Temperamental and physiological regulatory capacity in infancy: Links with toddler behavior problems

Although correlates of temperamental regulatory processes in childhood have been well established, there is considerably less work examining correlates and moderators of rudimentary forms of temperamental regulation in infancy. We examined whether infants' physiological regulation indexed via changes in respiratory sinus arrhythmia (RSA) across phases of the Still-Face Paradigm moderated the association between maternal-reported infant regulatory capacity at 8 months (N = 50, M_age = 8.51 months, SD_age = 0.28 months, 25 girls) and behavior problems at 14 months. We found that cardiac vagal regulation from baseline to still-face moderated the relation between infant regulatory capacity at 8 months and behavior problems at 14 months. Among infants who displayed relatively high cardiac vagal regulation from baseline to still-face, regulatory capacity was negatively associated with behavior problems. There was no relation between regulatory capacity and behavior problems among infants who displayed average or relatively low cardiac vagal regulation. We speculate that high levels of regulatory capacity and cardiac vagal regulation may allow infants to focus their attention outward and cope with emotionally evocative environmental demands as they arise even in the absence of external regulation provided by their caregivers.

Young mothers' use of and experiences with mental health care services in Ontario, Canada: a qualitative descriptive study

Background

Despite the high prevalence of mental health issues among young mothers, their subsequent needs for mental health care support does not correlate with their access and use of services. The purpose of this study, grounded in the experiences of young mothers living in Ontario, Canada, was to describe their experiences of using mental health services during the perinatal period, and to identify the attributes of services and professionals that influenced their decision to engage with mental health services.

Methods

As the qualitative component of a sequential explanatory mixed methods study, the principles of qualitative description informed sampling, data collection, and analysis decisions. In-depth, semi-structured interviews were conducted with a purposeful sample of 29 young mothers (≤ 21 years) who met diagnostic criteria for at least one psychiatric disorder, and who were ≥ 2 months postpartum. Interview data were triangulated with data from ecomaps and a sub-set of demographic data for this purposeful sample from the survey conducted in the quantitative study component. Qualitative data were analyzed using both conventional content analysis and reflexive thematic analysis; the subset of survey data extracted for these 29 participants were analyzed using descriptive statistics.

Results

Young mothers identified the need to have at least one individual, either an informal social support or formal service provider who they could talk to about their mental health. Among participants deciding to seek professional mental health support, their hesitancy to access services was grounded in past negative experiences or fears of being judged, being medicated, not being seen as an active partner in care decisions or experiencing increased child protection involvement. Participants identified organizational and provider attributes of those delivering mental health care that they perceived influenced their use of or engagement with services.

Conclusion

Organizations or health/social care professionals providing mental health services to young pregnant or parenting mothers are recommended to implement trauma-and violence-informed care. This approach prioritizes the emotional and physical safety of individuals within the care environment. Applying this lens in service delivery also aligns with the needs of young mothers, including that they are actively listened to, treated with respect, and genuinely engaged as active partners in making decisions about their care and treatment.

Family-based treatment for children and adolescents with eating disorders: a mixed-methods evaluation of a blended evidence-based implementation approach

In this study, we evaluated a blended implementation approach with teams learning to provide family-based treatment (FBT) to adolescents with eating disorders. Four sites participated in a sequential mixed method pre-post study to evaluate the implementation of FBT in their clinical settings. The implementation approach included: (a) preparatory site visits; (b) the establishment of implementation teams; (c) a training workshop; (d) monthly clinical consultation; (e) monthly implementation consultation; and (f) fidelity assessment. Quantitative measures examining attitudes toward evidence-based practice, organizational learning environment and organizational readiness for change, as well as, individual readiness for change were delivered pre- and postimplementation. Correlational analyses were used to examine associations between baseline variables and therapist fidelity to FBT. Fundamental qualitative description guided the sampling and data collection for the qualitative interviews performed at the conclusion of the study. Seventeen individuals participated in this study (nine therapists, four medical practitioners, and four administrators). The predetermined threshold of implementation success of 80% fidelity in every FBT session was achieved by only one therapist. However, mean fidelity scores were similar to those reported in other studies. Participant attitudes, readiness, and self-efficacy were not associated with fidelity and did not change significantly from pre- to postimplementation. In qualitative interviews, all participants reported that the implementation intervention was helpful in adopting FBT. Our blended implementation approach was well received by participants. A larger trial is needed to determine which implementation factors predict FBT fidelity and impact patient outcomes.

Assessing fidelity to family-based treatment: an exploratory examination of expert, therapist, parent, and peer ratings

INTRODUCTION

Fidelity is an essential component for evaluating the clinical and implementation outcomes related to delivery of evidence-based practices (EBPs). Effective measurement of fidelity requires clinical buy-in, and as such, requires a process that is not burdensome for clinicians and managers. As part of a larger implementation study, we examined fidelity to Family-Based Treatment (FBT) measured by several different raters including an expert, a peer, therapists themselves, and parents, with a goal of determining a pragmatic, reliable and efficient method to capture treatment fidelity to FBT.

METHODS

Each therapist audio-recorded at least one FBT case and submitted recordings from session 1, 2, and 3 from phase 1, plus one additional session from phase 1, two sessions from phase 2, and one session from phase 3. These submitted files were rated by an expert and a peer rater using a validated FBT fidelity measure. As well, therapists and parents rated fidelity immediately following each session and submitted ratings to the research team. Inter-observer reliability was calculated for each item using the intraclass correlation coefficient (ICC), comparing the expert ratings to ratings from each of the other raters (parents, therapists, and peer). Mean scale scores were compared using repeated measures ANOVA.

RESULTS

Intraclass correlation coefficients revealed that agreement was the best between expert and peer, with excellent, good, or fair agreement in 7 of 13 items from session 1, 2 and 3. There were only four such values when comparing expert to parent agreement, and two such values comparing expert to therapist ratings. The rest of the ICC values indicated poor agreement. Scale level analysis indicated that expert fidelity ratings for phase 1 treatment sessions scores were significantly higher than the peer ratings and, that parent fidelity ratings tended to be significantly higher than the other raters across all three treatment phases. There were no significant differences between expert and therapist mean scores.

CONCLUSIONS

There may be challenges inherent in parents rating fidelity accurately. Peer rating or therapist self-rating may be considered pragmatic, efficient, and reliable approaches to fidelity assessment for real-world clinical settings.

Preschool mental health: The Brief Child and Family Intake and Outcomes System

Despite the availability of effective early interventions, few preschoolers with mental health issues receive these services. This situation exists partly due to challenges in the identification of emotional and behavioral issues in young children. We developed the Brief Child and Family Intake and Outcomes System for Preschoolers, which is a 60-item standardized online parent questionnaire including three externalizing scales (Regulating Attention, Impulsivity, and Activity; Cooperating; Regulating Conduct), five internalizing scales (Separating from Parents; Managing Anxiety; Managing Social Anxiety; Regulating Compulsive Behaviour; Managing Mood), and two regulating states scales (Eating; Sleeping). We conducted a normative study of 1,200 Canadian children 3–5 years old, stratified by sex, age, geographic region, and parents’ marital status, income, and education. Confirmatory factor analyses demonstrated good model fit, and the relationship between items and scales did not vary significantly between boys and girls or among 3-, 4-, and 5-year-old children. Reliability estimates indicated high internal consistency and 2-month test–retest reliability for a subsample ( n = 100) ranging from .44 to .73. Providing preliminary evidence of validity, scale scores had positive relations with measures of child functioning challenges, family distress, caregiver mood, and demographic risk variables. We extend earlier work by including clinically relevant emotional-behavioral scales while at the same time minimizing respondent burden and providing norms for Canadian preschoolers. The questionnaire could be used in children’s mental health settings, primary care, child welfare, and day-care and school facilities, for intake, triage, and describing 3- to 5-year-old children.

Parenting Interventions for Mothers With Problematic Substance Use: A Systematic Review of Research and Community Practice

Women with problematic substance use are frequently referred to interventions to promote positive parenting. Parenting interventions that attend to the unique risks faced by this population may enhance engagement and outcomes. While reviews of extant parenting interventions in the research literature have been undertaken, no studies have examined parenting interventions being implemented in community practice and the extent to which these are informed by current research. We systematically compared parenting interventions offered in 12 maternal substance use treatment programs in one Canadian province with those described in the research literature (K = 21). Few parenting interventions were replicated, either within or across the two samples. However, parenting interventions within both samples were largely similar in their objectives. Across both research and community samples, approximately half of the interventions were developed or adapted for a problematic substance use population. Parenting knowledge, psychosocial risk, and maternal emotional regulation were most commonly addressed. Risks pertaining to the impact of drug craving and substance-related changes in neurobiology associted with parenting were less commonly addressed. Findings highlight current strengths and limitations of parenting interventions within research and community settings, with recommendations offered for future research and knowledge translation.

The Mental Health of Young Canadian Mothers

PURPOSE

Although many young mothers (aged <21 years) are exposed to multiple adversities that increase their risk for mental illness, prevalence data are largely limited self-report questionnaires estimating only the prevalence of postpartum depression. Gaining a greater understanding of the burden of a broader range of common mental illnesses affecting these young women has the potential to improve their health as well as the development and functioning of their children.

METHODS

The Young Mothers Health Study recruited 450 mothers aged <21 years and 100 comparison mothers (aged >20 years old at first delivery) living in urban and rural central-west Ontario. Age-matched young mothers were also compared with 15- to 17-year-old women without children (N = 630) from the 2014 Ontario Child Health Study. The prevalence of current mental disorders was assessed using the Mini-International Neuropsychiatric Interview for Children and Adolescents.

RESULTS

Nearly 2 of 3 young mothers reported at least one mental health problem, and almost 40% had more than one. Young mothers were 2 to 4 times as likely to have an anxiety disorder (generalized anxiety disorder, separation anxiety disorder, social phobia, and specific phobia), attention-deficit/hyperactivity disorder, oppositional defiant disorder, or conduct disorder and were 2 to 4 times more likely to have more than one psychiatric problem than older comparison mothers or women aged 15-17 years.

CONCLUSIONS

Given the high rates of mental health problems and complex needs of young mothers in Canada and the possible adverse effects of maternal psychopathology on their children, further efforts should be directed at engaging and treating this high-risk group.

Toddler mental health: The Brief Child and Family Intake and Outcomes System

Despite the availability of effective early interventions, few toddlers with emotional and behavioral issues receive these services. This situation exists partly due to challenges in the identification of mental health issues in young children. We developed the Brief Child and Family Intake and Outcomes System for toddlers, which is a 36-item standardized online parent questionnaire including two externalizing scales (Cooperating; Regulating Attention, Impulsivity, and Activity), two internalizing scales (Expressing Emotion; Responding to Change), and two regulatory scales (Eating; Sleeping). We conducted a normative study of 500 Canadian children 18–36 months old, stratified by sex, age, geographic region, and parents’ marital status, income, and education. Confirmatory factor analyses demonstrated good model fit, and the relationship between items and scales did not vary significantly between boys and girls or between younger and older toddlers. Reliability estimates indicated high internal consistency. Providing preliminary evidence of validity, scale scores had positive relations with measures of family distress, caregiver mood, and demographic risk variables. Analyses of latent variables revealed good evidence of discriminant validity of the scales. We extend earlier work by including scales particularly relevant to toddler emotional and behavioral regulation while at the same time minimizing respondent burden and providing norms for Canadian toddlers. The questionnaire could be used in children’s mental health settings, primary care, child welfare, and daycare facilities, for intake, triage, and describing toddlers.

Infant mental health: The Brief Child and Family Intake and Outcomes System

There is a need to identify children with potential mental health issues early in order to provide “an ounce of prevention.” Unfortunately, there are few instruments available to identify emotional and behavioral issues in infants and many never receive intervention. We developed the Brief Child and Family Intake and Outcomes System for Infants, which is a standardized online parent questionnaire including one externalizing scale (Cooperating), two internalizing scales (Expressing Emotion; Responding to Change), and two regulatory scales (Eating; Sleeping). We conducted a normative study of 542 Canadian children aged 8–17 months, stratified by sex, age, geographic region, and parents’ marital status, income, and education. Results of confirmatory factor analyses demonstrated good model fit and the relationship between items and subscales did not vary significantly between boys and girls or between younger and older infants. Reliability estimates indicated high internal consistency and adequate to high test-retest reliability. Providing preliminary evidence of validity, scale scores had moderate to strong positive relations with measures of family distress, caregiver mood, and demographic variables. Analyses of latent variables revealed good evidence of discriminant validity of the scales. We extend earlier work by addressing a very young age range, including subscales particularly relevant to infant emotional and behavioral regulation while at the same time minimizing respondent burden, and providing norms for Canadian infants. The questionnaire could be used in children’s mental health settings, primary care, child welfare, and daycare facilities, for intake, triage, and describing infants.

Themes arising during implementation consultation with teams applying family-based treatment: a qualitative study

BACKGROUND

This study describes themes arising during implementation consultation with teams providing Family-Based Treatment (FBT) to adolescents with eating disorders.

METHODS

Participants were implementation teams (one lead therapist, one medical practitioner and one administrator) at four sites. These teams agreed to support the implementation of FBT, and participated in monthly consultation calls which were audio-recorded, transcribed verbatim and coded for themes. Twenty percent of the transcripts were double-coded to ensure consistency. Fundamental qualitative description guided the sampling and data collection.

RESULTS

Twenty-five (average per site = 6) transcripts were coded using thematic content analysis. Six major themes emerged: 1) system barriers and facilitators 2) the role of the medical practitioner, 3) research implementation, 4) appropriate cases, 5) communication, and 6) program impact.

CONCLUSIONS

Implementation themes aligned with previous research examining the adoption of FBT, and provide additional insight for clinical programs seeking to implement FBT, emphasizing the importance of role clarity, and team communication.

Using a Discrete Choice Conjoint Experiment to Engage Stakeholders in the Design of an Outpatient Children’s Health Center

Objectives:

To engage users in the design of a regional child and youth health center.

Background:

The perspective of users should be an integral component of a patient-centered, evidence-based approach to the design of health facilities.

Methods:

We conducted a discrete choice conjoint experiment (DCE), a method from marketing research and health economics, as a component of a strategy to engage users in the preconstruction planning process. A sample of 467 participants (290 staff and 177 clients or community stakeholders) completed the DCE.

Results:

Latent class analysis identified three segments with different design preferences. A group we termed an enhanced design (57%) segment preferred a fully featured facility with personal contacts at the start of visits (in-person check-in, personal waiting room notification, volunteer-assisted wayfinding, and visible security), a family resource center with a health librarian, and an outdoor playground equipped with covered heated pathways. The self-guided design segment (11%), in contrast, preferred a design allowing a more independent use of the facility (e.g., self-check-in at computer kiosks, color-coded wayfinding, and a self-guided family resource center). Designs affording privacy and personal contact with staff were important to the private design segment (32%). The theme and decor of the building was less important than interactive features and personal contacts.

Conclusion:

A DCE allowed us to engage users in the planning process by estimating the value of individual design elements, identifying segments with differing views, informing decisions regarding design trade-offs, and simulating user response to design options.

Themes arising in clinical consultation for therapists implementing family-based treatment for adolescents with anorexia nervosa: a qualitative study

BACKGROUND

Our study aims to explore and describe themes arising in sessions of clinical consultation with therapists implementing Family-Based Treatment (FBT) for adolescents with Anorexia Nervosa (AN). There is currently no literature describing the content of clinical consultation for FBT. Thus, this knowledge will add to the evidence-base on what therapists need from consultants in ongoing clinical consultation.

METHODS

Eight therapists at four sites participated in this study, which spanned a two-year period. Following a two-day training workshop, each therapist treated at least one adolescent patient presenting with a restrictive eating disorder with FBT, focusing on adherence to the treatment manual. Clinical consultation sessions occurred monthly and were led by an external FBT expert. Thirty-five (average per site = 9) audio recorded group clinical consultation sessions were transcribed verbatim and coded for themes. Twenty percent of the transcripts were double-coded to ensure consistency. Fundamental qualitative description guided the sampling and data collection.

RESULTS

Thematic content analysis revealed ten common themes relating to the provision of clinical consultation to therapists implementing FBT in clinical practice: encouraging parental meal time supervision,discussing the role of mothers, how to align parents, ensuring parental buy-in, when to transition to Phase 2, weighing the patient and the patients' knowledge of their weight, the role of siblings in FBT sessions, how best to manage patient co-morbidities, the role of the father in FBT and how best to manage the family meal.

CONCLUSIONS

In conclusion, clinical consultation themes aligned with many of the central tenets of FBT, including how to help parents align their supportive approach during the refeeding process, and how to help parents assume control of eating disordered behaviours. This knowledge helps to guide consultants to anticipate common issues brought forward by therapists attempting to implement FBT.

Implementing highly specialized and evidence-based pediatric eating disorder treatment: protocol for a mixed methods evaluation

Background

Eating disorders, which include anorexia nervosa and bulimia nervosa, are common in adolescent females and can have serious emotional and physical consequences, including death. Despite our knowledge about the severity of these illnesses, previous research indicates that adolescent patients are not receiving the best available treatment with fidelity. The main goal of this project is to reduce the knowledge gap between what research indicates is the best known treatment and what is actually delivered in clinical practice. Informed by the National Implementation Research Network model and the Consolidated Framework for Implementation Research meta-theory, our primary study aim is to increase the capacity of Ontario-based therapists to provide family-based treatment, by providing training and ongoing supervision.

Methods/design

We will use a multi-site case study with a mixed method pre/post design to examine several implementation outcomes across four eating disorder treatment programs. We will provide a training workshop on family-based treatment as well as ongoing monthly supervision. In addition, we will assemble implementation teams at each site and coach them by phone on a monthly basis regarding any process issues. Our main outcomes include fidelity to the treatment model using quantitative evaluation of audio-recorded therapy sessions, as well as qualitative analysis of the perceptions of the implementation process using audio-recorded focus groups with all clinicians and administrators involved in the study.

Discussion

To our knowledge, this is the first study to evaluate an implementation strategy for an evidence-based treatment for eating disorders. Challenges to date include obtaining ethics approval at all sites, and recruitment. This research will help to inform future studies on how to best implement evidence-based treatments in this field.

Implementing stakeholder-informed research in the substance abuse treatment sector: strategies used by Connections, a Canadian knowledge translation and exchange project

Background

Researcher-stakeholder collaboration has been identified as critical to bridging research and health system change. While collaboration models vary, meaningful stakeholder involvement over time (“integrated knowledge translation”) is advocated to improve the relevance of research to knowledge users. This short report describes the integrated knowledge translation efforts of Connections, a knowledge translation and exchange project to improve services for women with substance abuse problems and their children, and implementation barriers and facilitators.

Findings

Strategies of varying intensities were used to engage diverse stakeholders, including policy makers and people with lived experience, and executive directors, program managers, and service providers from Canadian addiction agencies serving women. Barriers to participation included individual (e.g., interest), organizational (e.g., funding), and system level (e.g., lack of centralized stakeholder database) barriers. Similarly, facilitators included individual (e.g., perceived relevance) and organizational (e.g., support) facilitators, as well as initiative characteristics (e.g., multiple involvement opportunities). Despite barriers, Connections’ stakeholder-informed research efforts proved essential for developing clinically relevant and feasible processes, measures, and implementation strategies.

Conclusions

Stakeholder-researcher collaboration is possible and robust integrated knowledge translation efforts can be productive. Future work should emphasize developing and evaluating a range of strategies to address stakeholders’ knowledge translation needs and to facilitate sustained and meaningful involvement in research.

Using a knowledge transfer framework to identify factors facilitating implementation of family-based treatment

OBJECTIVE

To conduct a qualitative study to identify factors that would facilitate the transfer of the research evidence on Family-Based Treatment (FBT) into clinical practice.

METHOD

Fundamental qualitative description guided sampling, data collection, and analytic decisions for this study. Forty therapists who treat children and adolescents under the age of 18 with Anorexia Nervosa (AN) and belong to Ontario's provincial network of specialized eating disorder services completed an in-depth interview focusing on elements proposed by the Lavis knowledge transfer framework. An experienced coder conducted content analysis, with 20% of the interviews double-coded for reliability purposes.

RESULTS

Participants requested training in the FBT model, including the provision of research evidence (i.e., journal articles), as well as the specific tenets of the model according to the FBT manual. The suggested audience for implementation included not only therapists themselves, but administrators, physicians, and community members. The development of best practice guidelines was also supported. Local FBT experts were suggested as credible messengers. Infrastructure relating to financial support and time away from clinical duties were reported to be essential for training. Ongoing supervision and mentorship were reported to be important elements of implementation and evaluation processes.

DISCUSSION

Suggestions for moving FBT into practice were consistent with previous research, however, the importance of obtaining the evidence in the form of primary research articles and obtaining team buy-in were remarkable. Developing context-specific training programs and administrative processes for the implementation of FBT are warranted.

Decision-making processes for the uptake and implementation of family-based therapy by eating disorder treatment teams: a qualitative study

OBJECTIVE

To explore the decision-making processes involved in the uptake and implementation of evidence-based treatments (EBTs), namely, family-based treatment (FBT), among therapists and their administrators within publically funded eating disorder treatment programs in Ontario, Canada.

METHOD

Fundamental qualitative description guided sampling, data collection, and analytic decisions. Forty therapists and 11 administrators belonging to a network of clinicians treating eating disorders completed an in-depth interview regarding the decision-making processes involved in EBT uptake and implementation within their organizations. Content analysis and the constant comparative technique were used to analyze interview transcripts, with 20% of the data independently double-coded by a second coder.

RESULTS

Therapists and their administrators identified the importance of an inclusive change culture in evidence-based practice (EBP) decision-making. Each group indicated reluctance to make EBP decisions in isolation from the other. Additionally, participants identified seven stages of decision-making involved in EBT adoption, beginning with exposure to the EBT model and ending with evaluating the impact of the EBT on patient outcomes. Support for a stage-based decision-making process was in participants' indication that the stages were needed to demonstrate that they considered the costs and benefits of making a practice change. Participants indicated that EBTs endorsed by the Provincial Network for Eating Disorders or the Academy for Eating Disorders would more likely be adopted.

DISCUSSION

Future work should focus on integrating the important decision-making processes identified in this study with known implementation models to increase the use of low-cost and effective treatments, such as FBT, within eating disorder treatment programs.

Maternal pre-pregnancy body mass index and offspring temperament and behavior at 1 and 2 years of age

Recent research suggests that fetal exposure to increased maternal body mass index (BMI) during pregnancy may be associated with psychopathology later in life. When this link first emerges, and if it is due to intrauterine exposures or confounding variables is not known. We therefore assessed associations between maternal pre-pregnancy BMI and: (1) temperament at 1 year of age, and (2) Child Behavior Checklist internalizing and externalizing scales at age 2 in the 2900 mothers and infants enrolled in the Western Australian Pregnancy Study. Pre-pregnancy BMI was positively associated with externalizing scores (β = 0.131, 95 % CI 0.013-0.249) at age 2, even after adjustment for confounders, but not with internalizing scores or an increased risk of difficult temperament. These data suggest that fetal exposure to increased maternal BMI is associated with elevated levels of behavior problems as early as age 2, and that this may be linked to the intrauterine environment.

Understanding the uptake of family-based treatment for adolescents with anorexia nervosa: therapist perspectives

OBJECTIVE

To explore and describe therapists' perceptions of the factors affecting their uptake of family-based treatment (FBT) for adolescents with anorexia nervosa (AN).

METHOD

Fundamental qualitative description guided the sampling and data collection in this study. A purposeful sample of 40 therapists providing treatment to youth with AN, completed an in-depth interview. Conventional content analysis guided the development of initial codes and categories, whereas constant comparison analytic techniques were used to compare and contrast therapist perceptions across contexts. Summative content analysis was used to provide counts of keywords, phrases, and themes.

RESULTS

Therapists face several barriers to the implementation of FBT, divided broadly into interventional, organizational, interpersonal, patient/family, systemic, and illness factors. Therapists support the implementation of evidence-based practices, including FBT for AN, but fidelity to this model is not practiced. Specific concerns about the intervention included weighing the patient, providing nutritional advice, and the family meal. Ninety-five percent of therapists requested further training in the FBT model.

DISCUSSION

Further investigation into the barriers and facilitating factors to the use of FBT is warranted. Understanding effective dissemination and training strategies is critical to ensuring patients receive the best possible care.

Partnerships Among Canadian Agencies Serving Women with Substance Abuse Issues and Their Children

Women with substance use issues and their children have unique needs that are best met through collaborative and coordinated service delivery offered by a variety of agencies. However, in Canada and elsewhere, services tend to be fragmented and fail to address children's needs. This study aimed to describe the partnership patterns, activities, and qualities among Canadian agencies serving women with addictions and to determine predictors of partnerships. We found that a number of partnerships exist, and that the extent and characteristics of these partnerships vary. Agency responsiveness to clients was predictive of sending referrals whereas friendliness predicted joint programming and consultation. Four central agencies played key linkage roles. Efforts should be made to build on the social capital inherent in these agencies to strengthen existing networks, further develop linkages to improve service delivery, and promote evidence-informed practice in a field where there is an identified research-practice gap.

Reporting of feasibility factors in publications on integrated treatment programs for women with substance abuse issues and their children: a systematic review and analysis

Background

Implementation of evidence-based practices in real-world settings is a complex process impacted by many factors, including intervention, dissemination, service provider, and organizational characteristics. Efforts to improve knowledge translation have resulted in greater attention to these factors. Researcher attention to the applicability of findings to applied settings also has increased. Much less attention, however, has been paid to intervention feasibility, an issue important to applied settings.

Methods

In a systematic review of 121documents regarding integrated treatment programs for women with substance abuse issues and their children, we examined the presence of feasibility-related information. Specifically, we analysed study descriptions for information regarding feasibility factors in six domains (intervention, practitioner, client, service delivery, organizational, and service system).

Results

On average, fewer than half of the 25 feasibility details assessed were included in the documents. Most documents included some information describing the participating clients, the services offered as part of the intervention, the location of services, and the expected length of stay or number of sessions. Only approximately half of the documents included specific information about the treatment model. Few documents indicated whether the intervention was manualized or whether the intervention was preceded by a standardized screening or assessment process. Very few provided information about the core intervention features versus the features open to local adaptation, or the staff experience or training required to deliver the intervention.

Conclusions

As has been found in reviews of intervention studies in other fields, our findings revealed that most documents provide some client and intervention information, but few documents provided sufficient information to fully evaluate feasibility. We consider possible explanations for the paucity of feasibility information and provide suggestions for better reporting to promote diffusion of evidence-based practices.

Preferences for evidence-based practice dissemination in addiction agencies serving women: a discrete-choice conjoint experiment

AIM

  To model variables influencing the dissemination of evidence-based practices to addiction service providers and administrators.

DESIGN

  A discrete-choice conjoint experiment. We systematically varied combinations of 16 dissemination variables that might influence the adoption of evidence-based practices. Participants chose between sets of variables.

SETTING

  Canadian agencies (n = 333) providing addiction services to women.

PARTICIPANTS

  Service providers and administrators (n = 1379).

MEASUREMENTS

  We estimated the relative importance and optimal level of each dissemination variable. We used latent class analysis to identify subsets of participants with different preferences and simulated the conditions under which participants would use more demanding professional development options.

FINDINGS

  Three subsets of participants were identified: outcome-sensitive (52%), process-sensitive (29.6%) and demand-sensitive (18.2%). Across all participants, the number of clients who were expected to benefit from an evidence-based practice exerted the most influence on dissemination choices. If a practice was seen as feasible, co-worker and administrative support influenced decisions. Client benefits were most important to outcome-sensitive participants; type of dissemination process (e.g. active versus passive learning) was more important to process-sensitive participants. Brief options with little follow-up were preferred by demand-sensitive participants. Simulations predicted that initiatives selected and endorsed by government funders would reduce participation.

CONCLUSIONS

  Clinicians and administrators are more likely to adopt evidence-based addiction practices if the practice is seen as helpful to clients, and if it is supported by co-workers and program administration.

Integrated programs for mothers with substance abuse issues and their children: a systematic review of studies reporting on child outcomes

BACKGROUND

Integrated treatment programs (those that include on-site pregnancy-, parenting-, or child-related services with addiction services) were developed to break the intergenerational cycle of addiction, potential child maltreatment, and poor outcomes for children.

OBJECTIVES

To examine the impact and effects of integrated programs for women with substance abuse issues and their children, we performed a systematic review of studies published from 1990 to 2011.

METHODS

Literature search strategies included online bibliographic database searches, checking printed sources, and requests to researchers. Studies were included if all participants were mothers with substance abuse problems at baseline; the treatment program included at least 1 specific substance use treatment and at least 1 parenting or child treatment service; the study design was randomized, quasi-experimental, or cohort; and there were quantitative data on child outcomes. We summarized data on child development, growth, and emotional and behavioral outcomes.

RESULTS

Thirteen studies (2 randomized trials, 3 quasi-experimental studies, 8 cohort studies; N=775 children) were included in the review. Most studies using pre-post design indicated improvements in child development (with small to large effects, ds=0.007-1.132) and emotional and behavioral functioning (with most available effect sizes being large, ds=0.652-1.132). Comparison group studies revealed higher scores for infants of women in integrated programs than those not in treatment, with regard to development and most growth parameters (length, weight, and head circumference; with all available effect sizes being large, ds=1.16-2.48). In studies comparing integrated to non-integrated programs, most improvements in emotional and behavioral functioning favored integrated programs and, where available, most effect sizes indicated that this advantage was small (ds=0.22-0.45).

CONCLUSIONS

Available evidence supports integrated programs, as findings suggest that they are associated with improvements in child development, growth, and emotional and behavioral functioning. More research is required comparing integrated to non-integrated programs. This review highlights the need for improved methodology, study quality, and reporting to improve our understanding of how best to meet the needs of children of women with substance abuse issues.

Integrated programs for mothers with substance abuse issues: A systematic review of studies reporting on parenting outcomes

Background

Integrated treatment programs (those that include on-site pregnancy-, parenting-, or child-related services with addiction services) were developed to break the intergenerational cycle of addiction, dysfunctional parenting, and poor outcomes for mothers and children, yet there has been no systematic review of studies of parenting outcomes.

Objectives

As part of larger systematic review to examine the effectiveness of integrated programs for mothers with substance abuse issues, we performed a systematic review of studies published from 1990 to 2011 with data on parenting outcomes.

Methods

Literature search strategies included online bibliographic database searches, checking printed sources, and requests to researchers. Studies were included if all participants were mothers with substance abuse problems at baseline, the treatment program included at least one specific substance use treatment and at least one parenting or child service, and there were quantitative data on parenting outcomes. We summarized data on parenting skills and capacity outcomes.

Results

There were 24 cohort studies, 3 quasi-experimental studies, and 4 randomized trials. In the three randomized trials comparing integrated programs to addiction treatment-as-usual (N = 419), most improvements in parenting skills favored integrated programs and most effect sizes indicated that this advantage was small, ds = -0.02 to 0.94. Results for child protection services involvement did not differ by group. In the three studies that examined factors associated with treatment effects, parenting improvements were associated with attachment-based parenting interventions, children residing in the treatment facility, and improvements in maternal mental health.

Conclusions

This is the first systematic review of studies evaluating the effectiveness of integrated programs on parenting. The limited available evidence supports integrated programs, as findings suggest that they are associated with improvements in parenting skills. However, more research is required comparing integrated programs to addiction treatment-as-usual. This review highlights the need for improved methodology, study quality, and reporting to improve our understanding of how best to meet the parenting needs of women with substance abuse issues.

Evidence-informed decision-making by professionals working in addiction agencies serving women: a descriptive qualitative study

BACKGROUND

Effective approaches to the prevention and treatment of substance abuse among mothers have been developed but not widely implemented. Implementation studies suggest that the adoption of evidence-based practices in the field of addictions remains low. There is a need, therefore, to better understand decision making processes in addiction agencies in order to develop more effective approaches to promote the translation of knowledge gained from addictions research into clinical practice.

METHODS

A descriptive qualitative study was conducted to explore: 1) the types and sources of evidence used to inform practice-related decisions within Canadian addiction agencies serving women; 2) how decision makers at different levels report using research evidence; and 3) factors that influence evidence-informed decision making. A purposeful sample of 26 decision-makers providing addiction treatment services to women completed in-depth qualitative interviews. Interview data were coded and analyzed using directed and summative content analysis strategies as well as constant comparison techniques.

RESULTS

Across all groups, individuals reported locating and using multiple types of evidence to inform decisions. Some decision-makers rely on their experiential knowledge of addiction and recovery in decision-making. Research evidence is often used directly in decision-making at program management and senior administrative levels. Information for decision-making is accessed from a range of sources, including web-based resources and experts in the field. Individual and organizational facilitators and barriers to using research evidence in decision making were identified.

CONCLUSIONS

There is support at administrative levels for integrating EIDM in addiction agencies. Knowledge transfer and exchange strategies should be focussed towards program managers and administrators and include capacity building for locating, appraising and using research evidence, knowledge brokering, and for partnering with universities. Resources are required to maintain web-based databases of searchable evidence to facilitate access to research evidence. A need exists to address the perception that there is a paucity of research evidence available to inform program decisions. Finally, there is a need to consider how experiential knowledge influences decision-making and what guidance research evidence has to offer regarding the implementation of different treatment approaches within the field of addictions.

Maternal substance use and integrated treatment programs for women with substance abuse issues and their children: a meta-analysis

BACKGROUND

The rate of women with substance abuse issues is increasing. Women present with a unique constellation of risk factors and presenting needs, which may include specific needs in their role as mothers. Numerous integrated programs (those with substance use treatment and pregnancy, parenting, or child services) have been developed to specifically meet the needs of pregnant and parenting women with substance abuse issues. This synthesis and meta-analysis reviews research in this important and growing area of treatment.

METHODS

We searched PsycINFO, MedLine, PubMed, Web of Science, EMBASE, Proquest Dissertations, Sociological Abstracts, and CINAHL and compiled a database of 21 studies (2 randomized trials, 9 quasi-experimental studies, 10 cohort studies) of integrated programs published between 1990 and 2007 with outcome data on maternal substance use. Data were summarized and where possible, meta-analyses were performed, using standardized mean differences (d) effect size estimates.

RESULTS

In the two studies comparing integrated programs to no treatment, effect sizes for urine toxicology and percent using substances significantly favored integrated programs and ranged from 0.18 to 1.41. Studies examining changes in maternal substance use from beginning to end of treatment were statistically significant and medium sized. More specifically, in the five studies measuring severity of drug and alcohol use, the average effect sizes were 0.64 and 0.40, respectively. In the four cohort studies of days of use, the average effect size was 0.52. Of studies comparing integrated to non-integrated programs, four studies assessed urine toxicology and two assessed self-reported abstinence. Overall effect sizes for each measure were not statistically significant (d = -0.09 and 0.22, respectively).

CONCLUSIONS

Findings suggest that integrated programs are effective in reducing maternal substance use. However, integrated programs were not significantly more effective than non-integrated programs. Policy implications are discussed with specific attention to the need for funding of high quality randomized control trials and improved reporting practices.

Immediate and short-term outcomes of the 'COPEing with Toddler Behaviour' parent group

BACKGROUND

Controlling, uninvolved, and rejecting parenting in early childhood are strong predictors of later disruptive behavior disorders. However, there have been no evaluations of non-targeted groups for parents of very young children, despite their potential advantages.

METHODS

We randomly assigned 79 mothers of 12- to 36-month-olds to an 8-session parent training program (called 'COPEing with Toddler Behaviour') or to a waiting list control condition. We investigated the immediate and short-term impact on parent-reported child behavior problems, observed parent-child interaction, and self-reported parenting behavior and parent functioning.

RESULTS

In an intent-to-treat design, the program yielded significant effects on child behavior problems, positive parent-child interaction, and parental overreactivity and depression but not observed negative child behavior or parental laxness. Most effects were significant at both post-test and 1-month follow-up and effects sizes were small to medium for the intervention group and inverse to small for the control group.

CONCLUSIONS

The potential of the program to prevent later behavior problems is supported by improvements in six of the eight outcomes. As part of a community strategy, groups such as COPEing with Toddler Behaviour may promote positive parent-child interaction and children's mental health.

'Right from the Start': randomized trial comparing an attachment group intervention to supportive home visiting

BACKGROUND

Infant attachment security is a protective factor for future mental health, and may be promoted by individual interventions. Given service demands, it is important to determine if a group-based intervention for parents could be used to enhance infant attachment security.

METHODS

In a randomized trial involving 76 mothers, an 8-session attachment group called 'Right from the Start' (RFTS) was compared to home visiting (treatment as usual).

RESULTS

Intention-to-treat analyses indicated no significant differences between RFTS and home visiting, with both groups showing small improvements in infant attachment security and maternal sensitivity. RFTS cost significantly less and was more cost effective than home visiting, and was not significantly different in terms of participation ratings, client satisfaction, or follow-up service requests. There was differential compliance for the two interventions, with 89% and 58% attending 4 or more sessions of home visiting and RFTS, respectively. Secondary analyses considering non-attenders as a separate (nonrandomized) group indicated a significant advantage for those who attended RFTS on pre-test/post-test maternal sensitivity change scores (d = .52) and pre-test/6-month follow-up infant attachment security changes scores (d = .55).

CONCLUSIONS

RFTS is as effective as home visiting in improving infant attachment security and maternal sensitivity. The effect sizes for RFTS were comparable to those of individual attachment interventions in this relatively inexpensive, community-based group intervention.

The early years: child development in undergraduate medical school training

PROBLEM ADDRESSED

There are substantial gaps in knowledge about early child development among graduating family physicians.

OBJECTIVE OF PROGRAM

The main objective of this program was to develop, implement, and evaluate an early child development curriculum for undergraduate medical clerks doing their family medicine rotations.

PROGRAM DESCRIPTION

The Early Years Program at McMaster University in Hamilton, Ont, consists of 2 small group sessions during the family medicine rotation and a site visit to a community agency that provides services to families with young children. The curriculum is delivered by interprofessional facilitator dyads: a family physician and another professional. The content covers areas such as newborn assessment, developmental screening and referrals, parenting issues, pregnancy, preconception, and prevention, and is supported by case studies, videos, and community resources.

CONCLUSION

Based on casual feedback and formal evaluations, we conclude that the overall goal of launching the Early Years Program-to address previously identified gaps-has been achieved. We continue to improve the program to meet the challenges of the ever changing undergraduate health science education.

Frontal electroencephalogram asymmetry during affective processing in children with Down syndrome: a pilot study

BACKGROUND

Although the pattern of frontal electroencephalogram (EEG) asymmetry during the processing of emotion has been examined in many studies of healthy adults and typically developing infants and children, no published work has used these theoretical and methodological approaches to study emotion processing in children with Down syndrome. The purpose of this pilot study was to examine the feasibility of using brain-based measures of emotion (i.e. regional EEG asymmetry measures) with children with Down syndrome, and whether children with Down syndrome exhibit patterns of frontal brain activity during the processing of affective stimuli that are not different from typically developing children, but of lesser magnitude.

METHODS

Regional brain electrical activity (EEG) was measured in response to the presentation of popular children's video clips that varied in affective content in three children with Down syndrome and three typically developing children who were matched on reading level.

RESULTS

The children with Down syndrome appeared to show a similar pattern of frontal EEG asymmetry as the typically developing children for the video clips depicting happiness, sadness and fear. However, the magnitude of the frontal asymmetry scores for the children with Down syndrome was large across the affective stimuli, and they appeared to process the video clip depicting anger differently from the typically developing children.

CONCLUSION

This preliminary evidence suggests that brain-based measures of affective processing can be used to study the differentiation of emotion on an electrocortical level among children with Down syndrome.

Fetal alcohol syndrome and the developing socio-emotional brain

Fetal alcohol syndrome (FAS) is currently recognized as the most common known cause of mental retardation, affecting from 1 to 7 per 1000 live-born infants. Individuals with FAS suffer from changes in brain structure, cognitive impairments, and behavior problems. Researchers investigating neuropsychological functioning have identified deficits in learning, memory, executive functioning, hyperactivity, impulsivity, and poor communication and social skills in individuals with FAS and fetal alcohol effects (FAE). Investigators using autopsy and brain imaging methods have identified microcephaly and structural abnormalities in various regions of the brain (including the basal ganglia, corpus callosum, cerebellum, and hippocampus) that may account for the neuropsychological deficits. Results of studies using newer brain imaging and analytic techniques have indicated specific alterations (i.e., displacements in the corpus callosum, increased gray matter density in the perisylvian regions, altered gray matter asymmetry, and disproportionate reductions in the frontal lobes) in the brains of individuals prenatally exposed to alcohol, and their relations with brain function. Future research, including using animal models, could help inform our knowledge of brain-behavior relations in the context of prenatal alcohol exposure, and assist with early identification and intervention.

"New Choices" for women with addictions: perceptions of program participants

Background

Substance use in pregnancy is a major public health problem. It can have profound effects on pregnancy outcomes, and childhood health and development. Additionally, women who use substances have their own health-related issues. Although intervention is important, these women often have difficulty using traditional systems of care. The New Choices program is a centralized, multi-sector approach to service delivery that has attempted to overcome barriers to care by offering one-stop shopping in a supportive environment. As part of an evaluation of this program designed for women who are pregnant and/or parenting young children, interviews were conducted with participants to gain insight into their experiences in New Choices and perceptions of any changes attributed to program involvement.

Methods

A qualitative, exploratory design was used to guide data collection and analysis. Four women participated in a focus group interview and seven women agreed to individual interviews over the course of the program evaluation (N = 11). A semi-structured interview guide was used to explore women's experiences in New Choices and their perceptions of the program and its impact. The interview data were analyzed using NVivo software and an inductive approach to data analysis.

Results

The emergent themes captured women's motivations for attending New Choices, benefits of participation, and overall quality of the program. Children were the primary motivating factor for program enrollment. Perceived benefits included decreased substance use, improved maternal health, enhanced opportunity for employment, increased access to other resources, enhanced parenting skills, and improved child behaviour and development. Women highly valued the comprehensive and centralized approach to service delivery that provided a range of informal and formal supports.

Conclusions

Interview findings endorse the appropriateness and potential efficacy of a collaborative, centralized approach to service provision for women with substance use issues. Although the findings provide insight into an alternative model of service delivery for women with addictions, future research is needed to evaluate the effectiveness of the intervention. Research also is needed to determine which program components or constellation of components contribute to desired outcomes, and to learn more about processes that underlie changes in behaviour.

Mastery motivation in young children with Down's syndrome: relations with cognitive and adaptive competence

BACKGROUND

Prior research on relations between motivation and competence have focused on cognitive competence, despite theoretical predictions that mastery motivation spurs behaviour that is effective in meeting the demands of one's environment, i.e. adaptive competence. Issues of adaptive competence are especially relevant for children with developmental delay since functional independence is an important long-term goal for these children.

METHODS

In the present study, mastery motivation was examined in relation to both cognitive and adaptive competence in 5-year-old children with Down's syndrome (n = 41).

RESULTS

Scores on mastery task and parent-report measures of mastery motivation were generally low, but positively related to scores on standardized measures of cognitive competence and adaptive competence.

CONCLUSIONS

This is the first study of motivation-competence relations in pre-school-age children. The findings have implications for both developmental theory and early intervention efforts, and the authors hope that they will serve as a stimulus for future research on cross-domain relationships in atypical populations.

Attachment security: a meta-analysis of maternal mental health correlates

This meta-analysis addresses the association between attachment security and each of three maternal mental health correlates. The meta-analysis is based on 35 studies, 39 samples, and 2,064 mother-child pairs. Social-marital support (r = .14; based on 16 studies involving 17 samples and 902 dyads), stress (r = .19; 13 studies, 14 samples, and 768 dyads), and depression (r = .18; 15 studies, 19 samples, and 953 dyads) each proved significantly related to attachment security. All constructs showed substantial variance in effect size. Ecological factors and approach to measuring support may explain the heterogeneity of effect sizes within the social-marital support literature. Effect sizes for stress varied according to the time between assessment of stress and assessment of attachment security. Among studies of depression, clinical samples yielded significantly larger effect sizes than community samples. We discuss these results in terms of measurement issues (specifically, overreliance on self-report inventories) and in terms of the need to study the correlates of change in attachment security, rather than just the correlates of attachment security per se.