Emotional and behavioural outcomes later in childhood and adolescence for children with specific language impairments: meta-analyses of controlled prospective studies

BACKGROUND

Prospective evidence on psychological outcomes for children with specific language impairments (SLI) is accumulating. To date, there has been no attempt to summarise what this evidence says about the strength of link between SLI and later child and adolescent emotional and behavioural (EB) outcomes.

METHODS

We undertook a systematic review and meta-analysis (following PRISMA guidelines and involving a literature search to June 2012 of seven databases, including MEDLINE and PsychAPA) of prospective, cohort studies of children with SLI and typical language development (TLD) reporting on the incidence and severity of EB problems later in childhood or adolescence.

RESULTS

Nineteen follow-up reports of eight cohorts with 553 SLI children and 1533 TLD controls were identified. Initial assessment was at 3-8.8 years of age and follow-up duration from 2 to 12 years. Pooled across comparable studies, SLI children were about two times more likely to show disorder levels of overall internalising problems, overall externalising and ADHD problems than TLD children. Compared with the average TLD child (50 percentile), at follow-up, the symptom severity of the average SLI child was at the 72 percentile (95% CI 65-79 percentile) on internalising symptoms, the 69 percentile (95% CI 63-74 percentile) on externalising symptoms and the 60 percentile (95% CI 52-68 percentile) on AHDH severity. The findings about risk to specific mental disorders and the severity of specific problems were inconclusive.

CONCLUSIONS

Relative to typical children, SLI children experience clinically important increases in the severity of diverse emotional, behavioural and ADHD symptoms and more frequently show a clinical level of these problems. The small number of studies included in pooled analysis and methodological heterogeneity reduce the precision and generalisability of the findings. Most studies do not account for initial levels of EB problems.

A randomized controlled trial of problem-solving therapy compared to cognitive therapy for the treatment of insomnia in adults

STUDY OBJECTIVES

To compare the efficacy of problem-solving therapy (PST) combined with behavioral sleep strategies to standard cognitive therapy (CT) combined with behavioral sleep strategies in the treatment of insomnia.

DESIGN

A six-week randomized controlled trial with one month follow-up.

SETTING

The Australian National University Psychology Clinic, Canberra, Australia.

PARTICIPANTS

Forty-seven adults aged 18-60 years recruited from the community meeting the Research Diagnostic Criteria for insomnia.

INTERVENTIONS

Participants received 6 weeks of treatment including one group session (sleep education and hygiene, stimulus control instructions and progressive muscle relaxation) followed by 5 weeks of individual treatment of PST or CT.

MEASUREMENTS AND RESULTS

Primary outcomes included sleep efficiency (SE) from sleep diaries, the Insomnia Severity Index (ISI), and the Pittsburgh Sleep Quality Index (PSQI). Secondary measures assessed dysfunctional sleep beliefs, problem-solving skills and orientations, and worry. Both treatments produced significant post therapy improvements in sleep which were maintained at 1 month follow-up (on SE Cohen d = 1.42, 95% CI 1.02-1.87 for PST; d = 1.26, 95% CI 0.81-1.65 for CT; on ISI d = 1.46, 95% CI 1.03-1.88 for PST; d = 1.95, 95% CI 0.52-2.38 for CT; for PSQI d = 0.97, 95% CI 0.55-1.40 for PST and d = 1.34, 95% CI 0.90-1.79 for the CT). There were no differences in PST and CT in the size or rate of improvement in sleep although CT produced a significant faster rate of decline in negative beliefs about sleep than PST and there was a trend (P = 0.08) for PST to produce a faster rate of improvement in negative problem orientation than CT.

CONCLUSIONS

The results provide preliminary support for problem solving treatment as an equally efficacious alternative component to cognitive therapy in psychological interventions for insomnia.

Not just fear and sadness: meta-analytic evidence of pervasive emotion recognition deficits for facial and vocal expressions in psychopathy

The present meta-analysis aimed to clarify whether deficits in emotion recognition in psychopathy are restricted to certain emotions and modalities or whether they are more pervasive. We also attempted to assess the influence of other important variables: age, and the affective factor of psychopathy. A systematic search of electronic databases and a subsequent manual search identified 26 studies that included 29 experiments (N = 1376) involving six emotion categories (anger, disgust, fear, happiness, sadness, surprise) across three modalities (facial, vocal, postural). Meta-analyses found evidence of pervasive impairments across modalities (facial and vocal) with significant deficits evident for several emotions (i.e., not only fear and sadness) in both adults and children/adolescents. These results are consistent with recent theorizing that the amygdala, which is believed to be dysfunctional in psychopathy, has a broad role in emotion processing. We discuss limitations of the available data that restrict the ability of meta-analysis to consider the influence of age and separate the sub-factors of psychopathy, highlighting important directions for future research.

Individual differences in emotionality and peri-traumatic processing

BACKGROUND AND OBJECTIVES

Recent cognitive models propose that intrusive trauma memories arise and persist because high levels of emotional arousal triggered by the trauma disrupt conceptual processing of elements of the event, while enhancing sensory/perceptual processing. A trauma film analogue design was used to investigate if the predicted facilitating effects on intrusions from inhibiting conceptual processing and predicted attenuating effects on intrusions from inhibiting sensory processing are moderated by individual differences in emotionality.

METHODS

One hundred and five non-clinical participants viewed a traumatic film while undertaking a conceptual interference task, a sensory interference task, or no interference task. Participants recorded the frequency and intensity of intrusions over the following week.

RESULTS

There was no facilitating effect for the conceptual interference task compared to no interference task. A significant attenuation of the frequency of intrusions was evident for those undertaking sensory interference (ŋ(2) = .04). This effect, however, was only present for those with high trait anxiety (d = .82) and not for those with low trait anxiety (d = .08). Relative to high trait anxious controls, high anxious participants who undertook sensory interference also reported lower intensity of intrusions (d = .66).

CONCLUSIONS

This is the first trauma film analogue study to show that the attenuating effect of concurrent sensory/perceptual processing on the frequency and intensity of subsequent intrusions is evident only for people with high trait anxiety. The results have implications for conceptual models of intrusion development and for their application to the prevention of post traumatic distress.

Can a Theory of Mind Disruption Help Explain OCD Related Metacognitive Disturbances?

This study investigated whether individual differences in obsessive-compulsive symptoms and in thought–action fusion are related to theory of mind abilities. One hundred and ninety-two adult participants completed self-reports of obsessive–compulsive symptoms (OCI-R), thought–action fusion (TAF), private self-consciousness (PSC) and self-reflectiveness (SR) as mentalising abilities, and anxiety and depression. A nonintrospective method examining participants' implicit structure of their lexicon for ‘knowing’ was used to assess theory of mind. Private self-conciousness and SR added to the prediction of OCD symptoms independently of TAF and depression but did not mediate the relationship between TAF and OCD symptoms. Participants high in thought–action fusion gave a greater emphasis to the certainty dimension of the mental lexicon and placed lesser importance on the source of information dimension than those low in TAF. Our results provide preliminary evidence of a relationship between theory of mind and thought–action fusion. People disposed to thought–action fusion are more likely to make a significance judgment about ‘knowing’ based on the degree of certainty than on reference to the source of knowledge. Identifying disruptions to theory of mind abilities in OCD provides links to solid theory and evidence about metacognitive development and may help integrate cognitive processing and cognitive appraisal models of OCD.

Individual differences in the ability to recognise facial identity are associated with social anxiety

Previous research has been concerned with the relationship between social anxiety and the recognition of face expression but the question of whether there is a relationship between social anxiety and the recognition of face identity has been neglected. Here, we report the first evidence that social anxiety is associated with recognition of face identity, across the population range of individual differences in recognition abilities. Results showed poorer face identity recognition (on the Cambridge Face Memory Test) was correlated with a small but significant increase in social anxiety (Social Interaction Anxiety Scale) but not general anxiety (State-Trait Anxiety Inventory). The correlation was also independent of general visual memory (Cambridge Car Memory Test) and IQ. Theoretically, the correlation could arise because correct identification of people, typically achieved via faces, is important for successful social interactions, extending evidence that individuals with clinical-level deficits in face identity recognition (prosopagnosia) often report social stress due to their inability to recognise others. Equally, the relationship could arise if social anxiety causes reduced exposure or attention to people's faces, and thus to poor development of face recognition mechanisms.

Integration and organization of trauma memories and posttraumatic symptoms

To examine the connection between trauma memory integration in personal memory, memory organization, and posttraumatic symptom severity, 47 trauma-exposed adults undertook an event-cuing task for their trauma memory and for a memorable nontraumatic negative event. Measures of integration provided by self-endorsement, rated by naïve judges, or calculated from the language of the memories, did not significantly predict posttraumatic stress disorder symptom severity after adjusting for age, time since the event, anxiety when disclosing, familiarity of the memory, and integration of nontrauma memory. Less use of casual connectives in the trauma memory narrative was associated with higher trauma-related avoidance (r = .33; p = .03), whereas self-rating of the trauma memory as disorganized was associated with higher overall symptom severity (r = .42; p = .006).

Advance agreements for mental health care: an examination of process and outcomes

OBJECTIVE

Despite high demand for anticipatory planning tools in mental health there is little Australian research about their implementation. This study examines the processes and outcomes of the introduction of structured mental health advanced agreements in the Australian Capital Territory.

METHOD

Thirty-three patients with serious mental illness collaborated with a key clinician to develop an advanced agreement. Patients and clinicians were provided with appropriate education, workbooks and materials. The process and outcomes associated with developing and completing an agreement were evaluated with patient and clinician interviews and self-report measures.

RESULTS

The process was strongly accepted by the patients with only 16% discontinuing for reasons related to the advanced agreement. Participants strongly endorsed benefits both to themselves and to the management of patients' illnesses. Service level impediments, particularly clinician acceptance, limited treatment options, and the lack of legal force of the agreement were identified.

CONCLUSIONS

When supported, mental health patients can work collaboratively with clinicians to produce anticipatory treatment requests which are beneficial, feasible and consistent with good care. Implementation of anticipatory planning in mental health will require service-level changes to promote clinician acceptance and to embed practices which facilitate these tools as part of routine care.

Cultural differences in personal identity in post-traumatic stress disorder

OBJECTIVES

This study investigated cultural differences in goals, self-defining memories, and self-cognitions in those with and without post-traumatic stress disorder (PTSD).

METHOD

Trauma survivors with and without PTSD, from independent and interdependent cultures (N=106) provided major personal goals, self-defining memories, and self-cognitions.

RESULTS

Trauma survivors with PTSD from independent cultures reported more goals, self-defining memories, and self-cognitions that were trauma-related than non-PTSD trauma survivors from independent cultures. In contrast, for those from interdependent cultures, there was no difference between trauma survivors with and without PTSD in terms of trauma-centred goals, self-defining memories, and self-cognitions.

CONCLUSIONS

The results suggest cultural variability in the impact of trauma on memory and identity, and highlight the need for contemporary models of PTSD to more explicitly consider culture in their accounts of PTSD. Clinical implications of these findings, such as cultural considerations in assessment and treating trauma relevant self-schema in cognitive therapy for PTSD, are discussed.

A controlled trial of a school-based Internet program for reducing depressive symptoms in adolescent girls

BACKGROUND

This study evaluates the benefits of a self-directed Internet intervention for depression (MoodGYM) delivered as a part of the high school curriculum.

METHOD

One hundred and fifty-seven girls, aged 15 and 16 years, were allocated to undertake either MoodGYM or their usual curriculum. MoodGYM's impact on depressive symptoms, risk of depression, attributional style, depression literacy and attitudes toward depression was examined using random effect regression.

RESULTS

MoodGYM produced a significantly faster rate of decline in depressive symptoms over the trial period than the control condition. The effect size for MoodGYM was not significant immediately after the intervention (Cohen's d=.19, 95% CI -.18-.56) but was moderate and significant 20 weeks after the intervention (d=.46, 95% CI .10-.82). Girls with high depression scores before intervention showed the strongest benefits on self-reported depression at follow-up (d=.92, 95% CI .10-1.38). There were no significant intervention effects on depression status, attributional style, depression literacy, and attitudes. Approximately 70% of girls in the MoodGYM group completed less than three of its modules and completion of fewer modules was related to high depression score before intervention.

CONCLUSIONS

The findings suggest that there are benefits from MoodGYM on self-reported depressive symptoms but has low rates of completion highlight problems in ensuring adherence to Internet programs for depression.

Cultural Differences in Retrieval of Self-Defining Memories

Australians and Asians were asked to provide autobiographical memories of events they believe shaped who they are as individuals (self-defining memories). The authors found the anticipated cultural differences for the memories' themes. Contrary to previous suggestions, however, elaboration of personal memories occurred equally for both groups and was dependent on the content of the memory. Australians provided more elaborate autonomous memories and Asians more elaborate relatedness memories. The findings indicate that elaborating personal memories may function to enhance the dominant self-focus.

Smoking as a risk factor for dementia and cognitive decline: a meta-analysis of prospective studies

The authors assessed the association of smoking with dementia and cognitive decline in a meta-analysis of 19 prospective studies with at least 12 months of follow-up. Studies included a total of 26,374 participants followed for dementia for 2-30 years and 17,023 participants followed up for 2-7 years to assess cognitive decline. Mean study age was 74 years. Current smokers at baseline, relative to never smokers, had risks of 1.79 (95% confidence interval (CI): 1.43, 2.23) for incident Alzheimer's disease, 1.78 (95% CI: 1.28, 2.47) for incident vascular dementia, and 1.27 (95% CI: 1.02, 1.60) for any dementia. Compared with those who never smoked, current smokers at baseline also showed greater yearly declines in Mini-Mental State Examination scores over the follow-up period (effect size (beta)=-0.13, 95% CI: -0.18, -0.08). Compared with former smokers, current smokers at baseline showed an increased risk of Alzheimer's disease (relative risk=1.70, 95% CI: 1.25, 2.31) and an increased decline in cognitive abilities (effect size (beta)=-0.07, 95% CI: -0.11, -0.03), but the groups were not different regarding risk of vascular dementia or any dementia. The authors concluded that elderly smokers have increased risks of dementia and cognitive decline.

Benefits of cognitive-behavioural therapy for children and youth with obsessive-compulsive disorder: re-examination of the evidence

The aim of the present paper was to critically examine evidence about the benefits of cognitive-behavioural therapy (CBT) for pediatric obsessive-compulsive disorder (OCD) from controlled and single group studies, including its benefits relative to medication are critically reviewed. Selected studies were categorized by study type and by risk of bias classification. Standardized mean differences (Hedges' g or Cohen d) and, where appropriate, weighted mean difference (WMD) were calculated. All five comparison and 14 one-group studies showed a significant benefit for CBT within a wide range (ES = .78 to 4.38). Low risk of bias studies produced the lower adjusted effect sizes. The best available estimate of CBT efficacy relative to no treatment is about 1 standardized mean difference, equivalent to a treatment effect of 8 points on the Children's Yale-Brown Obsessive-Compulsive Scale. This represents a reduction in the risk of continuing to have OCD post-treatment of about 37% (95% CI 14% to 54%). Evidence from 3 studies indicates that the efficacy of CBT and medication do not differ significantly. CBT combined with medication is significantly more efficacious than non-active controls or medication alone but not relative to CBT alone. CBT should be regarded as a first line equivalent to anti-OCD medication with the potential to lead to better outcomes when combined with medication than medication alone can provide. Additional studies are needed to further clarify CBT's benefits and to investigate how it can be made more available as a treatment option for children and youth who suffer from OCD.

Language for emotions in adolescents with externalizing and internalizing disorders

This study compared the structure and quality of emotion language in adolescents with externalizing disorders (N = 21), internalizing disorders (N = 18), and without a behavioral or emotional disorder (N = 16). Emotion language was elicited in response to vignette material prototypical for anger/sadness and fear, to autobiographical experiences, and to an actual emotional challenge. The findings reveal different emphases in the emotion language of internalizing and externalizing youth rather than a relative weakness for externalizing adolescents. Overall, clinical adolescents used fewer emotion terms that were semantically specific for anger, sad, or fear than typical adolescents. The results also show that emotion language is affected differentially for externalizing and internalizing adolescents depending on the emotion domain. Internalizing youth's emotion language to anger/sad events used inner-directed terms, situational references, and reduced intensity while their representation of emotions in response to salient threatening material was dominated by terms with a cognitive focus. Externalizing adolescents' emotion language responses to anger/sad events were more outer directed and intense, and their emotion language in a salient threat situation more orientated to direct affective terms. The results suggest that examining emotion language for specific emotion domains in adolescents with specific disorders will better clarify the role of emotion language in the regulation of emotions than approaches that globalize emotion language competencies or deficits.

Effects of a cognitive-behavioural internet program on depression, vulnerability to depression and stigma in adolescent males: a school-based controlled trial

This study evaluated the effectiveness of a cognitive behaviour therapy Internet program (MoodGYM) for depressive symptoms, attributional style, self-esteem and beliefs about depression, and on depression and depression-vulnerable status in male youth. A total of 78 boys age 15 and 16 years were allocated to either undertake MoodGYM or to standard personal development activities. Outcomes were measured before commencement, post-program and 16 weeks post-program. There were no significant between-group differences in change scores pre- to post- or pre- to follow-up using the intention to treat sample or for participants with post- and/or follow-up data. For boys completing 3 or more modules there were small relative benefits of MoodGYM for depressive symptoms (Effect Size, ES = 0.34), attributional style (ES = 0.17) and self-esteem (ES = 0.16) at post-program, although only the effect for self-esteem was sustained at follow-up. Both groups showed improvement in their beliefs about depression at follow-up, with the control group showing a moderate relative benefit (ES = 0.40). While the numbers are small, there was a reduction in the risk of being depressed in the MoodGYM group of 9% at post-treatment compared with a slightly increased risk for the control group. The risk of being classified as vulnerable to depression reduced by 17% in the MoodGYM group at post-treatment compared with no change in risk for the control group. These reductions in risk for the MoodGYM group were not sustained at follow-up. The limitations of the study highlight several important challenges for MoodGYM and other self-directed Internet cognitive behaviour therapy programs. These include how to ensure enough of the program is received and that people who could potentially benefit access the program and continue to remain engaged with it, and how to enhance the sustainability of any benefits.

Trauma narratives in posttraumatic stress disorder: a review

Nineteen empirical studies providing evidence about the nature of trauma narratives in posttraumatic stress disorder (PTSD) were reviewed. Selected studies had participants with a diagnosis of PTSD or with PTSD symptoms. The studies used either linguistic indices or participants' rating of narrative quality. There was evidence of a relationship between PTSD specific pathology and the occurrence of sensory/perceptual references and disturbed temporal aspects. Evidence for PTSD-related narrative fragmentation was inconclusive, and there were little data about specific self-referential content. Poor validity and confusion of content and syntactic aspects of narrative organization limited the data on the organization of PTSD narratives. Approaches that address some of these limitations and allow narrative-based evaluation of memory for trauma in PTSD are outlined.

Mental health first aid training of the public in a rural area: a cluster randomized trial [ISRCTN53887541]

BACKGROUND

A Mental Health First Aid course has been developed which trains members of the public in how to give initial help in mental health crisis situations and to support people developing mental health problems. This course has previously been evaluated in a randomized controlled trial in a workplace setting and found to produce a number of positive effects. However, this was an efficacy trial under relatively ideal conditions. Here we report the results of an effectiveness trial in which the course is given under more typical conditions.

METHODS

The course was taught to members of the public in a large rural area in Australia by staff of an area health service. The 16 Local Government Areas that made up the area were grouped into pairs matched for size, geography and socio-economic level. One of each Local Government Area pair was randomised to receive immediate training while one served as a wait-list control. There were 753 participants in the trial: 416 in the 8 trained areas and 337 in the 8 control areas. Outcomes measured before the course started and 4 months after it ended were knowledge of mental disorders, confidence in providing help, actual help provided, and social distance towards people with mental disorders. The data were analysed taking account of the clustered design and using an intention-to-treat approach.

RESULTS

Training was found to produce significantly greater recognition of the disorders, increased agreement with health professionals about which interventions are likely to be helpful, decreased social distance, increased confidence in providing help to others, and an increase in help actually provided. There was no change in the number of people with mental health problems that trainees had contact with nor in the percentage advising someone to seek professional help.

CONCLUSIONS

Mental Health First Aid training produces positive changes in knowledge, attitudes and behaviour when the course is given to members of the public by instructors from the local health service.