Diagnostic Accuracy and economic value of a Tiered Assessment for Fetal Alcohol Spectrum Disorder (DATAforFASD): Protocol

INTRODUCTION

Australian practices for diagnosing fetal alcohol spectrum disorder (FASD) are lengthy and require specialist expertise. Specialist teams are based in urban locations; they are expensive and have prolonged waitlists. Innovative, flexible solutions are needed to ensure First Nations children living in rural/remote communities have culturally appropriate and equitable access to timely diagnosis and support. This study compares the accuracy of rapid assessments (index tests) that can be administered by a range of primary healthcare practitioners to specialist standardised FASD assessments (reference tests). The cost-efficiency of index tests will be compared with reference tests.

METHODS AND ANALYSIS

At least 200 children aged 6-16 years at-risk of FASD will be recruited across at least seven study sites. Following standards for reporting diagnostic accuracy study (STARD) guidelines, all children will complete index and reference tests. Diagnostic accuracy statistics (including receiver operating curves, sensitivity, specificity, positive and negative predictive values and likelihood ratios) will identify whether rapid assessments can accurately identify: (1) the presence of an FASD diagnosis and (2) impairment in each neurodevelopmental domain, compared to comprehensive assessments. Direct and indirect healthcare costs for index tests compared to reference tests will be collected in primary healthcare and specialist settings.

ETHICS AND DISSEMINATION OF RESULTS

Children's Health Queensland Hospital and Health Service Human Research Ethics Committee (HREC/20/QCHQ/63173); Griffith University Human Research Ethics Committee (2020/743). Results will assist in validating the use of index tests as part of a tiered neurodevelopmental assessment process that was co-designed with First Nations community and primary healthcare practitioners. Outcomes will be summarised and provided to participating practitioners and sites, and disseminated to community health services and consumers. Findings will be presented at national and international conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12622000498796.

Lived experiences of the diagnostic assessment process for fetal alcohol spectrum disorder: A systematic review of qualitative evidence

Early assessment and diagnosis of FASD are crucial in providing therapeutic interventions that aim to enhance meaningful participation and quality of life for individuals and their families, while reducing psychosocial difficulties that may arise during adolescence and adulthood. Individuals with lived experience of FASD have expertise based on their own lives and family needs. Their insights into the assessment and diagnostic process are valuable for improving service delivery and informing the provision of meaningful, person- and family-centered care. To date, reviews have focused broadly on the experiences of living with FASD. The aim of this systematic review is to synthesize qualitative evidence on the lived experiences of the diagnostic assessment process for FASD. Six electronic databases, including PubMed, the Cochrane Library, CINAH, EMBASE, PsycINFO, and Web of Science Core Collection were searched from inception until February 2021, and updated in December 2022. A manual search of reference lists of included studies identified additional studies for inclusion. The quality of included studies was assessed using the Critical Appraisal Skills Program Checklist for Qualitative Studies. Data from included studies were synthesized using a thematic analysis approach. GRADE-CERQual was used to assess confidence in the review findings. Ten studies met the selection criteria for inclusion in the review. Thematic analysis identified 10 first-level themes relating to four over-arching topics: (1) pre-assessment concerns and challenges, (2) the diagnostic assessment process, (3) receipt of the diagnosis, and (4) post-assessment adaptations and needs. GRADE-CERQual confidence ratings for each of the review themes were moderate to high. The findings from this review have implications for referral pathways, client-centered assessment processes, and post-diagnostic recommendations and support.

Child Sexual Abuse Prevention: Parental Discussion, Protective Practices and Attitudes

Understanding parental practices and attitudes regarding child sexual abuse (CSA) prevention could be used to improve CSA prevention, but little information is available. In this study, we summarise survey data collected from 248 Australian and UK parents (87% female) with at least one child aged 6-11 years (M = 8.6, SD = 1.8). This is the first study to quantify parental use of protective practices, other than prevention education, which may guard against CSA. Parental media mediation, which may safeguard against online dangers, was another unique focus of this study. Participants reported their discussion of sensitive topics with their children including CSA; behaviors that may reduce the incidence of CSA (e.g., monitoring, supervision, delegation of care and checking-in with the child); mediation of their child's media use; and attitudes towards CSA prevention education. Parents reported discussing sexual abuse less than other sensitive topics such as abduction dangers, drugs, and death but more than issues surrounding puberty, sex and pornography. Parents reported using high levels of protective behaviours, however some areas of concern were revealed. Of concern was the low-moderate level of parental media mediation, with substantial numbers of children potentially exposed to online risks such as using devices unsupervised in bedrooms or chatting to individuals unknown to their parents and not having their devices checked for concerning content. Almost all parents were supportive of CSA prevention education and felt they should provide this education. However, two-thirds of parents thought CSA education may be associated with harms for the child and two-thirds of parents believed children could prevent their own abuse. Reported results will aid in our understanding of which areas of parenting could be strengthened to create safer environments for children. This research has particularly highlighted the need for parents to be more protective around their children's access to online devices.

International Survey of Specialist Fetal Alcohol Spectrum Disorder Diagnostic Clinics: Comparison of Diagnostic Approach and Considerations Regarding the Potential for Unification

Fetal alcohol spectrum disorder (FASD) is a prevalent neurodevelopmental condition. Despite FASD being recognized as a clinical disorder there is no globally agreed set of diagnostic criteria. Accurate and timely diagnosis of FASD is imperative to inform clinical care, optimize outcomes for individuals accessing assessments and their families, as well as for research and prevention strategies. To inform movement towards a unified approach, the present study aimed to capture an international perspective on current FASD diagnostic criteria, as well as potential barriers and facilitators to unification. An online survey was created using REDCap and sent to clinics identified and contacted via internet searches. Quantitative data were presented using descriptive statistics and open-ended questions analysed using content analysis. The survey captured information about each clinic's current diagnostic approach, whether they would support a unified method, and the barriers and facilitators for a consistent international FASD diagnostic approach. Fifty-five (37.4%) of 147 FASD clinics identified worldwide participated. The majority (n = 50, 90.9%) of respondents supported a unified approach. Content analysis identified a lack of collaboration as a key barrier, while strong leadership in guideline creation and implementation emerged as a central facilitator. These barriers and facilitators can be used to guide future collaborative efforts towards implementing consistent diagnostic criteria.

Preventing Drift through Continued Co-Design with a First Nations Community: Refining the Prototype of a Tiered FASD Assessment

As part of the broader Yapatjarrathati project, 47 remote health providers and community members attended a two-day workshop presenting a prototype of a culturally-safe, tiered neurodevelopmental assessment that can identify fetal alcohol spectrum disorder (FASD) in primary healthcare. The workshop provided a forum for broad community feedback on the tiered assessment process, which was initially co-designed with a smaller number of key First Nations community stakeholders. Improvement in self-reported attendee knowledge, confidence, and perceived competence in the neurodevelopmental assessment process was found post-workshop, assessed through self-report questionnaires. Narrative analysis described attendee experiences and learnings (extracted from the workshop transcript), and workshop facilitator experiences and learnings (extracted from self-reflections). Narrative analysis of the workshop transcript highlighted a collective sense of compassion for those who use alcohol to cope with intergenerational trauma, but exhaustion at the cyclical nature of FASD. There was a strong desire for a shared responsibility for First Nations children and families and a more prominent role for Aboriginal Health Workers in the assessment process. Narrative analysis from workshop facilitator reflections highlighted learnings about community expertise, the inadvertent application of dominant cultural approaches throughout facilitation, and that greater emphasis on the First Nation's worldview and connection to the community was important for the assessment process to be maintained long-term. This study emphasised the benefit of continued co-design to ensure health implementation strategies match the needs of the community.

Can't Stop, Won't Stop? The Role of Inhibitory Control and Callous-Unemotional Traits in Childhood Conduct Problems and Aggression

Disruptive behaviors such as conduct problems and aggression are some of the most prevalent childhood psychological concerns. The etiology of disruptive behaviors is heterogenous and the relationships between the myriad risk factors that contribute to these problems are not yet fully understood. This study examined the relationship between inhibitory control and callous-unemotional traits (CU traits) with conduct problems and aggression in a community sample of children (aged 6 to 11 years). Caregivers (n= 148) completed a survey assessing a range of known risk factors (including hyperactivity and inattention). Children were found to display more conduct problems and aggression if they had greater difficulties with inhibitory control and a higher number of CU traits. Interestingly, when children had CU traits, inhibitory control difficulties exacerbated the severity of conduct problems (but not aggression). Differences in severity between conduct problems and aggression highlight the unique relationships between risk factors such as inhibitory control and CU traits, and lay the groundwork for future studies to explore the trajectories of this relationship.

Integrating cultural considerations and developmental screening into an Australian First Nations child health check

The aim of the present study was to integrate cultural considerations and developmental screening into a First Nations child health check. The 'Share and Care Check,' an optimised child health check, was co-designed with a remote Aboriginal Community Controlled Health Organisation and led by Aboriginal Health Practitioners/Workers. Of 55 families who completed the Share and Care Check, the majority of participants indicated that their family/child was connected with their tribe and country. However, half of the caregivers reported that they or their child would like to know more about their tribe. The most common developmental screening outcome was no functional concerns (32.7%), followed by having one area identified as a functional concern (24.5%) and two functional concerns (16.3%). All caregivers reported that the Share and Care Check was culturally appropriate, and the majority also reported that it was helpful. Data obtained from questions regarding cultural and developmental aspects of health can assist health providers regarding the best pathway of support for a child and their family. This could ultimately contribute to closing the gap through the provision of holistic culturally appropriate services.

Inhibitory Control Deficits in Children with Oppositional Defiant Disorder and Conduct Disorder Compared to Attention Deficit/Hyperactivity Disorder: A Systematic Review and Meta-analysis

Inhibitory control deficits are known to be characteristic of Oppositional Defiant Disorder (ODD), Conduct Disorder (CD), and Attention-Deficit/Hyperactivity Disorder (ADHD); but it is unclear whether children with ODD/CD have inhibitory control problems independent of ADHD comorbidity. Previous reviews of inhibitory control and ODD/CD have only focused on one type of measure of inhibitory control or used non-clinical samples. The current meta-analysis explored inhibitory control problems of children with ODD/CD by systematically reviewing studies where children have a diagnosis of ODD and/or CD. Comparisons were made across 25 studies between children with ODD/CD, ODD/CD + ADHD, ADHD, and healthy controls (HC) on various measures of inhibitory control and ADHD symptomatology to explore impacts of ADHD comorbidity. A small significant effect (g = -0.58, p < .001) suggested children with ODD/CD are likely to have more difficulties with inhibitory control than healthy children. However, comparisons between clinical groups suggested this effect may be due to ADHD symptomatology present in each group. As difficulties with inhibitory control are similar, across clinical groups, a dimensional approach to understanding ODD/CD and ADHD may be more useful to consider in future diagnostic criteria. Similarities across clinical groups highlight that therapeutic approaches that assist children with disruptive behaviours could benefit from teaching children and their families how to cope with inhibitory control deficits.

Protocol for the Yapatjarrathati project: a mixed-method implementation trial of a tiered assessment process for identifying fetal alcohol spectrum disorders in a remote Australian community

Background

Fetal alcohol spectrum disorder (FASD) is a highly prevalent neurodevelopmental disorder associated with prenatal alcohol exposure. Early identification can improve functioning for individuals and reduce costs to society. Gold standard methods of diagnosing FASD rely on specialists to deliver intensive, multidisciplinary assessments. While comprehensive, prevalence rates highlight that this assessment model cannot meet demand, nor is it feasible in remote areas where specialist services are lacking. This project aims to expand the capabilities of remote practitioners in north Queensland, Australia, where 23–94% of the community identify as First Nations people. Integrating cultural protocols with the implementation science theories of Knowledge-To-Action, Experience-Based Co-Design, and RE-AIM, remote practitioners with varying levels of experience will be trained in a co-designed, culturally appropriate, tiered neurodevelopmental assessment process that considers FASD as a potential outcome. This innovative assessment process can be shared between primary and tertiary health care settings, improving access to services for children and families. This project aims to demonstrate that neurodevelopmental assessments can be integrated seamlessly with established community practices and sustained through evidence-based workforce development strategies.

Methods

The Yapatjarrathati project (named by the local First Nations community and meaning ‘to get well’) is a mixed-method implementation trial of a tiered assessment process for identifying FASD within a remote Australian community. In collaboration with the community, we co-designed: (a) a culturally sensitive, tiered, neurodevelopmental assessment process for identifying FASD, and (b) training materials that up-skill remote practitioners with varying levels of expertise. Qualitative interviews for primary, secondary and end users will be undertaken to evaluate the implementation strategies. RE-AIM will be used to evaluate the reach, effectiveness, adoption, implementation and maintenance of the assessment and training process.

Discussion

Co-designed with the local community, integrated with cultural protocols, and based on implementation science theories, the assessment and training process from this project will have the potential to be scaled-up across other remote locations and trialed in urban settings. The Yapatjarrathati project is an important step towards increasing the availability of neurodevelopmental services across Australia and empowering remote practitioners to contribute to the FASD assessment process.

Does feedback improve psychotherapy outcomes compared to treatment-as-usual for adults and youth?

Objective: Client-informed outcome feedback has consistently been shown to enhance psychotherapy outcomes for adults, particularly for clients at risk of treatment failure. However, there is a paucity of studies examining feedback in youth psychotherapy. Specifically, there is no research examining the feedback effect of the Youth-Outcome Questionnaire [Burlingame, G. M., Wells, M. G., & Lambert, M. J. (1996). The youth outcome questionnaire. Stevenson, MD: American Professional Credentialing Services.], despite the dominance of the adult version of the measure (Outcome Questionnaire-45 [Lambert, M. J., & Burlingame, G. M. (1996). Outcome questionnaire 45.2. Wilmington, DE: American Professional Credentialing Services.]) in adult feedback studies. Method: The effectiveness results for adult (N = 398) and youth clients (N = 397) attending psychotherapy at two psychology training clinics are presented and benchmarked against treatment-as-usual (for adults and youth) and feedback (for adults). Results: Psychotherapy with a feedback-informed approach was more effective than treatment-as-usual benchmarks, with 50% of adults and 64% of youth significantly improving after psychotherapy. Rates of adult improvement were similar to feedback-informed benchmarks, although the current sample had a higher rate of deterioration. There are no previously identified feedback-informed benchmarks for the Y-OQ, making this sample the first benchmark for future studies. Conclusions: Results support the benefits of feedback at enhancing psychotherapy outcomes for adults, and replicate this finding in a youth sample. Results also replicate that trainee psychotherapists can be as effective as licenced psychotherapists.

Outcomes of In Situ Training for Disclosure as a Standalone and a Booster to a Child Protective Behaviors Education Program

In this study, the effectiveness of the Observed Protective Behaviors behaviors test, a single-session, disclosure-focused, in situ skills training (IST), was evaluated as a standalone program (IST only) or as a booster to the child protective education program, Learn to be safe with Emmy and friends ^™ (program + IST). Participants included 281 Year 1 children (5-7 years; 52% male), randomly assigned to IST only, program + IST, program only or waitlist, and followed across 6 months. At each assessment, children completed interviews to assess their intention and confidence to disclose unsafe situations (disclosure intentions and confidence) and their ability to identify unsafe situations (safety identification skills). Children also reported their anxiety symptoms to assess for a possible iatrogenic effect. The IST-only condition was effective, with children showing increased disclosure intentions relative to waitlist children. The program + IST condition was also effective, with children showing increased disclosure intentions relative to children in the waitlist or program-only conditions as well as greater increases in disclosure confidence relative to waitlist children. No differences were observed between conditions in children's safety identification skills, and no iatrogenic effect on anxiety was found. Future research may seek to develop an IST that will also boost children's safety identification skills.

"Tell, tell, tell again": The prevalence and correlates of young children's response to and disclosure of an in-vivo lure from a stranger

Despite being a key target outcome to prevent child maltreatment, little research has been conducted to examine the prevalence and predictors of interpersonal safety skills in a standardised manner. In this study, interpersonal safety skills were measured in a Year 1-2 student sample through use of a standardised simulated risk scenario, with three primary skills examined: withdrawal from an unknown confederate (motor safety response), verbal refusal of an abduction lure (verbal safety response) and disclosure of confederate presence. Children who participated in this study had not completed any prior behavioural skills training or child protective education programs. Overall, the prevalence of interpersonal safety skills varied, with 27% children withdrawing from the confederate, 48% refusing the lure and 83% disclosing the confederate's presence. For correlates, motor and verbal safety responses were positively associated with each other. However, the only other correlate of interpersonal safety skills was anxiety, with children who had greater anxiety disclosing earlier but also being more likely to agree to leave with the confederate. Future research may seek to examine whether these correlates remain present with different types of interpersonal safety risk (e.g., bullying) and to identify other potential predictors of interpersonal safety skill use.

Promoting young children's interpersonal safety knowledge, intentions, confidence, and protective behavior skills: Outcomes of a randomized controlled trial

Promoting young children's interpersonal safety knowledge, intentions confidence and skills is the goal of many child maltreatment prevention programs; however, evaluation of their effectiveness has been limited. In this study, a randomized controlled trial was conducted examining the effectiveness of the Australian protective behaviors program, Learn to be safe with Emmy and friends™ compared to a waitlist condition. In total, 611 Australian children in Grade 1 (5-7 years; 50% male) participated, with assessments at Pre-intervention, Post-intervention and a 6-month follow-up. This study also included a novel assessment of interpersonal safety skills through the Observed Protective Behaviors Test (OPBT). Analyses showed participating in Learn to be safe with Emmy and friends™ was effective post-program in improving interpersonal safety knowledge (child and parent-rated) and parent-rated interpersonal safety skills. These benefits were retained at the 6-month follow-up, with participating children also reporting increased disclosure confidence. However, Learn to be safe with Emmy and friends™ participation did not significantly impact children's disclosure intentions, safety identification skills, or interpersonal safety skills as measured by the OPBT. Future research may seek to evaluate the effect of further parent and teacher integration into training methods and increased use of behavioral rehearsal and modelling to more effectively target specific disclosure intentions and skills.

Parental Discussion of Child Sexual Abuse: Is It Associated with the Parenting Practices of Involvement, Monitoring, and General Communication?

We investigated whether parents who reported more positive parenting practices (i.e., monitoring, involvement, and communication) reported more discussion of child sexual abuse (CSA) with their children. Parents from Australia and the UK (N = 248), with children aged 6 to 11 years, completed an online survey. About half of parents reported directly discussing CSA, whereas 35% reported telling their children that CSA perpetrators may be family members. Rates of discussion were higher for other CSA-related topics such as body integrity and abduction. Correlational analyses showed that parents who reported speaking to their children about CSA also reported more positive parenting practices, more discussion of other sensitive topics, and assessed CSA risk for children (in general) to be higher. Discussion of CSA risk was not associated with parents' CSA knowledge, confidence or appraisal of own-child risk. Parents higher in positive parenting believed their children to be at less CSA risk. Parents who appraised higher own-child risk reported less positive parenting practices and were less confident about their parenting and their ability to protect their children from CSA. The findings are the first to report on the associations of parenting practices with parents' CSA discussion with their children.

Child Sexual Abuse Prevention Opportunities: Parenting, Programs, and the Reduction of Risk

To date, child sexual abuse (CSA) prevention has relied largely on child-focused education, teaching children how to identify, avoid, and disclose sexual abuse. The purpose of this article is to explore how prevention opportunities can include parents in new and innovative ways. We propose that parents can play a significant role as protectors of their children via two pathways: (i) directly, through the strong external barriers afforded by parent supervision, monitoring, and involvement; and (ii) indirectly, by promoting their children's self-efficacy, competence, well-being, and self-esteem, which the balance of evidence suggests will help them become less likely targets for abuse and more able to respond appropriately and disclose abuse if it occurs. In this article, we first describe why teaching young children about CSA protective behaviors might not be sufficient for prevention. We then narratively review the existing research on parents and prevention and the parenting and family circumstances that may increase a child's risk of experiencing sexual abuse. Finally, we make a number of recommendations for future approaches to prevention that may better inform and involve parents and other adult protectors in preventing CSA.

Cluster randomised-control trial for an Australian child protection education program: Study protocol for the Learn to be safe with Emmy and friends™

BACKGROUND

Child maltreatment has severe short-and long-term consequences for children's health, development, and wellbeing. Despite the provision of child protection education programs in many countries, few have been rigorously evaluated to determine their effectiveness. We describe the design of a multi-site gold standard evaluation of an Australian school-based child protection education program. The intervention has been developed by a not-for-profit agency and comprises 5 1-h sessions delivered to first grade students (aged 5-6 years) in their regular classrooms. It incorporates common attributes of effective programs identified in the literature, and aligns with the Australian education curriculum.

METHODS/DESIGN

A three-site cluster randomised controlled trial (RCT) of Learn to be safe with Emmy and friends™ will be conducted with children in approximately 72 first grade classrooms in 24 Queensland primary (elementary) schools from three state regions, over a period of 2 years. Entire schools will be randomised, using a computer generated list of random numbers, to intervention and wait-list control conditions, to prevent contamination effects across students and classes. Data will be collected at baseline (pre-assessment), immediately after the intervention (post-assessment), and at 6-, 12-, and 18-months (follow-up assessments). Outcome assessors will be blinded to group membership. Primary outcomes assessed are children's knowledge of program concepts; intentions to use program knowledge, skills, and help-seeking strategies; actual use of program material in a simulated situation; and anxiety arising from program participation. Secondary outcomes include a parent discussion monitor, parent observations of their children's use of program materials, satisfaction with the program, and parental stress. A process evaluation will be conducted concurrently to assess program performance.

DISCUSSION

This RCT addresses shortcomings in previous studies and methodologically extends research in this area by randomising at school-level to prevent cross-learning between conditions; providing longer-term outcome assessment than any previous study; examining the degree to which parents/guardians discuss intervention content with children at home; assessing potential moderating/mediating effects of family and child demographic variables; testing an in-vivo measure to assess children's ability to discriminate safe/unsafe situations and disclose to trusted adults; and testing enhancements to existing measures to establish greater internal consistency.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Register (ACTRN12615000917538). Registered (02/09/2015).

Empowering and protecting children by enhancing knowledge, skills and well-being: A randomized trial of Learn to BE SAFE with Emmy

Australia needs effective programs to protect children and prevent abuse, but there is little information available for policymakers or families. Using a randomized controlled trial, Learn to BE SAFE with Emmy, a school-based protection program for young children designed by Act for Kids, was evaluated to determine its effectiveness for promoting young children's knowledge and skills. Grade one children (n=245) from 15 classrooms across 5 primary schools completed assessment measures. A subset of these children received the program (n=131) or acted as a comparison group (n=114). Parents (n=72) completed questionnaires about their child's participation in the program. When compared with children who had not received the program, children who completed Learn to BE SAFE with Emmy demonstrated increased knowledge of interpersonal safety and were more likely to choose a safe response option to hypothetical unsafe scenarios 6 months after participation than at both pre- and post-intervention. Parents reported their children who participated used more safety strategies immediately and 6 months after participation compared to pre-intervention. Outcomes can assist in guiding future policies around the prevention of child abuse and protect the well-being of Australian children.

How Parents Seek Help for Children with Mental Health Problems

Parents seeking help for their child's mental health problem face a complicated system of services. We examined how parents navigate the various services available. Sixty parents contacting a children's mental health center were interviewed regarding their efforts and rationale in seeking help for their child. On average, in the year prior to the interview parents sought help for two different child problems, contacted five different agencies or professionals for help, and parents and/or children received two different treatments. One fifth of the time parents said they accepted treatments that they did not want. Almost all parents (87%) were simultaneously in contact with more than one agency at some point within the previous year. Future help-seeking models need to capture the iterative referral process that many parents experience.