Carer-reported sleep disturbance and carer- and teacher-rated executive functioning in children with prenatal alcohol exposure and Fetal Alcohol Spectrum Disorder

Children with prenatal alcohol exposure (PAE) and Fetal Alcohol Spectrum Disorder (FASD) have high rates of sleep disturbance and marked difficulties with executive functioning (EF). Sleep disturbance has been associated with poorer EF across development in typically developing children. The contribution of insomnia symptoms and nightmares to EF difficulties in children with PAE and FASD is unclear. The current study examined whether caregiver-reported insomnia symptoms and nightmares predicted difficulties with EF in children with PAE who were assessed at FASD diagnostic clinics. Archival data on 116 children with PAE assessed at FASD diagnostic clinics were extracted from databases. Children were assigned to a preschool-age group (3.1 to 5.9 years, n = 40) and a school-age group (5.9 to 10.9 years, n = 76). Insomnia symptoms and nightmares were measured using items extracted from the Child Behavior Checklist (CBCL) while EF was measured using the caregiver and teacher Behavior Rating Inventory of Executive Function (BRIEF) rating forms. Bootstrapped regression models were used examine the effects of insomnia symptoms and nightmares on domains of EF in each group while adjusting for potential confounds. For preschool children, insomnia symptoms were associated with greater daytime tiredness while nightmares were associated with greater difficulties with Emergent Metacognition according to their teachers. For school-age children, insomnia symptoms predicted greater EF difficulties across most domains according to their caregivers but not teachers. Sleep disturbance may compound EF impairments in children with PAE and should be screened for as part of FASD diagnostic assessment.

Numeracy and literacy attainment of children exposed to maternal incarceration and other adversities: A linked data study

Parental incarceration has been associated with educational disadvantages for children, such as lower educational attainment, increased grade retention, and truancy and suspensions. However, children exposed to parental incarceration often experience other adversities that are also associated with educational disadvantage; the contribution of these co-occurring adversities has not been considered in previous research. This study aimed to investigate the educational outcomes of children exposed to (a) maternal incarceration alone and (b) maternal incarceration plus other adversities (i.e., maternal mental illness and/or child protective services [CPS] contact). We used linked administrative data for a sample of children whose mothers were incarcerated during the children's childhood (i.e., from the time of mother's pregnancy through the child's 18th birthday; n = 3828) and a comparison group of children whose mothers had not been incarcerated (n = 9570). Multivariate multinomial logistic regressions examined the association between exposure to the three adversities (i.e., maternal incarceration, maternal mental illness, and child CPS contact) and above or below average reading and numeracy attainment in Grades 3, 5, 7 and 9. At all grade levels, children exposed to maternal incarceration alone and those exposed to maternal incarceration plus other adversities had increased odds of below average numeracy and reading attainment and decreased odds of above average numeracy and reading attainment compared to children without any of the recorded exposures. Children exposed to maternal incarceration and CPS contact and those exposed to all three adversities had increased odds of below average reading and numeracy attainment compared to children exposed to maternal incarceration alone. The findings highlight the complex needs of children of incarcerated mothers that must be considered when designing and delivering educational support programs. These children would benefit from the implementation of multi-tiered, trauma-informed educational and clinical services.

Understanding the impacts of childhood adversity on sleep problems in children with fetal alcohol spectrum disorder: A comparison of cumulative and dimensional approaches

BACKGROUND

The developmental impacts of prenatal alcohol exposure (PAE) and postnatal exposure to adversity are typically considered in isolation. However, both contribute independently to sleep problems. Children with fetal alcohol spectrum disorder (FASD) have PAE and significant sleep disturbances. What is not clear is the relative contribution to these disturbances of exposure to early life adversity. This study examined how exposure to such adversity impacts frequent insomnia symptoms and nightmares in children with FASD and "At Risk" designations.

METHODS

We compared two approaches to modeling adversity in children who had undergone a diagnostic assessment for FASD: a cumulative risk approach that sums adversities to create a total score and an approach that treats exposure to threat and deprivation as independent dimensions. Data on caregiver-reported exposure to adversity and sleep problems for 63 children (aged 3 years 4 months to 7 years 8 months) were extracted from clinical archives. Cumulative risk, threat exposure, and deprivation exposure scores were computed and were tested as predictors of insomnia symptoms and nightmares. All analyses controlled for age and gender.

RESULTS

There were high rates of caregiver-reported sleep problems with 60.3% (n = 38) of children having nightmares and 44.4% (n = 28) having a frequent insomnia symptom. The cumulative risk analysis showed that for every additional exposure to adversity, the odds of having a caregiver-reported insomnia symptom increased by 38%. The dimensional analysis showed no relationship between deprivation and sleep problems. However, every additional exposure to threat increased the odds of nightmares by 93%.

CONCLUSIONS

Exposure to postnatal adversity contributes to sleep disturbances in children with FASD, with unique roles for cumulative risk and the threat dimension of adversity. The implications of these findings for the etiology and treatment of sleep disturbances in children with FASD are discussed.

Maternal incarceration increases the risk of self-harm but not suicide: a matched cohort study

AIMS

Children of incarcerated mothers are at increased risk of experiencing multiple adversity such as poverty, mental illness and contact with child protection services (CPS), including being taken into out of home care (OOHC). However, little is known about whether these children are at increased risk of suicide or self-harm compared to children not exposed to maternal incarceration or about the factors that may contribute to this. We aimed to investigate differences in the risk of suicide and self-harm between children exposed to maternal incarceration and those not exposed and examine how socio-demographic factors, maternal mental illness and CPS contact (with or without OOHC) may affect these outcomes.

METHODS

We used a retrospective matched cohort study design, comparing 7674 children exposed to maternal incarceration with 7674 non-exposed children. We used multivariable Cox proportional hazards regression to compare the risk of suicide and self-harm between exposed and non-exposed groups, controlling for geographical remoteness, CPS contact and maternal mental illness.

RESULTS

There was no significant difference in the rate of suicide (rate ratio [RR] = 1.49; 95% confidence interval [CI]: 0.78, 2.87) or risk of suicide (adjusted hazard ratio [aHR] = 0.92; 95% CI: 0.43, 1.96) between the two groups. However, the exposed group had a significantly higher rate of self-harm (RR = 2.83; 95% CI: 2.50, 3.21) and a significantly higher risk of self-harm (aHR = 1.74; 95% CI: 1.45, 2.09) compared to those non-exposed. CPS contact with or without OOHC was independently associated with an increased risk of self-harm for both groups.

CONCLUSION

Children exposed to maternal incarceration are at an increased risk of self-harm and should be prioritized to receive targeted, multimodal support that continues after the mother's release from prison. The association between CPS contact and self-harm warrants further research.

Child protection system involvement in children of incarcerated mothers: A linked data study

BACKGROUND

Women prisoners are a growing portion of the prison population. Health and social outcomes of their children have been studied and found to be poor, but little is known about child protection outcomes.

OBJECTIVES

Ascertain child protection system contact of children exposed to maternal incarceration.

PARTICIPANTS AND SETTING

All children born between 1985 and 2011 exposed to the incarceration of their mothers in a Western Australian correctional facility and a matched comparison group.

METHODS

A matched cohort study using linked administrative data on 2637 mothers entering prison between 1985 and 2015 and their 6680 children. We estimated hazard ratios (HRs) and incidence rate ratios (IRRs) of child protection service (CPS) contact post maternal incarceration (four concern levels), comparing rates for children exposed to maternal incarceration with a matched non-exposed group, adjusting for maternal and child factors.

FINDINGS

Exposure to maternal incarceration increased risk of CPS contact. Unadjusted HRs exposed vs unexposed children were 7.06 (95%CI = 6.49-7.69) for substantiated child maltreatment and 12.89 (95%CI = 11.42-14.55) for out-of-home care (OOHC). Unadjusted IRRs were 6.04 (95%CI = 5.57-6.55) for number of substantiations and 12.47 (95%CI = 10.65-14.59) for number of removals to OOHC. HRs and IRRs were only slightly attenuated in adjusted models.

CONCLUSIONS

Maternal incarceration is a warning flag for a child at high risk of serious child protection concerns. Family-friendly rehabilitative women's prisons, incorporating support for more nurturing mother-child relationships could provide a placed-based public health opportunity for disrupting distressing life trajectories and intergenerational pathways of disadvantage of these vulnerable children and their mothers. This population should be a priority for trauma-informed family support services.

Corporal punishment of children in Australia: The evidence-based case for legislative reform

OBJECTIVE

Across all of Australia's states and territories, it is legal for a parent or carer to hit their child. In this paper, we outline the legal context for corporal punishment in Australia and the argument for its reform.

METHODS

We review the laws that allow corporal punishment, the international agreements on children's rights, the evidence on the effects of corporal punishment, and outcomes of legislative reform in countries that have changed their laws to prohibit corporal punishment.

RESULTS

Legislative reform typically precedes attitude changes and reductions in the use of corporal punishment. Countries with the most ideal outcomes have instigated public health campaigns educating the population about law reform while also providing access to alternative non-violent discipline strategies.

CONCLUSIONS

Extensive evidence exists demonstrating the adverse effects of corporal punishment. When countries change legislation, educate the public about these effects, and provide alternative strategies for parents, rates of corporal punishment decrease.

IMPLICATIONS FOR PUBLIC HEALTH

We recommend law reform in Australia to prohibit corporal punishment, a public health campaign to increase awareness of corporal punishment and its effects, provision of access for parents to alternative evidence-based strategies to assist in parenting, and a national parenting survey to monitor outcomes.

An investigation of the utility of the Australian Guide to the diagnosis of fetal alcohol spectrum disorder in young children

BACKGROUND

Early diagnosis of children with fetal alcohol spectrum disorder (FASD) assists in implementing critical early support. The challenge lies in having a diagnostic process that enables valid and reliable assessment of domains of functioning in young children, with the added complexity that many children will also have co-occurring exposure to childhood adversity that is likely to impact these domains.

METHODS

The aim of this study was to test a diagnostic assessment of FASD in young children using the Australian Guide to the Diagnosis of FASD. Ninety-four children (aged 3 to 7 years) with confirmed or suspected prenatal alcohol exposure were referred to two specialist FASD clinics for assessment in Queensland, Australia.

RESULTS

There was a significant risk profile with 68.1% (n = 64) children having had contact with child protection services, and most children living in kinship (n = 22, 27.7%) or foster (n = 36, 40.4%) care. Forty-one percent of the children were Indigenous Australians. The majority (64.9%, n = 61) of children met criteria for FASD, 30.9% were classified as "At Risk" for FASD (n = 29), and 4.3% received no FASD diagnosis (n = 4). Only 4 (4%) children were rated as severe for the brain domain. Over 60% of children (n = 58) had two or more comorbid diagnoses. Sensitivity analyses indicated that the removal of comorbid diagnoses in the Attention, Affect Regulation, or Adaptive Functioning domains resulted in a change in 7 of 47 cases (15%) to an "At Risk" designation.

CONCLUSIONS

These results highlight the complexity of presentation and the extent of impairment in the sample. The use of comorbid diagnoses to substantiate a "severe" designation in specific neurodevelopmental domains raises the question of whether there were false-positive diagnoses. The complexity of determining causal relationships between exposure to PAE and early life adversity on developmental outcomes continues to be a challenge in this young population.

Interventions for improving executive functions in children with foetal alcohol spectrum disorder (FASD): A systematic review

Background

The consequences for children born with birth defects and developmental disabilities encompassed by foetal alcohol spectrum disorder (FASD) are profound, affecting all areas of social, behavioural and cognitive functioning. Given the strong evidence for a core deficit in executive functioning, underpinned by impaired self-regulation skills, there has been a growing focus on the development of interventions that enhance or support the development of executive functions (EFs).

Objectives

The primary objective of this review is to synthesise the evidence for structured psychological interventions that explicitly aim to improve EF in children. The review also sought to ascertain if the effectiveness of interventions were influenced by characteristics of the intervention, participants or type of EF targeted by the intervention.

Search Methods

Sixteen databases, 18 grey literature search locations and 9 trial registries were systematically searched to locate eligible studies (up to December 2020). These searches were supplemented with reference harvesting, forward citation searching, hand searches of topic-relevant journals and contact with experts.

Selection Criteria

Studies were included in the review if they reported on an impact evaluation of a psychological intervention aiming to improve EF in children 3-16 years who either had confirmed prenatal alcohol exposure or a formal diagnosis falling under the umbrella term of FASDs. Eligible study designs included randomised controlled trials (RCTs) and quasi-experimental designs with either no treatment, wait list control or an alternative treatment as a comparison condition. Single-group pre-post designs were also included.

Data Collection and Analysis

Standard methodological procedures expected by the Campbell Collaboration were used at all stages of this review. Standardised mean differences (SMDs) were used to estimate intervention effects, which were combined with random effects meta-analysis (data permitting). Risk of bias was assessed using the Cochrane Risk of Bias Tool (RoB2) and Cochrane Risk of Bias in Non-Randomised Studies-Interventions tool (ROBINS-I).

Main Results

The systematic search identified 3820 unique records. After title/abstract and full-text screening, 11 eligible studies (reported in 21 eligible documents) were deemed eligible, with a combined 253 participants. Of the 11 studies, 6 were RCTs, 1 was a quasi-experiment and 4 were single-group pre-post intervention designs. All studies were rated as having an overall high or serious risk of bias, with some variation across domains for RCTs. For RCT and quasi-experimental studies, the overall effect of EF interventions on direct and indirect measures of EF generally favoured the experimental condition, but was not statistically significant. There was no difference between intervention and comparison groups on direct measures of auditory attention (k = 3; SMD = 0.06, 95% confidence interval [CI] = -1.06, 1.18), visual attention (k = 2; SMD = 0.90, 95% CI = -1.41, 3.21), cognitive flexibility (k = 2; SMD = 0.23, 95% CI = -0.40, 0.86), attentional inhibition (k = 2; SMD = 0.04, 95% CI = -0.58, 0.65), response inhibition (k = 3; SMD = 0.47, 95% CI = -0.04, 0.99), or verbal working memory (k = 1; d = 0.6827; 95% CI = -0.0196, 1.385). Significant heterogeneity was found across studies on measures of auditory attention and visual attention, but not for measures of cognitive flexibility, attentional inhibition or response inhibition. Available data prohibited further exploration of heterogeneity. There was no statistical difference between intervention and comparison groups on indirect measures of global executive functioning (k = 2; SMD = 0.21, 95% CI = -0.40, 0.82), behavioural regulation (k = 2; SMD = 0.18, 95% CI = -0.43, 0.79), or emotional control (k = 3; SMD = 0.01, 95% CI = -0.33, 0.36). Effect sizes were positive and not significant for meta-cognition (k = 1; SMD = 0.23, 95% CI = -0.72, 1.19), shifting (k = 2; SMD = 0.04, 95% CI = -0.35, 0.43), initiation (k = 1; SMD = 0.04, 95% CI = -0.40, 0.49), monitoring (k = 1; SMD = 0.25, 95% CI = -0.20, 0.70) and organisation of materials (k = 1; SMD = 0.25, 95% CI = -0.19, 0.70). Effect sizes were negative and not statistically different for effortful control (k = 1; SMD = -0.53, 95% CI = -1.50, 0.45), inhibition (k = 2; SMD = -0.08, 95% CI = -0.47, 0.31), working memory (k = 1; SMD = 0.00, 95% CI = -0.45, 0.44), and planning and organisation (k = 1; SMD = -0.10, 95% CI = -0.55, 0.34). No statistically significant heterogeneity was found for any of the syntheses of indirect measures of EF. Based on pre-post single-group designs, there was evidence for small to medium sized improvements in EF based on direct measures (cognitive flexibility, verbal working memory and visual working memory) and indirect measures (behavioural regulation, shifting, inhibition and meta-cognition). However, these results must be interpreted with caution due to high risk of bias.

Authors' Conclusions

This review found limited and uncertain evidence for the effectiveness of interventions for improving executive functioning in children with FASD across 8 direct and 13 indirect measures of EF. The findings are limited by the small number of high-quality studies that could be synthesised by meta-analysis and the very small sample sizes for the included studies.

A review of Australian Government funding of parenting intervention research

OBJECTIVES

Parenting is central to children's optimal development and accounts for a substantial proportion of the variance in child outcomes, including up to 40% of child mental health. Parenting is also one of the most modifiable, proximal, and direct factors for preventing and treating a range of children's problems and enhancing wellbeing. To determine the effectiveness of new approaches to parenting intervention, and to evaluate how to optimise reach and uptake, sufficient funding must be allocated for high quality research.

METHOD

We reviewed funding awarded by the National Health and Medical Research Council (NHMRC) and Australian Research Council (ARC) for parenting intervention research during 2011-2020.

RESULTS

Parenting intervention research received 0.25% of the NHMRC and ARC research budgets.

CONCLUSIONS

There is a substantial mismatch between the funding of parenting intervention research and the impact of improved parenting on short- and long-term child outcomes. To rectify this, it is critical that Australian Government funding schemes include parenting interventions as priority areas for funding.

IMPLICATIONS FOR PUBLIC HEALTH

Changes in allocation of funding to parenting research will support the establishment of evidence for the effective development, implementation and dissemination of parenting interventions to maximise health outcomes for children and their families.

The Parents under Pressure parenting programme for families with fathers receiving treatment for opioid dependence: the PuP4Dads feasibility study

Background

The impact of parental drug use on children is a major public health problem. However, opioid-dependent fathers have been largely ignored in parenting research.

Objective

To implement and test the feasibility and acceptability of the Parents under Pressure programme (PuP4Dads) for opioid-dependent fathers and their families, and to determine whether or not a full-scale evaluation could be conducted.

Design

A mixed-methods feasibility study.

Setting

Two non-NHS family support services for parents who use drugs in Scotland.

Participants

Fathers prescribed opioid substitution therapy (n = 25), their partners (n = 17) and children, as well as practitioners, supervisors, service managers and referrers.

Intervention

A home-visiting programme, including an integrated theoretical framework, case formulation, collaborative goal-setting and modules designed to improve parenting, the caregiving environment and child welfare. The programme was delivered flexibly over 6 months by accredited practitioners.

Main outcome measures

Feasibility progression criteria included the recruitment target (n = 24 fathers), acceptability of PuP4Dads, father engagement in the study (including a minimum of 66% of fathers completing PuP and a minimum of 10 fathers completing baseline and post-treatment research interviews), engagement in qualitative interviews (including a minimum of 10 fathers and 90% practitioner uptake and 80% manager uptake), focus groups (with a minimum of 80% referrer uptake), adequate fidelity and no adverse events.

Data sources

The following researcher-administered validated questionnaires were used: the Brief Child Abuse Potential Inventory, the Parenting Sense of Competence Scale, the Difficulties in Emotion Regulation Scale, the Paternal Antenatal Attachment Scale, the Maternal Antenatal Attachment Scale, the Emotional Availability Scale, the Brief Infant Toddler Social and Emotional Assessment, the Strengths and Difficulties Questionnaire, the Conflict Tactics Scale, Treatment Outcome Profile and the EuroQol-5 Dimensions, five-level version. Other sources included parent-completed service use (an economic measure), social work child protection data, NHS opioid substitution therapy prescription data and practitioner-reported attendance data. We also conducted interviews with fathers (n = 23), mothers (n = 14), practitioners (n = 8), supervisors (n = 2) and service managers (n = 7); conducted focus groups with referrers (n = 28); and held an ‘expert event’ with stakeholders (n = 39).

Results

The PuP4Dads was successfully delivered within non-NHS settings and was considered acceptable and suitable for the study population. Referrals (n = 44) resulted in 38 (86%) eligible fathers, of whom 25 (66%) fathers and 17 partners/mothers consented to participate. Most fathers reported no previous parenting support. A total of 248 sessions was delivered to the 20 fathers and 14 mothers who started the intervention. Fourteen fathers (and 10 mothers) completed ≥ 6 sessions and six fathers (and four mothers) completed ≤ 5 sessions. Father and mother attendance rates were equal (mean 71%). Median length of engagement for fathers was 26 weeks and for mothers it was 30 weeks. Twenty-three fathers completed interviews at baseline, 16 fathers completed interviews at follow-up 1 and 13 fathers completed interviews at follow-up 2. Outcome measures were well tolerated; however, the suitability of some measures was dependent on family circumstances. The researcher-administered questionnaires had few missing data. The perceived benefits of PuP4Dads reported by parents, practitioners and managers included the following: the therapeutic focus on fathers improved parental emotion regulation, there was improved understanding and responding to child’s needs, there was better multiagency working and the programme was a good fit with practice ‘ethos’ and policy agenda. Learning highlighted the importance of service-wide adoption and implementation support, strategies to improve recruitment and retention of fathers, managing complex needs of both parents concurrently, understanding contextual factors affecting programme delivery and variables affecting intervention engagement and outcomes.

Limitations

Lack of emotional availability and economic (service use) data.

Conclusions

A larger evaluation of PuP4Dads is feasible.

Future work

Further work is required to demonstrate the effectiveness of PuP4Dads and the cost implications. A better understanding is needed of how the intervention works, for whom, under what circumstances and why.

Trial registration

Current Controlled Trials ISRCTN43209618.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 3. See the NIHR Journals Library website for further project information.

Moderators and mediators of outcomes of parents with substance use problems: further evaluation of the Parents under Pressure programme

BACKGROUND AND AIMS

Family-focused interventions can improve family functioning when parents have substance use problems. However, there has been little focus upon potential predictors of change and analysis of mechanisms of change. This study aims to identify mediators and moderators of change in a pragmatic, multi-site, randomized controlled trial of the Parents under Pressure (PuP) programme, a family-focused intervention for parents with substance use and other problems, and treatment-as-usual (TAU).

DESIGN

Secondary analysis of data: multi-level modelling was used to investigate moderators of treatment outcome; mediation was tested with cross-lagged models.

SETTING

Community-based family support services in the United Kingdom.

PARTICIPANTS

Parents (n = 100) attending community-based addiction services with children aged 2.5 years or younger.

MEASUREMENTS

Predictors of the primary outcome, child abuse potential, were: baseline child age and gender, composite family risk score, parental substance use and parental emotional dysregulation. Mediation was tested across three time-points with the observed variables parental emotion dysregulation and child abuse potential.

FINDINGS

Increased child age [Z = 2.14, 95% confidence interval (CI) = 0.01, 0.33] at baseline was associated with greater reductions in child abuse potential for PuP programme participants compared with TAU. Poorer parental emotional regulation (Z = 2.48, 95% CI = -2.76, -0.32) was associated with greater reductions in child abuse potential for all participants. Parental substance use (either recent use or primary substance of concern) did not alter any treatment effects on child abuse potential. The mediation analysis showed that PuP produced greater improvements in emotional regulation at post-treatment (P < 0.001) compared with TAU, which predicted lower child abuse potential at 6-month follow up (P < 0.05).

CONCLUSIONS

For UK parents enrolled in a family-focused intervention, baseline measurements of higher child age appear to be associated with greater reductions in child abuse potential at 6-month follow-up in PuP participants compared with treatment as usual (TAU). Poorer parental emotional regulation and, potentially, higher family risk, appears to be associated with greater reductions in child abuse potential at 6-month follow-up in PuP and TAU. Emotional regulation appeared to act as a mediator as improvements in parental emotional regulation post-treatment appeared to be associated with greater reductions in child abuse potential at 6-month follow up. Notably, participation in the PuP programme led to better parental emotional regulation compared with TAU.

Direction of the relationship between methamphetamine use and positive psychotic symptoms in regular methamphetamine users: evidence from a prospective cohort study

BACKGROUND

Methamphetamine has been consistently associated with positive psychotic symptoms, but little is known about whether the reverse also occurs.

AIMS

This study determined whether the relationship between methamphetamine use and positive psychotic symptoms is bidirectional over 12 months. The impact of lifetime psychotic disorders and methamphetamine dependence on these relationships was also examined.

METHOD

A total of 201 regular (at least monthly) primary methamphetamine users were recruited from free needle and syringe programmes in three Australian cities. Data on the frequency of methamphetamine and other drug use (from Timeline Followback inteviews) and the severity of positive psychotic symptoms (using the Brief Psychiatric Rating Scale) in the past 2 weeks were collected in 12 contiguous monthly face-to-face interviews (mean of 9.14/11 (s.d. = 3.16) follow-ups completed). Diagnoses were derived using the Psychiatric Research Interview for DSM-IV Substance and Mental Disorders.

RESULTS

The mean age of participants was 31.71 years (s.d. = 8.19) and 39% (n = 77) were women. At baseline 55% (n = 110) were dependent on methamphetamine and 51% (n = 102) had a lifetime psychotic disorder. Cross-lagged dynamic panel models found a significant bidirectional relationship between psychotic symptoms and methamphetamine use (Comparative Fit Index (CFI) = 0.94, standardised root mean square residual (SRMR) = 0.05, root mean square error of approximation (RMSEA) = 0.05, 95% CI 0.04-0.06). The magnitude of the relationship in each direction was similar, and the presence of methamphetamine dependence or a lifetime psychotic disorder did not have an impact on results.

CONCLUSIONS

A dynamic, bidirectional relationship between methamphetamine and psychotic symptoms of similar magnitude in each direction was found over 1 year. This suggests integrated treatments that target methamphetamine, psychotic symptoms and their interrelationship may be of most benefit.

PROTOCOL: Psychosocial, pharmacological and legal interventions for improving the psychosocial outcomes of children with substance misusing parents

This review aims to first enhance and update existing reviews by comprehensively synthesising the full array of psychosocial, pharmacological and legal interventions that aim to improve the psychosocial outcomes of children with substance misusing parents. Second, the review aims to use network meta-analysis to integrate and examine the comparative impact of these interventions. Specifically, the review will address the following research questions: (1) What is the comparative impact of psychosocial, pharmacological, and legal interventions for improving the psychosocial outcomes of children with substance misusing parents? (2) Does the impact of interventions vary according to the child developmental period (e.g., infancy, early childhood, adolescence) or the type of (a) outcome measure; (b) substance misuse; (c) practitioner implementing the intervention; or (d) intervention setting? (3) Does the impact of interventions vary by the country of implementation?

Mindfulness-Based Program Embedded Within the Existing Curriculum Improves Executive Functioning and Behavior in Young Children: A Waitlist Controlled Trial

There is a growing evidence base for mindfulness-based interventions in educational settings. Notably, there has been little investigation of the potential benefits of classroom-based mindfulness programs in children in the early school years (Preparatory/Kindergarten, Grades 1 and 2) despite early childhood being a period characterized by the development of self-regulation and executive functions. The present study investigated the effects of a mindfulness program that was embedded within a school curriculum. This waitlist controlled trial investigated the effects of a mindfulness program, CalmSpace, delivered by classroom teachers across two school terms. A total of 55 students, M age = 76.4 months, SD = 8.62, were allocated to participate in CalmSpace in Terms 3 and 4. Thirty-six students in the waitlist control condition, M age = 80.53 months, SD = 13.04, participated in the intervention in Term 4. The start of Term 3 served as baseline (Time 1), and measures were obtained at the end of Term 3 (Time 2) and the end of Term 4 (Time 3). Direct measures of executive functioning using the Flanker Inhibitory Control and Attention Test (Flanker Task) and Dimensional Change Card Sort Task (DCCS) from the National Institute of Health Toolkit were obtained. Teachers' report of children's behavior was also obtained using the Strengths and Difficulties Questionnaire (Teacher version) at the beginning and at the end of Term 3, and at the end of Term 4. Children who received the CalmSpace program showed improvements on the DCCS relative to waitlist control at Time 2 (Cohen's d = 0.48) and Time 3 (Cohen's d = 1.10). Similar results were found on the Flanker Task with greater improvements found at Time 2 (Cohen's d = 0.77) and Time 3 (Cohen's d = 1.33). Teachers reported improvements for those receiving CalmSpace at Time 2 on total SDQ scores, Emotional Symptoms, Conduct Problems, Hyperactivity/Attention (Cohen's d = 0.32, 0.14, 0.46, 0.30, 0.33, and 0.53, respectively) compared to waitlist control and at Time 3 (Cohen's d = 0.85, 0.37, 0.48, and 0.90, respectively). The findings demonstrate that implementing the CalmSpace program can lead to improvements in EF and attention for young children. Despite limitations, this study provides promising evidence that the inclusion of focused, targeted mindfulness activities throughout the day may represent a value-added component to the regular school curriculum that can result in benefits for the students.

The Australian drug harms ranking study

BACKGROUND/AIM

The aim of the current study was to review drug harms as they occur in Australia using the Multi-criteria Decision Analysis (MCDA) methodology adopted in earlier studies in other jurisdictions.

METHOD

A facilitated workshop with 25 experts from across Australia, was held to score 22 drugs on 16 criteria: 9 related to harms that a drug produces in the individual and 7 to harms to others. Participants were guided by facilitators through the methodology and principles of MCDA. In open discussion, each drug was scored on each criterion. The criteria were then weighted using a process of swing weighting. Scoring was captured in MCDA software tool.

RESULTS

MCDA modelling showed the most harmful substances to users were fentanyls (part score 50), heroin (part score 45) and crystal methamphetamine (part score 42). The most harmful substances to others were alcohol (part score 41), crystal methamphetamine (part score 24) and cigarettes/tobacco (part score 14). Overall, alcohol was the most harmful drug when harm to users and harm to others was combined. A supplementary analysis took into consideration the prevalence of each substance in Australia. Alcohol was again ranked the most harmful substance overall, followed by cigarettes, crystal methamphetamine, cannabis, heroin and pharmaceutical opioids.

CONCLUSIONS

The results of this study make an important contribution to the emerging international picture of drug harms. They highlight the persistent and pervasive harms caused by alcohol. Policy implications and recommendations are discussed. Policies to reduce harm from alcohol and methamphetamine should be a priority.

Physiological self-regulation and mindfulness in children with a diagnosis of fetal alcohol spectrum disorder

OBJECTIVE

To explore the differences in baseline respiratory sinus arrhythmia (RSA) between children with fetal alcohol spectrum disorder (FASD) and typically developing children (TDC) and to investigate whether children with FASD have the capacity to engage in a brief mindfulness exercise.

METHODS

Participants were 14 children with FASD and 20 TDC. RSA was measured at baseline, during, and following a mindfulness exercise. A mindfulness compliance checklist was completed to ascertain if children could follow the task instructions.

RESULTS

Both groups obtained high scores on the mindfulness compliance checklist. There was a trend for children with FASD to have lower baseline RSA compared to TDC. Children in both groups demonstrated an increase in RSA during the mindfulness task.

CONCLUSIONS

Children with FASD could engage in a mindfulness task, and both groups showed an increase in RSA. Further research is needed to establish whether prolonged mindfulness practice could be beneficial.

A randomized controlled trial and economic evaluation of the Parents Under Pressure program for parents in substance abuse treatment

BACKGROUND

There is growing interest in the provision of parenting support to substance misusing parents.

METHODS

This pragmatic, multi-center randomized controlled trial compared an intensive one-to-one parenting program (Parents under Pressure, PuP) with Treatment as Usual (TAU) in the UK. Parents were engaged in community-based substance misuse services and were primary caregivers of children less than 2.5 years of age. The primary outcome was child abuse potential, and secondary outcomes included measures of parental emotional regulation assessed at baseline, 6 and 12-months. A prospective economic evaluation was also conducted.

RESULTS

Of 127 eligible parents, 115 met the inclusion criteria, and subsequently parents were randomly assigned to receive PuP (n = 48) or TAU (n = 52). Child abuse potential was significantly improved in those receiving the PuP program while those in TAU showed a deterioration across time in both intent-to-treat (p < 0.03) and per-protocol analyses (p < 0.01). There was also significant reliable change (recovery/improvement) in 30.6% of the PuP group compared with 10.3% of the TAU group (p < 0.02), and deterioration in 3% compared with 18% (p < 0.02). The probability that the program is cost-effective was approximately 51.8% if decision-makers are willing to pay £1000 for a unit improvement in the primary outcome, increasing to 98.0% at a £20,000 cost-effectiveness threshold for this measure.

CONCLUSIONS

Up to one-third of substance dependent parents of children under 3-years of age can be supported to improve their parenting, using a modular, one-to-one parenting program. Further research is needed.

The relationship between methamphetamine use and heterosexual behaviour: evidence from a prospective longitudinal study

AIMS

To estimate the extent to which specific sexual behaviours (being sexually active, having multiple sex partners, casual sex, condomless casual sex, anal sex and condomless anal sex) change during periods of methamphetamine use.

DESIGN

Within-person estimates for the relationship between methamphetamine use and sexual behaviour were derived from longitudinal panel data from the Methamphetamine Treatment Evaluation Study (MATES) cohort (2006-10).

SETTING

Sydney and Brisbane, Australia.

PARTICIPANTS

Participants (n = 319) were recruited through treatment and other health services, self-identified as heterosexual, were aged 17-51 years, 74% were male and all were dependent on methamphetamine on study entry.

MEASUREMENTS

Days of methamphetamine use in the past month and sexual behaviour in the past month were both assessed using the Opiate Treatment Index.

FINDINGS

When using methamphetamine, participants had double the odds of being sexually active compared with when they were not using, after adjustment for demographics and other substance use [adjusted odds ratio (aOR) = 1.9, P = 0.010]. When participants were sexually active, they were more likely to have multiple sex partners (aOR = 3.3, P = 0.001), casual sex partners (aOR = 3.9, P < 0.001) and condomless casual sex (aOR = 2.6, P = 0.012) when using methamphetamine than when they were not using. During months when participants had a casual sex partner, there was no significant reduction in their likelihood of condom use when they were using methamphetamine. There was no significant change in the likelihood of having anal sex or condomless anal sex during months of methamphetamine use.

CONCLUSIONS

Methamphetamine use is associated with an increase in being sexually active, having multiple sex partners and casual sex partners and having condomless sex with casual partners, but it is not associated with a change in condom use per se.

A qualitative evaluation of caregivers' experiences, understanding and outcomes following diagnosis of FASD

INTRODUCTION

The effects of prenatal exposure to alcohol are wide-ranging and pervasive in nature. In response to growing concerns about the lifelong disabilities related to prenatal alcohol exposure, a fetal alcohol spectrum disorder (FASD) diagnostic clinic was established in 2012. This was the first multi-disciplinary service operating permanently within an Australian health service. The current study aimed to explore the lived experience of the diagnostic process for caregivers of children with FASD.

METHODS

Twelve caregivers were approached and ten participated in audiotaped interviews about caring for a child with FASD. Qualitative analysis was undertaken on transcribed interviews using NVivo 10 for thematic analysis.

RESULTS

The major themes that emerged were: a desire for future support for their child although uncertainty about how this support could be accessed; an understanding of FASD prior to assessment but a concerted concern that this condition was not recognised as a disability across educational and related settings; that a formal assessment process provided validation for caregiver concerns and that caregivers felt respected and understood by the clinical team during this process.

DISCUSSION

These findings highlight the concerns of caregivers, emphasising both the importance of diagnostic services and the need for provision of further support beyond diagnosis for a child with FASD. WHAT DOES THIS PAPER ADD?: This study provides information on the lived experiences of caregivers who attended the first multi-disciplinary FASD assessment and diagnostic service in Australia. This study provides valuable insight into the ongoing difficulties that families are experiencing following diagnosis in the current Australian context.

Quality of Caregiving in Mothers With Illicit Substance Use: A Systematic Review and Meta-analysis

Background:

The quality of caregiving in mothers with substance abuse problems appears to be compromised. However, divergent findings, methodological variability, and sample characteristics point to the need for research synthesis.

Methods:

A comprehensive systematic search was undertaken. Studies were eligible if they (1) compared substance-misusing mothers with non–substance-misusing mothers, (2) involved children from birth to 3 years, and (3) maternal sensitivity and child responsiveness were measured using observational methodology.

Results:

A global meta-analysis for maternal sensitivity (n = 24 studies) and child responsiveness (n = 16 studies) on 3433 mother-infant dyads yielded significant population effect sizes and significant heterogeneity. Subgroup analyses found reduced heterogeneity when the meta-analysis was conducted on studies where groups were matched on key demographic characteristics; although the effect size was small, it was still significant for maternal sensitivity but not child responsiveness.

Conclusions:

Compromised quality of caregiving is found in high-risk, substance-misusing mothers, emphasising the importance of early intervention that draws from attachment-based interventions.

An Evidence-Based, Pre-Birth Assessment Pathway for Vulnerable Pregnant Women

The developmental needs of infants during the first year of life have been emphasised by recent research from a variety of sources highlighting the crucial role that early parent-infant interaction plays. Infants identified as being at significant risk of maltreatment need adequate protection within a time frame consistent with their developmental needs. This briefing paper describes a new care pathway established within a UK-based social care team, which aims to provide early identification, intensive support, timely assessment and decision making for a group of highly vulnerable, pregnant women, their partners and their infants. The pathway of care is described and a case study is presented to illustrate this care pathway. A mother is referred at eighteen weeks of pregnancy and supported post birth for six months. The combination of supporting structured professional judgement by the inclusion of standardised tools and training in a programme specifically developed for high-risk families suggests that this pre-birth risk-assessment process warrants further evaluation.

Correlates of transient versus persistent psychotic symptoms among dependent methamphetamine users

This study examined correlates of transient versus persistent psychotic symptoms among people dependent on methamphetamine. A longitudinal prospective cohort study of dependent methamphetamine users who did not meet DSM-IV criteria for lifetime schizophrenia or mania. Four non-contiguous one-month observation periods were used to identify participants who had a) no psychotic symptoms, (n=110); (b) psychotic symptoms only when using methamphetamine (transient psychotic symptoms, n=85); and, (c) psychotic symptoms both when using methamphetamine and when abstaining from methamphetamine (persistent psychotic symptoms, n=37). Psychotic symptoms were defined as a score of 4 or greater on any of the Brief Psychiatric Rating Scale items of suspiciousness, hallucinations or unusual thought content. Relative no psychotic symptoms, both transient and persistent psychotic symptoms were associated with childhood conduct disorder and comorbid anxiety disorders. Earlier onset methamphetamine use and being male were more specifically related to transient psychotic symptoms, while a family history of a primary psychotic disorder and comorbid major depression were specifically related to persistent psychotic symptoms. We conclude that there are overlapping but also distinct clinical correlates of transient versus persistent psychotic symptoms, suggesting potentially heterogeneous etiological pathways underpinning the psychotic phenomena seen amongst people who use methamphetamine.

The profile of psychiatric symptoms exacerbated by methamphetamine use

BACKGROUND

Methamphetamine use can produce symptoms almost indistinguishable from schizophrenia. Distinguishing between the two conditions has been hampered by the lack of a validated symptom profile for methamphetamine-induced psychiatric symptoms. We use data from a longitudinal cohort study to examine the profile of psychiatric symptoms that are acutely exacerbated by methamphetamine use.

METHODS

164 methamphetamine users, who did not meet DSM-IV criteria for a lifetime primary psychotic disorder, were followed monthly for one year to assess the relationship between days of methamphetamine use and symptom severity on the 24-item Brief Psychiatric Rating Scale. Exacerbation of psychiatric symptoms with methamphetamine use was quantified using random coefficient models. The dimensions of symptom exacerbation were examined using principal axis factoring and a latent profile analysis.

RESULTS

Symptoms exacerbated by methamphetamine loaded on three factors: positive psychotic symptoms (suspiciousness, unusual thought content, hallucinations, bizarre behavior); affective symptoms (depression, suicidality, guilt, hostility, somatic concern, self-neglect); and psychomotor symptoms (tension, excitement, distractibility, motor hyperactivity). Methamphetamine use did not significantly increase negative symptoms. Vulnerability to positive psychotic and affective symptom exacerbation was shared by 28% of participants, and this vulnerability aligned with a past year DSM-IV diagnosis of substance-induced psychosis (38% vs. 22%, χ(2)(df1)=3.66, p=0.056).

CONCLUSION

Methamphetamine use produced a symptom profile comprised of positive psychotic and affective symptoms, which aligned with a diagnosis of substance-induced psychosis, with no evidence of a negative syndrome.

Primary and substance-induced psychotic disorders in methamphetamine users

This study investigates the rates of primary psychotic disorders (PPD) and substance-induced psychotic disorders (SIPDs) in methamphetamine (MA) users accessing needle and syringe programs (NSPs). The aim was to determine if there are systematic differences in the characteristics of MA users with PPDs and SIPDs compared to those with no psychotic disorder. Participants were 198 MA users reporting use in the previous month. Diagnosis was determined using the Psychiatric Research Interview for DSM-IV Substance and Mental Disorders (PRISM-IV). Current psychiatric symptoms and substance use were also measured. Just over half (n=101) of participants met DSM-IV criteria for a lifetime psychotic disorder, including 81 (80%) with a SIPD and 20 (20%) with a PPD. Those with a younger age of onset of weekly MA use were at increased risk of a lifetime SIPD. A current psychotic disorder was found in 62 (39%), comprising 49 SIPDs (79%) and 13 PPDs (21%). MA users with a current PPD were more likely to have received psychiatric treatment in the past month than those with a current SIPD, despite a similar level of psychotic symptom severity. A high proportion of MA users accessing NSPs have psychotic disorders, the majority of which are substance-induced.

Modifying the risk associated with an impulsive temperament: a prospective study of drug dependence treatment

The evidence linking the personality trait of impulsivity and substance misuse is well established. Importantly, impulsivity not only predicts substance misuse problems but has an association with duration in treatment, likelihood of completing treatment and time to relapse. Treatment that focuses on increasing awareness and acceptance of thoughts and emotions may potentially address impulsive behaviour and in this respect improve treatment outcomes for substance misuse. The current paper investigated the relationship between the facet of impulsivity that taps into poor inhibitory control and treatment outcome. In addition, there was a specific focus on ascertaining the impact of an increase in awareness and attentional control measured in 144 adult substance users receiving treatment in a residential therapeutic community. Impulsivity predicted poorer treatment outcome (measured as drug use severity). Increases in awareness and acceptance of emotions and thoughts during treatment were related to better outcome although this was not associated with baseline levels of impulsivity. Clinical and theoretical implications are discussed.

Impulsivity: four ways five factors are not basic to addiction

Several impulsivity-related models have been applied to understanding the vulnerability to addiction. While there is a growing consensus that impulsivity is multifaceted, debate continues as to the precise number of facets and, more critically, which are most relevant to explaining the addiction-risk profile. In many ways, the current debate mirrors that which took place in the personality literature in the early 1990s (e.g., Eysenck's 'Big Three' versus Costa and McCrae's 'Big Five'). Indeed, many elements of this debate are relevant to the current discussion of the role of impulsivity in addictive behavior. Specifically, 1) the use of factor analysis as an atheoretical 'truth-grinding machine'; 2) whether additional facets add explanatory power over fewer; 3) the delineation of specific neurocognitive pathways from each facet to addictive behaviors, and; 4) the relative merit of 'top-down' versus 'bottom-up' approaches to the understanding of impulsivity. Ultimately, the utility of any model of impulsivity and addiction lies in its heuristic value and ability to integrate evidence from different levels of analysis. Here, we make the case that theoretically-driven, bottom-up models proposing two factors deliver the optimal balance of explanatory power, parsimony, and integration of evidence.

Does methamphetamine use increase violent behaviour? Evidence from a prospective longitudinal study

AIMS

To determine whether violent behaviour increases during periods of methamphetamine use and whether this is due to methamphetamine-induced psychotic symptoms.

DESIGN

A fixed-effects (within-subject) analysis of four non-contiguous 1-month observation periods from a longitudinal prospective cohort study.

SETTING

Sydney and Brisbane, Australia.

PARTICIPANTS

A total of 278 participants aged 16 years or older who met DSM-IV criteria for methamphetamine dependence on entry to the study but who did not meet DSM-IV criteria for life-time schizophrenia or mania.

MEASUREMENTS

Violent behaviour was defined as severe hostility in the past month on the Brief Psychiatric Rating Scale (BPRS) (corresponding to assault/damage to property). Days of methamphetamine and other substance use in the past month were assessed using the Opiate Treatment Index. Positive psychotic symptoms in the past month were identified using the BPRS.

FINDINGS

There was a dose-related increase in violent behaviour when an individual was using methamphetamine compared with when they were not after adjusting for other substance use and socio-demographics [cf. no use in the past month: 1-15 days of use odds ratio (OR) = 2.8, 95% confidence interval (CI) =1.6-4.9; 16+ days of use OR = 9.5, 95% CI = 4.8-19.1]. The odds of violent behaviour were further increased by psychotic symptoms (OR = 2.0, 95% CI = 1.1-3.6), which accounted for 22-30% of violent behaviour related to methamphetamine use. Heavy alcohol consumption also increased the risk of violent behaviour (OR = 3.1, 95% CI = 1.4-7.0) and accounted for 12-18% of the violence risk related to methamphetamine use.

CONCLUSIONS

There is a dose-related increase in violent behaviour during periods of methamphetamine use that is largely independent of the violence risk associated with psychotic symptoms.

Uptake of tamoxifen in consecutive premenopausal women under surveillance in a high-risk breast cancer clinic

BACKGROUND

Randomised trials of tamoxifen versus placebo indicate that tamoxifen reduces breast cancer risk by approximately 33%, yet uptake is low. Approximately 10% of women in our clinic entered the IBIS-I prevention trial. We assess the uptake of tamoxifen in a consecutive series of premenopausal women not in a trial and explore the reasons for uptake through interviews.

METHODS

All eligible women between 33 and 46 years at ≥17% lifetime risk of breast cancer and undergoing annual mammography in our service were invited to take a 5-year course of tamoxifen. Reasons for accepting (n=15) or declining (n=15) were explored using semi-structured interviews.

RESULTS

Of 1279 eligible women, 136 (10.6%) decided to take tamoxifen. Women >40 years (74 out of 553 (13.4%)) and those at higher non-BRCA-associated risk were more likely to accept tamoxifen (129 out of 1109 (11.6%)). Interviews highlighted four themes surrounding decision making: perceived impact of side effects, the impact of others' experience on beliefs about tamoxifen, tamoxifen as a 'cancer drug', and daily reminder of cancer risk.

CONCLUSIONS

Tamoxifen uptake was similar to previously ascertained uptake in a randomised controlled trial (IBIS-I). Concerns were similar in women who did or did not accept tamoxifen. Decision making appeared to be embedded in the experience of significant others.

Predicting posttraumatic stress disorder after childbirth

OBJECTIVE

around 50% of women report symptoms that indicate some aspect of their childbirth experience was 'traumatic', and at least 3.1% meet diagnosis for PTSD six months post partum. Here we aimed to conduct a prospective longitudinal study and examine predictors of birth-related trauma - predictors that included a range of pre-event factors - as a first step in the creation of a screening questionnaire.

METHOD

of the 933 women who completed an assessment in their third trimester, 866 were followed-up at four to six week post partum. Two canonical discriminant function analyses were conducted to ascertain factors associated with experiencing birth as traumatic and, of the women who found the birth traumatic, which factors were associated with those who developed PTSD.

FINDINGS

a mix of 16 pre-birth predictor variables and event-specific predictor variables distinguished women who reported symptoms consistent with trauma from those who did not. Fourteen predictor variables distinguished women who went on to develop PTSD from those who did not.

CONCLUSIONS

anxiety sensitivity to possible birthing problems, breached birthing expectations, and severity of any actual birth problem, predicted those who found the birth traumatic. Prior trauma was the single most important predictive factor of PTSD. Evaluating the utility of brief, cost-effective, and accurate screening for women at risk of developing birth-related PTSD is suggested.

Personality, cognition and hazardous drinking: Support for the 2-Component Approach to Reinforcing Substances Model

Personality and cognitive processes are both related to alcohol use and misuse. A recent model of hazardous drinking referred, the 2-CARS model, postulates two major pathways to hazardous drinking. One pathway primarily involves the association between Reward Drive and Positive Outcome Expectancies, the second involves the association between Rash Impulsiveness and Drinking Refusal Self-Efficacy. In previous tests of the model, Drinking Refusal Self-Efficacy was found to have the most proximal impact on drinking, being directly influenced by Rash Impulsiveness, and indirectly influenced by Reward Drive through Positive Outcome Expectancies. The aim of the current study was to test the 2-CARS model in a larger independent sample. Results found that individuals with a strong Reward Drive showed higher Positive Outcome Expectancies, while individuals high in Rash Impulsiveness were more likely to report reduced Drinking Refusal Self-Efficacy. The present results also showed a theoretically unexpected pathway with a direct association between Rash Impulsiveness and Positive Outcome Expectancies. However, overall the results support the view that a greater understanding of hazardous drinking can be achieved by investigating the relationship between these personality and cognitive variables.

An evaluation of the parents under pressure programme: a study protocol for an RCT into its clinical and cost effectiveness

BACKGROUND

Many babies in the UK are born to drug-dependent parents, and dependence on psychoactive drugs during the postnatal period is associated with high rates of child maltreatment, with around a quarter of these children being subject to a child protection plan. Parents who are dependent on psychoactive drugs are at risk of a wide range of parenting problems, and studies have found reduced sensitivity and responsiveness to both the infant's physical and emotional needs. The poor outcomes that are associated with such drug dependency appear to be linked to the multiple difficulties experienced by such parents.An increase in understanding about the crucial importance of early relationships for infant well-being has led to a focus on the development and delivery of services that are aimed at supporting parenting and parent-infant interactions. The Parents under Pressure (PuP) programme is aimed at supporting parents who are dependent on psychoactive drugs or alcohol by providing them with methods of managing their emotional regulation, and of supporting their new baby's development. An evaluation of the PuP programme in Australia with parents on methadone maintenance of children aged 3 to 8 years found significant reductions in child abuse potential, rigid parenting attitudes and child behaviour problems.

METHODS/DESIGN

The study comprises a multicentre randomised controlled trial using a mixed-methods approach to data collection and analysis in order to identify which families are most able to benefit from this intervention.The study is being conducted in six family centres across the UK, and targets primary caregivers of children less than 2.5 years of age who are substance dependent. Consenting participants are randomly allocated to either the 20-week PuP programme or to standard care.The primary outcome is child abuse potential, and secondary outcomes include substance use, parental mental health and emotional regulation, parenting stress, and infant/toddler socio-emotional adjustment scale.

DISCUSSION

This is one the first UK studies to examine the effectiveness of a programme targeting the parenting of substance-dependent parents of infants and toddlers, in terms of its effectiveness in improving the parent-infant relationship and reducing the potential for child abuse.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number Register: ISRCTN47282925.

Dose-related psychotic symptoms in chronic methamphetamine users: evidence from a prospective longitudinal study

CONTEXT

Methamphetamine is associated with psychotic phenomena, but it is not clear to what extent this relationship is due to premorbid psychosis among people who use the drug.

OBJECTIVE

To determine the change in the probability of psychotic symptoms occurring during periods of methamphetamine use.

DESIGN

Longitudinal prospective cohort study. A fixed-effects analysis of longitudinal panel data, consisting of 4 noncontiguous 1-month observation periods, was used to examine the relationship between changes in methamphetamine use and the risk of experiencing psychotic symptoms within individuals over time.

SETTING

Sydney and Brisbane, Australia.

PARTICIPANTS

A total of 278 participants 16 years of age or older who met DSM-IV criteria for methamphetamine dependence on entry to the study but who did not meet DSM-IV criteria for lifetime schizophrenia or mania.

MAIN OUTCOME MEASURES

Clinically significant psychotic symptoms in the past month, defined as a score of 4 or more on any of the Brief Psychiatric Rating Scale items of suspiciousness, hallucinations, or unusual thought content. The number of days of methamphetamine use in the past month was assessed using the Opiate Treatment Index.

RESULTS

There was a 5-fold increase in the likelihood of psychotic symptoms during periods of methamphetamine use relative to periods of no use (odds ratio [OR], 5.3 [95% CI, 3.4-8.3]; P < .001), this increase being strongly dose-dependent (1-15 days of methamphetamine use vs abstinence in the past month: OR, 4.0 [95% CI, 2.5-6.5]; ≥16 days of methamphetamine use vs abstinence in the past month: OR, 11.2 [95% CI, 5.9-21.1]). Frequent cannabis and/or alcohol use (≥16 days of use in the past month) further increased the odds of psychotic symptoms (cannabis: OR, 2.0 [95% CI, 1.1-3.5]; alcohol: OR, 2.1 [95% CI, 1.1-4.2]).

CONCLUSIONS

There was a large dose-dependent increase in the occurrence of psychotic symptoms during periods of methamphetamine use among users of the drug.

The contribution of mindfulness-based therapies for children and families and proposed conceptual integration

BACKGROUND

  Mindfulness is the development of a nonjudgmental accepting awareness of moment-by-moment experience. Intentionally attending to one's ongoing stream of sensations, thoughts, and emotions as they arise has a number of benefits, including the ability to react with greater flexibility to events and sustain attention. Thus the teaching of mindfulness-based skills to children and their carers is a potential means of improving family relationships and helping children achieve more positive developmental outcomes through increased ability to sustain attention and manage emotions. We provide a review of recent studies evaluating mindfulness-based interventions targeting children, adolescents, and families in educational and clinical settings.

METHOD

  Searches were conducted of several databases (including Medline, PsychINFO and Cochrane Reviews) to identify studies that have evaluated mindfulness-based interventions targeting children, adolescents or families published since 2009.

RESULTS

  Twenty-four studies were identified. We conclude that mindfulness-based interventions are an important addition to the repertoire of existing therapeutic techniques. However, large-scale, methodologically rigorous studies are lacking. The interventions used in treatment evaluations vary in both content and dose, the outcomes targeted have varied, and no studies have employed methodology to investigate mechanisms of change.

CONCLUSIONS

  There is increasing evidence that mindfulness-based therapeutic techniques can have a positive impact on a range of outcome variables. A greater understanding of the mechanisms of change is an important future direction of research. We argue that locating mindfulness-based therapies targeting children and families within the broader child and family field has greater promise in improving child and family functioning than viewing mindful parenting as an independent endeavor.

Evaluating the impact of community-based treatment options on methamphetamine use: findings from the Methamphetamine Treatment Evaluation Study (MATES)

AIMS

To evaluate the impact of community-based drug treatment on methamphetamine use using inverse probability of treatment-weighted (IPTW) estimators to derive treatment effects.

DESIGN

A longitudinal prospective cohort study with follow-ups at 3 months, 1 year and 3 years. Treatment effects were derived by comparing groups at follow-up. IPTW estimators were used to adjust for pre-treatment differences between groups.

SETTING

Sydney and Brisbane, Australia.

PARTICIPANTS

Participants were methamphetamine users entering community-based detoxification (n = 112) or residential rehabilitation (n = 248) services and a quasi-control group of methamphetamine users (n = 101) recruited from the community.

MEASUREMENTS

Frequency of methamphetamine use between interviews (no use, less than weekly, 1-2 days per week, 3+ days per week), continuous abstinence from methamphetamine use, past month methamphetamine use and methamphetamine dependence.

FINDINGS

Detoxification did not reduce methamphetamine use at any follow-up relative to the quasi-control group. Relative to quasi-control and detoxification groups combined, residential rehabilitation produced large reductions in the frequency of methamphetamine use at 3 months [odds ratio (OR) = 0.23, 95% confidence interval (CI) 0.15-0.36, P < 0.001), with a marked attenuation of this effect at 1 year (OR 0.62, 95% CI 0.40-0.97, P = 0.038) and 3 years (OR = 0.71, 95% CI 0.42-1.19, P = 0.189). The greatest impact was for abstinence: for every 100 residential rehabilitation clients there was a gain of 33 being continuously abstinent at 3 months, with this falling to 14 at 1 year and 6 at 3 years.

CONCLUSIONS

Community-based residential rehabilitation may produce a time-limited decrease in methamphetamine use, while detoxification alone does not appear to do so.

The Helping Families Programme: a new parenting intervention for children with severe and persistent conduct problems

BACKGROUND

  Severe and persistent conduct problems in children during the primary school years are associated with school exclusion, increased risk of delinquency and early substance abuse.

METHOD

  Literature reviews and consultation with experts in the field were used to better understand the factors that contribute to severe and persistent conduct problems and to identify the principles and potential methods to be included in a new intervention.

RESULTS

  Grounded in an ecological perspective, an innovative, multimodal intervention, the Helping Families Programme, has been developed. It uses a modular approach to systematically address parent behaviour, cognition and emotion across five key risk factor domains: parental mood and dysregulation; parent-child, family and school relationships; substance misuse; social support and networks; and managing life events and crises.

CONCLUSION

  Initial piloting of the Programme has offered early support for the potential value of the underlying principles and methods of the Programme.

Alcohol expectancies and drinking refusal self-efficacy mediate the association of impulsivity with alcohol misuse

BACKGROUND

Recent work suggests that 2 biologically based traits convey risk for alcohol misuse: reward sensitivity/drive and (rash) impulsiveness. However, the cognitive mechanisms through which these traits convey risk are unclear. This study tested a model predicting that the risk conveyed by reward sensitivity is mediated by a learning bias for the reinforcing outcomes of alcohol consumption (i.e., positive alcohol expectancy). The model also proposed that the risk conveyed by rash impulsiveness (RI) is mediated by drinkers' perceived ability to resist alcohol (i.e., drinking refusal self-efficacy).

METHODS

Study 1 tested the model in a sample of young adults (n = 342). Study 2 tested the model in a sample of treatment-seeking substance abusers (n = 121). All participants completed a battery of personality, cognitive, and alcohol use questionnaires and models were tested using structural equation modeling.

RESULTS

In both studies, the hypothesized model was found to provide a good fit to the data, and a better fit than alternative models. In both young adults and treatment-seeking individuals, positive alcohol expectancy fully mediated the association between reward sensitivity and hazardous alcohol use. For treatment seekers, drinking refusal self-efficacy fully mediated the association between RI and hazardous drinking. However, there was partial mediation in the young adult sample. Furthermore, neither trait was directly associated with the other cognitive mediator.

CONCLUSIONS

The hypothesized model was confirmed on a large sample of young adults and replicated on a sample of treatment-seeking substance abusers. Taken together, these findings shed further light on the mechanisms through which an impulsive temperament may convey risk for alcohol misuse.