1.9, p < or = 0.001) and larger family size (OR 1.8, 95% CI 1.2-2.7, p = 0.002) and only ever using a doctor (OR 1.6, 95% CI 1.1-2.3) was associated with incomplete immunisation. Main reasons for delaying immunisation were occurrence of minor illness and work commitments. Families would prefer immunisation services at Maternal and Child Health visits (39%), evening sessions (22%) and at day care (22%). Immunisation uptake could increase to 94% if those receiving Childcare Assistance (67%) immunised their children on time but would increase to 87% if these incentive only motivated those for whom Childcare Assistance was essential (15%). While 98% of day care co-ordinators and 71% of family day care co-ordinators documented immunisation status at commencement of child care, only 51% and 33% respectively regularly updated this information.

CONCLUSION

Providing client-focused, flexible immunisation services and government incentives and legislation may work together to boost immunisation levels for those in formal child care.

The Women and Infants Demonstration Project: an integrated approach to AIDS prevention and research

The Women and Infants Demonstration Project is a multisite, behavioral intervention research effort funded by the Centers for Disease Control. The project is evaluating a theory-based, integrated intervention model to increase the use of condoms for prevention of both sexually transmitted diseases (STDs) and unintended pregnancy among women and their partners at risk of infection with HIV. The importance of utilizing carefully targeted, credible and persistent risk reduction interventions to effect lasting behavior change has become evident over the last ten years of the AIDS epidemic. The theory-based intervention components being evaluated in this intervention study involve one-on-one stage-tailored outreach; the development and distribution of community-tailored HIV prevention materials, called role-model stories; and the development of organizational and peer networking, all within a community mobilization framework. This article describes each of the intervention components being evaluated during this 5-year study. Such an intervention effort represents an important contribution in the design of community-level AIDS prevention intervention efforts which support individual-level behavioral changes by women at risk for HIV and other sexually transmitted infections.

Distribution along a stages-of-behavioral-change continuum for condom and contraceptive use among women accessed in different settings. Prevention of HIV in Women and Infants Demonstration Projects

The numbers of women of childbearing age in the US with HIV and AIDS from heterosexual transmission continues to rise. Behavioral interventions remain the best means of preventing transmission of HIV. Program planners often implement interventions to promote behavioral change in a wide range of settings such as family planning or sexually transmitted disease clinics, drug treatment facilities, or medical facilities that serve high risk and HIV positive women. Women recruited in different types of settings, however, may differ with respect to their experience with, attitudes toward, and willingness to use condoms and contraception. Such differences should be considered when tailoring interventions to the populations being served. We examined the readiness to use condoms and contraception among 3784 women in four cities recruited in three different types of settings: community, facilities not targeted to HIV positive women and medical facilities for HIV positive populations. Readiness to use condoms or contraception was measured using The Transtheoretical Model of Change. Women reported being in different stages along the continuum of condom and contraceptive use in the three settings. A greater proportion of women in the HIV-facility, 45%, had used condoms consistently for the previous 6 months compared to women in the other two settings (12% and 11%). Similarly, variation across settings was seen for contemplation of consistent contraceptive use to prevent unintended pregnancies. The variability in the distribution of condom and contraceptive use across settings underscores the importance of assessing the readiness for the behavior change and designing interventions that meet the specific needs of the populations being served.

Exposure to a community-level HIV prevention intervention: who gets the message

As part of the evaluation of a community-level HIV prevention program for women, this study examined predictors of exposure to print media and community outreach and assessed the relationship between exposure to the intervention and condom use behavior. Data from interviews with 479 women randomly selected from the intervention community in 1995 and 1996 were examined. Analysis of demographic and risk characteristics were conducted to identify predictors of exposure to the project's HIV prevention messages. Additionally, logistic regression analyses were conducted to examine the effects of intervention exposure on condom use, controlling for factors related to exposure. The results revealed that the print media campaign reached the largest number of women. However, women at highest risk did not have high rates of exposure to print media, but had greater exposure to outreach. Exposure to print media had an effect on increased communication with a main partner about condom use, but was not significantly related to condom use last time had sex. There were no significant main effects for exposure to outreach on condom use behavior. An important finding of this analysis was that each intervention strategy was successful in reaching a different portion of the target population and that exposure had differential effects on the condom use behavior of particular segments of the target population.