The impact of sleep difficulties in children with attention deficit hyperactivity disorder on the family: a thematic analysis.

STUDY OBJECTIVES: Attention deficit hyperactivity disorder is a complex but common neurodevelopmental condition characterized by symptoms of inattention, hyperactivity, and impulsivity associated with a significant level of academic, social, and functional impairment. Problems around sleep frequently co-occur with attention deficit hyperactivity disorder and are thought to affect 50% to 80% of children and adults with the condition. Sleep issues typically include trouble falling asleep, bedtime resistance, night-time waking, and early rising. The impact of these problems on families and parents is profound but poorly researched. METHODS: Semistructured interviews took place with 12 mothers of children with attention deficit hyperactivity disorder who struggle with sleep. Participants were asked about sleeping patterns and issues, methods used to improve sleep, the impact on parents' sleep and wider family life, and involvement with clinical services and support groups. Data were analyzed using thematic analysis. RESULTS: Three themes were identified in the data: a constant battleground; the cumulative effect of lack of sleep: impact on functioning and the wider family; a mixed bag of strategies: the tried, tested, and needed. Long-term sleep issues and challenging behavior at bedtime had substantial negative effects on families. Parents experiencing sleep deprivation experienced functional impairments to daily life and well-being and strain on relationships with children and spouses. CONCLUSIONS: Findings revealed parents were consistently and profoundly impacted by their children's sleep problems. Parents sought strategies and support in many different ways but were often unsuccessful. CITATION: French B, Quain E, Kilgariff J, Lockwood J, Daley D. The impact of sleep difficulties in children with attention deficit hyperactivity disorder on the family: a thematic analysis. J Clin Sleep Med. 2023;19(10):1735-1741.

Tinnitus, Suicide, and Suicidal Ideation: A Scoping Review of Primary Research.

Tinnitus (the perception of sound in the absence of any corresponding external source) is highly prevalent and can be distressing. There are unanswered questions about how tinnitus, suicidal thoughts, and suicidal behaviours co-occur and interact. To establish the extent of scientific literature, this scoping review catalogued primary reports addressing the associations between tinnitus, suicidal ideation, attempted suicide, and death by suicide. We searched OvidSP, Medline, EMBASE, PsycINFO, CINAHL, Google Scholar, EThoS, and ProQuest for all studies and case reports on ideation and/or attempted and/or completed suicide in the context of tinnitus. Twenty-three studies were included, and data were charted according to study type. Several epidemiological and other observational studies gave evidence of risk factors and an association between suicidal ideation, suicidal behaviour, and tinnitus. However, there was no evidence of the direction of causality. Qualitative studies are indicated to explore the patient's experience and understand the dynamics of any interaction between tinnitus and suicidal thoughts and behaviours. A theory-informed model of tinnitus and suicide needs to be developed to inform the development of interventions and how tinnitus patients are supported clinically.

Alienated and unsafe: Experiences of the first national UK COVID-19 lockdown for vulnerable young people (aged 11-24 years) as revealed in Web-based therapeutic sessions with mental health professionals.

Background: The COVID-19 pandemic and subsequent lockdowns have disproportionately affected young people, and those who are vulnerable are disadvantaged further. Here, we seek to understand the experiences of vulnerable young people accessing Web-based therapeutic support during the pandemic and early lockdown, as revealed through the observations of mental health professionals. Methods: Four focus groups with 12 professionals from a digital mental health service were conducted to understand the experiences of vulnerable young people during the pandemic lockdown. Workshops with young people with diverse experiences resulted in the co-design of the focus group topic guide and the interpretation and validation of analysis. The experiential inductive-deductive framework of thematic analysis was used to analyse the workshop transcripts. Results: Four main themes and subsequent subthemes were identified: escalation of risk; the experience and consequence of loss; feeling supported and empowered; and feeling separate and isolated. Conclusions: Findings reflect early data that suggest that those with existing vulnerability face an increased risk of poor outcomes through the pandemic and the restrictions of lockdown, but evidence is also provided of positive outcomes from lockdown and its function as a catalyst for change. Results reinforce the need for focused support for vulnerable young people as we emerge from lockdown, and point to supportive and protective factors of relevance to online and offline support provision.

Effectiveness, User Engagement and Experience, and Safety of a Mobile App (Lumi Nova) Delivering Exposure-Based Cognitive Behavioral Therapy Strategies to Manage Anxiety in Children via Immersive Gaming Technology: Preliminary Evaluation Study.

BACKGROUND: Childhood anxiety disorders are a prevalent mental health problem that can be treated effectively with cognitive behavioral therapy, in which exposure is a key component; however, access to treatment is poor. Mobile-based apps on smartphones or tablets may facilitate the delivery of evidence-based therapy for child anxiety, thereby overcoming the access and engagement barriers of traditional treatment. Apps that deliver therapeutic content via immersive gaming technology could offer an effective, highly engaging, and flexible treatment proposition. OBJECTIVE: In this paper, we aim to describe a preliminary multi-method evaluation of Lumi Nova, a mobile app intervention targeting mild to moderate anxiety problems in children aged 7-12 years using exposure therapy delivered via an immersive game. The primary objective is to evaluate the effectiveness, user engagement and experience, and safety of the beta version of Lumi Nova. METHODS: Lumi Nova was co-designed with children, parents, teachers, clinicians, game industry experts, and academic partnerships. In total, 120 community-based children with mild to moderate anxiety and their guardians were enrolled to participate in an 8-week pilot study. The outcome measures captured the app's effectiveness (anxiety symptoms, child-identified goal-based outcomes, and functional impairment), user engagement (game play data and ease-of-use ratings), and safety (mood ratings and adverse events). The outcome measures before and after the intervention were available for 30 children (age: mean 9.8, SD 1.7 years; girls: 18/30, 60%; White: 24/30, 80%). Additional game play data were automatically generated for 67 children (age: mean 9.6, SD 1.53 years; girls: 35/67, 52%; White: 42/67, 63%). Postintervention open-response data from 53% (16/30) of guardians relating to the primary objectives were also examined. RESULTS: Playing Lumi Nova was effective in reducing anxiety symptom severity over the 8-week period of game play (t29=2.79; P=.009; Cohen d=0.35) and making progress toward treatment goals (z=2.43; P=.02), but there were no improvements in relation to functional impairment. Children found it easy to play the game and engaged safely with therapeutic content. However, the positive effects were small, and there were limitations to the game play data. CONCLUSIONS: This preliminary study provides initial evidence that an immersive mobile game app may safely benefit children experiencing mild to moderate anxiety. It also demonstrates the value of the rigorous evaluation of digital interventions during the development process to rapidly improve readiness for full market launch.

A comparison of temporal pathways to self-harm in young people compared to adults: A pilot test of the Card Sort Task for Self-harm online using Indicator Wave Analysis.

Background: Self-harm is complex, multifaceted, and dynamic, typically starts in adolescence, and is prevalent in young people. A novel research tool (the Card Sort Task for Self-harm; CaTS) offers a systematic approach to understanding this complexity by charting the dynamic interplay between multidimensional factors in the build-up to self-harm. Sequential analysis of CaTS has revealed differences in key factors between the first and the most recent episode of self-harm in adolescence. Rates of self-harm typically decline post-adolescence, but self-harm can continue into adulthood. A comparison between factors linked to self-harm in young people vs. adults will inform an understanding of how risk unfolds over time and clarify age-specific points for intervention. A pilot online adaptation (CaTS-online) and a new method (Indicator Wave Analysis; IWA) were used to assess key factors in the build-up to self-harm. Methods: Community-based young people (n = 66; 18-25 years, M = 21.4; SD = 1.8) and adults (n = 43; 26-57 years, M = 35; SD = 8.8) completed CaTS-online, documenting thoughts, feelings, events, and behaviours over a 6-month timeline for the first ever and most recent self-harm. A notable interdependence between factors and time points was identified using IWA. Results: Positive emotion at and immediately after self-harm exceeded the threshold for both groups for both episodes. Feeling better following self-harm was more pronounced for the first-ever episodes. Impulsivity was an important immediate antecedent to self-harm for both groups at both episodes but most markedly for young people. Acquired capability was notable for adults' most recent episodes, suggesting this develops over time. Burdensomeness was only more notable for adults and occurred 1 week prior to a recent episode. Both groups revealed patterns of accessing support that were helpful and unhelpful. Conclusion: Commonalities and differences in the temporal organisation of factors leading to and following self-harm were identified in young people and adult pathways which shed light on age-specific factors and possible points of intervention. This has implications for clinical support and services around approaches to positive feelings after self-harm (especially for first-ever self-harm), feeling of burdensomeness, impulsivity, and acquired capability leading up to self-harm. Support is provided for card-sort approaches that enable the investigation of the complex and dynamic nature of pathways to self-harm.

What young people say about impulsivity in the short-term build up to self-harm: A qualitative study using card-sort tasks.

Youth who self-harm report high levels of trait impulsivity and identify impulsive behaviour as a proximal factor directly preceding a self-harm act. Yet, impulsivity is a multidimensional construct and distinct impulsivity-related facets relate differentially to self-harm outcomes. Studies have yet to examine if and how a multidimensional account of impulsivity is meaningful to individual experiences and understandings of self-harm in youth. We explored the salience and context of multidimensional impulsivity within narratives of self-harm, and specifically in relation to the short-term build-up to a self-harm episode. Fifteen community-based adolescents (aged 16-22 years) attending Further Education (FE) colleges in the UK took part in individual face-to-face sessions (involving exploratory card-sort tasks and semi-structured interviews) which explored factors relating to self-harm, impulsivity and the broader emotional, developmental and cognitive context. Session data were analysed thematically. Two overarching themes, and associated subthemes, were identified: 'How I respond to strong negative emotions'; and 'Impulse versus deliberation- How much I think through what I'm doing before I do it'. Self-harm was typically a quick, impulsive act in the context of overwhelming emotion, underpinned by cognitive processing deficits. The dynamic tension between emotion-based impulsivity and controlled deliberation was articulated in the immediate moments before self-harm. However, impulsive responses were perceived as modifiable. Where self-harm patterns were established, these related to habitual behaviour and quick go-to responses. Young people identified with a multidimensional conception of impulsivity and described the impulsive context of a self-harm act as dynamic, contextual, and developmentally charged. Findings have implications for youth-focused work. Card-task frameworks are recommended to scaffold and facilitate discussion with young people, particularly where topics are sensitive, complex and multifactorial.

Impulsivity as a predictor of self-harm onset and maintenance in young adolescents: a longitudinal prospective study.

BACKGROUND: Rates of self-harm in young adolescents are increasing and self-harm typically emerges at this developmental stage. Greater specificity of impulsivity as a multifaceted construct is enabling investigation of links between individual impulsivity facets and self-harm outcomes. However, studies have yet to adequately explore these associations in young adolescents, and prospective relationships between multidimensional impulsivity and self-harm in younger adolescents remain untested. This study investigates unidimensional facets of impulsivity as risk-factors for the emergence and maintenance of self-harm, specifically within young community-based adolescents. METHODS: A school-based sample of 594 adolescents (aged 13-15 years) provided data at two time points, 12 weeks apart. Logistic regression analyses determined associations between impulsivity-related facets (as delineated by the UPPS-P scale) and self-harm outcomes over time. RESULTS: Overall, 23.6% of young people reported lifetime self-harm. A higher tendency towards Sensation Seeking was associated with self-harm onset over the study-period (OR 1.19, 95% CI 1.017-1.401). Deficits in Premeditation predicted maintained (versus remitted) self-harm behaviour during this time (OR 1.16, 95% CI 1.013-1.328). Negative Urgency was a significant cross-sectional correlate, but did not offer prospective predictive utility. LIMITATIONS: The study relied on self-report. Interpretations are cautious given low incidence of self-harm outcomes over the course of the study. CONCLUSIONS: Separate pathways to impulsive behaviour describe the psychological context in which self-harm starts and develops in young people. Findings support differential treatment targets and developmentally-focused early intervention. The predictive utility of impulsivity was inconsistent between cross-sectional and longitudinal analyses, underlining the role for temporality in the establishment of risk of self-harm.

What do young adolescents think about taking part in longitudinal self-harm research? Findings from a school-based study.

BACKGROUND: Research about self-harm in adolescence is important given the high incidence in youth, and strong links to suicide and other poor outcomes. Clarifying the impact of involvement in school-based self-harm studies on young adolescents is an ethical priority given heightened risk at this developmental stage. METHODS: Here, 594 school-based students aged mainly 13-14 years completed a survey on self-harm at baseline and again 12-weeks later. Change in mood following completion of each survey, ratings and thoughts about participation, and responses to a mood-mitigation activity were analysed using a multi-method approach. RESULTS: Baseline participation had no overall impact on mood. However, boys and girls reacted differently to the survey depending on self-harm status. Having a history of self-harm had a negative impact on mood for girls, but a positive impact on mood for boys. In addition, participants rated the survey in mainly positive/neutral terms, and cited benefits including personal insight and altruism. At follow-up, there was a negative impact on mood following participation, but no significant effect of gender or self-harm status. Ratings at follow-up were mainly positive/neutral. Those who had self-harmed reported more positive and fewer negative ratings than at baseline: the opposite pattern of response was found for those who had not self-harmed. Mood-mitigation activities were endorsed. CONCLUSIONS: Self-harm research with youth is feasible in school-settings. Most young people are happy to take part and cite important benefits. However, the impact of participation in research appears to vary according to gender, self-harm risk and method/time of assessment. The impact of repeated assessment requires clarification. Simple mood-elevation techniques may usefully help to mitigate distress.

A comparison of the clinical effectiveness and cost of specialised individually delivered parent training for preschool attention-deficit/hyperactivity disorder and a generic, group-based programme: a multi-centre, randomised controlled trial of the New Forest Parenting Programme versus Incredible Years.

The objective of this study is to compare the efficacy and cost of specialised individually delivered parent training (PT) for preschool children with attention-deficit/hyperactivity disorder (ADHD) against generic group-based PT and treatment as usual (TAU). This is a multi-centre three-arm, parallel group randomised controlled trial conducted in National Health Service Trusts. The participants included in this study were preschool children (33-54 months) fulfilling ADHD research diagnostic criteria. New Forest Parenting Programme (NFPP)-12-week individual, home-delivered ADHD PT programme; Incredible Years (IY)-12-week group-based, PT programme initially designed for children with behaviour problems were the interventions. Primary outcome-Parent ratings of child's ADHD symptoms (Swanson, Nolan & Pelham Questionnaire-SNAP-IV). Secondary outcomes-teacher ratings (SNAP-IV) and direct observations of ADHD symptoms and parent/teacher ratings of conduct problems. NFPP, IY and TAU outcomes were measured at baseline (T1) and post treatment (T2). NFPP and IY outcomes only were measured 6 months post treatment (T3). Researchers, but not therapists or parents, were blind to treatment allocation. Analysis employed mixed effect regression models (multiple imputations). Intervention and other costs were estimated using standardized approaches. NFPP and IY did not differ on parent-rated SNAP-IV, ADHD combined symptoms [mean difference - 0.009 95% CI (- 0.191, 0.173), p = 0.921] or any other measure. Small, non-significant, benefits of NFPP over TAU were seen for parent-rated SNAP-IV, ADHD combined symptoms [- 0.189 95% CI (- 0.380, 0.003), p = 0.053]. NFPP significantly reduced parent-rated conduct problems compared to TAU across scales (p values < 0.05). No significant benefits of IY over TAU were seen for parent-rated SNAP, ADHD symptoms [- 0.16 95% CI (- 0.37, 0.04), p = 0.121] or parent-rated conduct problems (p > 0.05). The cost per family of providing NFPP in the trial was significantly lower than IY (£1591 versus £2103). Although, there were no differences between NFPP and IY with regards clinical effectiveness, individually delivered NFPP cost less. However, this difference may be reduced when implemented in routine clinical practice. Clinical decisions should take into account parental preferences between delivery approaches.

Impulsivity and self-harm in adolescence: a systematic review.

Research supports an association between impulsivity and self-harm, yet inconsistencies in methodology across studies have complicated understanding of this relationship. This systematic review examines the association between impulsivity and self-harm in community-based adolescents aged 11-25 years and aims to integrate findings according to differing concepts and methods. Electronic searches of EMBASE, MEDLINE, PsychINFO, CINAHL, PubMed and The Cochrane Library, and manual searches of reference lists of relevant reviews identified 4496 articles published up to July 2015, of which 28 met inclusion criteria. Twenty-four of the studies reported an association between broadly specified impulsivity and self-harm. However, findings varied according to the conception and measurement of impulsivity and the precision with which self-harm behaviours were specified. Specifically, lifetime non-suicidal self-injury was most consistently associated with mood-based impulsivity-related traits. However, cognitive facets of impulsivity (relating to difficulties maintaining focus or acting without forethought) differentiated current self-harm from past self-harm. These facets also distinguished those with thoughts of self-harm (ideation) from those who acted on thoughts (enaction). The findings suggested that mood-based impulsivity is related to the initiation of self-harm, while cognitive facets of impulsivity are associated with the maintenance of self-harm. In addition, behavioural impulsivity is most relevant to self-harm under conditions of negative affect. Collectively, the findings indicate that distinct impulsivity facets confer unique risks across the life-course of self-harm. From a clinical perspective, the review suggests that interventions focusing on reducing rash reactivity to emotions or improving self-regulation and decision making may offer most benefit in supporting those who self-harm.

Linguistic analysis of the Preschool Five Minute Speech Sample: what the parents of preschool children with early signs of ADHD say and how they say it?

A linguistic analysis was performed on the Preschool Five Minute Speech Sample (PFMSS) of 42 parents. PFMSS is a validated measure for Expressed Emotion (EE) to assess parent-child relationship. Half of these parents (n = 21, clinical group) had preschool children with early symptoms of attention deficit hyperactivity disorder (ADHD), the rest had typically developing children. Early symptoms of ADHD were identified with the Werry-Weiss Peters Rating Scale. The linguistic component of the PFMSS was analysed with keyword and linguistic pattern identification. The results of these two complementary analyses (i.e., EE and linguistic analysis) provided relevant recommendations that may improve the efficacy of psychological treatment for ADHD such as parenting interventions. We discuss the practical implications of these findings.

Are self-directed parenting interventions sufficient for externalising behaviour problems in childhood? A systematic review and meta-analysis.

Externalising behaviour in childhood is a prevalent problem in the field of child and adolescent mental health. Parenting interventions are widely accepted as efficacious treatment options for reducing externalising behaviour, yet practical and psychological barriers limit their accessibility. This review aims to establish the evidence base of self-directed (SD) parenting interventions for externalising behaviour problems. Electronic searches of PubMed, Web of Knowledge, Psychinfo, Embase and CENTRAL databases and manual searches of reference lists of relevant reviews identified randomised controlled trials and cluster randomised controlled trials examining the efficacy of SD interventions compared to no-treatment or active control groups. A random-effect meta-analysis estimated pooled standard mean difference (SMD) for SD interventions on measures of externalising child behaviour. Secondary analyses examined their effect on measures of parenting behaviour, parental stress and mood and parenting efficacy. Eleven eligible trials were included in the analyses. SD interventions had a large effect on parent report of externalising child behaviour (SMD = 1.01, 95 % CI: 0.77-1.24); although this effect was not upheld by analyses of observed child behaviour. Secondary analyses revealed effects of small to moderate magnitude on measures of parenting behaviour, parental mood and stress and parenting efficacy. An analysis comparing SD interventions with therapist-led parenting interventions revealed no significant difference on parent-reported measures of externalising child behaviour. SD interventions are associated with improvements in parental perception of externalising child behaviour and parental behaviour and well-being. Future research should further investigate the relative efficacy and cost-effectiveness of SD interventions compared to therapist-led interventions.