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.

Girls talk: authorship and authenticity in the reception of Lena Dunham's Girls

By examining the discourse around Lena Dunham's HBO comedy Girls (2012– present), this article argues that the programme served as a space to think through female authorship, televisual representations and cultural tensions surrounding young womanhood. Central to this discourse was the narrative asserting Girls' and Dunham's 'authenticity', originality and universality, which sought to legitimate her gendered authorship and interest in the comedy of female intimacy within HBO' s masculine prestige channel identity. Charting three cycles of discourse surrounding the programme's debut, this article explores the paratextual framing by promotional concerns, television critics and women' s websites. It highlights how journalists and critics furthered HBO's paratextual framing of Dunham, which was later countered by the networked spaces of niche online media, which used the programme as a space to productively work through industrial and cultural tensions; particularly those surrounding female comic authorship, autobiography and intersectionality.

Reduced face preference in infancy: a developmental precursor to callous-unemotional traits?

Background Children with callous-unemotional (CU) traits, a proposed precursor to adult psychopathy, are characterized by impaired emotion recognition, reduced responsiveness to others’ distress, and a lack of guilt or empathy. Reduced attention to faces, and more specifically to the eye region, has been proposed to underlie these difficulties, although this has never been tested longitudinally from infancy. Attention to faces occurs within the context of dyadic caregiver interactions, and early environment including parenting characteristics has been associated with CU traits. The present study tested whether infants’ preferential tracking of a face with direct gaze and levels of maternal sensitivity predict later CU traits. Methods Data were analyzed from a stratified random sample of 213 participants drawn from a population-based sample of 1233 first-time mothers. Infants’ preferential face tracking at 5 weeks and maternal sensitivity at 29 weeks were entered into a weighted linear regression as predictors of CU traits at 2.5 years. Results Controlling for a range of confounders (e.g., deprivation), lower preferential face tracking predicted higher CU traits (p = .001). Higher maternal sensitivity predicted lower CU traits in girls (p = .009), but not boys. No significant interaction between face tracking and maternal sensitivity was found. Conclusions This is the first study to show that attention to social features during infancy as well as early sensitive parenting predict the subsequent development of CU traits. Identifying such early atypicalities offers the potential for developing parent-mediated interventions in children at risk for developing CU traits.

Parental responsibility beliefs: associations with parental anxiety and behaviours in the context of childhood anxiety disorders

Background: High levels of parental anxiety are associated with poor treatment outcomes for children with anxiety disorders. Associated parental cognitions and behaviours have been implicated as impediments to successful treatment. We examined the association between parental responsibility beliefs, maternal anxiety and parenting behaviours in the context of childhood anxiety disorders. Methods: Anxious and non-anxious mothers of 7-12 year old children with a current anxiety disorder reported their parental responsibility beliefs using a questionnaire measure. Parental behaviours towards their child during a stressor task were measured. Results: Parents with a current anxiety disorder reported a greater sense of responsibility for their child’s actions and wellbeing than parents who scored within the normal range for anxiety. Furthermore, higher parental responsibility was associated with more intrusive and less warm behaviours in parent-child interactions and there was an indirect effect between maternal anxiety and maternal intrusive behaviours via parental responsibility beliefs. Limitations: The sample was limited to a treatment-seeking, relatively high socio-economic population and only mothers were included so replication with more diverse groups is needed. The use of a range of stressor tasks may have allowed for a more comprehensive assessment of parental behaviours. Conclusions: The findings suggest that parental anxiety disorder is associated with an elevated sense of parental responsibility and may promote parental behaviours likely to inhibit optimum child treatment outcomes. Parental responsibility beliefs may therefore be important to target in child anxiety treatments in the context of parental anxiety disorders.

Contractual restrictions on lawful use of information: sole-source databases protected by the back door?

This article is concerned with the risks associated with the monopolisation of information that is available from a single source only. Although there is a longstanding consensus that sole-source databases should not receive protection under the EU Database Directive, and there are legislative provisions to ensure that lawful users have access to a database’s contents, Ryanair v PR Aviation challenges this assumption by affirming that the use of non-protected databases can be restricted by contract. Owners of non-protected databases can contractually exclude lawful users from taking the benefit of statutorily permitted uses, because such databases are not covered from the legislation that declares this kind of contract null and void. We argue that this judgment is not consistent with the legislative history and can have a profound impact on the functioning of the digital single market, where new information services, such as meta-search engines or price-comparison websites, base their operation on the systematic extraction and re-utilisation of materials available from online sources. This is an issue that the Commission should address in a forthcoming evaluation of the Database Directive.

Towards a meta-analysis and toolkit for port-related socio-economic impacts: a review of socio-economic impact studies conducted for seaports

Port authorities increasingly need to communicate with a variety of external stakeholders in order to maintain and strengthen the societal acceptance of seaport activities. The availability of socio-economic impact studies on port authority and regional development agency websites has often made this information accessible to the public at large. However, the differences in methodologies adopted, in terms of selecting, defining and measuring various types of socio-economic impacts, sometimes lead to misconceptions as well as misleading comparisons across ports within and between regions. In this paper, we suggest guidelines for the design and application of a potential best practice from an interregional perspective (UK, France and Belgium), based on research in the framework of a European Commission co-funded project, ‘IMPACTE’. The paper also aims to develop guidelines for comparing the socio-economic impacts of ports across regional and national borders and discusses the development of a European port economic impact measurement toolkit. We analyse a sample of 33 recent socio-economic impact assessment reports in terms of methodologies adopted and types of impacts measured. The review shows a great diversity among these studies, leading to important differences between the impacts of port activity communicated to stakeholders.

Communicating thematic data quality with web map services

Geospatial information of many kinds, from topographic maps to scientific data, is increasingly being made available through web mapping services. These allow georeferenced map images to be served from data stores and displayed in websites and geographic information systems, where they can be integrated with other geographic information. The Open Geospatial Consortium’s Web Map Service (WMS) standard has been widely adopted in diverse communities for sharing data in this way. However, current services typically provide little or no information about the quality or accuracy of the data they serve. In this paper we will describe the design and implementation of a new “quality-enabled” profile of WMS, which we call “WMS-Q”. This describes how information about data quality can be transmitted to the user through WMS. Such information can exist at many levels, from entire datasets to individual measurements, and includes the many different ways in which data uncertainty can be expressed. We also describe proposed extensions to the Symbology Encoding specification, which include provision for visualizing uncertainty in raster data in a number of different ways, including contours, shading and bivariate colour maps. We shall also describe new open-source implementations of the new specifications, which include both clients and servers.

Understanding digital literacies: a practical introduction

Understanding Digital Literacies provides an accessible and timely introduction to new media literacies. It supplies readers with the theoretical and analytical tools with which to explore the linguistic and social impact of a host of new digital literacy practices. Each chapter in the volume covers a different topic, presenting an overview of the major concepts, issues, problems and debates surrounding the topic, while also encouraging students to reflect on and critically evaluate their own language and communication practices. Features include: coverage of a diverse range of digital media texts, tools and practices including blogging, hypertextual organisation, Facebook, Twitter, YouTube, Wikipedia, websites and games an extensive range of examples and case studies to illustrate each topic, such as how blogs have affected our thinking about communication, how the creation and sharing of digital images and video can bring about shifts in social roles, and how the design of multiplayer online games for children can promote different ideologies a variety of discussion questions and mini-ethnographic research projects involving exploration of various patterns of media production and communication between peers, for example in the context of Wikinomics and peer production, social networking and civic participation, and digital literacies at work end of chapter suggestions for further reading and links to key web and video resources a companion website providing supplementary material for each chapter, including summaries of key issues, additional web-based exercises, and links to further resources such as useful websites, articles, videos and blogs.

A genome-wide test of the differential susceptibility hypothesis reveals a genetic predictor of differential response to psychological treatments for child anxiety disorders

Background: The differential susceptibly hypothesis suggests that certain genetic variants moderate the effects of both negative and positive environments on mental health and may therefore be important predictors of response to psychological treatments. Nevertheless, the identification of such variants has so far been limited to preselected candidate genes. In this study we extended the differential susceptibility hypothesis from a candidate gene to a genome-wide approach to test whether a polygenic score of environmental sensitivity predicted response to Cognitive Behavioural Therapy (CBT) in children with anxiety disorders. Methods: We identified variants associated with environmental sensitivity using a novel method in which within-pair variability in emotional problems in 1026 monozygotic (MZ) twin pairs was examined as a function of the pairs’ genotype. We created a polygenic score of environmental sensitivity based on the whole-genome findings and tested the score as a moderator of parenting on emotional problems in 1,406 children and response to individual, group and brief parent-led CBT in 973 children with anxiety disorders. Results: The polygenic score significantly moderated the effects of parenting on emotional problems and the effects of treatment. Individuals with a high score responded significantly better to individual CBT than group CBT or brief parent-led CBT (remission rates: 70.9%, 55.5% and 41.6% respectively). Conclusions: Pending successful replication, our results should be considered exploratory. Nevertheless, if replicated, they suggest that individuals with the greatest environmental sensitivity may be more likely to develop emotional problems in adverse environments, but also benefit more from the most intensive types of treatment.

Stem cell Researches in Brazil: Present and Future Challenges

A bill allowing researches with human embryonic stem cells has been approved by the Brazilian Congress, originally in 2005 and definitively by the Supreme Court in 2008. However, several years before, investigations in Brazil with adult stem cells in vitro in animal models as well as clinical trials, were started and are currently underway. Here, we will summarize the main findings and the challenges of going from bench to bed, focusing on heart, diabetes, cancer, craniofacial, and neuromuscular disorders. We also call attention to the importance of publishing negative results on experimental trials in scientific journals and websites. They are of great value to investigators in the field and may avoid the repeating of unsuccessful experiments. In addition, they could be referred to patients seeking information, aiming to protect them against financial and psychological harm.

Livssituationen för föräldrar vars barn drabbats av cancer : En systematisk litteraturstudie

I Sverige insjuknar årligen ungefär 300 barn och ungdomar i någon cancersjukdom. Cancer hos barn ansågs tidigare som någonting obotligt. De senaste årtiondenas medicinska framsteg har dock radikalt förändrat perspektivet på barncancer. I dag vet vi att två av tre barn blir botade. Förutom medicinskt - tekniskt kunnande är det också nödvändigt med ett riktigt omhändertagande och en god omvårdnad av patienten och familjen. Syftet med denna studie var att beskriva livssituationen för föräldrar vars barn drabbats av cancer. Studien utfördes med hjälp av 18 vetenskapliga artiklar från åren 1998 till 2006. Sökorden som använts var: children, cancer, childhood cancer, parents, parenting, families, wellbeing, stressors, coping, nursing. Resultatet visade att föräldrarna upplevde barnets cancersjukdom som att hamna i ett chocktillstånd. Föräldrarna upplevde en vånda att behöva se sitt sjuka barn lida. Sjukdomen drabbade föräldrarna både gemensamt och individuellt. Rollerna inom familjen genomgick ofta förändringar. Modern övertog ofta det största ansvaret för det sjuka barnet och fadern skötte försörjningen. Olika barriärer som barnets sjukdom och behandling medförde gjorde det svårt att upprätthålla ett normalt familjeliv. Det bästa stödet fick familjen genom varandra och sjukdomen förde dem samman på ett annat sätt än tidigare. För att hantera situationen använde sig familjen av olika copingstrategier som kunde växla över tid. Ett bra samarbete med vårdpersonalen var mycket viktigt för familjen.

Liten men stor : - om barn med övervikt

Syfte: Att ta reda på vilka uppfattningar föräldrar har kring deras barns övervikt och hur vårdpersonal ser på omvårdnaden av barn med övervikt. Samt att belysa vilket samband som finns mellan en osund livsstil och barn med övervikt. Design: En systematisk litteraturstudie med deskriptiv ansats. Inkluderade artiklarna i studien var både kvantitativa och kvalitativa och kommer från databaserna Pubmed och Cinahl. Resultat: Stillasittande aktiviteter ökar risken för övervikt medan deltagande i någon fysisk aktivitet dagligen minskar risken för övervikt. Det finns en signifikant betydelse mellan övervikt och barn som idrottar mindre än tre timmar per vecka. Barn som inte äter frukost löper 50 % större risk att bli överviktig än de barn som äter frukost. Att hoppa över skollunchen är direkt relaterat till övervikt. När föräldrar söker hjälp av sjukvården för sitt överviktiga barn, har de redan prövat att ändra kosten och uppmuntra till fysisk aktivitet hemma. När föräldrarna söker hjälp är några av deras uppfattningar att sjukvården inte vet vad de ska göra för att hjälpa barnen med övervikt eller att sjukvården är hjälpsamma. Sjuksköterskorna kände sig inte tillräckligt kompetenta till att rekommendera viktminskningsprogram och att det var svårt att ge sådana råd till föräldrarna Vårdpersonalen kände att det var viktigt att prata om kost, men att vissa mammor tyckte att ämnet var känsligt att prata om. Det som hjälpte i förebyggande arbete eller i behandling var att jobba i små steg med kortsiktiga mål.

Brand Awareness among Customers : A case study of ICA-Kvantum

This research paper has been prepared by Bachelor students from Dalarna University in Borlänge. The project is centered on a case study of ICA – Kvantum and its brand awareness among customers. The purpose of this study is to find out that which measures can help ICA-Kvantum to create brand awareness among its current and potential customers by looking in to the importance of information of its offerings and use of effective communication tools to convey this information. Further, to recommend them what they need to do, to increase brand awareness among their customers with the help of managerial implications. The research question was formulated as what actions could be seen effective for ICA-Kvantum to maintain or improve brand awareness among its current and potential customers.The project was created with the help of theoretical concepts of brand awareness, brand loyalty, perceived quality, consumer decision model, integrated marketing communication approach and strategic planning process. These theories were applied in this thesis in order to find out the most effective communication measures to maintain or improve brand awareness among current and potential customers of ICA-Kvantum.The primary and secondary data was collected. Primary data was gathered through the survey among ICA-Kvantum customers in the front of the store in Borlänge. The personal interview with manager was conducted in the office of ICA-Kvantum store located in Borlänge. Secondary data was gathered from textbooks, academic journals, theses and websites.The empirical findings have been presented in detail and then analyzed with the help of theoretical concepts. The analysis and further results from survey and interview focused on importance of information, marketing communication tools, brand awareness and loyalty, perceived quality and implementation of strategic planning process. Moreover, the main weaknesses and strengths of ICA-Kvantun have been evaluated. The conclusion including short summary of analysis and its results have been provided at the end. Each weakness of issues related to brand awareness i.e. importance of information, effectiveness of marketing communication tools and strengths and weaknesses of ICA-Kvantum discussed in the paper, has been pointed out along with solutions and managerial implications.

A corpus approach to discursive constructions of a hip-hop identity

This chapter is an analysis of a 100,000-word corpus consisting of message-board postings on hip-hop websites. A discourse analysis of this corpus reveals three strategies employed by the posters to identify themselves as members of the hip-hop community in the otherwise anonymous setting of the internet: (1) defined openings and closings, (2) repeated use of slang and taboo terms, and (3) performance of verbal art. Each strategy is characterized by the codification of non-standard grammar and pronunciations characteristic of speech, as well as by the use of non-standard orthography. The purpose of the discourse is shown to be a performance of identity, whereby language is used and recognized as the discursive construction of one’s hip-hop identity.

Tidig föräldrastress hos mammor med för tidigt födda barn

Bakgrund: Att bli mamma till ett för tidigt fött barn (<37 gestationsveckor) innebär en oväntad stress vilket påverkar hela familjen. Under de senaste årtionden har stora förbättringar skett inom perinatal vård och numera är chansen till överlevnad stor. Att barnet efter födseln vårdas på neonatal intensivvårdsavdelning (NICU) får konsekvenser för mamman både känslomässigt och i omvårdnaden av barnet. Syfte: Att undersöka föräldrastress och beskriva faktorer som påverkar tidig föräldrastress hos mammor till för tidigt födda barn när barnet är två månader i korrigerad ålder. Metod: Studien utfördes på fyra NICU i Sverige. Inklusionskriterierna för studien var att barnet var för tidigt fött samt vårdades på neonatalavdelning i minst 72 timmar. För att mäta upplevd föräldrastress fick mammorna (n=276) svara på enkäten Swedish Parental Stress Questionnaire (SPSQ) när barnet var två månader i korrigerad ålder. Resultat: Mammor vars barn inte vårdades på en samvårdsavdelning, som hade barn i kuvös, mammor till barn med äldre syskon, var äldre, rökte och/eller ammade helt upplevde mer föräldrastress än övriga mammor. Slutsats: Studien visar att faktorer i framför allt i miljön samt hos mamman har betydelse för upplevd föräldrastress. Våra resultat innebär att omhändertagandet bör bli bättre, både under tiden på neonatalavdelning men även efter utskrivning. Då studien också påvisar vikten av samvårdsavdelning bör förbättringar ske i den fysiska vårdmiljön för att minimera upplevelsen av föräldrastress.