Attachment-based family therapy versus nondirective supportive therapy for lesbian, gay, bisexual and questioning adolescents with depression, and suicidal ideation: An exploratory study.

INTRODUCTION: Lesbian, gay, bisexual, and questioning (LGBQ) adolescents are particularly at risk for suicidal ideation; however, little clinical research is focused on treating this population. Attachment-based family therapy (ABFT) is among the few empirically supported youth suicide treatments adapted for LGBQ adolescents. The purpose of this exploratory study is to determine the differential treatment effects and rates of change for LGBQ and heterosexual adolescents with depression and suicidal ideation receiving either ABFT or family enhanced nondirective supportive therapy (FE-NST). METHOD: The sample included 129 adolescents (31% LGBQ), ages 12-18 randomized to the two treatment groups. Multilevel modeling was used to examine individual changes in depression and suicidal ideation over the 16-week treatment. RESULTS: Results revealed that LGBQ adolescents in the ABFT condition showed a greater rate of reduction in depressive symptoms over treatment, slope = -0.94, p < 0.001, than did LGBQ adolescents in the NST condition, slope = -0.41, p = 0.12. Heterosexual adolescents showed symptom reduction in both treatment conditions (ABFT slope = -0.47, p < 0.001; NST slope = -0.79, t (113) = -7.48, p < 0.001). Changes in suicidal ideation were found across time, but not across conditions. CONCLUSION: LGBQ adolescents in the ABFT condition had a sharper decrease in depressive symptoms and better outcomes at week 16.

Immersive and reflective recall of a suicidal episode: Implications for assessing and treating suicidal adolescents.

OBJECTIVE: The present study tested the validity and clinical utility of adolescents' reports of two distinct modes of processing during the recall of a suicidal episode in the Suicide Narrative Interview (SNI). Recall Intensity (RI) items were designed to capture a tendency to become immersed in thoughts and feelings during the interview, while Meaning Making (MM) items were designed to assess more distant and reflective processing. METHOD: The construct and predictive validity of pretreatment MM and RI was tested in a 16-week randomized clinical trial (RCT) for depressed and suicidal adolescents (N = 113, Mage = 14.95, 84.1% female, 51.8% Black/African American). Adolescents rated MM and RI immediately following the SNI during a baseline assessment. RESULTS: Baseline MM was associated with protective factors related to reduced suicidality, and RI was associated with several risk factors for suicidal symptoms. Adolescents who reported high MM and low RI reported greater reductions in both suicidal ideation and depressive symptoms during the RCT. CONCLUSIONS: The results support MM and RI as two distinct modes of how adolescents process memories of suicidal episodes and highlight the potential clinical utility of RI and MM in assessing and treating suicidal adolescents. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Site-Specific, Critical Threshold Barefoot Peak Plantar Pressure Associated with Diabetic Foot Ulcer History: A Novel Approach to Determine DFU Risk in the Clinical Setting.

Background and Objectives: Barefoot peak plantar pressures (PPPs) are elevated in diabetes patients with neuropathic foot ulcer (DFU) history; however, there is limited reported evidence for a causative link between high barefoot PPP and DFU risk. We aimed to determine, using a simple mat-based methodology, the site-specific, barefoot PPP critical threshold that will identify a plantar site with a previous DFU. Materials and Methods: In a cross-sectional study, barefoot, site-specific PPPs were measured with normal gait for patients with DFU history (n = 21) and healthy controls (n = 12), using a validated carbon footprint system. For each participant, PPP was recorded at twelve distinct plantar sites (1st-5th toes, 1st-5th metatarsal heads (MTHs), midfoot and heel), per right and left foot, resulting in the analysis of n = 504 distinct plantar sites in the diabetes group, and n = 288 sites in the control group. Receiver operator characteristic curve analysis determined the optimal critical threshold for sites with DFU history. Results: Median PPPs for the groups were: diabetes sites with DFU history (n = 32) = 5.0 (3.25-7.5) kg/cm2, diabetes sites without DFU history (n = 472) = 3.25 (2.0-5.0) kg/cm2, control sites (n = 288) = 2.0 (2.0-3.25) kg/cm2; (p < 0.0001). Diabetes sites with elevated PPP (>6 kg/cm2) were six times more likely to have had DFU than diabetes sites with PPP ≤ 6 kg/cm2 (OR = 6.4 (2.8-14.6, 95% CI), p < 0.0001). PPP > 4.1 kg/cm2 was determined as the optimal critical threshold for identifying DFU at a specific plantar site, with sensitivity/specificity = 100%/79% at midfoot; 80%/65% at 5th metatarsal head; 73%/62% at combined midfoot/metatarsal head areas. Conclusions: We have demonstrated, for the first time, a strong, site-specific relationship between elevated barefoot PPP and previous DFU. We have determined a critical, highly-sensitive, barefoot PPP threshold value of >4.1 kg/cm2, which may be easily used to identify sites of previous DFU occurrence and, therefore, increased risk of re-ulceration. This site-specific approach may have implications for how high PPPs should be investigated in future trials.

An intelligent insole system with personalised digital feedback reduces foot pressures during daily life: An 18-month randomised controlled trial.

AIMS: High plantar pressure is a major risk factor in the development of diabetic foot ulcers (DFUs) and recent evidence shows plantar pressure feedback reduces DFU recurrence. This study investigated whether continued use of an intelligent insole system by patients at high-risk of DFUs causes a reduction in plantar pressures. METHODS: Forty-six patients with diabetic peripheral neuropathy and previous DFU were randomised to intervention (IG) or control groups (CG). Patients received an intelligent insole system, consisting of pressure-sensing insoles and digital watch. Patients wore the device during all daily activity for 18-months or until ulceration, and integrated pressure was recorded continuously. The device provided high-pressure feedback to IG only via audio-visual-vibrational alerts. High-pressure parameters at the whole foot, forefoot and rearfoot were compared between groups, with multilevel binary logistic regression analysis. RESULTS: CG experienced more high-pressure bouts over time than IG across all areas of the foot (P < 0.05). Differences between groups became apparent >16 weeks of wearing the device. CONCLUSIONS: Continuous plantar pressure feedback via an intelligent insole system reduces number of bouts of high-pressure in patients at high-risk of DFU. These findings suggest that patients were learning which activities generated high-pressure, and pre-emptively offloading to avoid further alerts.

Exploring the relations between interpersonal risk and adolescent suicidality during treatment.

OBJECTIVE: Despite considerable evidence that supports perceived burdensomeness (PB) and thwarted belongingness (TB) as risk factors for suicidal ideation (SI), far less is known about the direction of effects between these constructs in treatments for suicidal adolescents. The present study examined bidirectional relations between PB, TB, and adolescents' suicidal ideation (SI) during a 16-week randomized clinical trial. METHOD: 129 depressed and suicidal adolescents completed PB, TB, and SI measures at three time points: baseline (T1), mid-treatment (T2), and treatment completion (T3). Random-intercept cross-lagged panel models (RI-CLPM) examined within-subject direction of effects between interpersonal variables (PB & TB) and suicidal ideation (SI) in the first and second halves of treatment. RESULTS: Within-subjects, autoregressive paths indicated significant carryover in PB and SI. In the first half of treatment, a significant cross-lagged path indicated that T1 PB predicted change in T2 SI, and in the last half of treatment change in T2 SI predicted change in T3 PB. There were no significant auto-regressive or cross-lagged effects for TB. CONCLUSIONS: In the first half of treatment, baseline PB predicted fewer reductions in SI suggesting that PB initially moderated adolescents' response to treatment. However, in the last half of treatment, initial reductions in SI predicted subsequent reductions in PB suggesting that adolescents' initial response to treatment decreased their perceptions of burdening others. The clinical and treatment implications of these bidirectional findings are discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Development and validation of a clinical prediction rule for development of diabetic foot ulceration: an analysis of data from five cohort studies.

INTRODUCTION: The aim of the study was to develop and validate a clinical prediction rule (CPR) for foot ulceration in people with diabetes. RESEARCH DESIGN AND METHODS: Development of a CPR using individual participant data from four international cohort studies identified by systematic review, with validation in a fifth study. Development cohorts were from primary and secondary care foot clinics in Europe and the USA (n=8255, adults over 18 years old, with diabetes, ulcer free at recruitment). Using data from monofilament testing, presence/absence of pulses, and participant history of previous ulcer and/or amputation, we developed a simple CPR to predict who will develop a foot ulcer within 2 years of initial assessment and validated it in a fifth study (n=3324). The CPR's performance was assessed with C-statistics, calibration slopes, calibration-in-the-large, and a net benefit analysis. RESULTS: CPR scores of 0, 1, 2, 3, and 4 had a risk of ulcer within 2 years of 2.4% (95% CI 1.5% to 3.9%), 6.0% (95% CI 3.5% to 9.5%), 14.0% (95% CI 8.5% to 21.3%), 29.2% (95% CI 19.2% to 41.0%), and 51.1% (95% CI 37.9% to 64.1%), respectively. In the validation dataset, calibration-in-the-large was -0.374 (95% CI -0.561 to -0.187) and calibration slope 1.139 (95% CI 0.994 to 1.283). The C-statistic was 0.829 (95% CI 0.790 to 0.868). The net benefit analysis suggested that people with a CPR score of 1 or more (risk of ulceration 6.0% or more) should be referred for treatment. CONCLUSION: The clinical prediction rule is simple, using routinely obtained data, and could help prevent foot ulcers by redirecting care to patients with scores of 1 or above. It has been validated in a community setting, and requires further validation in secondary care settings.

Emotional processing in attachment-based family therapy for suicidal adolescents.

Objective: This study examined proposed sequential pathways through which suicidal adolescents are thought to shift from secondary global distress and rejecting anger to primary adaptive hurt, grief and assertive anger in the context of attachment-based family therapy (ABFT). Method: Participants were 39 suicidal adolescents who had received 16 weeks of ABFT as part of a randomized clinical trial, and who had been assigned to one of three outcome groups (i.e., good responders, slow responders and non-responders). Adolescents' in-session emotions were observationally coded using the Classification of Affective-Meaning States. Results: Across outcome groups, adolescents evidenced shifts from global distress to maladaptive shame, from maladaptive rejecting anger to adaptive assertive anger, and from adaptive assertive anger to adaptive grief/hurt. Adolescents who did not respond to treatment evidenced higher rates of maladaptive global distress. Conclusions: Findings are discussed in the context of ABFT and sequential emotional processing theories.

Diagnosis of Neuropathy and Risk Factors for Corneal Nerve Loss in Type 1 and Type 2 Diabetes: A Corneal Confocal Microscopy Study.

OBJECTIVE: To assess the diagnostic utility of corneal confocal microscopy (CCM) for diabetic peripheral neuropathy (DPN) and the risk factors for corneal nerve loss. RESEARCH DESIGN AND METHODS: A total of 490 participants, including 72 healthy control subjects, 149 with type 1 diabetes, and 269 with type 2 diabetes, underwent detailed assessment of peripheral neuropathy and CCM in relation to risk factors. RESULTS: Corneal nerve fiber density (CNFD) (P < 0.0001 and P < 0.0001), corneal nerve fiber branch density (CNBD) (P < 0.0001 and P < 0.0001), and corneal nerve fiber length (CNFL) (P < 0.0001 and P = 0.02) were significantly lower in patients with type 1 and type 2 diabetes compared with control subjects. CNFD (P < 0.0001), CNBD (P < 0.0001), and CNFL (P < 0.0001) were lower in type 1 diabetes compared with type 2 diabetes. Receiver operating characteristic curve analysis for the diagnosis of DPN demonstrated a good area under the curve for CNFD of 0.81, CNBD of 0.74, and CNFL of 0.73. Multivariable regression analysis showed a significant association among reduced CNFL with age (ß = -0.27, P = 0.007), HbA1c (ß = -1.1; P = 0.01), and weight (ß = -0.14; P = 0.03) in patients with type 2 diabetes and with duration of diabetes (ß = -0.13; P = 0.02), LDL cholesterol (ß = 1.8, P = 0.04), and triglycerides (ß = -2.87; P = 0.009) in patients with type 1 diabetes. CONCLUSIONS: CCM identifies more severe corneal nerve loss in patients with type 1 diabetes compared with type 2 diabetes and shows good diagnostic accuracy for DPN. Furthermore, the risk factors for a reduction in corneal nerve fiber length differ between type 1 and type 2 diabetes.

The role of foot pressure measurement in the prediction and prevention of diabetic foot ulceration-A comprehensive review.

The predominant risk factor of diabetic foot ulcers (DFU), peripheral neuropathy, results in loss of protective sensation and is associated with abnormally high plantar pressures. DFU prevention strategies strive to reduce these high plantar pressures. Nevertheless, several constraints should be acknowledged regarding the research supporting the link between plantar pressure and DFUs, which may explain the low prediction ability reported in prospective studies. The majority of studies assess vertical, rather than shear, barefoot plantar pressure in laboratory-based environments, rather than during daily activity. Few studies investigated previous DFU location-specific pressure. Previous studies focus predominantly on walking, although studies monitoring activity suggest that more time is spent on other weight-bearing activities, where a lower "peak" plantar pressure might be applied over a longer duration. Although further research is needed, this may indicate that an expression of cumulative pressure applied over time could be a more relevant parameter than peak pressure. Studies indicated that providing pressure feedback might reduce plantar pressures, with an emerging potential use of smart technology, however, further research is required. Further pressure analyses, across all weight-bearing activities, referring to location-specific pressures are required to improve our understanding of pressures resulting in DFUs and improve effectiveness of interventions.

Parent-teen communication predicts treatment benefit for depressed and suicidal adolescents.

OBJECTIVE: Although there are currently several efficacious treatments for depressed and suicidal adolescents, less is known about predictors and moderators of adolescents' treatment response. A growing literature has identified family functioning as a prognostic indicator of adolescents' likelihood of benefiting from treatment. The current study tested both observational and perceived measures of family functioning as indicators of adolescents' response to 2 treatment conditions. METHOD: The sample consisted of 129 depressed and suicidal adolescents (Mage = 14.96, 82.9% female, 56% Black/African American) who were randomized to attachment-based family therapy or family-enhanced nondirective supportive therapy (Diamond et al., 2019). Baseline assessments of family functioning included ratings of parent-adolescent communication coded with the Goal-Corrected Partnership in Adolescence Coding System (Lyons-Ruth, Hennighausen, & Holmes, 2005) and adolescent and parent reports of Family Conflict and Cohesion from the Self-Report of Family Functioning (Bloom, 1985). RESULTS: Adolescents who engaged in more uncooperative communication with their parents during a 10-min conflict discussion showed greater reductions in depressive symptoms in both treatments. Adolescents from traditionally underserved (non-White or lower income) families showed greater reductions in suicidal ideation in both treatments. CONCLUSIONS: Attachment-based family therapy and family-enhanced nondirective supportive therapy were most effective for adolescents from traditionally underserved families and adolescents who engaged in less cooperative communication with their caregivers. Observational ratings of parent-adolescent communication were better prognostic indicators of treatment response than were self-reported indicators of global family functioning. Implications for generalizing these results to other treatments for depressed and suicidal adolescents are discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Predicting Patterns of Treatment Response and Outcome for Adolescents Who Are Suicidal and Depressed.

OBJECTIVE: Although several treatments have been shown to be effective in treatment of youth suicidal thoughts and behaviors (STBs), there is a pressing need to account for the substantial variation in adolescents' response to and outcomes from these treatments. METHOD: Secondary analyses of data from a 16-week randomized trial of Attachment-Based Family Therapy (ABFT) and Family-Enhanced NonDirective Supportive Therapy (FE-NST) identified distinct classes of adolescents' treatment response. Established risk factors for STBs, along with treatment condition and sociodemographic variables, were then tested as predictors of class membership. RESULTS: Three patterns of adolescents' treatment response and outcome were identified: a) nonresponders (15.8%), b) good responders (57.5%), and c) partial responders (26.7%). After controlling for initial symptom severity, nonresponders were more likely to have higher levels of nonsuicidal self-injury and pessimism and were more likely to meet diagnostic criteria for major depressive disorder (MDD) than good or partial responders. Partial responders were more likely than good responders to meet criteria for MDD and to have higher perceived burdensomeness. CONCLUSION: Although most adolescents showed significant symptom reductions with both treatments, adolescents with higher pretreatment levels of pessimism, MDD, nonsuicidal self-injury, and perceived burdensomeness were less likely to show an optimal pattern of treatment benefit. The findings point to heterogeneity in treatment response that may require adapting treatments for adolescents with these pretreatment profiles. CLINICAL TRIAL REGISTRATION INFORMATION: Attachment-Based Family Therapy for Suicidal Adolescents; http://clinicaltrials.gov; NCT01537419.

Innovative intelligent insole system reduces diabetic foot ulcer recurrence at plantar sites: a prospective, randomised, proof-of-concept study.

BACKGROUND: Prevention of diabetic foot ulcer recurrence in high risk patients, using current standard of care methods, remains a challenge. We hypothesised that an innovative intelligent insole system would be effective in reducing diabetic foot ulcer recurrence in such patients. METHODS: In this prospective, randomised, proof-of-concept study, patients with diabetes, and with peripheral neuropathy and a recent history of plantar foot ulceration were recruited from two multidisciplinary outpatient diabetic foot clinics in the UK, and were randomly assigned to either intervention or control. All patients received an insole system, which measured plantar pressure continuously during daily life. The intervention group received audiovisual alerts via a smartwatch linked to the insole system and offloading instructions when aberrant pressures were detected; the control group did not receive any alerts. The primary outcome was plantar foot ulcer occurrence within 18 months. This trial is registered with ISRCTN, ISRCTN05585501, and is closed to accrual and complete. FINDINGS: Between March 18, 2014, and Dec 20, 2016, 90 patients were recruited and consented to the study, and 58 completed the study. At follow-up, ten ulcers from 8638 person-days were recorded in the control group and four ulcers from 11 835 person-days in the intervention group: a 71% reduction in ulcer incidence in the intervention group compared with the control group (incidence rate ratio 0·29, 95% CI, 0·09-0·93; p=0·037). The number of patients who ulcerated was similar between groups (six of 26 [control group] vs four of 32 [intervention group]; p=0·29); however, individual plantar sites ulcerated more often in the control group (ten of 416) than in the intervention group (four of 512; p=0·047). In an exploratory analysis of good compliers (n=40), ulcer incidence was reduced by 86% in the intervention group versus control group (incidence rate ratio 0·14, 95% CI 0·03-0·63; p=0·011). In the exploratory analysis, plantar callus severity (change from baseline to 6 months) was greater in re-ulcerating patients (6·5, IQR 4·0-8·3) than non-re-ulcerating patients (2·0, 0·0-4·8; p=0·040). INTERPRETATION: To our knowledge, this study is the first to show that continuous plantar pressure monitoring and dynamic offloading guidance, provided by an innovative intelligent insole system, can lead to a reduction in diabetic foot ulcer site recurrence. FUNDING: Diabetes UK and Orpyx Medical Technologies.

A Foreign Body Through the Shoe of a Person With Diabetic Peripheral Neuropathy Alters Contralateral Biomechanics: Captured Through Innovative Plantar Pressure Technology.

High plantar pressure as a result of diabetic peripheral neuropathy is often reported as a major risk factor for ulceration. However, previous studies are confined to laboratories with equipment limited by cables, reducing the validity of measurements to daily life. The participant concerned in this case report was wearing an innovative plantar pressure feedback system as part of a wider study. The system allows for continuous plantar pressure monitoring and provides feedback throughout all activities of daily living. The participant concerned was a 59-year-old male with type 2 diabetes who presented with severe peripheral neuropathy. In addition, the right ankle had previously undergone fusion. Between monthly study appointments, the participant unknowingly had a screw embedded in his right shoe, while pressure was being recorded. Although no significant differences in pressure were present for the right foot with the embedded screw, the contralateral foot showed significantly higher pressure when the screw was embedded, compared with pre and post time periods. The increase in pressure on the contralateral foot is expected to result from the protrusion of the screw in the right shoe, causing a perturbation to balance and a shift in the center of pressure toward the contralateral side. This compensatory effect is likely to have been magnified by the limited mobility of the fused right ankle. These findings highlight the importance of checking both feet for ulcer risk, in the event of receiving high-pressure feedback. This innovative technology may improve our understanding of diabetic plantar foot ulcer development.

Explanations for less small fibre neuropathy in South Asian versus European subjects with type 2 diabetes in the UK.

BACKGROUND: Low foot ulcer risk in South Asian, compared with European, people with type 2 diabetes in the UK has been attributed to their lower levels of neuropathy. We have undertaken a detailed study of corneal nerve morphology and neuropathy risk factors, to establish the basis of preserved small nerve fibre function in South Asians versus Europeans. METHODS: In a cross-sectional, population-based study, age- and sex-matched South Asians (n = 77) and Europeans (n = 78) with type 2 diabetes underwent neuropathy assessment using corneal confocal microscopy, symptoms, signs, quantitative sensory testing, electrophysiology and autonomic function testing. Multivariable linear regression analyses determined factors accounting for ethnic differences in small fibre damage. RESULTS: Corneal nerve fibre length (22.0 ± 7.9 vs. 19.3 ± 6.3 mm/mm2 ; P = 0.037), corneal nerve branch density (geometric mean (range): 60.0 (4.7-246.2) vs. 46.0 (3.1-129.2) no./mm2 ; P = 0.021) and heart rate variability (geometric mean (range): 7.9 (1.4-27.7) vs. 6.5 (1.5-22.0); P = 0.044), were significantly higher in South Asians vs. Europeans. All other neuropathy measures did not differ, except for better sural nerve amplitude in South Asians (geometric mean (range): 10.0 (1.3-43.0) vs. 7.2 (1.0-30.0); P = 0.006). Variables with the greatest impact on attenuating the P value for age- and HbA1C -adjusted ethnic difference in corneal nerve fibre length (P = 0.032) were pack-years smoked (P = 0.13), BMI (P = 0.062) and triglyceride levels (P = 0.062). CONCLUSIONS: South Asians have better preserved small nerve fibre integrity than equivalent Europeans; furthermore, classic, modifiable risk factors for coronary heart disease are the main contributors to these ethnic differences. We suggest that improved autonomic neurogenic control of cutaneous blood flow in Asians may contribute to their protection against foot ulcers.

Emotion regulation and spillover of interpersonal stressors to postsession insight among depressed and suicidal adolescents.

OBJECTIVE: Little is known about the extent to which previous weeks' stressful events spill over and influence adolescents' abilities to derive insight from treatment sessions. Even less is known about factors that moderate clients' vulnerabilities to these spillover effects. The current study examined the spillover of negative interpersonal events to postsession insight and the role of difficulties in emotion regulation in this spillover effect. METHOD: Participants were 129 adolescents with moderate to severe depressive symptoms and suicidal ideation (Mage = 14.96, 83% female, 56% African American/Black) participating in a comparative efficacy trial of Attachment-Based Family Therapy (ABFT) and Family-Enhanced Nondirective Supportive Therapy (FE-NST). A within-subject mediation model tested presession negative affect as a mediator of spillover of past week's events on postsession insight. We then examined baseline difficulties in emotion regulation (DERS) as a between-subjects moderator of the mediation model. RESULTS: Negative affect partially mediated (44%) the spillover of the past week's negative events on adolescents' ratings of postsession insight (p = .03, 95% confidence interval, CI [-.09., -.002]). Baseline DERS increased adolescents' vulnerabilities to spillover effects (p = .01, 95% CI [-.28, -.03]). Negative interpersonal events from the past week influence presession negative affect and spill over to adolescents' abilities to gain insight from their treatment sessions. Adolescents who began treatment with greater DERS were particularly vulnerable to these spillover effects. Findings indicate the need for therapists to adapt sessions to individual differences in depressed and suicidal adolescents' exposure to negative interpersonal events preceding treatment and in their vulnerabilities to spillover and emotion dysregulation. (PsycINFO Database Record

A New Mobile Application for Standardizing Diabetic Foot Images.

BACKGROUND: We describe the development of a new mobile app called "FootSnap," to standardize photographs of diabetic feet and test its reliability on different occasions and between different operators. METHODS: FootSnap was developed by a multidisciplinary team for use with the iPad. The plantar surface of 30 diabetic feet and 30 nondiabetic control feet were imaged using FootSnap on two separate occasions by two different operators. Reproducibility of foot images was determined using the Jaccard similarity index (JSI). RESULTS: High intra- and interoperator reliability was demonstrated with JSI values of 0.89-0.91 for diabetic feet and 0.93-0.94 for control feet. CONCLUSIONS: Similarly high reliability between groups indicates FootSnap is appropriate for longitudinal follow-ups in diabetic feet, with potential for monitoring pathology.

Adapting to the changing needs of adolescents: parenting practices and challenges to sensitive attunement.

Changes in adolescents' motivations and capabilities pose unique challenges to parents who play a continuing role in ensuring the youth's safety and well-being. We describe sensitively attuned parenting as an optimal response to this challenge and summarize practices of positive engagement, supervision/guidance and open communication that support sensitive attunement and facilitate the continuing development of the adolescent's self-confidence, autonomous decision-making, and communication skills. We then consider factors that require parents to adapt their practices to the particular needs and developmental level of the adolescent. Individual differences that may challenge parent's effectiveness in implementing these practices include: biological vulnerabilities, differential sensitivity to parenting, relationship history and temperament. Clinical interventions that seek to improve parenting offer an opportunity to test sensitive attunement as a mechanism for reducing adolescents' symptoms and problem behaviors.

A stakeholder-driven approach to improve the informed consent process for palliative chemotherapy.

OBJECTIVE: Patients often anticipate cure from palliative chemotherapy. Better resources are needed to convey its risks and benefits. We describe the stakeholder-driven development and acceptability testing of a prototype video and companion booklet supporting informed consent (IC) for a common palliative chemotherapy regimen. METHODS: Our multidisciplinary team (researchers, advocates, clinicians) employed a multistep process of content development, production, critical evaluation, and iterative revisions. Patient/clinician stakeholders were engaged throughout using stakeholder advisory panels, featuring their voices within the intervention, conducting surveys and qualitative interviews. A national panel of 57 patient advocates, and 25 oncologists from nine US practices critiqued the intervention and rated its clarity, accuracy, balance, tone, and utility. Participants also reported satisfaction with existing chemotherapy IC materials. RESULTS: Few oncologists (5/25, 20%) or advocates (10/22, 45%) were satisfied with existing IC materials. In contrast, most rated our intervention highly, with 89-96% agreeing it would be useful and promote informed decisions. Patient voices were considered a key strength. Every oncologist indicated they would use the intervention regularly. CONCLUSION: Our intervention was acceptable to advocates and oncologists. A randomized trial is evaluating its impact on the chemotherapy IC process. PRACTICE IMPLICATIONS: Stakeholder-driven methods can be valuable for developing patient educational interventions.

Atypical dimensions of caregiver-adolescent interaction in an economically disadvantaged sample.

The Goal-Corrected Partnership Adolescent Coding System (GPACS) has shown promise in assessing a secure as well as three atypical patterns of parent-adolescent interaction during a conflict discussion. The current study of 186 economically disadvantaged families examines the degree to which four GPACS patterns: secure/collaborative, hostile/punitive, role confused, and disoriented, prospectively predict adolescents' social competence and maladaptive behavior (internalizing, externalizing, and risk behaviors) at age 15 years after controlling for these social behaviors at age 13 years and contemporaneous GPACS scores. Adolescents from secure/collaborative dyads at age 13 were more likely to have a secure state of mind in the Adult Attachment Interview at age 15 and showed higher levels of teachers' ratings of empathy and lower levels of teachers' ratings of externalizing behaviors at age 15 years. Adolescents in disoriented dyads showed higher levels of teacher-rated internalizing problems, while male adolescents in role confused dyads reported higher levels of involvement in risk behaviors, including unprotected sexual activity and substance use problems.

The Suicide Narrative Interview: adolescents' attachment expectancies and symptom severity in a clinical sample.

Insecure attachment styles have consistently been identified as risk factors for adolescent psychopathology and, more specifically, suicidal ideation. However, much less is known about the mechanisms that account for the relationship between attachment styles and severity of suicidal ideation within clinical samples. In the current study, adolescents' expectancies for caregiver availability and responsiveness were coded from transcripts of the Suicide Narrative Interview in a clinical sample of 129 depressed and suicidal adolescents. Results indicated that negative expectancies for caregiver availability in the Suicide Narrative Interview were associated both with attachment insecurity and with the intensity of adolescents' suicidal ideation. The implications of adolescents' expectancies for caregiver availability as targets for clinical intervention are discussed.