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.

Graceful remedies: understanding grace in the Catholic Church's treatment of clerical child sexual abuse

This article examines advocacy of Catholic restorative justice for clerical child sexual abuse from the standpoint of feminist criminological critiques of the use of restorative mediation in sexual offence cases. In particular, it questions the Catholic invocation of grace and forgiveness of survivors of abuse in light of critical feminist concerns about the exploitation of emotions in restorative practices, especially in regard to sexual and other gender-based offences. In the context of sexual abuse, the Catholic appeal to grace has the potential for turning into an extraordinary demand made of victims not only to rehabilitate offenders and the church in the eyes of the community, but also to work towards the spiritual absolution of the abuser. This unique feature of Catholic-oriented restorative justice raises important concerns in terms of feminist critiques of the risk of abuses of power within mediation, and is also incompatible with orthodox restorative justice theory, which, although it advocates a ‘spiritual’ response to crime, is concerned foremost with the rights, needs and experiences of victims.

Older age of onset in child L2 acquisition can be facilitative: evidence from the acquisition of English passives by Spanish natives

We report a longitudinal comprehension study of (long) passive constructions in two native-Spanish child groups differing by age of initial exposure to L2 English (young group: 3;0-4;0 years; older group: 6;0-7;0 years); where amount of input, L2 exposure environment, and socio-economic status are controlled. Data from a forced-choice task show that both groups comprehend active sentences, not passives, initially (after 3.6 years of exposure). One year later, both groups improve, but only the older group reaches ceiling on both actives and passives. Two years from initial testing, the younger group catches up. Input alone cannot explain why the younger group takes 5 years to accomplish what the older group does in 4. We claim that some properties take longer to acquire at certain ages because language development is partially constrained by general cognitive and linguistic development (e.g. de Villiers, 2007; Long & Rothman, 2014; Paradis, 2008, 2010, 2011; Tsimpli, 2014).

Acquisition of inflected and uninflected infinitives in child L1 European Portuguese

This study investigates the child (L1) acquisition of inflected and uninflected infinitives in European Portuguese (EP). We test and contrast properties involving two interfaces, focusing on morpho-syntactic and syntax-semantics properties of inflected infinitives, in contrast with uninflected infinitives. We present experimental results from three monolingual EP child groups, between ages 6 and 12 (n=72), compared to EP adults (n=32). Results show that children as young as 6-7 have knowledge of the morpho-syntactic properties of inflected infinitives, although at first glance they show insufficient knowledge of their syntax-semantics interface properties (i.e. non-obligatory control properties), differently from older children, who show evidence of knowledge of both types of properties. We argue that, in general, morpho-syntactic and syntax-semantics interface distinctions are also accessible to 6-7 children, but children may not show the entire range of interpretations possible for adults.

Blending systems thinking approaches for organisational analysis: reviewing child protection in England

This paper concerns the innovative use of a blend of systems thinking ideas in the ‘Munro Review of Child Protection’, a high-profile examination of child protection activities in England, conducted for the Department for Education. We go ‘behind the scenes’ to describe the OR methodologies and processes employed. The circumstances that led to the Review are outlined. Three specific contributions that systems thinking made to the Review are then described. First, the systems-based analysis and visualisation of how a ‘compliance culture’ had grown up. Second the creation of a large, complex systems map of current operations and the effects of past policies on them. Third, how the map gave shape to the range of issues the Review addressed and acted as an organising framework for the systemically coherent set of recommendations made. The paper closes with an outline of the main implementation steps taken so far to create a child protection system with the critically reflective properties of a learning organisation, and methodological reflections on the benefits of systems thinking to support organisational analysis.

Incremental processing in head-final child language: online comprehension of relative clauses in Turkish-speaking children and adults

The present study investigates the parsing of pre-nominal relative clauses (RCs) in children for the first time with a realtime methodology that reveals moment-to-moment processing patterns as the sentence unfolds. A self-paced listening experiment with Turkish-speaking children (aged 5–8) and adults showed that both groups display a sign of processing cost both in subject and object RCs at different points through the flow of the utterance when integrating the cues that are uninformative (i.e., ambiguous in function) and that are structurally and probabilistically unexpected. Both groups show a processing facilitation as soon as the morphosyntactic dependencies are completed and parse the unbounded dependencies rapidly using the morphosyntactic cues rather than waiting for the clause-final filler. These findings show that five-year-old children show similar patterns to adults in processing the morphosyntactic cues incrementally and in forming expectations about the rest of the utterance on the basis of the probabilistic model of their language.

Reasonable adjustments for disabled pupils: what support do parents want for their child?

Schools in England (as elsewhere in Europe) have a duty to promote equality for disabled people and make reasonable adjustments for disabled children. There is, however, a degree of uncertainty about how well-placed parents are addressed to use the legislation to ensure their child’s needs. This paper presents data drawn from a national questionnaire designed for schools to use to identify their disabled pupils and examines, in detail, parental responses to a question on the kinds of support their child finds helpful in offsetting any difficulties they experience. It illustrates the complex and varied nature of the ‘reasonable adjustments’ that are required and an overriding sense that need to be underpinned by the values of a responsive child-centred approach, one that recognises that parents’ knowledge and understanding of their child are important. Schools need to have in place the two-way communication process that supports them in ‘knowing’ about the visible and invisible challenges that pupils with difficulties and disabilities face in participating in school life.