Is parental unemployment associated with increased risk of adverse childhood experiences? A systematic review and meta-analysis

BACKGROUND

Unemployment has adverse consequences for families and can put children at risk of harm. This study presents a systematic review and meta-analysis of global evidence on associations between parental unemployment and adverse childhood experiences (ACEs).

METHODS

Systematic literature searches across four databases identified cross-sectional, cohort or case-control studies measuring associations between parental employment and individual or cumulative ACEs in children. Available risk estimates were extracted and pooled odds ratios calculated using random-effects models.

RESULTS

Of 60 included studies, 37 provided risk estimates suitable for pooling across seven ACE types. Paternal/any parental unemployment was associated with a 29% increased risk of sexual abuse, 54% increased risk of neglect, 60% increased risk of physical abuse and around 90% increased risk of child maltreatment and parental mental illness. No associations were found between maternal unemployment and ACEs. Pooling estimates from representative general population studies also identified increased risk of child maltreatment with paternal/any parental unemployment (82%) but not maternal unemployment.

CONCLUSIONS

Children who grow up with parental unemployment can be at increased risk of ACEs. A combination of socioeconomic measures to increase employment opportunities and parental support targeting fathers and mothers may help break multigenerational cycles of abuse and deprivation.

Ethnic and Sexual Identity-Related Inequalities in Adolescent Health and Well-Being in a National Population-Based Study

Purpose: This study employed an intersectional framework to examine impact of inequalities related to sexual minority (SM) and ethnic minority (EM) identities in risk for health, well-being, and health-related behaviors in a nationally representative sample. Methods: Participants included 9789 (51% female) adolescents aged 17 years from the U.K.-wide Millennium Cohort Study, with data on self-identified sexual and ethnic identities. Adolescents were grouped into White heterosexual, White-SM, EM-heterosexual, and EM-SM categories. Questionnaires assessed mental health (e.g., self-reported psychological distress, doctor-diagnosed depression, attempted suicide), general health (self-rated health, chronic illness, body mass index), and health-related behaviors (e.g., smoking, substance use). Associations were analyzed using multivariable logistic regression. Results: SM individuals (White: 18% and EM: 3%) had increased odds for mental health difficulties and attempted suicide, with higher odds for White-SM individuals than for EM-SM individuals. Compared with White heterosexual individuals, White-SM and EM-SM individuals had higher risk for psychological distress (adjusted odds ratios [OR] 3.47/2.24 for White-SM/EM-SM, respectively) and emotional symptoms (OR 3.17/1.65). They had higher odds for attempted suicide (OR 2.78/2.02), self-harm (OR 3.06/1.52), and poor sleep quality (OR 1.88/1.67). In contrast, the White heterosexual and White-SM groups had similarly high proportions reporting risky behaviors except for drug use (OR 1.45) and risky sex (OR 1.40), which were more common in White-SM individuals. EM-heterosexual and EM-SM individuals had decreased odds for health-related behaviors. Conclusion: SM (White and EM) individuals had substantially worse mental health compared with heterosexual peers. Adverse health-related behaviors were more common in White-SM individuals. Investigation into the mechanisms leading to these differences is needed.

Parental Adverse Childhood Experiences and Perpetration of Child Physical Punishment in Wales

Child physical punishment is harmful to children and, as such, is being prohibited by a growing number of countries, including Wales. Parents' own childhood histories may affect their risks of using child physical punishment. We conducted a national cross-sectional survey of Welsh adults and measured relationships between the number of adverse childhood experiences (ACEs) parents (n = 720 with children aged < 18) had suffered during childhood and their use of physical punishment towards children. Overall, 28.2% of parents reported having ever physically punished a child, and 5.8% reported having done so recently (in the last year). Child physical punishment use increased with the number of ACEs parents reported. Parents with 4+ ACEs were almost three times more likely to have ever physically punished a child and eleven times more likely to have done so recently (vs. those with 0 ACEs). The majority (88.1%) of parents that reported recent child physical punishment had a personal history of ACEs, while over half reported recently having been hit themselves by a child. Child physical punishment is strongly associated with parents' own ACE exposure and can occur within the context of broader conflict. Prohibiting physical punishment can protect children and, with appropriate family support, may help break intergenerational cycles of violence.

Systematic review of factors associated with quality of life of asylum seekers and refugees in high-income countries

The stressful experiences that many asylum seekers and refugees (AS&R) are exposed to during forced migration, and during resettlement in host countries, can have a profound impact on their mental health. Comparatively less research attention has been allocated to exploring other indices of quality of life (QoL) in AS&R populations. This review aimed to (i) synthesize the predictors and correlates of QoL of AS&R populations in high-income countries, and (ii) to identify the methodological strengths and weaknesses of this body of research. Fourteen databases were systematically searched (Medline, PsychINFO, CINAHL, Cochrane Library, Health Technology Assessment, National Health Service Economic Evaluation, Educational Resource Index and Abstracts, BiblioMap, Scopus, Social Sciences Citation Index, Evidence Aid, DARE, Web of Science and PubMed). Eligibility criteria included: adults seeking asylum or refuge in a high-income country, primary quantitative data, the use of a measure based on the WHO's definition of QoL, published in a peer-reviewed journal. A narrative synthesis approach was used, and the quality was assessed using the AXIS tool for cross-sectional studies and the CASP tool for longitudinal studies. Of the 13.656 papers identified, 23 met the eligibility criteria. A wide range of factors were found to have significant associations with QoL. Both positive and negative correlates of QoL were largely dominated by social (e.g. social networks) and mental health factors (e.g. depression). Although all of the cross-sectional studies met over half of the quality criteria, only 12 met 75% or more of these criteria. For the longitudinal studies, for all but one study lacked statistical precision and the results cannot be applied to the local population. Key findings across the various forms of QoL (overall, physical, psychological, social and environmental) were that having established social networks and social integration were associated with higher QoL, whereas having mental disorders (i.e. PTSD or depression) was strongly associated with reduced QoL. More research is needed into physical and environmental predictors and correlates of QoL. The findings of the review can be used to inform policies and interventions aimed at supporting AS&R and promoting the integration and wellbeing of these populations.

Clients' experiences of one-to-one low-intensity interventions for common mental health problems: An interpretative phenomenological analysis

OBJECTIVES

Common mental health disorders such as depression and anxiety are highly prevalent and carry significant health care and economic burdens. The UK's improving access to psychological therapies (IAPT) initiative was developed as a cost-effective way of reducing the pernicious effects of these disorders. IAPT interventions, such as guided self-help, have been subjected to considerable quantitative evaluation. However, there has been minimal investigation into clients' experiences of the one-to-one low-intensity interventions (LIIs), which form a key component of IAPT service provision. Qualitative exploration could provide rich data regarding experiences of psychological change and factors affecting therapeutic experiences. This will enable informative, client led insights into how low-intensity therapy can be improved.

METHODS

Interpretative phenomenological analysis of eight semi-structured interviews was used to develop an idiosyncratic understanding of clients' experiences of one-to-one LIIs following entry into a randomized control trial (RCT).

RESULTS

Four superordinate themes were identified from clients' accounts: goals and expectations of therapy, beneficial aspects of therapy, non-beneficial aspects of therapy, and the experience of psychological change. A heuristic model of interrelationships between factors is proposed.

CONCLUSIONS

Both therapeutic techniques and relationships contribute to beneficial therapeutic experiences. The results reported here can be used to inform practice by harnessing the most beneficial aspects of therapy, such as developing adaptive therapeutic approaches to clients' clinical needs and facilitating idiosyncratic processes of psychological change. Due to limited qualitative research in this area, further research should be conducted in different service settings to assess differences and similarities in clients' experiences.

PRACTITIONER POINTS

Therapists who adapted to clients' individual needs were perceived as more effective than those who did not. Effective therapeutic experiences were exemplified by a personal therapeutic approach, enough time to discuss issues and normalizing client's experiences. Clients develop idiosyncratic models of change which should be encouraged by therapists over and above clinical models.

Mental health, social adversity, and health-related outcomes in sexual minority adolescents: a contemporary national cohort study

BACKGROUND

Sexual minority adolescents are more likely to have mental health problems, adverse social environments, and negative health outcomes compared with their heterosexual counterparts. There is a paucity of up-to-date population-level estimates of the extent of risk across these domains in the UK. We analysed outcomes across mental health, social environment, and health-related domains in sexual minority adolescents compared with their heterosexual counterparts in a large, contemporary national cohort.

METHODS

The Millennium Cohort Study (MCS) is a birth cohort study in the UK following up children born between Sept 1, 2000, and Jan 11, 2002 across England, Wales, Scotland, and Northern Ireland. Children recruited from the MCS have been followed up over six recruitment sweeps to date at ages 9 months, 3 years, 5 years, 7 years, 11 years, and 14 years. We analysed mental health, social, and health-related outcomes in sexual minority versus heterosexual adolescents at age 14 years. Additionally, we estimated the accumulation of multiple adverse outcomes in both groups. The primary aim of the study was to assess whether sexual minority adolescents experienced more adverse outcomes than heterosexual adolescents.

FINDINGS

Between January, 2015, and April, 2016, 9885 adolescents provided a response about their sexual attraction. 629 (6%) of 9885 adolescents (481 female participants and 148 male participants) were identified as sexual minorities. 9256 (94%) of 9885 participants (4431 female and 4825 male) were attracted to the opposite sex or not attracted to the same sex and identified as heterosexual. Sexual minority adolescents were more likely to experience high depressive symptoms (odds ratio [OR] 5·43, 95% CI 4·32-6·83; p<0·0001), self-harm (5·80, 4·55-7·41; p<0·0001), lower life satisfaction (3·66, 2·92-4·58; p<0·0001), lower self-esteem (β 1·83, 95% CI 1·47-2·19; p<0·0001), and all forms of bullying and victimisation. Sexual minorities were more likely to have tried alcohol (OR 1·85, 95% CI 1·47-2·33; p<0·0001), smoking (2·41, 1·92 -3·03; p<0·0001), and cannabis (3·22, 2·24-4·61; p<0·0001), and also had increased odds of being less physically active (β 0·36, 95% CI 0·25-0·46; p<0·0001), perceiving themselves as overweight (OR 1·73, 95% CI 1·40-2·14; p<0·0001), and dieting to lose weight (1·98, 1·58-2·48; p<0·0001). Sexual minority adolescents had more co-occurring mental health outcomes (mean 1·43 of 3 outcomes, 95% CI 1·34-1·52) compared with heterosexual adolescents (0·40 of 3 outcomes, 0·38-0·41), and more total cumulative difficulties (mean 9·43 of 28 outcomes, 95% CI 9·09-9·76 in sexual minority adolescents vs 6·16 of 28 outcomes, 6·08-6·23 in heterosexual adolescents).

INTERPRETATION

Sexual minority adolescents in the UK experience disparities in mental health, social, and health-related outcomes despite living in a time of substantial progress in rights for sexual minorities. These adverse outcomes co-occur, with implications for lifelong health and social outcomes. Health and educational practitioners should be aware of the increased risk for adverse outcomes in sexual minority adolescents.

FUNDING

None.

The clinical effectiveness of sertraline in primary care and the role of depression severity and duration (PANDA): a pragmatic, double-blind, placebo-controlled randomised trial

BACKGROUND

Depression is usually managed in primary care, but most antidepressant trials are of patients from secondary care mental health services, with eligibility criteria based on diagnosis and severity of depressive symptoms. Antidepressants are now used in a much wider group of people than in previous regulatory trials. We investigated the clinical effectiveness of sertraline in patients in primary care with depressive symptoms ranging from mild to severe and tested the role of severity and duration in treatment response.

METHODS

The PANDA study was a pragmatic, multicentre, double-blind, placebo-controlled randomised trial of patients from 179 primary care surgeries in four UK cities (Bristol, Liverpool, London, and York). We included patients aged 18 to 74 years who had depressive symptoms of any severity or duration in the past 2 years, where there was clinical uncertainty about the benefit of an antidepressant. This strategy was designed to improve the generalisability of our sample to current use of antidepressants within primary care. Patients were randomly assigned (1:1) with a remote computer-generated code to sertraline or placebo, and were stratified by severity, duration, and site with random block length. Patients received one capsule (sertraline 50 mg or placebo orally) daily for one week then two capsules daily for up to 11 weeks, consistent with evidence on optimal dosages for efficacy and acceptability. The primary outcome was depressive symptoms 6 weeks after randomisation, measured by Patient Health Questionnaire, 9-item version (PHQ-9) scores. Secondary outcomes at 2, 6 and 12 weeks were depressive symptoms and remission (PHQ-9 and Beck Depression Inventory-II), generalised anxiety symptoms (Generalised Anxiety Disorder Assessment 7-item version), mental and physical health-related quality of life (12-item Short-Form Health Survey), and self-reported improvement. All analyses compared groups as randomised (intention-to-treat). The study is registered with EudraCT, 2013-003440-22 (protocol number 13/0413; version 6.1) and ISRCTN, ISRCTN84544741, and is closed to new participants.

FINDINGS

Between Jan 1, 2015, and Aug 31, 2017, we recruited and randomly assigned 655 patients-326 (50%) to sertraline and 329 (50%) to placebo. Two patients in the sertraline group did not complete a substantial proportion of the baseline assessment and were excluded, leaving 653 patients in total. Due to attrition, primary outcome analyses were of 550 patients (266 in the sertraline group and 284 in the placebo group; 85% follow-up that did not differ by treatment allocation). We found no evidence that sertraline led to a clinically meaningful reduction in depressive symptoms at 6 weeks. The mean 6-week PHQ-9 score was 7·98 (SD 5·63) in the sertraline group and 8·76 (5·86) in the placebo group (adjusted proportional difference 0·95, 95% CI 0·85-1·07; p=0·41). However, for secondary outcomes, we found evidence that sertraline led to reduced anxiety symptoms, better mental (but not physical) health-related quality of life, and self-reported improvements in mental health. We observed weak evidence that depressive symptoms were reduced by sertraline at 12 weeks. We recorded seven adverse events-four for sertraline and three for placebo, and adverse events did not differ by treatment allocation. Three adverse events were classified as serious-two in the sertraline group and one in the placebo group. One serious adverse event in the sertraline group was classified as possibly related to study medication.

INTERPRETATION

Sertraline is unlikely to reduce depressive symptoms within 6 weeks in primary care but we observed improvements in anxiety, quality of life, and self-rated mental health, which are likely to be clinically important. Our findings support the prescription of SSRI antidepressants in a wider group of participants than previously thought, including those with mild to moderate symptoms who do not meet diagnostic criteria for depression or generalised anxiety disorder.

FUNDING

National Institute for Health Research.

Experiences of a transdiagnostic group, the Take Control Course, for clients with common mental health problems: A qualitative study

OBJECTIVES

Despite the promising effectiveness findings for transdiagnostic groups, studies have not explored clients' experiences. There is a risk that clients could perceive that the content of transdiagnostic groups is not sufficiently tailored to their specific problems. Our aims were to examine whether a brief transdiagnostic group, the Take Control Course (TCC), was acceptable to participants and to explore participants' perceptions of psychological change.

METHODS

Qualitative data were collected via 12 semistructured, in-depth interviews. Data collection and thematic analysis were concurrent and iterative.

RESULTS

Three superordinate themes were identified: "Style and format," "Control and flexibility," and "Change." The flexible group format was appreciated, as participants felt able to engage at their own pace and adapt relevant aspects. Greater clarity regarding what was within participants' control reduced distress and enabled effective pursuit of valued goals. Participants described significant (predominantly gradual) changes, including substantial improvements within relationships.

CONCLUSIONS

The transdiagnostic format did not prevent participants experiencing the TCC as individually relevant. The flexibility and consistent theoretical framework seemed to contribute to this. The results indicated that greater consideration of control and mindfulness allowed greater cognitive flexibility, an ability to reprioritize and let go of unhelpful habits, which better enabled participants to meet their goals. Implications for group therapy include (a) clearly explaining the format of such groups to clients and (b) providing flexibility in the way the group is delivered where possible. Additional qualitative studies of transdiagnostic groups are required to establish if themes generalize to other transdiagnostic groups.

Proton Beam Therapy - the Challenges of Delivering High-quality Evidence of Clinical Benefit

The use of proton beam therapy (PBT) offers the opportunity to improve greater conformality of radiotherapy treatment delivery in some patients. However, it is associated with a high capital cost and the need to build new dedicated facilities. We discuss how the global radiotherapy community can respond to the challenge of producing high-quality evidence of clinical benefit from PBT in adult patients. In the UK, the National Cancer Research Institute-funded Clinical and Radiotherapy Translational group has established the PBT Clinical Trial Strategy Group. An eight-point framework is described that can assist the development and delivery of high-quality clinical trials.

Evaluating dentin surface treatments for resin-modified glass ionomer restorative materials

This in vitro study evaluated the effect of six surface treatments on the shear bond strength of three resin-modified glass ionomers (RMGIs) to dentin. Occlusal surfaces of caries-free third molars were reduced to expose only dentin. Surface treatments were smear layer intact (negative control), Cavity Conditioner, EDTA, Ketac Primer, Self Conditioner, and etching with 35% phosphoric acid followed by the application of Optibond Solo Plus. Filtek Z250 composite resin bonded with Optibond Solo Plus served as a positive control. Conditioning agents were used according to the manufacturers' instructions. After surface treatments, Fuji II LC, Riva LC, Ketac Nano, and Filtek Z250 were placed in copper-band matrices 5 mm in diameter and 2 mm in height and were light-cured for 20 seconds. Specimens were stored in 100% humidity for 24 hours, after which they were placed in deionized water for 24 hours at 37°C. They were then tested under shear forces in an Instron Universal Testing Machine at a crosshead speed of 0.5 mm/min. A two-way analysis of variance and Tukey honestly significant difference statistical analyses (p<0.05) indicated significant interaction between RMGIs and conditioning agents. Acid etching followed by Optibond Solo Plus provided highest bond strengths for all three RMGIs, which were not statistically different from the positive control.

A biologically important single nucleotide polymorphism within the toll-like receptor-4 gene is not associated with rheumatoid arthritis

BACKGROUND

Rheumatoid arthritis (RA) is a heterogeneous condition affecting 1-2% of the population. Genetics account for 30% of disease susceptibility, with one third arising from the Major Histocompatibility Complex. The toll-like receptor 4 (TLR-4) gene which has been mapped to chromosome 9 (9q32-q33) is involved in innate immune recognition with subsequent proinflammatory cytokine release including TNF. A single nucleotide polymorphism (+896A-->G) resulting in the amino acid substitution (Asp299Gly) has been shown to interrupt TLR-4 mediated signalling.

OBJECTIVE

We sought to determine if this TLR-4 polymorphism influences susceptibility to rheumatoid arthritis.

METHODS

DNA was extracted from 879 healthy controls and 212 rheumatoid arthritis patients recruited from the north of England. Genotyping was performed using a 5' nuclease Taqman allelic discrimination assay. Allele frequencies were compared between the two groups. We also examined whether an association existed in non-carriers of the DRB1 shared epitope alleles.

RESULTS

The frequency of the rare allele was 5.9% in the controls and 7% in the patients. Comparison of rare allele carriage between controls and patients revealed no significant difference p = 0.13. This was also the case in shared epitope negative individuals p = 0.92.

CONCLUSION

The TLR-4 +896 polymorphism does not appear to influence susceptibility to rheumatoid arthritis.

Root-lesion nematode (Pratylenchus thornei) limits response of wheat but not barley to stored soil moisture in the Hermitage long-term tillage experiment

The cumulative effects of factorial treatments of tillage (no tillage, conventional), stubble retention (burnt, retained), and nitrogen fertiliser (0, 23, 69 kg N/ha) on yield of continuous winter cereals and on soil properties have been tested in the Hermitage fallow management experiment since 1969. Despite increased soil water stored from the combination of no tillage and stubble retention, wheat responses to the extra water were disappointing in the first 11 years of the experiment. Soil samples from the experiment were shown to be heavily infested with the root-lesion nematode (Pratylenchus thornei Sher and Allen), and therefore in 1980, the main plots were split for crop (wheat cv. Timgalen, barley cv. Clipper) and nematicide treatment (nil, aldicarb). Barley (maximum yield 3.2 t/ha) tolerated the nematodes and responded in this dry year to the extra stored water accumulated with no tillage and stubble retention, but wheat (maximum yield 1.22 t/ha) did not. Nematicide increased wheat yields by 42%. The results from the changes to the Hermitage experiment in 1980 show the importance of considering root-lesion nematodes in interpreting results from long-term experiments involving wheat and in applying those results to farms. Control of root-lesion nematodes on farms by crop rotation and by growing tolerant and resistant wheat varieties is needed to obtain full yield benefits from improved tillage practices.

A multicentre pilot study of sulphasalazine in juvenile chronic arthritis

In this multicentre pilot study of sulphasalazine in juvenile chronic arthritis, the mode of onset and course of the disease, and when available, the HLA status, was recorded on the entry form. After appropriate clinical and laboratory appraisal, sulphasalazine up to 40 mg/kg/day was given for one year with assessments at 0, 1, 3, 6, 9 and 12 months. Fifty-one patients enrolled, 8 of whom were withdrawn because of side effects. In the remainder by 12 months a good effect was noted in 12, 8 having pauci-articular onset disease commencing after the age of 9 years, of whom 6 carried HLA B27. It was relatively ineffective in the other subgroups. The frequency and severity of side effects was similar to that seen in adults. Further evaluation in controlled trials is required in older onset pauci-articular arthritis, taking due note of the patient's HLA status, and also in juvenile psoriatic arthritis and seropositive juvenile rheumatoid arthritis.

Haemolytic anaemia associated with ingestion of naphthalene-containing anointing oil

We present a patient who developed a severe haemolytic anaemia as a result of ingestion of a naphthalene-containing anointing oil. Previous reports of naphthalene-induced haemolytic anaemia are reviewed. Predisposing factors to haemolysis are outlined and the variability in the haematological response to naphthalene is discussed. It is clear that ingestion of anointing oil is dangerous; even topically, significant absorption of naphthalene may occur especially in infants, as it is oil-based. Because of these dangers, the use of naphthalene-containing anointing oils should be strongly condemned.