Treatment of child anxiety in the context of maternal anxiety disorder: a randomised controlled trial and economic analysis

Background Cognitive–behavioural therapy (CBT) for childhood anxiety disorders is associated with modest outcomes in the context of parental anxiety disorder. Objectives This study evaluated whether or not the outcome of CBT for children with anxiety disorders in the context of maternal anxiety disorders is improved by the addition of (i) treatment of maternal anxiety disorders, or (ii) treatment focused on maternal responses. The incremental cost-effectiveness of the additional treatments was also evaluated. Design Participants were randomised to receive (i) child cognitive–behavioural therapy (CCBT); (ii) CCBT with CBT to target maternal anxiety disorders [CCBT + maternal cognitive–behavioural therapy (MCBT)]; or (iii) CCBT with an intervention to target mother–child interactions (MCIs) (CCBT + MCI). Setting A NHS university clinic in Berkshire, UK. Participants Two hundred and eleven children with a primary anxiety disorder, whose mothers also had an anxiety disorder. Interventions All families received eight sessions of individual CCBT. Mothers in the CCBT + MCBT arm also received eight sessions of CBT targeting their own anxiety disorders. Mothers in the MCI arm received 10 sessions targeting maternal parenting cognitions and behaviours. Non-specific interventions were delivered to balance groups for therapist contact. Main outcome measures Primary clinical outcomes were the child’s primary anxiety disorder status and degree of improvement at the end of treatment. Follow-up assessments were conducted at 6 and 12 months. Outcomes in the economic analyses were identified and measured using estimated quality-adjusted life-years (QALYs). QALYS were combined with treatment, health and social care costs and presented within an incremental cost–utility analysis framework with associated uncertainty. Results MCBT was associated with significant short-term improvement in maternal anxiety; however, after children had received CCBT, group differences were no longer apparent. CCBT + MCI was associated with a reduction in maternal overinvolvement and more confident expectations of the child. However, neither CCBT + MCBT nor CCBT + MCI conferred a significant post-treatment benefit over CCBT in terms of child anxiety disorder diagnoses [adjusted risk ratio (RR) 1.18, 95% confidence interval (CI) 0.87 to 1.62, p = 0.29; adjusted RR CCBT + MCI vs. control: adjusted RR 1.22, 95% CI 0.90 to 1.67, p = 0.20, respectively] or global improvement ratings (adjusted RR 1.25, 95% CI 1.00 to 1.59, p = 0.05; adjusted RR 1.20, 95% CI 0.95 to 1.53, p = 0.13). CCBT + MCI outperformed CCBT on some secondary outcome measures. Furthermore, primary economic analyses suggested that, at commonly accepted thresholds of cost-effectiveness, the probability that CCBT + MCI will be cost-effective in comparison with CCBT (plus non-specific interventions) is about 75%. Conclusions Good outcomes were achieved for children and their mothers across treatment conditions. There was no evidence of a benefit to child outcome of supplementing CCBT with either intervention focusing on maternal anxiety disorder or maternal cognitions and behaviours. However, supplementing CCBT with treatment that targeted maternal cognitions and behaviours represented a cost-effective use of resources, although the high percentage of missing data on some economic variables is a shortcoming. Future work should consider whether or not effects of the adjunct interventions are enhanced in particular contexts. The economic findings highlight the utility of considering the use of a broad range of services when evaluating interventions with this client group. Trial registration Current Controlled Trials ISRCTN19762288. Funding This trial was funded by the Medical Research Council (MRC) and Berkshire Healthcare Foundation Trust and managed by the National Institute for Health Research (NIHR) on behalf of the MRC–NIHR partnership (09/800/17) and will be published in full in Health Technology Assessment; Vol. 19, No. 38.

Roman barrows and their landscape context: a GIS case study at Bartlow, Cambridgeshire

This paper examines the landscape context of the Bartlow Hills, a group of large Romano-British barrows that were excavated in the 1840s but have been largely neglected since. GIS is employed to test whether it was possible to view the mounds from nearby roads, barrows and villas. Existing research on provincial barrows, and especially their landscape context, and some recent relevant applications of GIS are reviewed. We argue that barrows are active and symbolically charged statements about power and identity. The most striking pattern to emerge from the GIS analysis is a focus on display to a local rather than a transient audience.

Seasonality of modern pollen and sediment deposition in an estuarine context: the Severn Estuary Levels, southwest England

Recent sedimentological and palynological research on subfossil Holocene banded sediments from the Severn Estuary Levels suggested seasonality of deposition, registered by variations in mineral grain-size and pollen assemblages between different parts of the bands. Here we provide data that strengthen this interpretation from sampling of modern sediments and pollen deposition on an active mudflat and saltmarsh on the margin of the Severn Estuary, and comparison with a vegetation survey and contemporary records of climate, river and tidal regimes. The results of grain-size analysis indicate deposition of comparatively coarse-grained silts during the relatively cool and windy conditions of winter and comparatively fine-grained sediments during relatively warm and calm summer months. Pollen analysis demonstrates the significance of long-term storage of pollen grains and fern spores in the estuarine waterbody, superimposed on which seasonal variations in pollen inputs from local and regional vegetation remain detectable. Copyright (C) 2007 John Wiley & Sons, Ltd.

Starting well: Gender, care and health in the family context

In this article we present a critique of a series of public policy documents that aim at improvement in health for the general population, particularly families, but fail to recognize or appreciate the implications of gender for the everyday and the long-term experiences of family members. Drawing upon considerations of gender, families, health time and space and previous theoretical work (McKie et al, 2002), we propose the concept of healthscapes to aid the analysis and development of public policies. A healthscapes approach allows analysis of health policy within the diverse and multi-dimensional notions of time, space and gender that infuse the lifecourse. We assert that consideration of the gendered and generational project of caring particularly in relation to the (re)production of health, should involve a reflective inter-play between theory research and policy.

The Representative Soil Sampling Scheme of England and Wales: a statistical analysis of topsoil nutrient status and pH between 1971 and 2001

The Representative Soil Sampling Scheme of England and Wales has recorded information on the soil of agricultural land in England and Wales since 1969. It is a valuable source of information about the soil in the context of monitoring for sustainable agricultural development. Changes in soil nutrient status and pH were examined over the period 1971-2001. Several methods of statistical analysis were applied to data from the surveys during this period. The main focus here is on the data for 1971, 1981, 1991 and 2001. The results of examining change over time in general show that levels of potassium in the soil have increased, those of magnesium have remained fairly constant, those of phosphorus have declined and pH has changed little. Future sampling needs have been assessed in the context of monitoring, to determine the mean at a given level of confidence and tolerable error and to detect change in the mean over time at these same levels over periods of 5 and 10 years. The results of a non-hierarchical multivariate classification suggest that England and Wales could be stratified to optimize future sampling and analysis. To monitor soil quality and health more generally than for agriculture, more of the country should be sampled and a wider range of properties recorded.

An analysis of the management of a public sector project: a systems-based case study

The management of a public sector project is analysed using a model developed from systems theory. Linear responsibility analysis is used to identify the primary and key decision structure of the project and to generate quantitative data regarding differentiation and integration of the operating system, the managing system and the client/project team. The environmental context of the project is identified. Conclusions are drawn regarding the project organization structure's ability to cope with the prevailing environmental conditions. It is found that the complexity of the managing system imposed on the project was unable to achieve this and created serious deficiencies in the outcome of the project.

Roles in construction projects: analysis and terminology

Standard form contracts are typically developed through a negotiated consensus, unless they are proffered by one specific interest group. Previously published plans of work and other descriptions of the processes in construction projects tend to focus on operational issues, or they tend to be prepared from the point of view of one or other of the dominant interest groups. Legal practice in the UK permits those who draft contracts to define their terms as they choose. There are no definitive rulings from the courts that give an indication as to the detailed responsibilities of project participants. The science of terminology offers useful guidance for discovering and describing terms and their meanings in their practical context, but has never been used for defining terms for responsibilities of participants in the construction project management process. Organizational analysis enables the management task to be deconstructed into its elemental parts in order that effective organizational structures can be developed. Organizational mapping offers a useful technique for reducing text-based descriptions of project management roles and responsibilities to a comparable basis. Research was carried out by means of a desk study, detailed analysis of nine plans of work and focus groups representing all aspects of the construction industry. No published plan of work offers definitive guidance. There is an enormous amount of variety in the way that terms are used for identifying responsibilities of project participants. A catalogue of concepts and terms (a “Terminology”) has been compiled and indexed to enable those who draft contracts to choose the most appropriate titles for project participants. The purpose of this terminology is to enable the selection and justification of appropriate terms in order to help define roles. The terminology brings an unprecedented clarity to the description of roles and responsibilities in construction projects and, as such, will be helpful for anyone seeking to assemble a team and specify roles for project participants.

Context-aware visual exploration of molecular databases

Facilitating the visual exploration of scientific data has received increasing attention in the past decade or so. Especially in life science related application areas the amount of available data has grown at a breath taking pace. In this paper we describe an approach that allows for visual inspection of large collections of molecular compounds. In contrast to classical visualizations of such spaces we incorporate a specific focus of analysis, for example the outcome of a biological experiment such as high throughout screening results. The presented method uses this experimental data to select molecular fragments of the underlying molecules that have interesting properties and uses the resulting space to generate a two dimensional map based on a singular value decomposition algorithm and a self organizing map. Experiments on real datasets show that the resulting visual landscape groups molecules of similar chemical properties in densely connected regions.

Case-based analysis in user requirements modelling for knowledge construction

Context: Learning can be regarded as knowledge construction in which prior knowledge and experience serve as basis for the learners to expand their knowledge base. Such a process of knowledge construction has to take place continuously in order to enhance the learners’ competence in a competitive working environment. As the information consumers, the individual users demand personalised information provision which meets their own specific purposes, goals, and expectations. Objectives: The current methods in requirements engineering are capable of modelling the common user’s behaviour in the domain of knowledge construction. The users’ requirements can be represented as a case in the defined structure which can be reasoned to enable the requirements analysis. Such analysis needs to be enhanced so that personalised information provision can be tackled and modelled. However, there is a lack of suitable modelling methods to achieve this end. This paper presents a new ontological method for capturing individual user’s requirements and transforming the requirements onto personalised information provision specifications. Hence the right information can be provided to the right user for the right purpose. Method: An experiment was conducted based on the qualitative method. A medium size of group of users participated to validate the method and its techniques, i.e. articulates, maps, configures, and learning content. The results were used as the feedback for the improvement. Result: The research work has produced an ontology model with a set of techniques which support the functions for profiling user’s requirements, reasoning requirements patterns, generating workflow from norms, and formulating information provision specifications. Conclusion: The current requirements engineering approaches provide the methodical capability for developing solutions. Our research outcome, i.e. the ontology model with the techniques, can further enhance the RE approaches for modelling the individual user’s needs and discovering the user’s requirements.

Effectiveness of landmark analysis for establishing locality in p2p networks

Locality to other nodes on a peer-to-peer overlay network can be established by means of a set of landmarks shared among the participating nodes. Each node independently collects a set of latency measures to landmark nodes, which are used as a multi-dimensional feature vector. Each peer node uses the feature vector to generate a unique scalar index which is correlated to its topological locality. A popular dimensionality reduction technique is the space filling Hilbert’s curve, as it possesses good locality preserving properties. However, there exists little comparison between Hilbert’s curve and other techniques for dimensionality reduction. This work carries out a quantitative analysis of their properties. Linear and non-linear techniques for scaling the landmark vectors to a single dimension are investigated. Hilbert’s curve, Sammon’s mapping and Principal Component Analysis have been used to generate a 1d space with locality preserving properties. This work provides empirical evidence to support the use of Hilbert’s curve in the context of locality preservation when generating peer identifiers by means of landmark vector analysis. A comparative analysis is carried out with an artificial 2d network model and with a realistic network topology model with a typical power-law distribution of node connectivity in the Internet. Nearest neighbour analysis confirms Hilbert’s curve to be very effective in both artificial and realistic network topologies. Nevertheless, the results in the realistic network model show that there is scope for improvements and better techniques to preserve locality information are required.

Never the twain shall meet: A memetic analysis of poverty perceptions

Poverty, as defined within development discourse, does not fully capture the reality in which the poor live, which is formed also by values and beliefs specific to a given culture and setting. This article uses a memetic approach to investigating the reality of poverty among pastoralists and urban dwellers in Kenya. By distinguishing the semantic space and the cultural context in which the definitions are framed, it enables the researcher to make sufficient generalisations while also recognising the differences between cultures. The results demonstrate how pastoralists and urban dwellers conceptualise poverty differently particularly in regard to causes. Further, the article suggests that development actors often utilise a Western construct which does not entirely reflect the values and beliefs of the poor.

Landscape typology in the Mediterranean context: a tool for habitat restoration

Despite the wide use of Landscape Character Assessment (LCA) as a tool for landscape planning in NW Europe, there are few examples of its application in the Mediterranean. This paper reports on the results from the development of a typology for LCA in a study area of northern Sardinia, Italy to provide a spatial framework for the analysis of current patterns of cork oak distribution and future restoration of this habitat. Landscape units were derived from a visual interpretation of map data stored within a GIS describing the physical and cultural characteristics of the study area. The units were subsequently grouped into Landscape Types according to the similarity of shared attributes using Two Way Indicator Species Analysis (TWINSPAN). The preliminary results showed that the methodology classified distinct Landscape Types but, based on field observations, there is a need for further refinement of the classification. The distribution and properties of two main cork oak habitats types was examined within the identified Landscape Types namely woodlands and wood pastures using Patch Analyst. The results show very clearly a correspondence between the distribution of cork oak pastures and cork oak woodland and landscape types. This forms the basis of the development of strategies for the maintenance, restoration and recreation of these habitat types within the study area, ultimately for the whole island of Sardinia. Future work is required to improve the landscape characterisation , particularly with respect to cultural factors, and to determine the validity of the landscape spatial framework for the analysis of cork oak distribution as part of a programme of habitat restoration and re-creation.