Cognitive behavioural anger management intervention for people with intellectual disabilities: costs of intervention and impact on health and social care resource use.

BACKGROUND: Anger and aggression among adults with intellectual disability (ID) are associated with a range of adverse consequences for their well-being and that of their family or staff carers. The aims were to evaluate the effectiveness of an anger management intervention for adults with mild to moderate ID and to evaluate the costs of the intervention and its impact on health and social care resource use. This paper is concerned with the latter aim. METHODS: A cluster-randomised controlled trial was conducted involving day services for adults with ID in Scotland, England and Wales. Incremental costs of delivering the intervention and its impact on subsequent total health and social care package costs were calculated. Full data comparing costs between baseline and follow-up 10 months later were collected for 67 participants in the intervention arm and 62 participants in the control arm. Cost differences between the groups at follow-up, adjusted for baseline levels, were calculated using non-parametric bootstrapping controlling for clustering. RESULTS: The mean hourly excess cost of intervention over treatment as usual was £12.34. A mean adjusted cost difference of £22.46 per person per week in favour of the intervention group was found but this was not statistically significant. CONCLUSIONS: The baseline-adjusted cost difference at follow-up would result in a fairly immediate compensation for the excess costs of intervention, provided the difference is not a statistical artefact. Further research is needed to clarify the extent to which it might represent a real saving in service support costs.

'It's made all of us bond since that course ' - a qualitative study of service users' experiences of a CBT anger management group intervention.

BACKGROUND: People with intellectual disabilities (ID) are rarely asked about their experiences as users of psychological services and little is known about the views of clients with ID who have undergone cognitive behavioural therapy (CBT). This study aimed to gather the views of adults with ID who had recently taken part in a cluster randomised control trial (RCT) of a staff-delivered manualised CBT anger management group intervention. METHOD: A qualitative method, Interpretative Phenomenological Analysis (IPA), was employed and eleven participants were interviewed. The interviews took place after the intervention, within two weeks of the end of the group, to gain an understanding of service users' experiences of participating in a CBT group. RESULTS: IPA of the interview transcripts indicated that the intervention was experienced as effective and enjoyable and a number of themes were identified including: 'the importance of relationships', 'a new me', 'new and improved relationships', 'presenting myself in a positive light' and 'what the group didn't change'. CONCLUSIONS: The results will be discussed in the context of applying group CBT for adults with ID and implications for service development.

A cluster randomised controlled trial of a manualised cognitive behavioural anger management intervention delivered by supervised lay therapists to people with intellectual disabilities.

BACKGROUND: Anger is a frequent problem for many people with intellectual disabilities, and is often expressed as verbal and/or physical aggression. Cognitive-behaviour therapy (CBT) is the treatment of choice for common mental health problems, but CBT has only recently been adapted for people with intellectual disabilities. Anger is the main psychological presentation in which controlled trials have been used to evaluate CBT interventions for people with intellectual disabilities but these do not include rigorous randomised studies. OBJECTIVES: To evaluate (1) the impact of a staff-delivered manualised CBT anger management intervention on (a) reported anger among people with mild to moderate intellectual disabilities, and (b) anger coping skills, aggression, mental health, quality of life and costs of health and social care; (2) factors that influence outcome; and (3) the experience of service users, lay therapists and service managers. DESIGN: A cluster randomised controlled trial based on 30 day centres (15 intervention and 15 control). Intention-to-treat comparisons of outcomes used a two-level linear regression model to allow for clustering within centres with baseline outcome levels as a covariate. Comparison of cost data used non-parametric bootstrapping. Qualitative analysis used interpretative phenomenological analysis and thematic analysis. SETTING: Recruited day centres had four-plus service users with problem anger who were prepared to participate, two-plus staff willing to be lay therapists, a supportive manager and facilities for group work, and no current anger interventions. PARTICIPANTS: A total of 212 service users with problem anger were recruited. Thirty-three were deemed ineligible (30 could not complete assessments and three withdrew before randomisation). Retention at follow-up was 81%, with 17 withdrawals in each arm. Two to four staff per centre were recruited as lay therapists. Eleven service users, nine lay therapists and eight managers were interviewed. INTERVENTIONS: The manualised intervention comprised 12 weekly 2-hour group sessions supplemented by 'homework'. Lay therapists received training and ongoing supervision from a clinical psychologist. Treatment fidelity, group attendance and resources used in intervention delivery were monitored. MAIN OUTCOME MEASURES: The primary outcome was the service user-rated Provocation Index (PI), a measure of response to hypothetical situations that may provoke anger. Secondary trial outcomes were the key worker-rated PI; the service user- and key worker-rated Profile of Anger Coping Skills (PACS); the service user-rated PACS imaginal provocation test (PACS-IPT), a measure of response to actual situations known to provoke anger; aggression; mental health; self-esteem; quality of life; and health and social care resource use. Assessments were administered before randomisation and at 16 weeks and 10 months after randomisation. RESULTS: Fourteen treatment groups were delivered, each with 12 sessions lasting an average of 114 minutes, with a mean of 4.9 service users and 2.0 lay therapists. The mean hourly cost per service user was £ 25.26. The mean hourly excess cost over treatment as usual was £ 12.34. There was no effect of intervention on the primary outcome - self-rated PI. There was a significant impact on the following secondary outcomes at the 10-month follow-up: key worker-rated PI, self-rated PACS-IPT and self- and key worker-rated PACS. Key workers and home carers reported significantly lower aggression at 16 weeks, but not at 10 months. There was no impact on mental health, self-esteem, quality of life or total cost of health and social care. Service users, key workers and service managers were uniformly positive. CONCLUSIONS: The intervention was effective at changing anger coping skills and staff-rated anger. Impact on self-rated anger was equivocal. With hindsight there are reasons, from an analysis of factors influencing outcomes, to think that self-rated PI was not a well-chosen primary outcome. Widespread implementation of manualised lay therapist-led but psychologist-supervised anger management CBT for people with mild to moderate intellectual disabilities is recommended.

Practical aspects of a visual aid to decision making.

BACKGROUND: Previous research has demonstrated that people with mild intellectual disabilities (ID) have difficulty in 'weighing up' information, defined as integrating disparate items of information in order to reach a decision. However, this problem could be overcome by the use of a visual aid to decision making. In an earlier study, participants were taught to translate information about the pros and cons of different choices into a single evaluative dimension, by manipulating green (good) and red (bad) bars of varying lengths (corresponding to the value ascribed). Use of the visual calculator increased the consistency of performance (and decreased impulsive responding) in a temporal discounting task, and increased the amount of information that participants provided to justify their decisions in scenario-based financial decision-making tasks. METHODS: The present study examined some practical aspects of visual calculator training, using a pen-and-paper version of two temporal discounting tasks. Participants with mild ID were tested, individually and in a group setting, before and after training in the group setting, and 2 months later. RESULTS: (i) The visual aid improved temporal discounting performance using pen-and-paper presentation in a group setting as effectively as previously demonstrated using computer-based individual presentation. (ii) Following withdrawal of the aid, improvements in temporal discounting performance were maintained at 1 day post training, but lost following a 2-month hiatus; however, participants showed perfect retention, over 2 months, of how to use the aid. (iii) In addition to decreasing impulsivity in a hypothetical task, as previously demonstrated, use of the visual calculator also increased the ability of impulsive participants to wait in real time. CONCLUSION: The results suggest that the visual calculator has practical applicability to support decision making by people with mild ID in community settings.

Evaluation of executive functioning in people with intellectual disabilities.

BACKGROUND: Executive functioning (EF) is an important concept in cognitive psychology that has rarely been studied in people with intellectual disabilities (IDs). The aim of this study was to examine the validity of two test batteries and the structure of EF in this client group. METHODS: We administered the children's version of the Behavioural Assessment of the Dysexecutive Syndrome (BADS-C) and the Cambridge Executive Functioning Assessment (CEFA) for people with ID, to 40 participants who attended day centres for people with mild to moderate learning disabilities [mean full-scale intelligence quotient (IQ) = 59]. The BADS-C consists of six EF subtests while the CEFA contains eight EF (including two executive memory) subtests and four memory subtests. IQ and receptive language ability were also assessed. The results were subjected to principal components analysis, and regression analysis was used to examine the relationship of the ensuing factors to other cognitive variables. RESULTS: Scores on both sets of EF tests were only weakly related to receptive language ability, and even more weakly related to IQ. Scores on the BADS-C were substantially lower than predicted from the published norms for people in higher IQ ranges, and many participants scored zero on three of the six subtests. This potential floor effect was less evident with scores on the CEFA. Principal components analyses produced one usable factor for the BADS-C, and two factors for the CEFA that differed in both the extent of involvement of working memory and the predominant sensory modality. A combined analysis of the subtests retained from both analyses produced three factors that related uniquely to aspects of IQ and memory. CONCLUSIONS: The CEFA is suitable for use with people with mild to moderate learning disabilities, whereas the BADS-C is at the lower limit of usability with this client group. The lower-than-expected scores observed on the BADS-C may indicate that people known to learning disability services may be more impaired than people of comparable IQ not known to services. The structure of EF seen in people with IDs closely resembles a model of EF in the general population that has received a broad level of support.

Evaluation of the ability of people with intellectual disabilities to 'weigh up' information in two tests of financial reasoning.

BACKGROUND: An assessment of mental capacity includes an evaluation of the ability to 'weigh up' information, but how to do this is uncertain. We have previously used a laboratory decision-making task, temporal discounting, which involves a trade-off between the value and the delay of expected rewards. Participants with intellectual disabilities (ID) showed very little evidence of 'weighing up' of information: only a third of participants showed consistent temporal discounting performance, and when present, consistent performance was usually impulsive; and the ability to perform consistently was more strongly related to executive functioning than to IQ. The aim of the present study was to replicate these observations and extend them to a more realistic financial decision-making task. METHODS: We administered a temporal discounting task and a financial decision-making task, as well as tests of executive functioning and IQ, to 20 participants who attended day services for people with learning disabilities (mean Full-Scale IQ = 59), and to 10 staff members. RESULTS: Performance in both decision-making tasks was related more strongly to executive functioning than to IQ. In both tasks, decisions by service users were made largely on the basis of a single item of information: there was very little evidence in either task that information from two sources was being 'weighed'. CONCLUSIONS: The results suggest that difficulty in 'weighing up' information may be a general problem for people with ID, pointing to a need for psycho-educational remediation strategies to address this issue. The importance of executive functioning in decision-making by people with ID is not recognized in the legal test for mental capacity, which in practice includes a possibly irrelevant IQ criterion.

Clarification of the memory artefact in the assessment of suggestibility.

AIM: The Gudjonsson Suggestibility Scale (GSS) assesses suggestibility by asking respondents to recall a short story, followed by exposure to leading questions and pressure to change their responses. Suggestibility, as assessed by the GSS, appears to be elevated in people with intellectual disabilities (ID). This has been shown to reflect to some extent the fact that people with ID have poor recall of the story; however, there are discrepancies in this relationship. The aim of the present study was to investigate whether a closer match between memory and suggestibility would be found using a measure of recognition memory rather than free recall. METHOD: Three modifications to the procedure were presented to users of a learning disabilities day service. In all three experiments, a measure of forced-choice recognition memory was built into the suggestibility test. In experiments 1 and 2, the GSS was presented using either divided presentation (splitting the story into two halves, with memory and suggestibility tests after each half) or multiple presentation (the story was presented three times before presentation of the memory and suggestibility tests). Participants were tested twice, once with the standard version of the test and once with one of the modified versions. In experiment 3, an alternative suggestibility scale (ASS3) was created, based on real events in a learning disabilities day service. The ASS3 was presented to one group of participants who had been present at the events, and a second group who attended a different day service, to whom the events were unfamiliar. RESULTS: As observed previously, suggestibility was not closely related to free recall performance: recall was increased equally by all three manipulations, but they produced, respectively, no effect, a modest effect and a large effect on suggestibility. However, the effects on suggestibility were closely related to performance on the forced-choice recognition memory task: divided presentation of the GSS2 had no effect on either of these measures; multiple presentation of the GSS2 produced a modest increase in recognition memory and a modest decrease in suggestibility; and replacing the GSS with the ASS3 produced a large increase in recognition memory and a large decrease in suggestibility. IMPLICATIONS: The results support earlier findings that the GSS is likely to overestimate how suggestible a person will be in relation to a personally significant event. This reflects poor recognition memory for the material being tested, rather than increased suggestibility per se. People with ID may in fact be relatively non-suggestible for well-remembered events, which would include personally significant events, particularly those witnessed recently.

Can attribution theory explain carers' propensity to help men with intellectual disabilities who display inappropriate sexual behaviour?

AIM: This study examined the responses of care managers and direct care staff to vignettes of inappropriate sexual behaviour by a man with an intellectual disability. The aim was to test the theory that helping behaviour is determined by emotional responses (positive and negative emotional reactions, and optimism), which in turn are determined by causal attributions (respectively: controllability and stability of the incident depicted in the vignette). METHOD: The vignettes varied in response topography and the age of the victim. Regression analysis was used to examine the relationships between causal attributions, emotional responses, and willingness to invest extra time and effort in the service user's care. RESULTS: No support was found for the pathway: low controllability --> increased sympathy and/or decreased negative emotions --> increased helping. However, strong support was found for the pathway: low stability --> high optimism --> increased helping, particularly in direct care staff. High levels of sympathy were also associated with increased helping, the effect again being mediated by feelings of optimism. CONCLUSIONS: The data provide support for one (but not the other) strand of attribution theory as applied to inappropriate sexual behaviour. The discussion considers the discrepancy between the present data and the far less encouraging literature on attribution theory as applied to challenging behaviour.

Pancreatic injury from blunt abdominal trauma in childhood.

BACKGROUND: Pancreatic trauma in children is relatively uncommon, but carries high morbidity and mortality rates when diagnosis is delayed. Preoperative diagnosis of pancreatic lesion might be difficult, especially in the case of isolated injury. METHODOLOGY: Authors analyse seven cases of pancreatic trauma in childhood. In three cases surgical intervention was required due to pancreatic transection with main pancreatic duct rupture. The injuries of the 5-10 years old male patients were diagnosed and operated on within 24 hours. RESULTS: In two cases distal resection were performed with splenic preservation. In one case--where the operation was performed within 8 hours--preservation of the distal pancreas was also achieved by distal pancreatogastrostomy. The postoperative period was uneventful in all cases. Impaired glucose metabolism was not found in the operated cases during the follow up. CONCLUSIONS: Authors emphasise the importance of CT scan and the responsibility of the first attending physician regarding both diagnosis and correct surgical management.

Assessment of anger coping skills in individuals with intellectual disabilities.

Recent controlled studies have supported the effectiveness of anger management training for people with intellectual disabilities (IDs). This report describes an evaluation instrument designed to assess their usage of specific anger coping skills. The Profile of Anger Coping Skills (PACS) is designed for completion by a staff member or carer. Three situations are first elicited in which a client frequently displays anger. The respondent then rates each situation for the extent to which the client deploys each of eight behavioural and cognitive coping skills. In a preliminary reliability study, 20 users of a day service for people with IDs were rated independently by two staff members, with one of them completing the assessment on two separate occasions: the PACS showed good test-retest reliability and lower, but still acceptable, interrater reliability. The PACS was subsequently used, in a different day service, as part of the assessment pack administered before and after a 12-week anger management group, with a parallel assessment of an untreated control group. The treated group showed substantial decreases in measures of anger, which were maintained at 6-month follow-up. Increases in PACS-rated anger coping skills were also seen in all participants in the anger management group, but not in the control group. There were differences in the extent to which different coping skills were acquired by the treated group, and there were also individual differences in the profile of specific skills acquired. It is concluded that the PACS is a reliable instrument for assessing anger coping skills, particularly when used repeatedly with the same informant. It provides information that is useful for both individual care planning and the design of future anger management programmes.

The effectiveness of psychotherapeutic interventions for people with learning disabilities: a critical overview.

Historically, people with learning disabilities have had little or no access to psychotherapeutic interventions, although there are signs that, over the past decade, this situation has seen some gradual improvement. This paper provides an overview of the evidence for the effectiveness of psychodynamic, cognitive-behavioural and cognitive therapies in this client group. The available data support the position that all three approaches can be effective in people with mild learning disabilities and in a proportion of people with more severe conditions. However, the literature reporting outcomes of psychotherapeutic interventions in people with learning disabilities is extremely limited, and there is a conspicuous and unjustified poverty of randomized controlled trials. There is also very little evidence regarding either the importance of specific components of therapeutic packages, or the optimal manner of delivering these interventions to people with learning disabilities.

Cavernous transformation of the portal vein causing jaundice, presenting in the form of Wilson's disease.

The following is a case review of portal vein cavernous malformation presenting with intermittent cholestasis and jaundice in a 4 year old child. Correct assessment was supported by radiology, later laparoscopy, yet hindered by histopathology representative Wilson's disease and elevated urinary copper excretion. During surgical procedure the stenosis of the common bile duct secondary to extremely dilated portal vein reticulation was solved by Roux-en-Y choledochojejunostomy. After a one-year follow up the child remains asymptomatic.

Influence of nicotine gum on acute cravings for cigarettes.

Reviews of nicotine gum trials generally confirm the efficacy of this substitute in smoking cessation. However, little research has considered the efficacy of nicotine gum as a method for alleviating acute cravings in situations where smokers are not permitted to smoke. The aim of the present study was to evaluate the efficacy of nicotine gum in alleviating acute cravings for cigarettes using the subjective multi-dimensional Questionnaire of Smoking Urges (QSU) and the objective progressive ratio (PR) measures of craving. Forty-five regular smokers participated in a double-blind placebo-controlled trial. All participants were required to abstain from cigarettes for a period of 4 h. Fifteen of the participants were required to chew nicotine gum, 15 were required to chew placebo gum and 15 received no intervention during this abstinence period. All participants then completed the QSU, PR and mood and anxiety questionnaires. The results revealed that participants who had been in either of the gum conditions reported significantly lower QSU factor 1 and factor 2 craving scores after 4 h abstinence than those who had received no intervention. Although a significant partial correlation between QSU factor 1 and 2 scores and the number of reinforcers earned under the PR procedure was observed, the results revealed no significant difference between groups on measures of PR performance or mood and anxiety. Both nicotine and placebo gum are equally effective at reducing acute cravings for cigarettes.

The validity of animal models of predisposition to depression.

Some animal models of depression, including the majority of the more recently introduced models, are better characterized as models of predisposition to depression. In the first part of this paper, we show that the basis for such a model could be either a procedure that increases the ease with which an analogue of major depression may be evoked, or a presentation analogous to dysthymia (chronic mild depression). We then consider how the concepts of predictive, face, and construct validity apply to such models. Next, we review the validity of the available models of predisposition to depression, which derive from genetics, genomics, developmental manipulations, and brain lesioning. Finally, we compare the performance of the different models, using a novel scoring system that formalizes the evaluation of animal models against each of the three sets of validation criteria.

Motivation for alcohol assessed by multiple variable interval schedule behaviour: effects of reward size and alcohol cues.

Altered motivation for drugs of abuse is a central feature of most definitions of drug dependence and the impact of drug-related cues on motivation is of current interest. However, since most studies of cue-reactivity have not used behavioural measures of motivation, their results are often difficult to interpret in motivational terms. In the current paper we describe two experiments in which a behavioural technique, based on multiple variable interval (VI) schedules of reinforcement, was used to study motivation for alcohol in human subjects. In both experiments, subjects attended for several sessions and, during each session, were exposed to a 6-ply VI schedule (values ranged from 1 to 720 s), during which they earned points that were later exchanged for a preferred beer or lager. In Experiment 1 the procedure was validated by showing that changes in the magnitude of reinforcement altered behaviour appropriately. In Experiment 2 we found evidence that the presence of an alcohol-related cue increased the value of alcohol rewards. The results are discussed with reference to a model for the behavioural effects of drug-related cues in triggering relapse and a number of problems we found in using the multiple variable interval schedule procedure.

A view through the gateway: expectancies as a possible pathway from alcohol to cannabis.

AIM: The aim of this study was to test the hypothesis that cannabis outcome expectancies would be more positive in adolescents who drink alcohol than in non-drinkers. PARTICIPANTS AND SETTING: The participants in the study were 4544 11-16-year-olds attending eight secondary schools located in the north-west midlands of England. PROCEDURE: Participants completed an anonymous self-report questionnaire that incorporated sections designed to tap adolescents' expectancies of positive and negative outcomes of alcohol and cannabis use, together with other questions relating to substance use and associated issues. RESULTS: Four reliable six-item scales were derived, and used to measure positive and negative alcohol and cannabis outcome expectancies. Negative expectancies were relatively stable across age and frequency of substance use, particularly for alcohol. However, positive expectancies for both substances increased markedly with age and, independently, with frequency of use. Positive alcohol and cannabis outcome expectancies were meaningfully related to expectancies of future substance use, and to measures of problem drug use and resistance to peer influence, supporting the validity of these expectancy measures, and their possible value as diagnostic screening instruments. The main hypothesis of the study was supported: among respondents who reported never using cannabis, positive cannabis outcome expectancies increased and negative cannabis outcome expectancies decreased with increasing frequency of alcohol use. CONCLUSIONS: The results are consistent with a version of the 'gateway hypothesis' for the relationship between alcohol and cannabis use (alcohol use leads to changes in cannabis expectancies and thereby to cannabis use), but a proper test of the hypothesis requires a longitudinal study.

Mediation of depression by perceptions of defeat and entrapment in high-stress mothers.

Previous studies have demonstrated a causal role of stress in depression, and an association between depression and perceptions of defeat and entrapment. The present study was conducted to determine whether perceptions of defeat/entrapment mediate the relationship between stress and depression. Seventy-six mothers of children attending specialist educational provision for a range of special needs completed the Parenting Stress Index-Short Form (PSI-SF), Defeat and Entrapment Scales, the Beck Depression Inventory (BDI), and the Fawcett-Clark Pleasure Capacity Scale (FCPCS). Relative to population norms, respondents reported very high levels of stress, moderately high levels of defeat/entrapment, mild depression, and very low hedonic capacities. Most of these measures were more extreme in younger mothers and those with a prior history of depression. FCPCS scores were correlated negatively with stress, after controlling for levels of defeat/entrapment, but were not correlated with BDI scores, suggesting that the FCPCS may be an unsuitable instrument for use in the present participant population. Significant positive correlations were found between all measures of stress, defeat/entrapment and depression. After controlling for PSI-SF scores, correlations between BDI and defeat/entrapment scores remained highly significant. However, after controlling for defeat/entrapment, correlations between BDI and PSI-SF scores were non-significant. Hence, perceptions of defeat/entrapment mediate the relationship between stress and depression. This relationship was confirmed formally using regression analysis. Because respondents reported high levels of stress in contrast to mild levels of depression, a causal link can be inferred, running from stress via defeat/entrapment to depression.

Smoking-related cues elicit craving in tobacco "chippers": a replication and validation of the two-factor structure of the Questionnaire of Smoking Urges.

RATIONALE: The reliability and validity of the Questionnaire of Smoking Urges (QSU), a multi-factorial measure of cravings to smoke cigarettes has recently been called into question. OBJECTIVE: In the first phase of the present study, the reliability of the two-factor structure of QSU was examined. The new and original factor structures were then used to investigate the effects of 2 h of abstinence from smoking, and exposure to smoking-related cues, in a subset of the same sample of regular smokers. The present study also investigated the effects of smoking-related cues on QSU measures in tobacco "chippers" (occasional non-dependent smokers). METHODS: The factor structure of the QSU was investigated with a factor analysis of responses to the 32 QSU items produced by a sample of 271 regular smokers. A subset of these data was used to assess the influence of abstinence and cues on QSU factor scores. The final study used a sample of 32 tobacco chippers to assess the effect of smoking-related cues on their QSU factor scores. RESULTS: The results revealed a two-factor structure almost identical to that published by Tiffany and Drobes. In the second experiment, a brief period of abstinence significantly elevated factor 1 scores, but not factor 2 scores, compared to the non-abstinent condition. Exposure to smoking-related cues significantly elevated factor 2 scores and also tended to elevate factor 1 scores. In experiment 3, exposure to smoking-related cues significantly elevated factor 1 scores, but not factor 2 scores, in tobacco chippers. CONCLUSION: The QSU is a psychometrically sound instrument for the assessment of urges to smoke, which shows good construct validity. The two factors of the QSU show differential discriminative properties.

Alcohol sales to underage adolescents: an unobtrusive observational field study and evaluation of a police intervention.

AIMS: The aims of this study were to assess the ease with which adolescents in the United Kingdom are able to buy alcohol, to obtain information concerning vendors' perceptions of alcohol sales to adolescents, and to evaluate a police intervention intended to reduce underage alcohol sales. DESIGN, SETTING, SUBJECTS: An unobtrusive naturalistic field study was conducted in two urban locations. Pairs of 13- and 16-year-old boys and girls were trained to attempt the purchase of different types of alcohol (alcopops, beer, cider, wine, spirits) from four different types of retail outlets (corner shops, off-licence, public houses and supermarkets), under the supervision of a researcher and typically a parent. The assessment was repeated, with the omission of the 13-year-old boys, following a police intervention in one of the performance sites, consisting of warning letters and visits to vendors, and the issue of a small number of police cautions. A total of 62 underage confederates in all attempted 470 test purchases in phase 1 and 348 in phase 2. Between the two waves of test purchases a sample (n = 95) of the same vendors was surveyed by telephone. FINDINGS: In phase 1, sales resulted from 88.1% of purchase attempts by 16-year-old girls, 77% of attempts by 16-year-old boys, 41.6% of 13-year-old girls and 4.1% of 13-year-old boys. These figures were generally comparable across locations, alcohol types and outlet types. Refusals were more likely when another vendor was present. Eighty per cent of sales to 16-year-olds and 65% of sales to 13-year-old girls were made without challenge. "Prove-It" ID cards were requested in fewer than 12% of purchase attempts in both age groups. Overall, there was no evidence that the police intervention reduced sales of alcohol to 16-year-olds. There was a hint that the intervention may have caused a very short-lasting decrease in sales to 13-year-old girls, but this was contained within an overall increase in sales to this group. Alcohol vendors reported that they rarely encountered underage customers or refused sale though 90% of vendors said that if they became suspicious, they would request ID. Only two vendors believed that they were likely to suffer adverse consequences if they sold alcohol to minors. CONCLUSIONS: These data suggest that 16-year-olds, and girls as young as 13, have little difficulty in purchasing alcohol, and that there is little difference between different types of outlets in their willingness to sell alcohol to minors. Vendors perceive little risk in selling alcohol to adolescents. The fact that the police intervention failed to decrease sales suggests that vendors do not change their behaviour in response to the threat of legal action.

Further validation and development of a screening instrument for the assessment of substance misuse in adolescents.

AIM: The aim of this study was to investigate the validity of the Substance Misuse in Adolescence Questionnaire, which has been proposed as a screening instrument for problem drug use in adolescents. PARTICIPANTS AND SETTING: The participants in the study were 4544 11-16-year-olds attending eight secondary schools located in the north-west midlands of England. PROCEDURE: Participants completed an anonymous self-report questionnaire that incorporated a modified version of the SMAQ (the Assessment of Substance Misuse in Adolescence: ASMA), together with other questions relating to substance use and associated issues. RESULTS: The ASMA showed good reliability, both within the overall sample of respondents, and in a drug-using subsample. Principal-components analysis returned a single factor when applied either to the whole sample or to the drug-using subsample; 1.4% of respondents met a criterion equivalent to that proposed by Swadi (1997) for 'problem drug use' (ASMA > 12). A further 6.4% reached a threshold for potentially problematic drug use (ASMA > 8) and could be considered 'at risk'. In regression analyses, ASMA scores were predicted by drug-related variables, and by low resistance to peer influence (RPI), but not by alcohol-related variables. The highest ASMA scores and lowest levels of RPI were found in heroin users. Respondents' perceptions of their future risk of drug or alcohol problems were predicted by RPI and by frequency of drug use and drunkenness. CONCLUSIONS: The ASMA may be a useful screening instrument for identifying problem drug use in adolescents unknown to treatment services.